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Clinical nurse specialists define advanced nursing practice and describe their practice in relation to… Cox, Katherine Margaret 1996

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CLINICAL NURSE SPECIALISTS DEFINE ADVANCED NURSING PRACTICE AND DESCRIBE THEIR PRACTICE IN RELATION TO CLIENT HEALTH OUTCOMES By KATHERINE MARGARET COX R.N., Royal Inland Hospital, 1973 B.S.N., University of V i c t o r i a , 1992 THESIS SUBMITTED IN PARTIAL FULFILMENT THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES The School of Nursing We accept t h i s thesis as conforming to the /required jsJ^andard THE UNIVERSITY OF BRITISH COLUMBIA A p r i l , 1996 ©Katherine M. Cox, 1996 A P R - 1 7 - 9 6 WED 1 0 : 3 7 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission (or extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of _ The University of British Columbia Vancouver, Canada Date QfMbll, Ml? DE-6 (2/88) 11 ABSTRACT C l i n i c a l Nurse S p e c i a l i s t s Define Advanced Nursing Practice and Describe Their Practice i n Relation to C l i e n t Health Outcomes Advanced nursing practice (ANP) i s a term well u t i l i z e d i n the l i t e r a t u r e and i n nursing discussions, yet i s not c l e a r l y understood. Recently, nursing authors have been strongly supporting the need to develop a clear d e f i n i t i o n of ANP. The current focus on outcome measures throughout health care has prompted e f f o r t s to examine d i s c i p l i n e s p e c i f i c , as well as broad influences on c l i e n t health outcomes (CHO). The need for nurses i n ANP to be able to a r t i c u l a t e t h e i r practice i n r e l a t i o n to CHO has been heightened during the l a s t few years. This i s due to factors such as the examination of various nursing roles during times of decreasing health care resources inherent i n health reform. The purpose of t h i s study was to explore and describe how C l i n i c a l Nurse S p e c i a l i s t s (CNSs) define ANP and describe t h e i r practice i n r e l a t i o n to CHO. An exploratory-descriptive q u a l i t a t i v e methodology was used for t h i s study. Data were co l l e c t e d through semi-structured, audio-taped interviews with 6 female and 1 male CNSs who had a master's degree and had been i n t h e i r role for a mean of 6 . 3 years. From the thematic analysis of the data, three broad categories or descriptors that were common to participants were i d e n t i f i e d and developed. Together these three broad categories represent participant attempts to define ANP and describe t h e i r practice i n r e l a t i o n to CHO. The f i r s t category relates to d i f f i c u l t i e s i n c l e a r l y defining ANP. The second category relates to descriptors of ANP. The t h i r d category relates to possible r e l a t i o n s h i p between ANP and CHO. These findings revealed that ANP i s a term that i s broad and vague i n nature and not amenable to a clear and concise d e f i n i t i o n . Furthermore, i t was found that i t may not be possible to a r t i c u l a t e a d i r e c t r e l a t i o n s h i p between ANP and CHO i n an i n t e r d i s c i p l i n a r y collaborative practice environment. The implications for graduate education, p o l i c y and administration as well as research are i d e n t i f i e d i n l i g h t of research findings. I l l TABLE OF CONTENTS Chapter One - Introduction Introduction 1 Background and Significance of the Problem 1 Conceptual Background 5 Statement of the Problem 10 Purpose of the Study. 11 De f i n i t i o n of Terms 11 Assumptions 13 Limitations 13 Chapter Summary 14 Chapter Two - Literature Review Introduction 15 Advanced Nursing Practice 16 Research-Based A r t i c l e s Related to Advanced Nursing Practice 18 Other Literature Related to Advanced Nursing Practice 21 C l i n i c a l Nurse S p e c i a l i s t s and Cl i e n t Health Outcomes 24 Research-Based A r t i c l e s Related to C l i n i c a l Nurse S p e c i a l i s t s and Cl i e n t Health Outcomes 2 6 Other Literature Related to C l i n i c a l Nurse S p e c i a l i s t s and C l i e n t Health Outcomes 28 F i n a l Word on the Literature Review 31 Chapter Summary 32 Chapter Three - Methodology Introduction 33 Research Design 33 Selection of Participants 34 Selection C r i t e r i a . . . . 35 Procedure for Recruitment of Participants 35 Characteristics of Participants 37 Data C o l l e c t i o n Procedures 38 Data Analysis 41 E t h i c a l Considerations 46 Chapter Summary 47 Chapter Four - Findings Introduction 48 D i f f i c u l t i e s i n Clearly Defining Advanced Nursing Practice 52 I n i t i a l Attempts at Defining Advanced Nursing Practice 52 Broad and Vague Term 53 Lack of Concern 55 Cautions Around Trying to Clearly Define 57 i v Reasons for Lack of C l a r i t y About Advanced Nursing Practice 59 Role Inconsistencies 59 Imprecision Regarding Nursing 60 Terminology Changes 62 Lack of Time for Reflection 63 Descriptors of Advanced Nursing Practice 6 6 •Minimal Requirement Triad of Advanced Nursing Practice 66 Graduate Education . 67 C l i n i c a l Specialty Focus 71 Research-Based Practice 77 Essent i a l Qualities of Advanced Nursing Practice 80 Global.Thinking.. .... 80 Indirect C l i n i c a l Focus 86 Assistive Care Delivery 92 Effective Leadership 9 6 Interdisciplinary Collaboration 100 Possible Relationship Between Advanced Nursing Practice and Clien t Health Outcomes 107 Problems i n A r t i c u l a t i n g C l i e n t Health Outcomes 108 Communicating the Relationship Between Advanced Nursing Practice and Cl i e n t Health Outcomes I l l Detailed C l i n i c a l Stories I l l Broad System Perspective 115 Theoretical Problems i n Linking Advanced Nursing Practice With C l i e n t Health Outcomes 118 Long Term Versus Short Term 118 Strong Influence of Other Variables 120 Chapter Summary 128 Chapter Five - Discussion of Findings Introduction 130 Issues Related to a D e f i n i t i o n of Advanced Nursing Practice 131 Support for Advanced Nursing Practice Remaining a Broad and Vague Term. . . 132 Global Thinking as an Essential Quality 138 Minimal Requirement Triad 141 Graduate Education and Advanced Nursing Practice 146 Advanced Nursing Practice and I n t e r d i s c i p l i n a r y Collaboration 151 Chapter Summary 159 Chapter Six - Summary, Conclusions and Implications Summary 162 Conclusions 166 Nursing Implications 168 Graduate Education 168 Policy and Administration 173 V Research 175 Concluding Remarks 179 References 181 Appendix A - Letter of Invitation to Participants 194 Appendix B - E l i g i b i l i t y C r i t e r i a and Demographics 19 6 Appendix C - Prompts 197 Appendix D - Consent for Interview 198 1 CHAPTER ONE INTRODUCTION Advanced nursing practice (ANP) i s a term u t i l i z e d throughout nursing l i t e r a t u r e and i n discussions yet i s poorly understood. Over the course of the l a s t few years, there has been a heightened i n t e r e s t by health p o l i c y decision makers and funders to evaluate outcomes of health care practices. This inte r e s t has been prompted by current health care expenditures, gaps i n primary health care and awareness that some health care professionals, such as nurses, are not able to practise to t h e i r f u l l scope (Henning & Cox, 1993; Ministry of Health, 1993; Roch 1992). C l i n i c a l Nurse S p e c i a l i s t s (CNSs) are nurses recognized as p r a c t i s i n g under the umbrella of ANP. Consultants- from the B r i t i s h Columbia (B.C.) Ministry of Health, i n t e r - m i n i s t e r i a l health p o l i c y decision makers, professional regulatory bodies and nursing authors, generally express concern that there i s not a clear understood d e f i n i t i o n of ANP and how t h i s practice lin k s with c l i e n t health outcomes (CHO). Background and Significance of the Problem The term ANP i s u t i l i z e d extensively i n nursing discussions and i n the l i t e r a t u r e , yet nurses are not able to c l e a r l y a r t i c u l a t e what i t i s (Calkin, 1984; Canadian Nurses Association, 1992; Fenton, 1985; Haddad, 1992a; Schaefer & Lucke, 1990). Despite t h i s lack of c l a r i t y , CNSs are recognized and i d e n t i f i e d as conducting ANP (American Nurses 2 Association, 1985; Canadian Nurses Association, 1992; Fenton, 1985; Sparacino, 1992; Spross & Baggerly, 1989). Other nurses are also recognized as advanced nurse p r a c t i t i o n e r s , for example, nurse p r a c t i t i o n e r s , c e r t i f i e d nurse midwives and c e r t i f i e d registered nurse anesthetists (Inglis & Kjervik, 1993). In Canada, CNSs are generally educated at the master's l e v e l and practice i n a variety of settings that include: hospitals, c l i n i c s , community health units and independent practice. CNSs are active members of i n t e r d i s c i p l i n a r y teams attempting to meet current gaps i n primary health care. The CNS role i s quite well established i n North American health care systems. In Canada, there are approximately 220 CNSs (Jessie Mantle, personal communication, September 7, 1993). In B.C., there are approximately 50 CNSs employed primarily i n hospitals i n the Lower Mainland and V i c t o r i a . At the time of t h i s research, there were 3 community health CNSs i n B.C.: 2 employed i n the Vancouver Health Department and 1 i n Community Home Care Nursing Services i n the Ministry of Health. During times of economic r e s t r a i n t , there i s a heightened need for nurses to define ANP and subsequently develop a model of t h i s practice (Spross & Baggerly, 1989). Nurses who are i n ANP roles are paid s a l a r i e s higher than other nurses, and therefore are viewed as "costing" the health care system "more" than other nurses (Brunk, 1992; 3 Sparacino, 1992). Despite salary issues, numerous a r t i c l e s i d e n t i f y benefits of employing advanced nursing p r a c t i t i o n e r s such as CNSs (Brunk, 1992; Girouard, 1989; Hawkins & Thibodeau, 1989). Authors argue that the system wide c l i e n t care benefits r e s u l t i n o v e r a l l cost savings to the health care system ( F r a l i c , 1988; Gournic, 1989; Koetters, 1989). Despite these benefits,-nursing roles such as those of CNSs are being examined p a r t i c u l a r l y during times of health care budget crunches. There i s a growing trend that CNSs are being asked to take on more administrative r e s p o n s i b i l i t i e s i n t h e i r various agencies. This has the pote n t i a l to spread the CNS "too thin" or cause a loss of the c l i n i c a l emphasis i n t h e i r o v e r a l l practice. The CNS role w i l l continue to be challenged as program administrators and managers are forced to engage i n increasingly c o s t - e f f e c t i v e approaches to health care (Brunk, 1992; Schaefer & Lucke, 1990). The i d e n t i f i c a t i o n of a d e f i n i t i o n and model of ANP w i l l enable CNSs to c l e a r l y a r t i c u l a t e and demonstrate the competencies (knowledge, s k i l l s , attitudes and judgements), inherent i n t h e i r roles. This may a s s i s t administrators/managers to continue j u s t i f i c a t i o n and potential expansion i n the employment of nurses i n ANP (Spross & Baggerly, 1989). Currently i n the B.C. health care system, there i s int e r e s t i n exploring CHO due to an increased focus on s e l f care, health promotion, c l i e n t advocacy and contracts between c l i e n t s and providers. The need for c o s t - e f f e c t i v e health care practices, plus the appropriate use of health care providers, have become c r i t i c a l concerns (Ministry of Health, 1993; Seaton, 1991). With the current "hospital to community s h i f t " , i n t e r - m i n i s t e r i a l s t a f f are questioning "do we need more nurses i n ANP?" and "can nurses i n ANP demonstrate the impact that t h e i r practice has on CHO?" Minimal research has been done with CNSs to examine t h e i r actual practice (Amos-Taylor & Elberson, 1989; Sparacino, 1986). Various nursing researchers have i d e n t i f i e d i n t e r e s t i n examining ANP from a q u a l i t a t i v e perspective (Beecroft, 1992; Brown & Waybrant, 1988; Schaefer & Lucke, 1990). Limited e f f o r t s have been made to explore the r i c h , d i r e c t , and unique contribution that nurses can make to the health outcomes of c l i e n t s . Although work has been done i n i d e n t i f y i n g competencies of CNSs (Fenton, 1985), the next step i s to determine the effectiveness of these on c l i e n t l i f e s t y l e and health (Brown & Waybrant, 1988), as well as other outcome measures. It was the researcher's b e l i e f that CNSs, as nurses i n ANP, did p o s i t i v e l y and s i g n i f i c a n t l y influence CHO somehow, yet t h i s had not been c l e a r l y r e f l e c t e d i n the l i t e r a t u r e . It was also the researcher's b e l i e f that nurses i n ANP could do much to shape health care during health reform. In order for nurses to maximize accountability, and for ANP to continue and grow, two areas were worthy of further 5 exploration: nurses i n ANP defining t h e i r practice and describing how i t relates to CHO. Conceptual Background A s p e c i f i c theory or framework that could c l e a r l y be u t i l i z e d as a guide for t h i s study was not available. Although there existed an extensive amount of nursing l i t e r a t u r e related to ANP and some with regard to CHO, there had been no comprehensive, systematic study done from the perspective of t h i s research. Therefore, q u a l i t a t i v e exploratory-descriptive research was appropriate for the phenomena of i n t e r e s t . There were three well known nursing leaders who developed "theories" related to expert and ANP, namely P a t r i c i a Benner (1984), Mary Fenton (1985) and Joy Calkin (1984). Although the work of these nursing scholars did not provide a s p e c i f i c s t r u c t u r a l "theory" for t h i s study, i t formed both a basis and a rationale for further study of the l i n k between ANP and CHO. Benner (1984) conducted research using an i n t e r p r e t i v e method, s p e c i f i c a l l y that of hermeneutic phenomenology, and, i n her book From Novice to Expert, i d e n t i f i e s f i v e levels of professional nursing competency i n c l i n i c a l practice, namely: novice, advanced beginner, competent, p r o f i c i e n t and expert. The highest l e v e l of professional competency i s "expert." Although expert practice has received extensive scrutiny primarily because of Benner's work, what i s not clear i s i f 6 there i s an implication that expert practice i s the same as ANP or whether ANP i s a sixth level? Benner began to use the term ANP but does not d i f f e r e n t i a t e expert from advanced practice. Often there i s the use of the term "expert" i n conjunction with "advanced," such as, the expert p r a c t i t i o n e r has not always been an expert. The nurse entering practice,, l i k e the person learning to f l y an airplane, requires a l l the guidance possible to avoid mistakes so that patients and nurses a l i k e survive long enough to develop advanced s k i l l s (p. 20) An additional example: "the exemplars taken from expert practice demonstrate the notion of good and the knowledge embedded i n advanced levels of practice" (Benner, 1989, p. 21) . Benner's use of "exemplars" to support her conceptualizations i s well known. She alludes to the l i n k of expert practice and CHO by publishing only those exemplars "where the nurse made a po s i t i v e difference i n the patient's outcome" (Benner, 1984, p. x v i i ) . These exemplars i l l u s t r a t e only immediately recognizable CHO. Benner's work does not address long term CHO that may d i r e c t l y r e s u l t from any of the f i v e levels of nursing competencies, nor does i t consider whether there may be differences i n these outcomes dependent upon the " l e v e l " of nursing practice. In addition, one i s l e f t wondering i f CHO can be d i r e c t l y linked back to the nurse. What about other influencing factors i n c l i e n t care? Benner subsequently co-authored another book with Judith 7 Wrubel (1989), e n t i t l e d the Primacy of Caring. The book i s "devoted to an interp r e t i v e theory of nursing practice as i t i s concerned with helping people cope with the stress of i l l n e s s " (p. 7). This work outlines that caring i s a central component of e f f e c t i v e nursing practice and i s key for expert practice. A component of caring i s concern and "within each arena of concern are many d i f f e r e n t ways of caring" (Benner & Wrubel, 1989, p. ,87). If nurses are concerned, they are alerted to the knowledge of the features of the si t u a t i o n that make a difference and are attuned to the cues that signal a change i n status (Benner & Wrubel, 1989). Is there a difference i n the concern that nurses i n ANP have i n the features of the si t u a t i o n they i d e n t i f y , and the cues to which they are attuned, and how i s t h i s r e f l e c t e d i n t h e i r caring? A l l nurses can c l e a r l y i d e n t i f y colleagues who represent expert practice i n nursing. Often these nurses are highly competent yet may be educated at the diploma l e v e l . I f , t r a d i t i o n a l l y , nurses engaged i n ANP require at least a master's degree, must there not be some difference i n ANP versus expert practice? If not, then how can there be j u s t i f i c a t i o n for the time and f i n a n c i a l costs associated with educational preparation for nurses at the master's and doctoral level? Fenton (1985) conducted an ethnographic study that i d e n t i f i e d common competencies of master's prepared CNSs. 8 Using Benner's (1984) description of expert practice, Fenton confirmed that CNSs are nursing experts. However, Fenton i d e n t i f i e d some behaviours of CNSs that had not been noted by Benner i n expert nurses, such as: organizational and work role competencies, consulting role, monitoring and ensuring the qu a l i t y of health care practices (Fenton, 1985). She also found that CNSs c l e a r l y i d e n t i f i e d the important role of being supportive to s t a f f nurses. Additionally, CNSs often "massage the system" for the goal of improvement i n c l i e n t / p a t i e n t and nurse situations (Fenton, 1985). This leadership function i s often unrecognized by administrators and therefore not t r a d i t i o n a l l y found i n job descriptions. Fenton's work represents a clearer attempt to address how ANP d i f f e r s from expert practice. Calkin (1984) outlines what she describes as "a model for advanced nursing practice." In t h i s model, she d i f f e r e n t i a t e s the practice of nurses according to t h e i r experience i n r e l a t i o n to human responses to health problems. She refers to Benner (1984) and uses the same terms to describe the nurses. She attempts to define ANP but the d e f i n i t i o n i s vague and applicable to a wide range of nurses. She recognizes that " i t i s important to think about the essence of advanced nursing practice" (Calkin, 1984, p. 24). Additionally, she notes that "the i d e n t i f i c a t i o n of p o s i t i v e responses to actual and potential health problems provides nurses with high-quality outcomes or goals for nursing 9 interventions" (Calkin, 1984, p. 27). It i s i n t e r e s t i n g that she uses the phrase "high-quality outcomes or goals." The two are not necessarily the same, in that goals can d i r e c t nursing interventions but outcomes r e s u l t from nursing interventions and may be more s p e c i f i c than goal attainment. In Calkin's (1988) discussion on s p e c i a l i z a t i o n i n nursing, she notes that "for more than a decade I have used the term 'advanced nurse p r a c t i t i o n e r ' to refer to the master's prepared nurse i n an attempt to avoid using the term s p e c i a l i z a t i o n " (p. 285). She also recognizes that given the current trends i n health care i t i s not possible to keep a command of the "breadth of knowledge needed for precision i n practice" (p. 280). Thus ''Clinical Nurse S p e c i a l i s t s with advanced knowledge and s k i l l are required" (Calkin, 1988, p. 280). It i s i n t e r e s t i n g to note that the t i t l e of the CNS contains the word " s p e c i a l i s t . " How do the terms: expert, s p e c i a l i s t and ANP relate? Calkin claims that nurses w i l l need to come to terms with the educational requirements that are most appropriate for ANP. This may be key! A l l of these nursing scholars have made a l i n k between ANP and CHO, yet none of these linkages has been c l e a r l y a r t i c u l a t e d . They allude to nurses influencing CHO, yet how t h i s influence i s achieved i s not discussed, l e t alone measured. Nurses must be able to make the links between ANP and CHO i n order to: • increase understanding of the effectiveness of d i f f e r e n t 10 levels of nursing practice; • enhance decision making by themselves and with c l i e n t s ; • develop standards to guide nursing and health care decision makers i n optimizing the use of resources (Epstein, 1990); and, • a r t i c u l a t e the value and benefit of graduate nursing education. Statement of the Problem The l i t e r a t u r e reveals an increasingly important need to c l e a r l y define ANP as well as to a r t i c u l a t e the influence that t h i s practice has on CHO. Nurses i n ANP can be the victims of " s t a f f i n g cuts" and elimination of positions, or change to administrative roles with organizations lessening the c l i n i c a l component emphasis. It i s important for nurses i n ANP to be able to c l e a r l y discuss the value and significance of t h e i r role p a r t i c u l a r l y during health care reform. Competencies to do t h i s w i l l not only be of assistance i n the continuation of c l i n i c a l l y based positions within organizations but w i l l . a l s o provide opportunities for nurses i n ANP to p o s i t i v e l y shape health care. This study sought to answer the following question: "How do C l i n i c a l Nurse S p e c i a l i s t s define advanced nursing practice and how do they describe t h e i r practice i n r e l a t i o n to c l i e n t health outcomes?" These phenomena remain not well understood within the nursing community. For c l a r i f i c a t i o n , CNSs were not the only appropriate 11 source to define ANP and i t s r e l a t i o n s h i p to CHO. Other sources that could have been contacted include c l i e n t s , educators, nurse p r a c t i t i o n e r s , s t a f f nurses, nurse midwives and health p o l i c y decision-makers. The researcher had a personal inte r e s t i n further understanding ANP and i t s l i n k s to CHO from the perspectives of nurses i n the CNS r o l e . Purpose of the Study The purpose of t h i s study was to explore and describe how a group of CNSs as nurses formally recognized as conducting ANP, a r t i c u l a t e d two areas of t h e i r p r a c t i c e : • How did they define ANP; and, • How did they describe t h e i r practice i n r e l a t i o n to CHO. D e f i n i t i o n of Terms Two s i m i l a r d e f i n i t i o n s of a CNS were used for t h i s study. The f i r s t states that the CNS i s a registered nurse who i s an expert p r a c t i t i o n e r holding a Master's or doctoral degree i n nursing, having majored i n a c l i n i c a l s pecialty (Registered Nurses Association of B r i t i s h Columbia, 1988). The second states that a CNS i s a registered nurse "who, through study and supervised practice at the graduate l e v e l (master's or doctorate), has become expert i n a defined area of knowledge and practice i n a selected c l i n i c a l area of nursing" (American Nurses Association, 1985). The f i r s t d e f i n i t i o n refers to graduate education i n nursing whereas the second does not specify the faculty focus of graduate studies. 12 For t h i s study, i t would have been helpful i f "expert" was c l e a r l y defined i n the l i t e r a t u r e . As was alluded to e a r l i e r , although Benner (1984) uses the term expert, she does not e x p l i c i t l y define i t . Her work does not attempt to c l e a r l y define the levels of nursing practice but rather describes these levels from the perspectives of the nurses interviewed and observed (Benner, 1984). In the glossary section of Benner's book From Novice to Expert (19 84) "expertise" i s defined as: Developed only when the c l i n i c i a n tests and refines t h e o r e t i c a l and p r a c t i c a l knowledge i n actual c l i n i c a l s ituations. Expertise develops through a process of comparing whole sim i l a r and d i s s i m i l a r c l i n i c a l situations with one another, so an expert has a deep background understanding of c l i n i c a l situations based upon many past paradigm cases. Expertise i s a hybrid of p r a c t i c a l and t h e o r e t i c a l knowledge (p. 294). English (1993) further develops the argument that Benner needs to define expert nurse. However, for the purposes of t h i s research, expert was defined as the nurse who may or may not have an underlying t h e o r e t i c a l education but i s none-the-less consistently accurate i n her/his c l i n i c a l judgements of complex c l i e n t scenarios. At the beginning of t h i s study, neither ANP nor CHO was pre-defined. The researcher was interested i n determining i f and how participants defined these terms and how they related them to t h e i r practice. In the l i t e r a t u r e section of t h i s report, some other d e f i n i t i o n s related to t h i s study are explored. These were compared i n the analysis of findings to p a r t i c i p a n t s ' own ideas about the phenomena of i n t e r e s t . 13 Assumptions The following assumptions were recognized: a) i f the participants were p r a c t i s i n g i n a CNS role and met the e l i g i b i l i t y c r i t e r i a (presented i n methodology section of t h i s report) they were p a r t i c i p a t i n g i n ANP; b) the participants would be able to define ANP and t h i s would be a f a m i l i a r topic to them; c) the participants would be able to describe ANP i n r e l a t i o n to CHO despite how they defined c l i e n t ( i n d i v i d u a l , family, group or community); and, d) participants have an important and s i g n i f i c a n t role i n the future of nursing and health care. Limitations A l l participants were from one large hospital society i n one region of B.C. As CNSs, participants met regularly and t h e i r consistencies about ANP and CHO may have stemmed from the organizational culture, previous educational course work, professional experiences as well as discussions that they had with each other and as a group. In addition, a l l participants had described themselves as being c l i n i c a l experts p r i o r to t h e i r graduate education. Even those participants who undertook non-nursing graduate education maintained a c l i n i c a l s p e c i a l i t y focus during t h e i r studies. These factors, plus the small sample size pose li m i t a t i o n s to the g e n e r a l i z a b i l i t y of the study's findings. F i n a l l y , CNSs represent only one group of nurses that are recognized under the umbrella of ANP. This study i s not i n c l u s i v e of a l l 14 nurses i n ANP. For example, Nurse Practitioners have been studied extensively and have demonstrated many p o s i t i v e outcomes of t h e i r practice (Brunt, 1988; Ontario Ministry of Health, 1993), which may be explained by t h e i r emphasis on di r e c t c l i e n t care (Williams & Valdivieso, 1994). Chapter Summary This chapter has presented introductory information for the study which sought to answer the question: "How do C l i n i c a l Nurse S p e c i a l i s t s define advanced nursing practice and how do they describe t h e i r practice i n r e l a t i o n to c l i e n t health outcomes?" In t h i s chapter, the research problem was described from a nursing perspective which provided rationale for the study. The conceptual background that was used as a basis for the study was described. Additionally, terms central to the research question were explored and assumptions and lim i t a t i o n s of the study were outlined. In the following chapter, the ex i s t i n g l i t e r a t u r e pertinent to the i d e n t i f i e d research problem i s reviewed. 15 CHAPTER TWO LITERATURE REVIEW The purpose of t h i s chapter i s to present an exploration and analysis of pertinent l i t e r a t u r e related to ANP and i t s re l a t i o n s h i p to CHO. The l i t e r a t u r e was reviewed i n i t i a l l y for the purposes of gaining a preliminary understanding of what authors had discussed, as well as what questions were raised. In q u a l i t a t i v e research, the l i t e r a t u r e i s generally not reviewed extensively at the beginning of a study i n order to eliminate the r i s k of developing a sedimented view (Burns & Grove, 1987), or for the researcher to be constrained and/or s t i f l e d i n creative e f f o r t s by the knowledge of i t (Strauss & Corbin, 1990). However, for t h i s inexperienced researcher, an i n i t i a l review of the l i t e r a t u r e assisted i n having a more precise understanding of the phenomena under study, as well as the notion of what the results of a q u a l i t a t i v e study of t h i s nature would look l i k e (Ammon-Gaberson & Piantanida, 1988). Additionally, reviewing the l i t e r a t u r e at that point allowed for the study to "build on" e x i s t i n g work, rather than progressing with research that had already been well documented. The l i t e r a t u r e review i s organized into general knowledge, research-based a r t i c l e s and other l i t e r a t u r e related to ANP and i t s rel a t i o n s h i p to CHO. For c l a r i f i c a t i o n , l i t e r a t u r e related to other nurses involved i n ANP, such as nurse p r a c t i t i o n e r s , was not reviewed as the 16 researcher was interested i n the phenomena of i n t e r e s t from the perspectives of CNSs only. Advanced Nursing Practice Nursing l i t e r a t u r e frequently incorporates the term ANP but authors rarely define i t (Brunk, 1992; Calkin, 1988; Hawkins & Thibodeau, 1989; Nichols, 1992; Sparacino & Cooper, 1990). In practice settings, nurses accept and frequently use the term ANP, yet authors of nursing l i t e r a t u r e i d e n t i f y the need to c l e a r l y define i t (Fenton, 1985; Forbes, Rafson, Spross & Kozlowski, 1990; Patterson & Haddad, 1992; Spross & Baggerly, 1989). If d e f i n i t i o n s of ANP are given they are often vague, i n that they could apply to many nurses, such as those prepared at the diploma l e v e l . What i s not clear, from these authors, i s how preparation at the master's i n nursing l e v e l d i f f e r e n t i a t e s ANP from other practice. There i s a wealth of nursing l i t e r a t u r e related to the CNS roles and subroles. These are often l i s t e d as educator, consultant, expert p r a c t i t i o n e r and researcher (Barron, 1989; Calkin, 1984; Hawkins & Thibodeau, 1989; Koetters, 1989; McCaffrey, 1991; McGuire & Harwood, 1989; P r i e s t , 1989; Spross, 1989). However, the common thread that i n t e r l i n k s the roles associated with ANP and c l a r i f i e s t h e i r common goal has not been made (Patterson & Haddad, 1992). Although the term "advanced l e v e l " i s used i n d e f i n i t i o n s , i t i s not defined, l e t alone clear. For ' example, i t i s not clear how CNSs as advanced nursing 17 pr a c t i t i o n e r s d i f f e r from expert nurses, i f at a l l . Examples of t h i s are the d e f i n i t i o n s of Calkin (1984) and King (1990). Calkin's d e f i n i t i o n of ANP i s : Advanced nursing practice i s the del i b e r a t i v e diagnosis and treatment of a f u l l range of human responses to. actual and potential health problems. Advanced pr a c t i t i o n e r s can provide a rationale for choosing diagnostic and treatment processes. Advanced practice i s accompanied by specialized knowledge and s k i l l i n dealing with a human response that cuts across health problems (e.g. pain) or with a cluster of human responses to an i d e n t i f i a b l e actual or potential problem (e.g. diabetes mellitus) or a clus t e r of age-s p e c i f i c human responses to health problems (e.g. infants) or a combination of these (e.g. changes i n self-concept i n pregnant adolescents) (p. 27). King (1990) notes that: being an expert, a CNS p r a c t i t i o n e r provides patient care from a nursing perspective at an advanced l e v e l and i s able to model a nursing practice that demonstrates a high degree of c l i n i c a l competence with s k i l l s i n professional judgement and the possession of a knowledge base (p. 174). The following d e f i n i t i o n by Haddad (1992a) i s clearer but some components present challenges to measure: An advanced nurse practitioner...may be described as a nurse with nursing preparation at the Master's l e v e l , with a c l i n i c a l s p e c i a l i t y who practices within that s p e c i a l i t y and i s committed to ongoing learning, education, and development within the d i s c i p l i n e of nursing. He/she also maintains currency i n recent developments i n nursing and health care, has attained and maintains a l e v e l of knowledge and s k i l l beyond that of that of s t a f f nurses, and u t i l i z e s that knowledge and s k i l l to develop and advance nursing practice through active roles i n education, consultation and research (p. 7). There i s a frequently noted assumptive leap with expert practice to ANP i n the l i t e r a t u r e . The researcher believes that there are differences but i s not able to c l e a r l y 18 a r t i c u l a t e what they are. Despite the lack, of c l a r i t y about ANP, there i s renewed inter e s t i n further exploring and developing i t i n Canada (Canadian Nurses Association, 1992; Haddad, 19 92a; Haddad, 1992b; Patterson & Haddad, 1992; Registered Nurses Association of B r i t i s h Columbia, 1990; Schroer, 1991; Van der Horst, 1992). Is i t that health care professionals i n t u i t i v e l y know that nurses i n ANP o f f e r something that i s unique and worth further development but are just not able to a r t i c u l a t e what i t is? In order to decrease t h i s lack of c l a r i t y related to ANP, further exploration can a s s i s t nurses to define, continue to develop, and explore ANP i n ways that meet some of the ongoing needs of the nursing profession and the c l i e n t s that are involved i n nurse/client interactions. Research-Based A r t i c l e s Related to Advanced Nursing Practice In a cursory review of the l i t e r a t u r e , minimal research-based reports could be found related d i r e c t l y to t h i s study. The related ANP research-based l i t e r a t u r e was reviewed to attempt to l i n k what was reported with the study. Schaefer and Lucke (1990) conducted a study to describe c l i n i c a l practice as reported by p r a c t i s i n g CNSs. The sample consisted of 17 Master's prepared CNSs who had functioned i n the role of a CNS for a minimum of one year. Additionally, they used three recorded case studies found i n the l i t e r a t u r e as a part of the analysis. Using grounded theory methodology, the researchers concluded that s c i e n t i f i c and 19 humanistic caring was the central component to the practice of CNSs. The CNSs cared for c l i e n t s and t h e i r families but were also of major support to the s t a f f . These findings were subsequently validated i n the l i t e r a t u r e . Schaefer and Lucke asked the question: Does caring d i f f e r depending upon the educational preparation of the nurses? They also noted that t h e i r study did not examine the impact of CNS practice on c l i e n t / p a t i e n t outcomes. In r e l a t i o n to the exploration of the role of the CNS i n community health, Mason, Knight, Toughill, DeMaio, Beck and Christopher (1992), conducted a needs survey which consisted of two questionnaires: one to assess the current and future needs of community health agencies for Master's-prepared nurses i n community health nursing and the roles i n which the agencies would use these nurses, and another to assess the i n t e r e s t of baccalaureate-prepared nurses i n attending a graduate program i n community health nursing (Mason et a l . , 1992, p. 8). This survey suggested that "community health agencies may not be clear about the benefits of employing t h i s advanced p r a c t i t i o n e r " nor how to use the community health CNS most e f f e c t i v e l y (p. 6). Their sample included 126 agencies and 256 i n d i v i d u a l nurses. Findings of both groups r e f l e c t e d a lack of understanding of the role of the community health CNS. However, the findings also demonstrated that community health agencies have great present and future needs related to Master's prepared nurses. Of i n t e r e s t , study participants wanted to put community health educated CNSs into management 20 r o l e s . Mason and colleagues (1992) i d e n t i f i e d that the community health CNS i s "desperately needed to advance c l i n i c a l practice i n community health nursing and to promote the health of communities. This need w i l l only be f u l f i l l e d i f an adequate number of these s p e c i a l i s t s are not only educated but u t i l i z e d properly" (p. 12). They also add that " i f nursing w i l l promote t h i s s p e c i a l i t y of nursing, i t w i l l also be promoting the health of communities" (p. 13). Although t h i s was an American study there are implications for the B.C. and Canadian context given the current focus on community health. The researcher believes that Mason and colleagues (1992) underscore the need for more nurses i n ANP to be employed i n the community i n B.C. The current " s h i f t " of c l i e n t s from hospital to home requires a previously undeveloped and untapped expertise of community nurses. For community nurses to develop t h i s expertise and be supported i n t h e i r ongoing e f f o r t s , ANP support i s mandatory. The researcher wondered i f the current study participants would i d e n t i f y t h e i r roles i n r e l a t i o n to the community as c l i e n t . Benner, Tanner and Chesla (1992) published a portion of a larger phenomenological study related to s k i l l a c q u i s i t i o n i n the practice of c r i t i c a l care nursing through use of the Dreyfus Model of Skill Acquisition. This study was another attempt to c l a r i f y the f i v e levels of practice previously 21 i d e n t i f i e d by Benner (1984). Although t h i s research i s only peripherally linked with t h i s study, i t i s worth noting since the authors reinforced the need to d i f f e r e n t i a t e between expert and advanced nursing practice. Their sample consisted of 130 nurses who practiced i n Intensive Care Units. Of these nurses, 98% were baccalaureate prepared. Findings from t h e i r study further develop the notion of practice from the c l i n i c a l worlds of nurses' varying levels of experience. The discussion i n the a r t i c l e relates to an i n d i v i d u a l nurse caring for an i n d i v i d u a l c r i t i c a l l y i l l c l i e n t although the nurse may involve the c l i e n t ' s family i n that care. The focus i n the exemplars i s c l e a r l y c l i e n t s p e c i f i c and strongly related to the medical model of practice. This experiential learning i s c l e a r l y linked to development of expert practice. Other Literature Related to Advanced Nursing Practice Spross and Baggerly (1989) i d e n t i f y two concepts that they believe are essential to a model of advanced nursing practice. These are "exquisite c l i n i c a l judgement and e f f e c t i v e leadership" (p. 21). Exquisite c l i n i c a l judgement i s defined as: a complex i n t e l l e c t u a l process of decision-making which t y p i c a l l y includes: (1) decisions regarding what to observe i n a patient s i t u a t i o n ; (2) i n f e r e n t i a l decisions, deriving meaning from data observed (diagnosis); and (3) decisions regarding actions that should be taken which w i l l be of optimal benefit to the patient (p. 21). E f f e c t i v e leadership i s defined as: 22 uses communication processes to influence the a c t i v i t i e s of an i n d i v i d u a l or group toward the attainment of a goal or goals i n a given s i t u a t i o n . For the CNS t h i s includes guiding s t a f f nurses i n the a c q u i s i t i o n of c l i n i c a l s k i l l s and knowledge, in t e r p r e t i n g nursing practice to nurses and non-nurses, developing innovative approaches to c l i n i c a l practice, promoting i n t e r d i s c i p l i n a r y collaboration, and advancing the practice and profession of nursing (p.21). These authors note that any advanced practice model that incorporates these two elements can a s s i s t CNSs to analyze t h e i r advanced practice. They add however, that "conceptualizing advanced practice and being able to discriminate i t from the practice of a neophyte or an expert by experience i s v i t a l " (Spross & Baggerly, 1989, p. 39). English's (1993) c r i t i q u e of Benner's model prompts another dimension for consideration. He notes that "aspects of expertise are described, but expertise i s not c l e a r l y defined" (p. 387). In addition, he outlines that "according to t h i s model i t i s unclear at what stage one becomes an expert, and i f there are better experts than others, i . e . are there stages of expertise or i s 'expert' a unique and f i n a l state" (p. 389)? In order to explain, j u s t i f y and support d i f f e r e n t levels of nursing practice, Spross and Baggerly (1989) outline the following models of ANP: Benner's Model of Expert Practice (1984); Fenton's Application of Benner's Model to CNSs (1985); Roy and Martinez' Conceptual Framework For CNS Practice (1983); Holt's Theoretical Model For C l i n i c a l S p e c i a l i s t Practice (1984); Calkin's Model of Advanced ' 23 Nursing Practice (1984); and, Brown's Model: The CNS In A M u l t i d i s c i p l i n a r y Partnership (1983). In the cr i t i q u e s of these models done by Spross and Baggerly, they note that " i t i s clear that none are f u l l y developed i n terms of advanced practice and the CNS" (p. 39). Having f u l l y reviewed these models of ANP, the researcher agreed with t h i s conclusion. Patterson and Haddad (1992) add to t h i s i n that " i t i s our contention...that the attributes and behaviours of advanced pr a c t i t i o n e r s have not been made e x p l i c i t i n the l i t e r a t u r e " (p. 18). These authors presented a l i s t of some possible behaviours and attributes associated with ANP. They are clear to point out that t h i s l i s t i s not a l l - i n c l u s i v e and that further refinement and expansion of a l l of the concepts are required. Interestingly enough, the l i s t contains attributes and some behaviours/indicators that are not consistently found i n the l i t e r a t u r e . Their l i s t includes the following: Attributes Some behaviours/indicators Risk Taker * i d e n t i f y and develop a nursing perspective i n new areas of Visionary health care * u t i l i z e and evaluate nursing Inquiring Mind research to guide c l i e n t care * p a r t i c i p a t e i n nursing research F l e x i b i l i t y * i d e n t i f y and comment on current issues i n nursing A b i l i t y to A r t i c u l a t e * a r t i c u l a t e and disseminate nursing knowledge by informal and formal methods Leadership S k i l l s * demonstrate the use of theory-based practice to other nurses Despite the i d e n t i f i c a t i o n of these attributes and 24 behaviours/indicators, Patterson and Haddad (1992) add that, i n t h e i r review of the l i t e r a t u r e related to ANP, very l i t t l e attention has been paid to the c h a r a c t e r i s t i c s of the i n d i v i d u a l that would be necessary to f u l f i l the demands of an ANP r o l e . C l i n i c a l Nurse S p e c i a l i s t s and C l i e n t Health Outcomes Decision makers i n Canada's health care system conduct an expensive business without any outcome measurements, goals or plans (Rachlis & Kushner, 1989). In attempts to improve qual i t y of health care, "outcomes matter most" (Health Services Research, 1992, p. 175). In recent years, the B.C. Ministry of Health has focused e f f o r t s on evaluation and outcomes. There i s renewed inter e s t i n explaining and analyzing current health care practices so that funding decisions can be made on p o s i t i v e outcomes. It i s well known that funding decisions have t r a d i t i o n a l l y not been c l e a r l y linked to CHO. In the l a s t couple of years i n p a r t i c u l a r there has been renewed in t e r e s t i n attempting to make t h i s l i n k e x p l i c i t . Increasingly, funding decision makers are recognizing the value of evaluation p r i o r to consideration of funding and budget issues (Wood, 1989). Nurses p a r t i c i p a t i n g i n an established ANP role are a worry to health care funders since they often secure higher wages than most nurses (Sparacino, 1992). Yet these same nurses are educated to conduct research and evaluation of t h e i r practice, as well as outcome 25 measures of t h i s practice (Waltz & Sylvia, 1991). Donabedian (1992; 1988) i s a well known leader of outcomes management and incorporates a c l a s s i c t r i a d to define the q u a l i t y of care, s p e c i f i c a l l y that of: structure, process and outcome. Some of the attributes of q u a l i t y i n health care include: effectiveness, e f f i c i e n c y , optimality, a c c e p t a b i l i t y , legitimacy and equity (Donabedian, 1992). Outcomes may be defined as "states or conditions of individuals and populations attributed or a t t r i b u t a b l e to antecedent health care" (Donabedian, 1992, p. 356). Another d e f i n i t i o n i s that "outcomes are the end results of care, the changes i n a patient health status that can be attributed to the delivery of health care services" (Naylor, Munro & Brooten, 1991, p. 210). Nurses, are however, i n the early stages of research related to outcome measures that can be linked to nursing practice (Bond & Thomas, 1991; Higgins, McCaughan, G r i f f i t h s & C a r r - H i l l , 1992). Additionally, CNSs are i n a p i v o t a l position to assure the delivery of q u a l i t y nursing care (Naylor, Munro & Brooten, 1991), and have the p o t e n t i a l to be a strong voice for care quality, often l o s t i n the discussions of cost-effectiveness (Redfern & Norman, 1990). Yet "research to date...has not adequately shown that the nursing practice of the CNS p o s i t i v e l y affects patient outcomes" (Montemuro, 1987, p. 109). However, i t i s important not to focus only on the 26 p o s i t i v e outcomes. Both unintended and unexpected "consequences of nursing interventions are equally v a l i d as outcomes and indeed could be important and revealing" (Bond & Thomas, 1991, p. 1494). As far as t h i s researcher i s concerned, nurses need to examine more that just "immediate" CHO. They need to begin exploration of "long term" nursing care outcomes and CHO. As "increasing numbers of exploratory, descriptive, and c o r r e l a t i o n a l studies lay the groundwork for changes i n nursing practice, research on the effectiveness of nursing interventions becomes more c r i t i c a l " 1 (Stewart & Archbold, 1992, p. 477). Research-Based Literature Related to C l i n i c a l Nurse S p e c i a l i s t s and C l i e n t Health Outcomes As noted e a r l i e r , minimal research-based information could be found related d i r e c t l y to t h i s research. Two studies which support e f f o r t s of the research were found. F i t z p a t r i c k and colleagues (1991) conducted research with experienced CNSs using the Delphi technique and a four-round survey to capture information related to research p r i o r i t i e s . The r e s u l t s , i n t e r e s t i n g l y enough, did not focus on p o t e n t i a l s p e c i f i c c l i n i c a l research but rather o v e r a l l general c l i n i c a l nursing research p r i o r i t i e s . The results indicated that top p r i o r i t i e s for nursing research are: "(1) factors which influence longevity i n c l i n i c a l nursing practice, (2) patient delivery systems as related to nurse s a t i s f a c t i o n , and (3) indicators of qu a l i t y of nursing care" ( F i t z p a t r i c k 27 et a l , 1991, p. 94). Clearly there i s the recognition by these CNSs of the value of outcomes from c l i e n t , patient and professional domains. Higgins, McCaughan, G r i f f i t h s and C a r r - H i l l (1992) conducted research related to assessing outcomes of nursing care. The researchers recognized the d i f f i c u l t y i d e n t i f y i n g which outcome variables could be attributed to nursing alone. As a r e s u l t , they focused on immediate outcomes that "would then r e f l e c t a r e s u l t that could be related with some confidence to nursing intervention v i a d i r e c t observation" (p. 562). This approach went beyond the t r a d i t i o n a l outcome studies such as those "exclusively concerned with measuring the c l i n i c a l outcomes of care such as changes i n patient's symptoms and survival following diagnosis" (p. 566). These authors co l l e c t e d data from outcome measures i n acute medical and surgical wards at seven hospital s i t e s . At the same time, the Quality of Patient Care Scale (Qualpacs) was used. Measures focused on the outcomes of care delivery. The amended Qualpacs instrument was used to measure the process of nursing care i n f i v e areas: psychosocial care, physical care, general care, communication on behalf of the patient, and the professional implications of care. Despite i d e n t i f i e d l i m i t a t i o n s , the main purpose of the data analysis was to test for the r e l i a b i l i t y and v a l i d i t y of the outcome measures, and a high degree was demonstrated. As a r e s u l t , the researchers present t h e i r chosen outcome measures as a 28 possible way to assess the outcomes of nursing care. They i d e n t i f y the lack of other studies of nursing and outcomes, which results i n t h e i r i n a b i l i t y to make comparisons. This work represents a good beginning e f f o r t to l i n k nursing practice and CHO i n a general way. Other Literature Related to C l i n i c a l Nurse S p e c i a l i s t s and C l i e n t Health Outcomes Nurses, as participants i n t o t a l q u a l i t y management, have been directed to evaluate programs and to explore outcomes of c l i e n t care (Beecroft, 1992; Stanhope & Lee, 1992). However, t h i s task i s often not p o s i t i v e l y received and can become the r e s p o n s i b i l i t y of a var i e t y of personnel. Total q u a l i t y management has routinely examined structure and some process, but r a r e l y outcomes of health care practices. General health outcomes, or i n p a r t i c u l a r CHO, are both r e l a t i v e l y new areas of in t e r e s t for nursing and other health care professionals (Bond & Thomas, 1991). Waltz and Sylvi a (1991) note: It i s essential that v a l i d a t i o n of CNS e f f e c t on patient outcomes be undertaken and that studies designed for t h i s purpose employ the most relevant and appropriate outcome variables to be studied across practice settings and that they be measured i n a manner that allows for a p p l i c a b i l i t y and hence comparison across studies, settings, and times (p. 203). Under the umbrella of ANP, the consistent focus of the CNS i s on client-based practice. For any CNS, the ultimate goal i s to improve the o v e r a l l q u a l i t y of care delivered to clie n t s / p a t i e n t s by nurses (Sparacino & Cooper, 1990). 29 Despite t h i s goal, CNSs often lack formal education to prepare them to partake i n t o t a l q u a l i t y management. Nol l and Girard (1993) outline the CNS curriculum from the University of Texas Health Science Center School of Nursing i n San Antonio, which has recently added a course i n q u a l i t y assurance to formally prepare CNSs for t h i s major aspect of t h e i r role i n health care. This approach has not t r a d i t i o n a l l y been a routine component of CNS graduate education. If the CNS i s to be involved i n measuring the effectiveness of nursing practice, what outcomes should be included and measured? At the present time i n nursing there i s a lack of consistency i n what i s measured and often these outcomes are not c l e a r l y documented on c l i e n t / p a t i e n t care records. Anecdotally, authors may observe a p o s i t i v e immediate c l i e n t / p a t i e n t outcome when the CNS becomes involved with someone whom the s t a f f has i d e n t i f i e d as " d i f f i c u l t " (Koetters, 1989). Moritz (1991) notes that "there i s considerable research work to be done to determine the best measures to r e f l e c t the outcomes of nursing practice" (p. 114). What about other outcome measures that can c l e a r l y be influenced by nursing care? Examples include: functional status, mental status, stress, o v e r a l l well-being, s a t i s f a c t i o n with care (including a c c e s s i b i l i t y , continuity, thoroughness, humaneness, informativeness and effectiveness), 30 burden of care, q u a l i t y of l i f e , and cost of care (Beecroft, 1992; Donabedian, 1992; Naylor, Munro & Brooten, 1991; Roch, 1992). Are these currently being measured? And i f so, how? Very l i t t l e e f f o r t to date has been directed at assessing the eff e c t of nurses' contribution to the outcomes of c l i e n t care (Higgins, McCaughan, G r i f f i t h s & C a r r - H i l l , 1992). CNSs are i n a key pos i t i o n i n that they recognize excellence i n c l i e n t / p a t i e n t care. They have c l e a r l y displayed i n t e r e s t and enthusiasm for nursing care that w i l l improve outcomes for c l i e n t s (Beecroft, 1992; Kerr, 1991). CNSs are also keen to develop and adopt "new ideas to maintain or improve q u a l i t y patient care i n a timely and cos t - e f f e c t i v e manner" (King, 1990, p. 174). Yet t h e i r role related to t o t a l q u a l i t y management or qu a l i t y assurance has not been emphasized (Noll & Girard, 1993). Authors are beginning to make the l i n k between the CNS role and outcomes vi a t o t a l q u a l i t y management but the linkage i s not yet well established. Beecroft (1992) supports the role of CNSs i n r e l a t i o n to outcomes. She says that "in t h i s era of increased emphasis on c l i n i c a l , f i n a n c i a l , and health outcomes, I believe the time i s right for CNSs to apply t h e i r research s k i l l s to outcomes management and bring themselves to the forefront of the health care arena" (Beecroft, 1992, p. 175). Girouard (1989) adds to t h i s when she notes, "the CNS has r e s p o n s i b i l i t i e s related to the advancement of the 31 profession, working with others to plan and evaluate health programs for people at r i s k and to address health care trends" (p. 367). Societal trends and health care p o l i c i e s are d i r e c t l y linked to health-related outcomes and health behaviours (Girouard, 1989). Waltz and Sylvia (1991) strengthen t h i s view by claiming that, i n order to document the worth of nursing programs and services, investigations must be undertaken related to the relat i o n s h i p between nursing process and outcomes. Through the process of l i n k i n g outcomes to nursing practices, "CNSs w i l l more c l e a r l y define those health outcomes that they are i n the best position to influence" (Naylor, Munro & Brooten, 1991, p. 214). F i n a l Word on the Literature Review After review of the l i t e r a t u r e , i t became clear that t h i s research was timely. It i s appropriate that nurses as individuals and the nursing profession as a whole, have answers to these key areas of inquiry. To date, there has been a d e f i n i t e lack of knowledge related to a clear d e f i n i t i o n of ANP despite i t s widely accepted use. Nor has there been a clear e f f o r t to d i r e c t l y l i n k ANP with CHO. Given today's health care environment, the resultant pressures for f i s c a l r e s t r a i n t , and the need for measurement of CHO, t h i s study provides further knowledge about the phenomena of in t e r e s t . It also provides research that others can b u i l d on to further explore relationships 32 between ANP and CHO. Chapter Summary In t h i s chapter, pertinent l i t e r a t u r e related to ANP and i t s r elationship to CHO was reviewed. Although a wealth of l i t e r a t u r e i s available related to the phenomena of i n t e r e s t , minimal research has been published that further c l a r i f i e s these d e f i n i t i o n s and/or relationships. Through t h i s l i t e r a t u r e review process, the need for t h i s study has been validated. The following chapter describes the methodology that was used for t h i s study. 33 CHAPTER THREE METHODOLOGY Since t h i s study i s i n a r e l a t i v e l y new area of inquiry, i t was not possible to define the terms ANP and CHO and t h e i r r e l a t i o n s h i p p r e c i s e l y . Therefore, for t h i s research a qu a l i t a t i v e methodology was appropriate so that the research participants could o f f e r t h e i r d e f i n i t i o n s and relationships among the phenomena of int e r e s t (Ammon-Gaberson & Piantanide, 1988; Strauss & Corbin, 1990). The study u t i l i z e d an exploratory-descriptive method to generate thematic analysis of the interviews between the researcher and part i c i p a n t s . This chapter commences with an overview of the research design. Following that, the selection of participants, data c o l l e c t i o n and data analysis are described. The chapter concludes with a discussion of the study's e t h i c a l considerations. Research Design This study did not c l e a r l y and d i r e c t l y " f i t " any of the t r a d i t i o n a l q u a l i t a t i v e research methods. The use of an exploratory-descriptive method was appropriate since the l i t e r a t u r e r e f l e c t e d that there have not been indepth studies of the phenomena of int e r e s t (Brink & Wood, 1989), p a r t i c u l a r l y from a Canadian perspective. As a re s u l t , nurses have l i t t l e clear t h e o r e t i c a l or factual knowledge about ANP, l e t alone i t s rel a t i o n s h i p to CHO (Carter, 1991). Because CNSs are understood as a focused culture i n 34 nursing (Morse, 1991), the use of ethnographic methods would have been i d e a l . However, the research plan included interviews only. Although interviews are valuable, they represent only one component of an authentic ethnographic study (Agar, 1986; Brink, 1989; F i e l d , 1982; Hammersley & Atkinson, 1983; Leininger, 1970; Morse, 1991; Spradley, 1979). However, ethnography s t i l l provided considerable guidance to the data c o l l e c t i o n and analysis phases of t h i s research. The research report w i l l describe how participants knew, understood, and gave meaning to experiences of t h e i r world (Hunt, 1991). These findings w i l l contribute to the development of nursing knowledge and ANP (Muecke, 1994). S p e c i f i c a l l y , the ethnographic t r a d i t i o n helped the researcher to be clear about the emic and e t i c sources of data, as well as how they were presented (Boyle, 1994). Every e f f o r t was made to have research findings emic i n nature, i n that they were derived from the p a r t i c i p a n t s ' view of t h e i r experiences and practices, as opposed to any influence of the researcher ( F i e l d & Morse, 1985). Selection of Participants Using an exploratory-descriptive design, the participants become contributors i n the generation of new knowledge about topics where l i t t l e i s known (Burns & Grove, 1987). A purposive sample i s one sampling design used i n q u a l i t a t i v e research, whereby participants are selected because of t h e i r a b i l i t i e s to discuss the phenomena of 35 i n t e r e s t knowledgeably (Burns & Grove, 1987). The following i s a description of the selection c r i t e r i a , procedures for recruitment of participants and the c h a r a c t e r i s t i c s of the CNSs who participated i n t h i s study. Selection C r i t e r i a The following c r i t e r i a for selection of participants were developed for the purpose of ensuring a sampling of informants who were experienced i n an ANP role, and therefore knowledgeable about the phenomena of i n t e r e s t . Each participant was required: • to have a master's degree (Registered Nurses Association of B r i t i s h Columbia, 1988); and, • to be currently employed and have been p r a c t i s i n g i n a CNS position i n a c l i n i c a l s etting for a minimum of one year (Haddad, 1992a; Sparacino, 1992). Rationale for the c r i t e r i o n of a master's degree i s provided i n the l i t e r a t u r e . The researcher made a conscious decision not to focus s o l e l y on participants who had master's degrees i n nursing due to the recognition that there are currently some nurses i n ANP with non-nursing graduate degrees. A minimum of one year i n the CNS role was viewed as enabling participants to o f f e r " r e a l " or "experiential knowledge" rather than s o l e l y academic knowledge to discussions. Procedure for Recruitment of Participants As was noted above, a purposive sample was used for the 36 research. The Vancouver Island based CNSs, employed i n a large hospital society, were recognized by t h e i r peers and t h e i r supervisors as Advanced Nursing Practitioners (P. Fullerton, personal communication, October 9, 1992). The f i n a l number of participants needed for the research was related to saturation of data categories (Sirnms, 1981; Strauss & Corbin, 1990). This was achieved with seven participants i n t o t a l . Appropriate documentation was completed and the proposed research was designed to ensure that the p r i n c i p l e s of non-maleficence were maintained ( P o l i t & Hungler, 1991). The research design was reviewed and approved by The University of British Columbia Behavioural Sciences Screening Committee For Research and Other Studies Involving Human Subjects. The Vancouver Island CNSs were sent a personally addressed l e t t e r (Appendix A, p. 194) that introduced them to the research. This l e t t e r outlined the type of research and the reasoning behind i t , the areas of i n t e r e s t , what t h e i r involvement would e n t a i l , the assurance of c o n f i d e n t i a l i t y , as well as contact names and numbers. In addition, the l e t t e r outlined that, i f the potential participant did not contact the researcher within two weeks, then the researcher would establish telephone contact i n order to inquire about in t e r e s t and to answer any questions or address issues the potential participant may have had. At no time did the researcher use pressure or coercion with the pote n t i a l 37 par t i c i p a n t s . A l l seven participants telephoned the researcher to say they were interested i n p a r t i c i p a t i n g i n the study. When potential participants contacted the researcher for inclu s i o n i n the study, the researcher asked questions to determine i f the participants met the e l i g i b i l i t y c r i t e r i a . Appendix B, (p. 196), l i s t s these questions as well as o u t l i n i n g the demographic information that was c o l l e c t e d . If the participants met the e l i g i b i l i t y c r i t e r i a , an interview was arranged. Charact e r i s t i c s of Participants A t o t a l of seven CNSs, six female and one male, part i c i p a t e d i n the research. For the purposes of anonymity, a l l w i l l be here-after referred to as females. Their ages ranged from 40 to 62 years with a median of 47.4 years. S p e c i f i c a l l y ages were d i s t r i b u t e d as follows: two age 40, two age 46, one age 49, one age 50 and one age 62. A l l participants had a master's degree with 5 being i n nursing, 1 i n health sciences and 1 i n science. They had a l l been employed i n the CNS position i n a c l i n i c a l s e t t i n g for a minimum of one year, s p e c i f i c a l l y 2-13 years with a median of 6.3 years. This experience was d i s t r i b u t e d as follows: 2, 3, 3.5, 5.5, 7, 10.5 and 13 years. Their specialty areas of practice were: r e h a b i l i t a t i o n , maternal c h i l d , mental health with a sub-specialty i n gerontology, pain management, g e r i a t r i c psychiatry and two i n gerontology. A l l were 38 employed i n a 1639 bed hospital society which includes acute and extended care beds. Data C o l l e c t i o n Procedures Once participants consented to p a r t i c i p a t e i n the study and i t was found that they met e l i g i b i l i t y requirements, interviews were set up and data c o l l e c t i o n began. Semi-structured interviews, which are appropriate for exploratory-descriptive design were held (Brink, 1989; Burns, 1989; Corbin, 1986; Hammersley, 1990; Hunt, 1991). This type of interview i s purposefully f l e x i b l e (Brink, 1989), and allows for participants to reveal as much as they wish about the topic under discussion. The aim of the semi-structured interview i s to "elucidate the respondent's perceptions of the world without imposing any of the researcher's views on them" ( P o l i t & Hungler, 1991, p. 279). Appendix C (p. 197), outlines prompts that guided the i n i t i a l interviews. These prompts guided the researcher i n attempting to operationalize the questions during the early phases of the interviews (Swanson, 1986). Since the researcher was inexperienced, i t was important to consult frequently with the chair of the thesis committee in order that: relevant information was captured; openness to data was present without being clouded by nursing, medical or psychologically oriented viewpoints; researcher confidence could develop during v e r i f i c a t i o n of data; the researcher could be reminded that f l e x i b i l i t y and ambiguity were 39 int e g r a l parts of the q u a l i t a t i v e research process (Corbin, 1986); and, i n sense could be made of the data ( F i e l d & Morse, 1985). The setting for the interviews was determined by the participants and a l l wished to hold them i n t h e i r o f f i c e s . The researcher was prepared to request uninterrupted time during interviews but t h i s was not required. Participants put t h e i r phones on " c a l l forward" and closed t h e i r o f f i c e doors without being asked. The researcher accommodated the part i c i p a n t s ' choice of time. This assisted i n e f f o r t s for a relaxed atmosphere since participants did not f e e l they should be somewhere else at that p a r t i c u l a r time. Interviews were approximately one hour long. Participants a l l consented to interviews being audio-taped. If taping was not acceptable, then detailed notes would have been taken. The audio-tapes were supplemented by f i e l d notes made immediately a f t e r the interview which included researcher thoughts and observations. At the beginning of the i n i t i a l interviews, i n order to establish a sharing relationship, the researcher again informed participants what was being studied and why, as well as what had aroused the researcher's i n t e r e s t i n the topic (Brink, 1989). Since the researcher was a colleague of the Vancouver Island CNSs, data c o l l e c t i o n became more quickly focussed and e f f i c i e n t than i f the researcher were unknown ( F i e l d & Morse, 1985). However, the researcher was also a 40 CNS so r e f l e x i v i t y was a factor i n data c o l l e c t i o n (Boyle, 1994; Hammersley & Atkinson, 1983). During the interviews a tone was set that encouraged sharing, i n t e r e s t , respect and appreciation for the time the participants were taking to p a r t i c i p a t e i n the research. This approach further promoted the r e l a t i o n s h i p and assisted i n encouraging follow up interviews (Chenitz, 1986). Each participant was assigned an i d e n t i f i c a t i o n number and an interview number. As soon as possible a f t e r the interview, the audio-tapes were transcribed by a t y p i s t , using wide margins on the right hand side of the paper so that notations and codes could be entered by the data. The lines of the transcriptions, as well as the pages were numbered to make r e t r i e v a l of data easier and to f a c i l i t a t e organization. A face sheet was attached to the transcribed interview data that assisted i n r e t r i e v i n g demographic data and s p e c i f i c content of the interviews (Swanson, 1986). Accuracy of the verbatim transcriptions was checked by the researcher r e - l i s t e n i n g to the tapes while following the t r a n s c r i p t s . The researcher listened to the audio-tapes once or twice more so that she could acquire a sense of each participant's implied or expressed meanings, changes i n tone or voice and s i g n i f i c a n t pauses and/or i n f l e c t i o n s ( F i e l d & Morse, 1985; P o l i t & Hungler, 1991). These were noted on the t r a n s c r i p t s . As soon as possible a f t e r the i n i t i a l analysis of the 41 f i r s t interviews, findings were c l a r i f i e d , elaborated upon, and/or validated with the pa r t i c i p a n t s . These additional interviews (arranged as noted e a r l i e r ) allowed for checking the researcher's observations and interpretations, as well as increasing the depth and richness of data (Corbin, 1986). There were two to three one hour v i s i t s between the researcher and each par t i c i p a n t . Inherent i n q u a l i t a t i v e research i s the interpersonal in t e r a c t i o n between the researcher and the pa r t i c i p a n t . The researcher was aware of personal preconceptions, values and b e l i e f s and noted these i n a journal. These assisted i n the maintenance of researcher awareness of the data and i t s meaning to the participant (Hutchinson, 1986). Anything that the researcher was a part of either verbally or non-verbally by way of experiences, feelings, sight and hearing, as well as general impressions during interactions, i n other words, the "dynamics of the setting" ( F i e l d & Morse, 1985, p. 96), were kept as additional f i e l d notes. These were written up immediately aft e r the interview, further c l a r i f i e d while re-l i s t e n i n g to the tapes, and were included with the taped interviews ( F i e l d & Morse, 1985; Lincoln & Guba, 1985; Swanson, 1986) . Data Analysis The research question was broad i n nature and i t progressively narrowed and became more focused during the research process. The research data analysis "requires a 42 f l u i d , f l e x i b l e , somewhat i n t u i t i v e i n t e r a c t i o n " (Brink, 1989, p. 151), between the researcher and the data. In addition to the f l e x i b i l i t y and i n t u i t i o n , data analysis requires researcher insight (Carter, 1991). Qualitative thematic analysis i s made up of two types of coding that f a c i l i t a t e d t h i s narrowing, namely open coding and a x i a l coding. Data analysis and data c o l l e c t i o n occurred simultaneously and moved from inductive to deductive thinking and back again (Guba & Lincoln,. 1981; Strauss & Corbin, 1990). The researcher offered f l e x i b i l i t y , i n t u i t i o n and insight throughout a l l phases (Brink, 1989; Carter, 1991; P o l l i c k , 1991). Open coding occurred when the data were i n i t i a l l y broken down l i n e by l i n e and paragraph by paragraph so that persistent words, phrases, concepts and themes were i d e n t i f i e d . These were coded and developed into categories. This ongoing analysis allowed for the refinement of prompts so that subsequent interviews further elaborated emerging categories or themes. Axial coding followed and the categories were re-examined and re-connected by use of a coding paradigm involving conditions, context, a c t i o n / i n t e r a c t i o n a l strategies and consequences (Strauss & Corbin, 1990). The researcher was constantly asking questions of the data throughout analysis (Corbin, 1986). S i g n i f i c a n t statements, thematic descriptions, and verbatim quotes were organized 43 around each category or theme. Through ongoing data analysis, concepts and t h e i r relationships were discovered to be relevant or i r r e l e v a n t to the research question (Morse, 1994; Strauss & Corbin, 1990). Phenomena were discovered, developed and p r o v i s i o n a l l y v e r i f i e d through systematic data c o l l e c t i o n and analysis (Strauss & Corbin, 1990). The researcher developed s k i l l related to t h e o r e t i c a l s e n s i t i v i t y as the study was conducted by: p e r i o d i c a l l y stepping back and asking questions; maintaining an attitude of scepticism; and, following the research procedures with the guidance of her thesis committee (Strauss & Corbin, 1990).. The researcher developed a data f i l i n g system that included a f l e x i b l e storage system, as well as procedures for r e t r i e v i n g the data ( F i e l d & Morse, 1985). Due to the researcher's previous lack of expertise i n q u a l i t a t i v e data analysis, i t was challenging to develop an appropriate method of " f i l i n g " or "organizing" the data. This unfolded as the study progressed and the researcher became more knowledgeable about the capacity of her computer, as well as u t i l i z a t i o n of "cutting and pasting" t r a n s c r i p t i o n s . Throughout any phase of data analysis the researcher returned to the f i e l d , through interview, when there was a need to further c l a r i f y and/or validate data (Corbin, 1986; Strauss & Corbin, 1990). The information that participants shared was similar i n basic structure to what the researcher 44 had generated (Corbin, 1986). If, through the v e r i f i c a t i o n process, the thematic analysis did not hold up, then i t was discarded and the process began again (Corbin, 1986). Literature was reviewed throughout data c o l l e c t i o n and analysis i n order to: stimulate t h e o r e t i c a l s e n s i t i v i t y , stimulate questions, d i r e c t t h e o r e t i c a l sampling and to provide supplementary v a l i d a t i o n (Strauss & Corbin, 1990). The l i t e r a t u r e was used to expand and c l a r i f y codes and to become sensitized to additional ways of exploring the emerging data analysis (Charmaz, 1983). After data analysis and the emergence of categories, the l i t e r a t u r e was again reviewed to determine i f others had i d e n t i f i e d the same categories and what they had said about them (Burns & Grove, 1987; Strauss & Corbin, 1990). Once the conceptual categories and properties were established and t h e i r i n t e r r e l a t i o n s h i p s evaluated, the resultant information was used to describe the phenomena of in t e r e s t (Simms, 1981; Strauss & Corbin, 1990). The description consists of categories that are both dense with concepts and saturated to the degree that a range of v a r i a t i o n was accounted for, hypothesis t e s t i n g v e r i f i e d and the categories integrated (Corbin, 1986; Strauss & Corbin, 1990). Qualitative r i g o r was assured through the following: • truth value - the theory developed contains f a i t h f u l descriptions or interpretations of p a r t i c i p a n t s . The researcher v e r i f i e d data with participants and ensured that i t was "true" so they recognized i t as t h e i r own (Guba & Lincoln, 1981; Sandelowski, 1986). Journal entries ( f i e l d notes) documented how the researcher was influenced by participants so that t h e i r experiences were c l e a r l y separate from those of the researcher. • a p p l i c a b i l i t y - findings from the research " f i t " the data and are well grounded i n the p a r t i c i p a n t s ' experiences. This was confirmed by v a l i d a t i o n with participants, and the checking for the representativeness of the data by way of codes and categories (Guba & Lincoln, 1981; Sandelowski, 1986). •. consistency - since the researcher was inexperienced, r e l i a b i l i t y was ensured with having the chair of the thesis committee review a section of the data to ensure there were consistencies .in interpretations. The aim was that the chair arrived at the same or comparable conclusions (Guba & Lincoln, 1981; Sandelowski, 1986). A u d i t a b i l i t y was ensured by the researcher describing, explaining or j u s t i f y i n g a l l steps of the research process i n t h i s f i n a l written report (Guba & Lincoln, 1981; Sandelowski, 1986). • n e u t r a l i t y - freedom of researcher bias i n the data was ensured by way of the researcher c a r e f u l l y tracking and documenting a l l phases of the research. This i s r e f l e c t e d i n the research report (Guba & Lincoln, 1981; 46 Sandelowski, 1986). E t h i c a l Considerations At the beginning of the interviews, the purpose of the research was again reviewed with pa r t i c i p a n t s . The researcher confirmed the e l i g i b i l i t y c r i t e r i a and asked participants i f they had any questions or issues that had not been addressed. These were answered or resolved to the s a t i s f a c t i o n of the part i c i p a n t s . At the beginning of the i n i t i a l interviews, p r i o r to any data c o l l e c t i o n , duplicate consent forms were signed by participants and the researcher (Appendix D, p. 198). The signing of the consent documents that participants had been informed about adequate information and were w i l l i n g to pa r t i c i p a t e i n the research ( P o l i t & Hungler, 1991; Swanson, 1986). Once the consent forms were signed, a copy was retained by participants and the duplicate was kept by the researcher ( P o l i t & Hungler, 1991). There was not any f i n a n c i a l remuneration for the participants of t h i s research. Participants were a l l informed that they were free to: withdraw from the study at any time without jeopardy and refuse to discuss any s p e c i f i c topics (Munhall, 1988). Participants were assured of c o n f i d e n t i a l i t y . This was attained through the use of codes known only to the researcher to i d e n t i f y participants on the interview audio-tapes and any of the written materials for example transcripts and/or journal entries. Participant names and 47 s p e c i f i c work settings were not used at any time. Data was stored i n a locked cupboard i n the researcher's home and accessible only to the researcher. Any resultant publications of t h i s research w i l l not i d e n t i f y participants either d i r e c t l y or i n d i r e c t l y . The data co l l e c t e d during a l l interviews was used only for the purposes of the research and upon completion of the study a l l audio-tapes w i l l be erased. Participants were informed that for those interested a summary of the research findings would be made available. Chapter Summary This chapter has described the methodology that guided t h i s study i n i t s exploration of the d e f i n i t i o n of ANP and the rel a t i o n s h i p of ANP to CHO. Discussion was included that described the exploratory-descriptive research design, participant selection, data c o l l e c t i o n , data analysis and et h i c a l considerations. In the next chapter, findings of the study are presented. 48 CHAPTER FOUR FINDINGS In t h i s chapter, the research findings are presented. The research area of intere s t generated thoughtful and r e f l e c t i v e discussions by part i c i p a n t s . As nurses i n ANP, participants attempted to define ANP as well as describe t h e i r practice i n r e l a t i o n to CHO. Although participants e n t h u s i a s t i c a l l y began discussions about the research phenomena of int e r e s t , i t quickly became obvious that ANP was not a term that was e a s i l y and concisely definable. I n i t i a l l y , participants made comments such as "could you start with an easier question," "I really haven't thought about this a lot" and "I should know this." Participants thought ANP was a term that was broad and vague i n nature, however was able to be a r t i c u l a t e d through descriptors. Participants found i t challenging to describe t h e i r practice i n r e l a t i o n to CHO. I n i t i a l l y , they focused on CHO, again as a term that needed a clearer understanding. This too presented challenges. Participants thought that the c l i n i c a l focus for nurses i n ANP was s t a f f nurses. Therefore, participants believed that any influence they might have had on CHO would be of an i n d i r e c t nature rather than a d i r e c t c o r r e l a t i o n . Participants chose i n t e r e s t i n g ways to a r t i c u l a t e the possible r e l a t i o n s h i p between t h e i r practice and CHO. 49 A l l participants confirmed confidently that they considered themselves to be advanced nursing p r a c t i t i o n e r s . They were able to describe t h e i r practice from the perspective of t h e i r i n d i v i d u a l understanding of ANP. A common understanding was evidenced i n that a l l participants c i t e d , without prompting, indepth knowledge of Joy Calkin and P a t r i c i a Benner's research, related to f i v e levels of professional nursing competency i n c l i n i c a l practice, as well as ANP. Participants made reference to the wealth of l i t e r a t u r e that had been published over several years related to the CNS role and ANP. They also described how a CNS was formally acknowledged by nursing scholars and professional associations as being under the umbrella of ANP. By way of setting the stage for reader consideration of research findings, information i s presented now related to participant context of practice. A l l participants recognized that despite e f f o r t s to understand, define or describe ANP, a b i l i t i e s to enact t h e i r role and any influence they may have on CHO was strongly dependent upon the context of practi c e . They saw t h i s as the single major determinant of how they practiced: Context of practice is probably the major determiner of how we practice... i t is the environment of your practice but not just the physical environment... i t i s the actual nature of the client population..a multidisciplinary setting. It is all those things that impinge on what I do, that are a feature of the social environment, the physical environment, the client populations... and then the context of the individual giving care.... right from the micro to the macro. 50 Participants wanted the researcher to be clear that what they might have believed during t h i s study about ANP may not continue to be r e a l i z e d due to many of the i n i t i a t i v e s involved i n health care reform. During the time of the research, many nursing positions were being examined and participants were being asked to j u s t i f y t h e i r roles, and to take on more and more of what they considered to be administrative functions, as well as broader scopes of practice. For these reasons, they strongly believed that ANP was ever-changing and required a great deal of f l e x i b i l i t y : I have had to take on, at times, especially lately, duties and responsibilities that I normally would not take on. They would normally have gone to management people. What can I say? I mean in times of need, in times of crunch, if my boss or somebody says "I need somebody to do this and you're the only one I can call on right now to do it" what am I going to say but okay? I am so flexible. I just go with the flow. Just watch how fast I can re-define my role. My motto these days is " f l e x i b i l i t y and insecurity is the future"...if I am inflexible I won't survive, I won't be employed in the agency first of all. Then I am not going to affect client* care if I am not employed first and foremost. Participants recognized that health reform was s i g n i f i c a n t l y impacting a l l health care providers but believed that inherent i n ANP was the consistent and ever-NOTE: * The term c l i e n t w i l l continue to be used throughout the presentation of research findings. The participants used terms of client, patient, resident and consumer i n t h e i r discussions. However, for brevity, participant anonymity as well as consistency form the previous three chapters, client w i l l be inserted wherever the participants spoke of the recipients of, or participants i n nursing care. 51 changing context of practice. Thus, participants believed that they frequently needed to provide evidence of t h e i r value to nursing services and o v e r a l l c l i e n t care. The researcher has chosen to present findings according to three broad categories, or descriptors, that resulted from the thematic analysis. The f i r s t broad category relates to d i f f i c u l t i e s i n c l e a r l y defining ANP. This category of data consisted of two components: i n i t i a l attempts at defining ANP and reasons for lack of c l a r i t y about ANP. Participants were not concerned about t h e i r lack of c l a r i t y around a term that was routinely linked with t h e i r practice. They i d e n t i f i e d many factors that influenced the vagueness associated with ANP. The second broad category relates to descriptors of ANP. This category of data consisted of two components: minimal requirement t r i a d of ANP and essential q u a l i t i e s of ANP. Participants b u i l t on t h e i r attempts to define ANP and were able to a r t i c u l a t e what they considered to be the foundation for ANP, as well as essential q u a l i t i e s . The t h i r d broad category relates to possible rel a t i o n s h i p between ANP and CHO. This category of data consisted of three components: problems i n a r t i c u l a t i n g CHO; communicating the r e l a t i o n s h i p between ANP and CHO; and, t h e o r e t i c a l problems i n l i n k i n g ANP with CHO. This data r e f l e c t s participant attempts to describe t h e i r practice i n r e l a t i o n to CHO. It builds on the previous categories by way 52 of exploration and description of how nurses i n ANP roles influence CHO. Together these three broad categories represent participant attempts to define ANP and to describe t h e i r practice i n r e l a t i o n to CHO. Throughout the presentation, findings are i l l u s t r a t e d with verbatim excerpts from participant accounts. D i f f i c u l t i e s i n Clearly Defining Advanced Nursing Practice In presenting these findings, i t i s important to again emphasize that participants were CNSs who addressed the research phenomena of intere s t from the perspective of t h e i r own roles. CNSs have been consistently i d e n t i f i e d i n nursing l i t e r a t u r e and i n nursing discussions as being advanced nursing p r a c t i t i o n e r s . The assumption has been made for the purposes of t h i s research, that since CNSs have been c l e a r l y linked with ANP, participants were able to speak from that perspective. Participants had d i f f i c u l t y c l e a r l y defining ANP and i n i t i a l attempts to do so r e f l e c t e d t h i s . However, participants offered reasons for t h e i r lack of c l a r i t y about ANP. A description of t h e i r perceptions of what makes t h i s d i f f i c u l t w i l l provide a context within which t h e i r views about ANP and CHO can be understood. I n i t i a l Attempts at Defining Advanced Nursing Practice When participants i n i t i a l l y t r i e d to a r t i c u l a t e a d e f i n i t i o n of ANP, they could not provide a clear or concise 53 one. The following accounts are r e f l e c t i v e of p a r t i c i p a n t s ' i n i t i a l lack of c l a r i t y regarding a d e f i n i t i o n of ANP. They recognized that a d e f i n i t i o n of ANP was open to many interpretations: I don't know, I really don't know how (pause) how you define it. I am sure there is a basic core thing of what most people mean when they use that term. But everyone has a different idea. It is a concept that is not concrete nor easily defined (pause) there are not a lot of easy boundaries around that concept you know. A l l participants recognized that t h e i r role as a CNS was d i r e c t l y associated with ANP. However, they also believed that ANP was a term that remained broad and vague i n nature. They were not concerned about t h e i r lack of c l a r i t y about ANP, and as the data w i l l show, cautioned the researcher i n her attempts towards a clearer understanding of i t . Broad and Vague Term A l l participants were f a m i l i a r with nursing l i t e r a t u r e on ANP and c i t e d various nursing scholars such as Calkin and Benner's e f f o r t s at defining and/or describing ANP. However, participants thought that these d e f i n i t i o n s and/or descriptions, although valuable and a s s i s t i v e i n t h e i r r o l e s , were not clear or consistently practiced. Participants referred to Benner's work and believed that the lack of e x p l i c i t linkage between expert and ANP added to the lack of c l a r i t y about ANP. They thought that Benner's work did not f u l l y capture "ANP" although they knew she 54 referred to, and used the term along with "expert." Participants believed that ANP was something more than the indepth c l i n i c a l knowledge that was often associated with the expert nurse: I think that whole business around the experienced nurse is so baffling. I don't think we really understand a whole lot about it. I mean I meet people who do become experts by experience but I think they are limited. I mean one is limited by one's knowledge and experience generates, at least in Benner's terms, it generates clinical knowledge. But there is more to the practice of nursing than just clinical knowledge. That is where I think there is a problem with her work. Contributors to the o v e r a l l lack of c l a r i t y around ANP were thought to include nursing language/rhetoric that was not e a s i l y understood and/or meaningful within nursing, l e t alone outside nursing. Participants also c i t e d the o v e r a l l s e n s i t i v i t y that nurses had towards the various levels of nursing education. The following account summarizes these contributors and r e f l e c t s p a rticipant awareness of the influence of t h e i r practice related to CHO: Advanced practice is not easy to define without putting down colleagues with less education, because we do know that because we have more education, we make a bigger difference in the lives of our clientele. You know, when you take all that rhetoric aside, don't you find often that you're trying to tell people about what a clinical nurse specialist is? You try to tell your mother or a friend who has nothing to do with health care and you're at a loss, because the language that we use is not day-to-day language. We've got a lot of flowery or technical words or you know fluctuating language that we use to describe it. And yet the bottom line for me about advanced practice and client health outcomes has more to do with my willingness to really try my hardest to provide leadership and guide people in the right directions so they can find the client health outcomes that are meaningful for them....We haven't been using language that is meaningful. 55 Thus, according to participants, ANP was a term that was broad and vague i n nature. They c i t e d nursing l i t e r a t u r e and work of nursing scholars such as Calkin and Benner but thought that current research did not adequately capture the differences between the expert nurse and the nurse i n ANP. Participants believed that there i s more to ANP than c l i n i c a l knowledge and that providing leadership and guidance to others were an important part of influencing them to f i n d meaningful CHO. Lack of Concern Not one of the participants was concerned about her lack of c l a r i t y around ANP. A l l were very w i l l i n g to engage i n discussion for the purposes of the research. However, i t was obvious to the researcher that a clearer understanding of ANP was not a p r i o r i t y area for participant consideration. Overall, although gracious i n taking part i n t h i s study, participants believed that i n t h e i r day-to-day practice they had more important things, such as program planning and consultations to consider rather than t r y i n g to define ANP more c l e a r l y : I know that ANP is not a clear term but I have other more important things to think about. It is not a burning issue. It's interesting, all of this role confusion that people have and all this, all this angst I suppose with the role. I don't have it... I don't know (pause) I have too many other things on my desk to get done in terms of program planning, consultations and all that kind of stuff to really worry about how other people define my role or try to define my role or what it should be. 56 A l l participants were comfortable with t h e i r own understanding of ANP and voiced confidence i n how they defined i t for themselves and how they enacted i t . They were not concerned i f t h e i r own understanding was not clear to others. In fact, as the following account demonstrates participants got "fed up" and " t i r e d " of what they perceived to be exhaustive and f u t i l e e f f o r t s to more c l e a r l y define ANP: So we have a hard time defining it. It doesn't bother me. I know how to define it for myself and for the people that I work with and I'm comfortable with my definition or with my perception of it. And this may sound sacrilegious but I don't really care how anyone else defines it. I use it as a framework as to how to interact with the client and -the rest of the health care team. As long as I am comfortable in how I perform my role and define my role that is enough!....I get tired of it. I think that we work so hard at trying to define our role that we get carried away and our focus gets displaced. Participants elaborated on t h e i r own lack of concern by pointing out that very credible and well known nursing scholars had made s i g n i f i c a n t e f f o r t s toward t r y i n g to further understand ANP, as well as the in d i v i d u a l roles i n i t , but without much success. Although participants valued these e f f o r t s , the lack of success reinforced t h e i r own ideas about not needing to be d i r e c t l y involved i n these e f f o r t s : How do you define advanced nursing practice or how do you define a CNS or a Nurse Practitioner or a Nurse Anesthetist? With a great deal of difficulty. And how many years have people been trying to do this? People with much better qualifications than you or I will ever have! How many years have they been trying to define what nursings' mission is? Some forty and we s t i l l haven't answered that question either. So why should I try? 57 Thus, participants were not concerned about t h e i r lack of c l a r i t y about ANP. From t h e i r own perspective, they understood i t well enough to be able to enact i t . Although participants supported the researcher i n her e f f o r t s to define ANP, c l e a r l y they did not share t h i s need. Day-to-day demands of practice were thought to be far more important areas for consideration. Participants recognized the exhaustive, but non-conclusive e f f o r t s of nursing leaders around various components of ANP. Although participants found these e f f o r t s worthy of applause, they believed that defining ANP was not something they needed to spend any more time with. In fact, they thought e f f o r t s to do so were t i r i n g and f u t i l e . Cautions Around Trying to Clearly Define Not only were participants not concerned about the lack of c l a r i t y about ANP, they cautioned the researcher i n e f f o r t s aimed at a clearer understanding. They believed that i t was b e n e f i c i a l for ANP to remain broad and vague. This allowed for the f l e x i b i l i t y required for ANP to continue to evolve, l i k e the rest of nursing. Participants i d e n t i f i e d the r i s k of what they referred to as forcing a definition. Although recognizing that some nurses wanted things l i k e d e f i n i t i o n s to be i n "black and white," participants saw c l a r i t y as p o t e n t i a l l y r e s u l t i n g i n negative consequences for nursing. Given the ever-changing health care environments and the resultant ambiguity i n nursing, participants thought 58 ANP was understood well enough. The following account captures t h i s most c l e a r l y : I think we are in the process of evolution so to prematurely pin it down too tightly would be dangerous. I mean I think we are in the process of evolving that level of practice and that it is very difficult to do, so you don't want to force it. The risk if you force a definition is that it will not serve us....And I worry that someone will force some definition onto the floor that actually won't serve us because they have such a great need to have things in black and white. I think that nursing is in a state of great ambiguity right now...great greyness. So I think we have to be really cautious! Participants reinforced that nurses knew enough about ANP yet may never know enough to have a clear d e f i n i t i o n . They thought ANP was something to be described and these descriptions allowed for ongoing changes and f l e x i b i l i t y for the r o l e . The descriptions also involved t e l l i n g paradigm s t o r i e s : I mean I think we know something about it, it is just that we don't know and we may never know enough to make it a clear definition. What you have to do is to talk in terms of "at this moment in time these are the kinds of things that advanced nurse practitioners are able to do"...it would probably be very descriptive and more told in paradigm stories and I don't know that it will ever become more clear than that. Thus, participants believed that nursing was evolving and ANP needed to be f l e x i b l e to respond to these changes. Participants also believed that nurses understood ANP well enough and may never know enough to have a clear d e f i n i t i o n . They thought ANP was something to be described i n paradigm st o r i e s , with the descriptions allowing for ongoing changes to the enactment of the r o l e . 59 Reasons for Lack of C l a r i t y About Advanced Nursing Practice As has been mentioned, participants had d i f f i c u l t y with a clear d e f i n i t i o n of ANP. Besides not being concerned, participants could a r t i c u l a t e v a l i d explanations for t h e i r lack of c l a r i t y i n attempting to define ANP. These included: role inconsistencies; imprecision regarding nursing; terminology changes; and, lack of time for r e f l e c t i o n . Role Inconsistencies Participants recognized that nurses i n ANP brought t h e i r i n d i v i d u a l focus and v a r i a t i o n to the enactment of that practice. This was believed to r e s u l t i n o v e r a l l inconsistencies related to ANP. Although recognized as a factor i n lack of c l a r i t y about ANP, participants thought these very inconsistencies were valuable, as they supported the i n d i v i d u a l i t y of the nurse. Participants supported the unique personal and professional competencies* that each nurse brought to ANP: We certainly do not have a singular view of l i f e as a CNS....I think there is a real variation in how we all practice. Every single one of us is very different, very, very different. Participants believed that nurses who went i n to ANP had very strong p e r s o n a l i t i e s . These strong p e r s o n a l i t i e s combined with advanced education and experience resulted i n NOTE: ^competencies - participants defined competencies as the knowledge, s k i l l s , attitudes and judgements that nurses brought to ANP. 60 unique, powerful competencies which had the poten t i a l to p o s i t i v e l y and s i g n i f i c a n t l y impact nursing and health care. Participants also believed that despite the varying personalties, nurses i n ANP were very supportive of each other and would t r y hard to embrace nurses new to the r o l e . The following account r e f l e c t s p a rticipant attempts to explain why ANP was not c l e a r l y definable and how nurses i n ANP would support and mentor others: I don't know if I even have a handle on why it is that it is not able to be defined clearly. I think it is just the amorphous operationalization of the role, of the roles., I mean we don't even have consistent terminology for the roles. And I think of it being kind of amoeba-like. You get someone coming in to the role, an advanced practice role and they've got qualifications you didn't expect or experience you didn't expect and all that kind of thing. So then the amoeba kind of reaches out and takes that person in to the fold. Thus, participants believed that there were s i g n i f i c a n t differences i n how nurses i n ANP enacted t h e i r r o l e s . These differences were supported as participants thought that nurses who chose ANP brought some strong p e r s o n a l i t i e s , as well as professional competencies that had the poten t i a l to p o s i t i v e l y and s i g n i f i c a n t l y influence nursing and health care. Nurses i n ANP valued supporting t h e i r peers. Imprecision Regarding Nursing Participants thought that ANP, similar to so many other terms i n nursing, lacked c l a r i t y . They therefore questioned the focus within nursing on ANP. Participants believed that despite an apparent unclear understanding of s p e c i f i c terms, most nurses were competently able to practice nursing. In 61 other words, although most nurses could competently practice nursing, they couldn't c l e a r l y a r t i c u l a t e i t . Participants recognized the controversy concerning c l a r i t y of nursing i t s e l f , l e t alone s p e c i f i c roles within i t . As a re s u l t , participants thought many factors influenced attempts at clear d e f i n i t i o n s of ANP. They thought the variety of understandings of ANP were influenced by "hidden agendas" and "protecting t u r f " of those t r y i n g to develop d e f i n i t i o n s : I t i s almost like everything else in professional nursing. There is so much controversy about nursing itself never mind specific roles within nursing. I think everybody has so many different perspectives as to what advanced practice is. Often it is people with very specific hidden agendas to define it one way, and other people define it another way. I think a lot of people are interested in protecting their turf when they are defining it or trying to define it as nursing practice. The following account r e f l e c t s these ideas as well as participant views that i t was "the experts" who were most concerned about confusion associated with a l l of nursing practice. However, despite o v e r a l l lack of c l a r i t y , participants thought ANP was a useful term: I would ask well why should we be using the term nursing? Only experts have disagreement about what nursing truly is and what nurses do. How come we've had such difficulty truly defining what nurses do? It is a concept that is very broad and can mean a lot of things to a lot of different people. But it s t i l l represents a concept, represents an idea. So I think it is a useful term. But where I think it is problematic is whenever a specific group refers to themselves as advanced nursing practitioners without looking at how broad the role of an advanced nursing practitioner can be and how many people, how many types of nurses that could apply too. Thus, according to participants, part of the lack of 62 c l a r i t y associated with ANP was r e f l e c t i v e of the broader imprecision regarding nursing i t s e l f . Although participants believed that most nurses could quite competently practice nursing, these same nurses had d i f f i c u l t y t r y i n g to a r t i c u l a t e t h e i r practice. Participants did believe that factors such as "hidden agendas" and "protecting t u r f " influenced the varying understandings of ANP. Despite expert disagreement on the d e f i n i t i o n s and practice of nursing, participants believed that ANP was a useful term. Terminology Changes Participants thought that ANP was a complex and " r e l a t i v e l y new" yet ever-changing term. Participants believed that one possible influencing factor as to whether a nurse could t a l k about ANP i n d e t a i l was whether or not i t was a topic i n the l i t e r a t u r e during attendance at graduate school. If i t was, participants believed i t would then have been included i n t h e i r course work. Even though participants recognized the scope of nursing l i t e r a t u r e i n c i r c u l a t i o n during the time of t h i s research related to ANP, they thought that to t r u l y understand ANP i t might have been useful to have "the luxury of graduate student time" for indepth discussion. They believed that once nurses completed graduate education, they would be u n l i k e l y to have the time to f u l l y explore terms such as ANP. This lack of time was thought to be primarily due to the extensive day-to-day demands of practice: 63 The term advanced nursing practice is new to me, having been out of graduate school for five years now...it was not tossed around in graduate school. So you are being exposed to a certain body of literature where you are at in this point and time. That is the beauty of being a student. It gets you right back into the current literature. The reality of practice for me is that it is impossible for me in my current position, I can't talk about the others, but to really keep abreast of all the literature on the CNS role and advanced practice and all that. Thus, participants recognized the value of being able to f u l l y explore terms such as ANP i n graduate school. The extent that a nurse could discuss ANP was thought to be r e f l e c t i v e of whether or not the term was i n the l i t e r a t u r e , and therefore part of education, while the nurse was attending graduate school. If not, once the nurse was i n day-to-day demands of practice, time required for f u l l exploration of ANP was not available. Lack of Time for Reflection Participants believed that to understand terms such as ANP, c r i t i c a l thinking about practice was required. Participants referred to t h i s as " r e f l e c t i v e time." They defined r e f l e c t i v e time as time when nurses i n ANP could "step back" and spend q u a l i t y time c r i t i c a l l y thinking about a variety of terms and/or concepts that were linked with t h e i r practice. This r e f l e c t i v e time, although highly sought, was referred to as "a luxury" and b a s i c a l l y unattainable due to workload pressures. However, participants i d e n t i f i e d that when r e f l e c t i v e time i s not b u i l t i n to nursing practice, i t could be an important factor 64 related to the o v e r a l l lack of c l a r i t y about ANP: One of the reasons that we might have difficulty doing that (defining ANP) is that we don't build in reflective time. We are very versed in front line work and it is very hard to do conceptual thinking of the order that you are asking us to do unless in fact we have done reflective thinking about our practice. The following account further exemplifies that t h i s r e f l e c t i v e thinking would only be done when the nurse i n ANP was involved i n research. Otherwise participants thought that, i n day-to-day practice, they were not required to be "practiced i n a r t i c u l a t i n g ANP": No one ever asks me what it is I do or why it is that I am called this or you know, in terms of the people that I work with so maybe the opportunity to explain myself arises only in these settings, when someone is doing research. I am really not practiced in articulating it. Thus, according to participants, r e f l e c t i v e time was required for nurses i n ANP to understand terms such as ANP. They r e a l i z e d that due to day-to-day workload pressures i n t h e i r practice, they could not b u i l d r e f l e c t i v e time i n . So r e f l e c t i v e time was thought to be a luxury that was usually only engaged i n when participants were involved i n research. In summary, ANP was a term that did not allow for a clear or concise d e f i n i t i o n but rather was thought to be inherently broad and vague i n nature. This nature was thought to be influenced by the lack of understanding that nursing scholars had between expert and ANP, nursing language/rhetoric and s e n s i t i v i t y of issues related to nursing education. Participants were not concerned about t h e i r lack of 65 c l a r i t y about ANP and believed that t h e i r personal understanding was s u f f i c i e n t to adequately conduct t h e i r practice. Out of support to the researcher, participants attempted to address the phenomena of i n t e r e s t . However, they believed that i f nursing scholars were not clear about ANP, then nurses i n ANP had more important and pressing issues for consideration. Although supportive of the research, participants were cautious around e f f o r t s to c l e a r l y define ANP. They believed that nurses i n ANP could adequately describe t h e i r practice using paradigm stories that would allow for the f l e x i b i l i t y required for on-going changes that influenced the evolvement of ANP. Participants offered reasons for the general lack of c l a r i t y about ANP. Nurses i n ANP were thought to have s i g n i f i c a n t inconsistencies i n how they enacted t h e i r r o l e , although t h i s v a r i a t i o n was strongly supported and encouraged. The lack of precision or d e f i n i t i o n regarding nursing was another reason c i t e d . Participants recognized that most nurses could competently practice nursing but could not c l e a r l y a r t i c u l a t e t h e i r practice. Despite factors such as the general disagreement around many d e f i n i t i o n s associated with nursing and the influence that various agendas and tur f issues had i n t r y i n g to develop a clearer understanding about ANP, participants thought that ANP was a useful term es p e c i a l l y to represent a concept or idea. 66 Participants also believed that graduate school was a setting where concepts or terms such as ANP could be f u l l y explored. They believed that i f a term such as ANP was not part of a nurse's graduate education, then busy day-to-day practice would preclude time required to be able to c l e a r l y a r t i c u l a t e a d e f i n i t i o n . F i n a l l y , time for r e f l e c t i o n i n practice was thought to be a c r u c i a l factor for understanding ANP. Although believed to be c r u c i a l , participants recognized r e f l e c t i v e time as a luxury that was usually only possible during the process of a s s i s t i n g others i n research. Descriptors of Advanced Nursing Practice Although participants could not c l e a r l y and concisely define ANP, they believed i t was a term that was amenable to description. Two main descriptors were i d e n t i f i e d . The f i r s t was what participants believed to be minimal requirements of ANP namely: graduate education, c l i n i c a l s p ecialty focus and research-based practice. The second was the essential q u a l i t i e s of ANP. Minimal Requirement Triad of Advanced Nursing Practice Participants outlined what.they believed to be the basics, the foundation or minimal requirements of ANP. These have been categorized as the three minimal requirements of ANP, namely graduate education, c l i n i c a l s pecialty focus and research-based practice. According to participants, each one of these requirements was thought to be equally c r u c i a l for 67 ANP. However, i t was the combination of the three that formed a t r i a d of minimal requirements for ANP. Graduate Education A l l participants strongly supported the need for graduate education. Graduate education formed the f i r s t element of the minimal requirement t r i a d of ANP: The bottom line for me is that the person have advanced education, at least at the master's level. I say very simply that you must have a master's degree...to me it is simple because I believe at the bachelor level we're just beginning to provide that basic level of a liberal education. Graduate education was thought to contribute s i g n i f i c a n t l y and p o s i t i v e l y to ANP. Participants believed that, during graduate education, nurses developed many competencies that were v i t a l for ANP. These competencies were thought to be influenced by an exposure to indepth pertinent theories, research methodologies and interpersonal communication s k i l l s : Graduate learning...to learn pertinent theory to apply to situations, learn research methods that help me understand those things, learn interpersonal communication skills that help me as a Clinical Nurse Specialist. During graduate education, participants believed they developed: a broader knowledge base, enhanced problem solving s k i l l s , p r i n c i p l e s of research-based practice and a higher l e v e l of o v e r a l l analysis of nursing practice: I suppose I have a much broader base of knowledge than I did. I know more about where to go to learn about things. I know more about setting up programs. I know more about utilizing research and in fact being active 68 in research or knowing where I can't do research. I think that it is as much knowing when you can't do as knowing what you can do, that is so critical. So the master's program really developed me in my specialization. Advanced practice and the education that goes with that forces you to analyze what you do in a different way. Participants believed that graduate education also provided a l i b e r a l education i n domains of s o c i a l sciences and the ove r a l l health care system.. Participants thought t h i s resulted i n a foundation for ongoing learning related to practice: Advanced practice rests on having been provided that liberal education in all domains of the social sciences plus a liberal in-depth knowledge of the health care system and the knowledge that you always need to know more about your health care system. You can't sit s t i l l , you always have to keep on learning! Graduate education also s i g n i f i c a n t l y enhanced c r i t i c a l thinking: I think it is a combination of education as I do think you learn to think differently the more you go to school, learn to look at things differently. You learn more critical thinking and nurses in ANP are constantly engaged in critical thinking. Although a l l participants c l e a r l y supported graduate education, they had strong and d i f f e r i n g views on what faculty the graduate degree should be from. Participants were graduates of varying programs and had d e f i n i t e opinions on t h i s matter. Graduate nursing education was strongly supported by those who had graduate degrees i n nursing: The graduate degree has to be in nursing. I know it may be contentious but if we really want to advance nursing, I mean really if we are talking about advanced nursing practice how do you get that advanced nursing 69 preparation in another faculty? I don't think you do. Those participants also understood why some nurses chose to undertake non-nursing graduate education. Reasons c i t e d included proximity to a university and whether or not the nurse had respect for the nursing graduate program. Participants with nursing graduate degrees were sensitive to the issue of some of t h e i r colleagues having non-nursing graduate education. Obviously wanting to be supportive, these participants s t i l l questioned whether or not non-nursing graduate education contributed p o s i t i v e l y to ANP. They did not think i t did: I think the thing is the fallacy of people taking a master's degree outside of nursing is the fact that we don't really know what that contributes to advanced practice. We know why they do it, and that has nothing to do with advanced practice. It has a lot more to do with if there was a school close enough that they could go to or that they had any respect for. They often aren't decisions made about advanced practice. Conversely, participants who had non-nursing graduate degrees vigorously questioned the ongoing support for nursing graduate education as a basic requirement for CNS practice and ANP: There is a lot of discrepancy then over...what kind of degree that should be. These participants seemed as sensitive as participants with nursing graduate degrees to the issue of education, yet believed they were making a s i g n i f i c a n t and valuable contribution to ANP. They based some of t h e i r questioning about the support for nursing graduate education on the fact 70 that many of these nursing programs did not contain a c l i n i c a l s p e c i a l i z a t i o n focus: Now exactly what that master's degree is in and what its focus is in is a real bone of contention as far as I am concerned. Many nursing master's are not clinically focused anyway and why would we suddenly say that the person is an advanced nursing practitioner as opposed to somebody who might have a master's degree in another area other than nursing but has really focused on a clinical speciality area. At the same time, occasionally these participants questioned i f part of t h e i r d i f f i c u l t y related to addressing aspects of the research phenomena was due to t h e i r non-nursing graduate education: Some of us may have difficulty in defining client health outcomes because we don't have a nursing master's. I don't know... Despite strongly i d e n t i f y i n g the need for graduate education, participants believed that t h i s education alone did not r e s u l t i n ANP. Although recognized as a v i t a l minimal requirement, they believed graduate education only formed the f i r s t element of what has been conceptualized as the minimal requirement t r i a d of ANP. Although graduate education was thought to provide valuable competencies that led to ANP, participants thought most graduate nursing education programs did not s i g n i f i c a n t l y contribute to advanced c l i n i c a l expertise: Why do we zero in on the advanced preparation? Because that in itself doesn't make an expert does it? You can have someone who has all the degrees but they are not the advanced practice nurse that we want to know today. I think the d i f f i c u l t l y is in our graduate educational programs. They are not designed to define expertise. 71 Thus, according to participants, graduate education was thought to be a c r u c i a l minimum requirement of ANP. During graduate education, nurses learned: indepth pertinent theories, research methodologies, interpersonal communication s k i l l s , a broader knowledge base, enhanced problem solving s k i l l s , research-based practice and a higher l e v e l of o v e r a l l analysis i n nursing practice. They also developed a constant questioning of, and learning, related to practice and the broader health care system, as well as enhanced c r i t i c a l thinking. A l l of these competencies were thought to contribute p o s i t i v e l y to ANP. The issue of whether graduate education needed to be i n nursing or another fa c u l t y remained contentious. However, participants recognized that graduate education alone did not re s u l t i n ANP. C l i n i c a l Specialty Focus Participants believed that nurses i n ANP must combine graduate education with a c l i n i c a l s pecialty focus. This focus formed the second element of the minimal requirement t r i a d of ANP. Even those participants with non-nursing graduate education believed that, despite the graduate program, nurses who wanted to practice ANP needed to combine t h e i r graduate education with an indepth nursing c l i n i c a l s pecialty focus: First of all that i t would be in terms of the person, someone who had a particular education, master's degree I would define where in fact they specialized in a particular area of nursing. An area that you were most interested in and then become further educated in that focusing that practice to the specialty area and 72 applying that specialty knowledge in a clinical setting. It is a combination of graduate education plus clinical experience in the field, you know, your specialty. I think those are the two major components of what makes advanced practice. Participants r e f l e c t e d on t h e i r own experience about t h e i r c l i n i c a l practice p r i o r to graduate education. They described themselves as having been "expert" c l i n i c a l p r a c t i t i o n e r s p r i o r to t h e i r graduate work. They c l e a r l y described how they brought t h e i r i n d i v i d u a l specialty area of nursing to graduate education and then during t h e i r studies focused on more indepth c l i n i c a l competencies. On completion of t h e i r programs, participants could e a s i l y describe how t h e i r practice had changed by way of personal growth and enhancement of t h e i r o v e r a l l c l i n i c a l s p e c i a l i z a t i o n : Until you attend graduate education, you really don't know how much more you can offer your clients, your profession and yourself. I was an expert in my field before I did my master's degree. Now I know I was an expert, yes, but a very limited expert. Now after going to graduate school and linking that education with significant clinical practicums in my field, I am capable of so much more. You grow in leaps and bounds and then can help others to grow as well. Back when I was a diploma nurse in ICU, I was very good in my field. I had good practice skills and to some nurses they might have called it advanced practice. Maybe I was a expert practitioner as opposed to advanced practice. But at that point and time, I did not see the world of ICUs. I did not analyze why people were coming in or if they should be coming in or if they should not.... Advanced practice is broader and you develop that ability to stand back and look at it from a systems perspective and what is the impact on a whole specific population. Despite being an expert p r i o r to graduate education, 73 participants thought that the c l i n i c a l specialty focus of th i s education needed to include c l i n i c a l practice that was mentored. They believed t h i s to be c r i t i c a l i f nurses were to r e a l l y develop into ANP. Participants believed the mentor needed to be a role model that the nurse could respect and be challenged by. Again, participants believed that the mentoring system needed to include dedicated time so that r e f l e c t i v e practice did occur: The thing that advances nursing is education that contains within it a lot of clinical practice that is mentored. I don't believe...I mean it is not just throwing people out. It is a reflective practice and it is done within a mentoring system. Mentoring is necessary to have at some point in preparing for a role like this so that you can know what it is about and have as a group a shared vision of what it is you are trying to accomplish. Participants believed that the c l i n i c a l s pecialty focus combined with graduate education was b e n e f i c i a l for ANP for a couple of reasons. F i r s t l y , they thought that i t enhanced the a b i l i t y of nurses i n ANP to l i n k academic experience with practice. This linkage was thought to enable nurses i n ANP to draw from a number of v a l i d theories whether i n f a m i l i a r or non-familiar scenarios related to c l i e n t care. Participants believed t h i s to be very e f f e c t i v e i n problem solving complex c l i n i c a l practice challenges that nurses i n ANP were presented with on a day-to-day basis: The thing that differentiates me as an advanced nursing practitioner from the expert nurse is that pursuit of learning, experience being able to integrate a lot of my academic experience into practice. When I arrive into a situation that requires a particular theoretical 74 framework I can reflect on my academic experience. And even if the theoretical framework does not exist, i t is easier for me, I think, to pull a number of theories together to form a framework for a particular situation or client. I think that if I was strictly and advanced practitioner, an expert like Benner describes where my skills have been acquired strictly through clinical practice, I wouldn't have the theoretical background to be able to expand that practice into areas that might be unfamiliar. I think that is one of the things, even being an expert you always run into things that are a l i t t l e unfamiliar, something that you haven't run into before and I think that my academic preparation and my way of approaching the problem solving process allows me to accommodate those strange situations a lot easier that if I focused strictly on clinical practice. Secondly, participants thought the c l i n i c a l s pecialty focus linked with graduate education was a s s i s t i v e i n developing d i f f e r e n t approaches to the ongoing evaluation of actions: Advanced clinical practice and the education that goes with that forces you to consistently analyze what you do in a different way. This analysis began a process that developed into what participants described as a constant questioning of pr a c t i c e . They believed that the process of graduate education supported and encouraged behaviours inherent i n c r i t i c a l thinking such as challenging colleagues and faculty, as well as questioning everything from basic c l i n i c a l practice protocols to broad health p o l i c y . Participants believed that nurses i n ANP had the confidence to question the practice of a l l levels of health care providers, as well as p o l i c y makers. Participants saw t h e i r l e v e l and frequency of questioning practice as being very d i f f e r e n t from that of 75 other nurses: We are constantly questioning the practices that we have and whether we can do things differently. We are the ones that are not afraid to ask the stupid questions. We are always questioning. Participants also valued t h e i r a b i l i t y to prompt others to begin to question practice more: I have the luxury of questioning what it is that we do and then by doing that, then I expect the nurses will also begin to question. So I kind of 'trigger their questions. Participants recognized that by asking questions of s t a f f nurses, rather than providing answers, they could further develop competencies s t a f f nurses might already possess: The CNS is often the "what-if" person, not rushing in with all the answers but asking the questions. Because staff nurses can do it, they have a lot of knowledge, sometimes they need to hear the questions rather than the answers. To me that is one of the biggest roles of the CNS, to ask the questions. Participants believed the confidence of nurses i n ANP to consistently question practice, combined with other competencies noted above, enabled nurses i n ANP to be "proactive" rather than "reactive" to c l i n i c a l practice scenarios and ov e r a l l health care: As a profession, nursing can't actively participate and progress if we can only manage to keep up to day-to-day client needs. That is one big influence of advanced nursing practice.• Those of us in the role can be proactive and try to influence overall health care. The following account r e f l e c t s a combination of the competencies of ov e r a l l system analysis, questioning of practice and proactive approaches to care related to ANP: 76 What I am looking at...looking at identifying client populations within our agency that...by and large lack something in their care, that would improve their outcomes, that would get them out of here faster, that we would question why they are even here in the first place. And then what I try to do in that role is that I try to develop an overall approach to that particular group of clients. I do believe in looking at trends and with what is happening with the clients in the areas and filling gaps in care. As well I am trying to be proactive in looking at what are the gaps in care in our community. Thus, according to participants, an indepth c l i n i c a l s p ecialty focus combined with nursing or non-nursing graduate education were minimal requirements for ANP. Participants described how they entered graduate education having been recognized as a c l i n i c a l expert i n t h e i r f i e l d . Once they focused t h e i r studies with more indepth c l i n i c a l work, they thought they graduated being able to practice at a d i f f e r e n t and advanced l e v e l of nursing. Participants believed that inherent i n graduate studies was the need for mentors and r e f l e c t i v e time i n order to f u l l y develop as a nurse i n ANP. A c l i n i c a l specialty focus combined with graduate education was believed to have many po s i t i v e outcomes such as use of v a l i d theories for decision making, a b i l i t y to e f f e c t i v e l y problem solve complex c l i n i c a l practice challenges, development of an awareness of and a b i l i t y to influence the broad health care system and development of d i f f e r e n t approaches to analysis of practice which included a constant questioning of practice. Participants saw t h i s questioning of practice as being d i f f e r e n t from that of other nurses. Participants also believed these competencies 77 enabled nurses i n ANP to be proactive rather than reactive to c l i n i c a l practice issues and ov e r a l l health care. Of interes t i s the fact the participants were quite clear about what d i f f e r e n t i a t e d expert from ANP, yet they were unable to a r t i c u l a t e that i n response to being asked to define ANP. Research-Based Practice Participants believed that another v i t a l requirement of ANP was research-based practice. This formed the t h i r d element of the minimal requirement t r i a d of ANP. When participants referred to research-based practice, they meant the research competencies gained through graduate education linked with a c l i n i c a l s pecialty focus. Participants c i t e d research-based practice from the perspectives of consistently thinking about, p a r t i c i p a t i n g i n , and u t i l i z a t i o n of research as c r u c i a l for ANP: CNSs think c r i t i c a l l y in the research mode. As CNSs, we have to constantly be thinking about practice and how the trends of practice f i t or don't f i t with research that has been done. We also have to participate in research and consistently ensure research-based practice. Participants believed that research needed to be the foundation of a l l nursing practice when that was possible. They recognized that a great deal of nursing practice was not based on research. However, they strongly believed that when v a l i d and r e l i a b l e research related to practice had been done, nurses i n ANP often led the way into incorporating i t into practice: 78 I realize there is a great deal of what we do that is not based on research. But if valid and reliable research has been done, we need to examine how we can incorporate it into practice. Participants believed that the wealth of information contained i n research l i t e r a t u r e was extremely useful i n learning about, understanding and influencing nursing practice. Participants thought that t h i s l i t e r a t u r e assisted them to work, with and educate s t a f f about practice from a variety of perspectives. It was also thought to provide a strategy for nurses i n ANP to get s t a f f nurses to question t h e i r own practice: CNSs regularly go to the literature, especially the research literature, to learn more about, understand and influence practice. The research is a way for us to assist other nurses. We may have to translate the findings or results but we can do that and put it into terms that the staff nurse will understand. The research also helps us to get the nurses to question why they are doing some of the things that they do regularly. Participants c l e a r l y valued partnerships with colleagues, i n t e r d i s c i p l i n a r y professionals and univer s i t y educators i n the conduct of research and/or dissemination of findings: Everything we do needs to be based on research. It is great when we can, yet it is vital that we do participate in research with either other CNSs and/or interdisciplinary professionals or when we link with the university faculty. Although participants thought the conduct of research to be important and recognized the value of partnerships with others toward t h i s aim, an important area of t h e i r consideration was whether the master's prepared nurse i n ANP 79 could adequately assume the p r i n c i p l e investigator role i n research. Participants believed they played a s i g n i f i c a n t role i n research-based practice but that r e a l l y d e f i n i t i v e research involved a partnership between a nurse i n ANP and a doctorally prepared nurse. They believed the doctorally prepared nurse should be the p r i n c i p l e investigator: I'm not actually committed to the master's level practitioner as the principle researcher. The advanced practitioner is someone who in fact understands where there are not answers in research. And I am not at all convinced that advanced practice at the master's level means you should be able to do research. I think that you should certainly understand the research process and you can do some subtle research.... I think that the really definitive research is done jointly between the CNS and a PhD researcher. Thus, according to participants, research-based practice by way of research competencies, gained through graduate education linked with a c l i n i c a l specialty focus, was a c r i t i c a l minimum requirement of ANP. They saw research-based practice as i n c l u s i v e of thinking about, p a r t i c i p a t i n g i n and u t i l i z a t i o n of research. Participants recognized that much of nursing practice was not based on research, however they believed that when v a l i d and r e l i a b l e research had been done, nurses i n ANP needed to make strong e f f o r t s that i t be incorporated into nursing practice. Information contained within research l i t e r a t u r e was thought to be useful for nurses i n ANP, i n order to a s s i s t them i n e f f o r t s with s t a f f nurses about o v e r a l l examination of practice. Participants also valued partnerships with others for the conduct of 80 research and/or dissemination of findings. Participants questioned i f master's prepared nurses i n ANP could adequately assume the p r i n c i p l e investigator role i n research. According to participants, t r u l y d e f i n i t i v e research involved partnerships between a nurse i n ANP and a doctorally prepared nurse. Es s e n t i a l Q u a l i t i e s of Advanced Nursing Practice Participants believed that there were a number of essential q u a l i t i e s that were c h a r a c t e r i s t i c of ANP. Participants thought that nurses i n ANP incorporated the competencies mastered i n r e l a t i o n to the minimal requirement t r i a d and combined these with experience and time. This resulted i n what participants believed were the essential q u a l i t i e s of ANP: global thinking; i n d i r e c t c l i n i c a l focus; a s s i s t i v e care delivery; e f f e c t i v e leadership; and, i n t e r d i s c i p l i n a r y collaboration. Global Thinking A l l participants strongly believed that ANP involved an indepth a b i l i t y to consistently think g l o b a l l y . This global thinking represented the f i r s t essential q u a l i t y of ANP. It was mentioned frequently and thought to be part of the "world view" and "system" perspective. According to par t i c i p a n t s , global thinking included o v e r a l l l o g i c a l , a n a l y t i c a l and global views of the nursing practice world: I think you develop a lot more of a world view. I think that most people who have come through the advanced educational programs have developed some more logical, analytical, global views of the world, which I think 81 also has to be part of advanced practice. Global thinking was believed by participants to be thinking about the "bigger picture." It was frequently obvious to the researcher that participants were consistently t r a n s l a t i n g information into a global perspective. In other words, they were frequently thinking and t a l k i n g about how any p a r t i c u l a r i n d i v i d u a l c l i e n t scenario had relevance for understanding the whole of c l i e n t care. They believed t h e i r a b i l i t y to think g l o b a l l y was extremely b e n e f i c i a l for nursing, as well as for i n t e r d i s c i p l i n a r y practice. Participants thought that nurses i n ANP were aware of issues i n the worlds of nursing and i n health care and had made some personal stands about these. This was viewed as useful i n interactions with s t a f f , such as t e l l i n g s t a f f what was going on i n other areas, as well as what kinds of things they should have been considering for t h e i r own areas of practice: To be an advanced practitioner I believe that you need that global view and you need to know what is going on in the world of health care, you need to know what is going on in the world of nursing. You need to have made some stands, otherwise you can't get back down there with the bedside practice nurses and try and tell them what kinds of things are going on out there, and what kinds of things mean something or should mean something to them at the bedside. Participants described how they never interacted with one c l i e n t without thinking about the implications that the care of that p a r t i c u l a r c l i e n t would have for other c l i e n t s as well as o v e r a l l practice: 82 Care is not just for one client but for other clients that will do better because of that one scenario. The following accounts exemplify p a r t i c i p a n t s ' a b i l i t i e s to translate i n d i v i d u a l c l i e n t scenarios into a whole or pattern. The f i r s t demonstrates recognition of "patterns" related to practice and resultant analysis of practice: Sometimes you end up dealing with the same problem over and over again and you suddenly realize that there is a pattern here.... in order for us to nurse in the best way possible and the most effective way we have to analyze what it is we are doing, analyze our practice. The second refers to recognition of patterns but assurance that decisions were not made because of one or two occurrences: You are forced to look more broadly and you then start to look more broadly and I think that is part of it...you say okay this is happening here...but I am not making my decision based on my sample size of one or two. Lets see what has happened elsewhere, lets see if there are some commonalities here, lets see if other people have this problem and maybe they have even come up with some solutions. At the same time, participants recognized the benefit of bringing "the whole" to any one c l i e n t scenario for an improvement i n c l i n i c a l status of individuals/groups through working with s t a f f : In a complex clinical situation I look to the research, I look to trends, I consult with experts from the world of available information to try to determine how to assist any individual client or groups of clients via the staff. This thinking was influenced by synthesis of competencies i n nurses i n ANP linked with t h e i r awareness of agency, community, p r o v i n c i a l , national and international health care 83 trends, issues and i n i t i a t i v e s . Participants believed t h i s thinking could have an impact on t h e i r communities, as well as e t h i c a l decision making and p o l i c y formation: As nursing practice is about broadening the way in which you practice such that it touches on a whole bunch of people rather than your clients for the day. So it is much more global and it can even have community effects and ethical decision making and policies and all that kind of thing. During t h i s research, a l l participants were available for consultation to t h e i r entire agency. This large geographical r e s p o n s i b i l i t y was believed to be useful i n i d e n t i f y i n g and monitoring trends and sharing information between units, as well as allowing global thinking to influence and be a part of c l i n i c a l practice: Many of the client groups that I have dealt with are so diverse and in such diverse areas of the hospital, that if you worked in a specific clinical area you would not see the other groups throughout the hospital. Whereas, in my role travelling throughout the hospital and at the variety of sites, you pick up some things that other people may not see. Participants believed there were many benefits of bringing global thinking to c l i n i c a l nursing practice. F i r s t l y , they thought i t assisted i n t h e i r e f f o r t s to p o s i t i v e l y influence the "bedside" or " s t a f f " nurse and thus enhance o v e r a l l practice: The more global you can be, the more knowledgeable you can be, the more advanced your practice is going to be. Because you can pass all that, you can somehow pass all that, or have an impact if you're lucky on some bedside nurse or a number of bedside nurses. To p o s i t i v e l y influence s t a f f nurses was thought to be extremely important. Overall, participants thought that the 84 majority of nurses t r a d i t i o n a l l y practiced from a "narrow" focus and were subsequently generally "reactive" to c l i e n t care and o v e r a l l health care and thus were consistently managing c r i s i s . They explained that, due to day-to-day pressures and r e s p o n s i b i l i t i e s , most nurses were "barely able to keep up" during t h e i r s h i f t s , and often ended up being only able to practice i n the "reactive" mode. However, participants also recognized that, due to system r e s t r i c t i o n s , i t may have been impossible for s t a f f nurses to do anything but react: In acute care in particular, nurses are so busy running around trying to meet individual client needs, they don't have time to stand back and think of the meaning of what they are seeing. They can only focus on the clients that they are assigned to for any given day. The system does not allow them to be proactive. Participants believed that one r e s p o n s i b i l i t y of nurses i n ANP was to bring t h e i r global thinking to c l i n i c a l practice and thus t r y to work with nurses i n e f f o r t s to move them from a less reactive and c r i s i s management mode to one of being proactive. However, participants recognized that t h e i r role enabled them to be "once removed" from the c l i e n t , therefore able to see issues that many nurses saw, but with more o b j e c t i v i t y . Participants believed t h i s enhanced the a b i l i t y of nurses i n ANP to be proactive: When you are in it you sometimes don't know...you don't generate as many questions as when you are once removed. The beauty of my job is that I am once removed from what is going on, from the actual work, the day-to-day work of the nurse. So I look at it through a nurse's eyes but I look at it more objectively, not caught up in the emotion of the job, the stress and the pressure of the 85 tasks. Secondly, participants believed many c l i e n t needs went un-met i n an agency that did not have a nurse i n ANP. The following account r e f l e c t s p a rticipant attempts to explain the value they saw i n bringing the global thinking to c l i n i c a l practice i n an agency: Part of the difficulty that we often have with staff is, even expert staff out there that are t e r r i f i c clinical practitioners, they are so focused on their clinical practice that they have a hard time seeing beyond that and beyond client needs except as related to their specific practice setting. There are a lot of client needs that would not get met unless you have a more global vision. Thirdly, participants believed nurses i n ANP u t i l i z e d global thinking, proactive strategies and monitoring of trends to make changes to the health of c l i e n t s i n t h e i r agency and therefore improve c l i e n t care: I can also with advanced practice say that this will happen to the next person that comes in, and this will happen over here and I can almost predict what the problems are going to be over there....And to look at how the system is functioning here and what do we do. As well as within t h e i r agency, participants also believed that nurses i n ANP needed to expand/extend global thinking to outside agencies/groups: I always try to see that big picture...whether it is within our system or I am being consulted from outside...you are coming from out there, the world view and helping people to solve the problem that they are trying to address. Thus, according to participants, ANP involved an indepth a b i l i t y to think g l o b a l l y . Global thinking was believed to be the nurse's a b i l i t y to think broadly about the lin k s 86 between in d i v i d u a l c l i e n t s and groups/populations as well as o v e r a l l health care. Nurses i n ANP were thought to have competencies to translate i n d i v i d u a l c l i e n t scenarios into a whole or pattern as well as bringing that whole or pattern to any i n d i v i d u a l c l i e n t . Participants i d e n t i f i e d a number of benefits of bringing t h e i r global thinking to c l i n i c a l p ractice. It was believed to be a p o s i t i v e influence when working with s t a f f . Participants recognized that s t a f f nurses practiced i n the reactive mode, primarily due to system constraints. Participants believed that nurses i n ANP practiced from a proactive mode, and i t was t h e i r r e s p o n s i b i l i t y to use t h e i r global thinking i n e f f o r t s to move s t a f f away from c r i s i s management. Participants believed that i f an agency did not have a nurse i n ANP, many c l i e n t needs would go un-met. Another benefit of global thinking, proactive strategies and monitoring of trends was that they were thought to be a s s i s t i v e for nurses i n ANP to make changes to the health of c l i e n t s within t h e i r agency, as well as external agencies. Indirect C l i n i c a l Focus Rather than focus on i n d i v i d u a l c l i e n t s , as would most nurses, a l l but one of the participants i d e n t i f i e d that nurses i n ANP had an i n d i r e c t c l i n i c a l focus on c l i e n t s . This i n d i r e c t c l i n i c a l focus represented the second e s s e n t i a l q u a l i t y of ANP. Participants thought most nurses t r a d i t i o n a l l y c l i n i c a l l y focused d i r e c t l y on c l i e n t s as 87 recipients of care, whereas nurses i n ANP c l i n i c a l l y focused d i r e c t l y on s t a f f nurses and i n d i r e c t l y on c l i e n t s . Participants thought that nurses i n ANP used leadership and modelling with nurses to i n d i r e c t l y influence safe c l i e n t care: Our effect on client care comes sort of indirect. I t is indirect because of where we try to influence. I believe who we do influence is the bedside nurse. We are trying to influence her/him in a leadership way, in a modelling way. We are trying to provide what is current, what the literature deems current, what is safe. Participants believed that the anticipated outcome from d i r e c t l y c l i n i c a l l y focusing on s t a f f and i n d i r e c t l y on c l i e n t s was improvement i n practice and enhancement of health outcomes for both nurses and c l i e n t s , as well as appropriate others involved i n care. Participants spoke very highly of s t a f f nurses and described them as the "most valuable nursing care p r a c t i t i o n e r " : I think what we really have to recognize as a group is that at least from my perception, the most valuable nursing care practitioner is the staff nurse, the practicing nurse at the bedside. We are here to support them, period, that is the end! One participant had a somewhat d i f f e r e n t slant on her d i r e c t c l i n i c a l focus i n that she i d e n t i f i e d i t as c l i e n t s or groups of c l i e n t s , rather than s t a f f nurses. She believed she was somewhat unique i n t h i s approach. However, as the following account demonstrates, she s t i l l described working d i r e c t l y with the nursing s t a f f to f a c i l i t a t e c l i e n t care and outcomes: 88 I have or at least I think I might have a l i t t l e different perspective and it is often to the chagrin of the nursing staff that I work with. My focus isn't the staff. My focus is the client. My sole reason for being here, if I had one sole reason, would be to enhance outcomes for that client. Now that often means creating things or doing things that are not beneficial to the staff, in their eyes. In other words, it might create more of a workload, it might create more complexity for them. I see that as being a secondary focus and I try to modify that as much as possible and try to facilitate that as much as possible, but my primary focus is the client or groups of clients. Participants very strongly valued t h e i r i n d i r e c t r e l a t i o n s h i p with c l i e n t s and had a great deal of personal s a t i s f a c t i o n i n solving s t a f f / c l i e n t challenges through t h e i r work with s t a f f : Well you see I have only ever wanted to work with clients. It is the kind of situations that people need help with in health care. These are the kinds of situations that I am challenged to work with. I love working with staff and clients in that they present me with the kind of challenges that have great meaning to me in solving. Due to an i n d i r e c t relationship, participants believed that i t was almost impossible to d i r e c t l y l i n k t h e i r practice to CHO. Due to t h e i r o v e r a l l a s s i s t i v e care delivery q u a l i t i e s , participants thought that t h e i r influence on CHO was act u a l l y from the broader perspective, i n other words, from the second or t h i r d person down: My personal perspective of the CNS role wasn't so much getting hands on involved in client care but in teaching, in modelling and showing other people how to carry out client care, how to look at nursing practice.... So if you are looking at advanced nursing practice and nursing outcomes from my perspective, what we are looking at is outcomes maybe two or third person down. Participants recognized that i t would be advantageous to 89 be able to measure the influence of t h e i r practice on CHO, even i n as associative type way. However, they saw that as being very d i f f i c u l t due to t h e i r i n d i r e c t r e l a t i o n s h i p with c l i e n t s : The only thing I wish, is that we could somehow develop some kind of system, some kind of method, some kind of tool that would be actually able to connect maybe not a cause and effect type of thing, but just an associative type of thing on our role with client outcomes. But I think that is going to be incredibly difficult. A l l participants had made informed decisions to remain close to c l i n i c a l practice thus close to s t a f f nurses and c l i e n t s , as opposed to pursuing careers i n administration. Participants believed that a l l nurses i n ANP were very clear about the personal value they placed on c l i n i c a l p ractice: Clinical Nurse Specialists have never wanted to move away from what is referred to as bedside care, client care or direct client contact. This has always been something that is highly prized. Participants believed that although administrators were very important and played a key role, nurses i n ANP found r e a l meaning and challenge i n working with s t a f f nurses and c l i e n t s . The following account demonstrates participant passion about nurses i n ANP involvement i n c l i n i c a l p r a c t i c e : I am grateful, immensely grateful to administrators because I think they are terribly important. I am bored to death by the problems that they encounter. But the situations of human beings and health and illness are situations that are very, very challenging and meaningful to me to work with and that has been true all my career. An i n d i r e c t c l i n i c a l focus with c l i e n t s was in c r e d i b l y important to part i c i p a n t s . So much so that, despite the 90 ongoing f l e x i b i l i t y required i n t h e i r roles, participants thought that i f there was ever a s i g n i f i c a n t threat to t h e i r focus, they would resign from t h e i r agency: I would not be able to move away from direct care orientation because I think that is a distortion of the role. So if I was required to take on more and more management areas I would leave, I know that. Participants believed that an issue associated with ANP was whether or not nurses i n these roles should assume r e s p o n s i b i l i t y for d i r e c t c l i e n t care. Participants believed that nurses i n ANP should not assume r e s p o n s i b i l i t y for di r e c t c l i e n t care as t h i s was contradictory to the very essence of ANP, as well as not being cost e f f e c t i v e : I would love to go in and solve the problem. It makes you feel good, you sleep good. But after a while you sense that something is missing here. I am not helping the staff to be able to do what they need to be able to do. And so I think the advanced practice role is to say how can I assist others to elevate their level of practice, move the standards above the basic level of what is required.... it is too expensive to have this level of person (participant pointing to herself) dealing on a one to one in these economic times. Participants occasionally had some minor personal struggles with t h i s since they enjoyed d i r e c t c l i e n t care. However, another reason they i d e n t i f i e d for nurses i n ANP not assuming r e s p o n s i b i l i t y for d i r e c t c l i e n t care was because one would get "buried" and then not be able to continue to see the global picture: I think that is one of the biggest frustrations in the role. You spend a lot of time trying to help other people to either gain knowledge or expertise so that they can do something that you would probably rather like to do yourself...I don't carry a caseload and I don't really want to do that because then one gets 91 buried. Participants also believed that i f nurses i n ANP did assume r e s p o n s i b i l i t y for d i r e c t c l i e n t care, i t would be counter-productive for nursing s t a f f . Participants were very sensitive to the potential of giving the impression that they were "better than" s t a f f . Instead they wanted to work, with s t a f f i n order to a s s i s t them to continue to learn and to recognize t h e i r own competencies i n solving c l i n i c a l scenarios: I think that you do get into trouble as an advanced practitioner if you take on client care. Then you exclude the nurses who would normally look after that client because they are not going to learn anything new if you are going to do it. And you also then give the message that I am better than you and I can do it. Thus, according to participants, since nurses i n ANP worked d i r e c t l y with s t a f f nurses and i n d i r e c t l y with c l i e n t s , any influence that nurses i n ANP had on CHO was of an i n d i r e c t nature. Participants recognized the benefits of being able to measure t h i s influence, even i n an associative manner, but thought t h i s to be d i f f i c u l t . Participants believed that nurses i n ANP had s t a f f nurses as a d i r e c t c l i n i c a l focus and worked with them to enhance CHO. Participants believed that nurses i n ANP made very informed decisions to remain involved i n c l i n i c a l p ractice. This involvement was highly valued and participants found meaning and challenge working with s t a f f nurses and c l i e n t s . If t h i s was ever seriously threatened, participants thought they would resign from t h e i r agency. 92 Participants thought that, although the temptation was strong, i t was inappropriate for nurses i n ANP to assume r e s p o n s i b i l i t y for d i r e c t c l i e n t care. They believed t h i s to be contradictory to the very essence of ANP as well as not being c o s t - e f f e c t i v e . In addition, participants expressed s e n s i t i v i t y about s t a f f nurses, i n that i t was important they continue to learn and recognize t h e i r own competencies to solve c l i n i c a l scenarios. A s s i s t i v e Care Delivery Closely aligned with the i n d i r e c t c l i n i c a l focus, participants believed that nurses i n ANP had a primary r e s p o n s i b i l i t y to be of assistance to "others" i n care delivery. A s s i s t i v e care delivery represented the t h i r d e ssential q u a l i t y of ANP. "Others" primarily referred to st a f f nurses but participants also spoke of a s s i s t i n g i n t e r d i s c i p l i n a r y professionals, as well as working with c l i e n t s and f a m i l i e s / s i g n i f i c a n t others i n order to enhance CHO. Participants believed t h i s a s s i s t i v e role to be c r u c i a l for ANP and thus c l i e n t care, as well as advancement of nursing and o v e r a l l health care. Participants gained a great deal of personal and professional s a t i s f a c t i o n by way of a s s i s t i n g others to d e l i v e r care: To me there is a lot of personal satisfaction seeing that staff nurses or even a physician, but anyone else that asks for my assistance in a difficult situation. They are not sure on how to progress. And then you come in and help the whole situation and then step out and let them take over. To me that is more of what I want to do. That is advanced nursing practice. 93 Participants c i t e d indepth use of consultation and education as strategies to a s s i s t care delivery. The following account r e f l e c t s p a rticipant descriptions of ANP v i a the a s s i s t i v e care delivery perspective. As i s i l l u s t r a t e d i n the account, participants described being able to r e l a t e to and validate both c l i e n t and s t a f f experiences, being able to a s s i s t them to take action and to f e e l p o s i t i v e about t h e i r decisions and to use a p a r t i c u l a r experience as an opportunity to increase s t a f f competencies. Participants strongly believed i n the "use of s e l f " with others rather than demonstrating advanced c l i n i c a l expertise: When staff or clients have an experience that I am somehow able to relate to it, that I am able to validate it, help them what to do next, help them with their reactions, help them feel good about themselves and where they are at, to help them to grow. That to me is advanced practice, what I am trying to give to people to work with. I see it as a giving up of myself much more than a giving out of some sort of expertise. By way of a s s i s t i v e care delivery, participants were p a r t i c u l a r l y intrigued and challenged by complex c l i n i c a l practice scenarios. They believed nurses i n ANP were predominantly involved i n those scenarios. The following account i l l u s t r a t e s how participants thought nurses i n ANP, using Joy Calkin's model as a reference, targeted complex, r e a l l y unusual c l i n i c a l scenarios and were able to be a s s i s t i v e to others to solve these: Advanced Nursing Practice is working with people on the extreme ends of the curve. People who experience the unusual problems,, both in terms of health and in terms of deficits. And that is where I see the differentiation in advanced practice. Advanced practice 94 to me is essentially that the scope of client situations, in whatever the target population is, whatever the person with advanced practice has chosen to specialize in, that population group that the advanced practitioner can work with is in fact much greater. It goes right across the whole spectrum, for instance all the populations. Participants believed that nurses i n ANP, through being involved i n an a s s i s t i v e care delivery, u t i l i z e d many strategies related to empowerment of s t a f f . They also believed that these strategies needed to be so e f f e c t i v e that often s t a f f nurses.would not remember who i n i t i a t e d an idea. Participants thought t h i s was a true r e f l e c t i o n of r e a l l y e f f e c t i v e empowerment. They thought that nurses i n ANP "started things," "planted seeds," " i n i t i a t e d programs" and by t h e i r a s s i s t i v e care delivery could get the s t a f f to the point where they owned the ideas and/or programs: The nurses don't attribute it or very seldom do they attribute an idea back to how it all got started. You can help the nurses look at care delivery. I have had some come to me and say on one unit, they would like to look at their care delivery system. They are thinking that it is not very effective, the way they are doing it. I like to think I had planted some seeds. Usually you go back in the area six or eight months later and there is a whole different perspective the staff have. They see that the client outcomes have been enhanced and they see eventually that their workload may have decreased because of these changes. Unfortunately, they often don't recognize that it is because of something that you have pushed. Participants were so committed to improving and/or enhancing s t a f f competencies that they aimed towards working themselves out of a job: I t i s g e t t i n g better and better as time goes on. Now I 95 see staff have worked part way through it and need a l i t t l e bit of help to get the rest of the way through it....In fact, I would be very happy to work myself out of a job because that would mean the staff have learned enough to do all that is needed for care. I guess the best thing for us to do is in a sense to assist people to take on what it is that we start out doing....In a sense it is working yourself out of a job but there is always enough to do. However, at the same time, p a r t i c u l a r l y i f participants had spent a great deal of time and e f f o r t on a complex c l i n i c a l scenario, they occasionally had some personal challenges associated with not being given c r e d i t for i t . These reactions were b r i e f and participants were able to overcome t h e i r personal feelings and obtain s a t i s f a c t i o n about the ov e r a l l improvement i n c l i e n t care and outcomes: I t is pretty rough sometimes. I say you have to develop a thick skin....I just keep focusing on the client and take my pats on the back from knowing that client outcomes are going to improve....I get my strokes from seeing the staff recognize that client outcomes have changed for the better. When working with others, participants believed that nurses i n ANP also wanted to educate and empower c l i e n t s at the same time as other health care providers. They described learning scenarios where education was aimed at both nurses and c l i e n t s . The goal was that both nurses and c l i e n t s a c t i o n s / a c t i v i t i e s changed not only during that p a r t i c u l a r scenario but they would be able "to r e c a l l " the learning and use i t e f f e c t i v e l y the next time. Participants consistently aimed at an increased l e v e l of knowledge, decision making and actions related to care for both s t a f f and c l i e n t s : 96 If the nurses learn, clicks will go off in their head the next time. That client will have seen it happen...and clients will question next time and they will have a better experience the next time. Thus, according to participants, nurses- i n ANP were a s s i s t i v e to s t a f f nurses, i n t e r d i s c i p l i n a r y professionals, c l i e n t s and f a m i l i e s / s i g n i f i c a n t others by way of care delivery. Participants extensively u t i l i z e d consultation and education as strategies for t h i s approach. They thought that nurses i n ANP were p a r t i c u l a r l y intrigued, challenged and s a t i s f i e d by complex c l i n i c a l scenarios that they were able to solve. Participants also believed that the empowerment of s t a f f was c r u c i a l even to the point of willingness to work themselves out of their, jobs. This empowerment was r e f l e c t e d by the fact that although nurses i n ANP may have i n i t i a t e d an idea/program, they were f u l l y able to allow other nurses to assume ownership of these. Often t h i s resulted i n s t a f f not remembering that the nurse i n ANP i n i t i a t e d these ideas/actions but participants were s a t i s f i e d with obvious improvement i n c l i e n t care and outcomes. Participants also believed i n education and empowering c l i e n t s while working with nurses aiming for the o v e r a l l goal of an increased l e v e l of care for both s t a f f and c l i e n t s . E f f e c t i v e Leadership Participants believed that nurses i n ANP provided a high l e v e l of e f f e c t i v e leadership. E f f e c t i v e leadership represented the fourth essential q u a l i t y of ANP. 97 Participants believed that nurses i n ANP had c r e d i b i l i t y , r e s p o n s i b i l i t y and authority to shape c l i n i c a l p ractice. Participants valued the contribution that they made to t h e i r agencies. The following account r e f l e c t s p a r ticipant b e l i e f s that nurses i n ANP were on the "cutting edge" of c l i n i c a l nursing practice: I think we are the cutting edge of the practice discipline and I think we are the clinical conscience of the organization... I think that is the greatest contribution that we make. Participants believed there were leadership t r a i t s inherent i n ANP. These included providing d i r e c t i o n and role modelling to s t a f f that were based on nurses i n ANP having an indepth, r i c h competency base: We are in a leadership role. We provide direction to bedside nurses and we do that because we have that knowledge base and practice base as well. The CNS role is a leadership role mainly and therefore we are able to provide some modelling and some direction to nurses. Other leadership t r a i t s were being high achievers who strove for excellence i n c l i n i c a l practice and thus c l i e n t care, educators who s i g n i f i c a n t l y wanted to p o s i t i v e l y influence health care, a b i t p e r f e c t i o n i s t i c and not wanting to maintain the status quo: I think we are people who are either high achievers or striving to be high achievers, who are wanting the best for client care. We want to teach, want to share, feel like if we weren't in that role or a role that is a teaching kind of role then we wouldn't be influencing health care enough...a l i t t l e bit perfectionistic... not too crazy about the status quo. Other leadership t r a i t s were being interested i n r a d i c a l , 98 although appropriate change, demonstrated i n i t i a t i v e and c r e a t i v i t y , as well as possessing a high tolerance for c o n f l i c t : CNSs have opinions, they are well read, they speak for nursing, they are interested in change but not for change sake. They resent being boxed in or being told what to do. They tend to be creative.... They are self starters and have initiative and a high tolerance for conflict. Another t r a i t was advanced group f a c i l i t a t i o n s k i l l s used to address problem solving and/or learning s i t u a t i o n s : Being able to facilitate groups of people in problem solving or learning situations. You need to be able to collect information systematically and do something with it so you can show people and say hey we've got a problem here and it is not just what I think, look here is the data. Other t r a i t s included being change agents, r i s k takers and extremely dedicated to nursing. For participants, there was a fine l i n e from being dedicated to nursing to being consumed by nursing: CNSs are change agents because that is a big part of the role. To be that you have to be a risk taker and CNSs are often pretty excited and dedicated about the kind of nursing they do, maybe to a fault....That is a quality that I see in Clinical Nurse Specialists. They become swallowed up by nursing. Related to dedication, participants believed that nurses i n ANP were " r e a l l y hard workers." Participants thought that nurses i n ANP put a great deal of time i n over and above t h e i r regularly scheduled s h i f t s : Most CNSs have already caught fire, you know, they have the burning desire to be really hard workers and other kinds of things, you know, they don't want to go home until the work is done, a lot of work on their own time. 99 Related to e f f e c t i v e leadership, participants recognized that nurses i n ANP needed to work closely, i n a complementary manner, with senior nursing administration. This resultant partnership was seen as c r i t i c a l for e f f e c t i v e and thorough ANP: Most of the senior administrative personnel in nursing right now see very much a complimentary thing between themselves and...the CNSs. We oversee practice, practice issues, issues in clinical practice, you name it but practice, practice, practice. They see us as the practice people, them as the management people and obviously the twain does meet. The role should be lending the clinical voice, practising the clinical perspective and relating that to administration. Participants also believed that nurses i n ANP needed strong administrative support. They thought that i f nurses i n ANP did not have t h i s support many of t h e i r e f f o r t s would be i n vain: There is organizational management support for the role. That is incredibly important. Thus, according to participants, nurses i n ANP provided a high l e v e l of e f f e c t i v e leadership. Participants believed there were many leadership t r a i t s inherent i n ANP which included providing d i r e c t i o n and role modelling based on an advanced competency base. Participants thought nurses i n ANP were high achievers who constantly strove for excellence i n c l i n i c a l practice and c l i e n t care. They also saw ANP as inc l u s i v e of education aimed at p o s i t i v e l y influencing health care. Participants thought nurses i n ANP were p e r f e c t i o n i s t s who were interested i n r a d i c a l but appropriate change, had 100 demonstrated i n i t i a t i v e and c r e a t i v i t y as well as possessing a high tolerance for c o n f l i c t . Other leadership t r a i t s included advanced group f a c i l i t a t i o n s k i l l s , change agents, r i s k takers and extremely dedicated to nursing. Participants believed that nurses i n ANP were hard workers who put i n very long hours. F i n a l l y , participants thought that for the successful continuation and effectiveness of ANP, nurses i n ANP needed to have complementary relationships with, as well as strong support from senior nursing administration. I n t e r d i s c i p l i n a r y Collaboration A l l participants had developed strong, highly valued i n t e r d i s c i p l i n a r y collaborative relationships and c l e a r l y recognized the merits of other members of the health care team. I n t e r d i s c i p l i n a r y collaboration represented the f i f t h e s s ential q u a l i t y of ANP. Participants a r t i c u l a t e d the very s i g n i f i c a n t contribution that nurses made to c l i e n t care but seriously questioned a d i s c i p l i n e s p e c i f i c approach. They recognized that " d i s c i p l i n e s p e c i f i c " and " i n t e r d i s c i p l i n a r y practice" were issues of concern and debate for many health care providers. Providers were thought to be concerned about "unique" aspects of t h e i r d i s c i p l i n e ' s practice and wanting to "protect t u r f . " However, participants believed that as a re s u l t , health care was often d i s j o i n t e d which resulted i n gaps, fragmentation and duplication p a r t i c u l a r l y from the c l i e n t ' s perspective. Participants believed that they had much to o f f e r 101 c l i n i c a l practice and c l i e n t care from a nursing perspective, but that nursing was usually not a l l that was required. Participants valued approaching c l i e n t care scenarios not from a singular nursing perspective, but instead from the context of i n t e r d i s c i p l i n a r y collaboration and practice. Participants recognized that when care was approached by s p e c i f i c d i s c i p l i n e s , often decisions were made i n i s o l a t i o n . Instead, participants thought that nurses i n ANP approached c l i e n t care recognizing that other d i s c i p l i n e s had much to of f e r : The fact that I am working within a multidisciplinary setting means that I don't run around saying oh well we will just do this and just do that. Participants strongly believed that i n order to enhance c l i e n t care, a l l nurses needed to practice more clos e l y and co l l a b o r a t i v e l y with other d i s c i p l i n e s . Although recognizing that s t a f f nurses worked with other health care providers, participants thought s t a f f nurses did not routinely collaborate with other d i s c i p l i n e s , nor f e e l comfortable doing so. Participants believed that one contributing factor was that the majority of nurses were educated i n non-university settings, therefore were not as a r t i c u l a t e about, nor aware that they could benefit from, and thus value i n t e r d i s c i p l i n a r y collaboration; The other disciplines are often more articulate and they have been educated at university, everyone except nurses. I think that nurses, at least many of them, have never had that experience. They don't know that they could value interdisciplinary collaboration. 102 Participants believed that t h e i r acceptance of, consultation with, and collaborative relationships with other d i s c i p l i n e s was quite unique to ANP, as compared to other nurses. Participants thought nurses i n ANP were more aware and able to a c t i v e l y p a r t i c i p a t e i n collaborative practice and research, as well as recognize that no one health care provider could "do i t alone:" An advanced practice nurse works differently with other disciplines. I think there is more of an awareness, more operationalization of the interdisciplinary collaborative practice, collaborative research, of knowing you can not do it alone. Participants described a d i f f e r e n t "degree" or "matter of knowledge" related to i n t e r d i s c i p l i n a r y collaboration when comparing nurses i n ANP with s t a f f nurses. Participants believed that a major function of nurses i n ANP was to be the l i n k between s t a f f nurses and other d i s c i p l i n e s i n order to enhance c l i e n t care. They recognized that both s t a f f nurses and nurses i n ANP sought resources needed for c l i e n t care, however these resources might be d i f f e r e n t based on levels of expertise. Participants believed that nurses i n ANP had a higher l e v e l of expertise to draw from compared to s t a f f nurses. Participants expressed hopes that s t a f f nurses would be able to recognize t h e i r own l i m i t a t i o n s and c a l l i n nurses i n ANP when they reached t h e i r personal l i m i t s : I think that it might be a matter of degree or it might be a matter of knowledge as to when to involve other disciplines.... I think nursing staff might not get involved to the same level. It might be all part of the degree. I would hope that nursing staff are seeking the resources they need for client care, and I hope I would 103 seek the resources I need for client care. Now the resources might be different based on our level of expertise but I hope we both recognize our limitations and hope we both recognize that we can help. My knowledge in some of the resources in especially my particular area are probably greater, so I can maybe call on some resources that the staff nurse may not and hopefully they will recognize that is when they call me in, when they see something is required. Participants believed that nurses i n ANP had a clear understanding of when to involve other d i s c i p l i n e s and a freedom to then approach and communicate with them: In my role there are no bounds to basically who I can communicate with. I like working with other disciplines. I know spatterings of all the different areas to help my group of clients but there is lots of expertise that I don't have. But I do know when to get it and that is important. Participants believed that t h e i r education, demonstrated and recognized c l i n i c a l expertise, confidence, a b i l i t y to a r t i c u l a t e and t h e i r t i t l e gave them additional c r e d i b i l i t y and legitimate access to and acceptance from other d i s c i p l i n e s . This c r e d i b i l i t y , access and acceptance was thought to be enhanced by the fact that nurses i n ANP usually had a broader competency base than so l e l y from nursing. This base came from formal and informal education with and from other d i s c i p l i n e s . This was thought to be a s s i s t i v e i n appropriate consultation and prevention of turf issues between d i s c i p l i n e s : Our knowledge is not just strictly nursing knowledge. It draws from sociology, psychology or medicine or whatever but I feel strongly about that. I think nurses perhaps undervalue the other disciplines but...in advanced practice, you begin to really understand their 104 expertise and know when to bring them in and what they offer and not have territorial issues. Participants believed that they routinely used t h e i r strong nursing competency base, along with information and resources from other d i s c i p l i n e s to enhance c l i e n t care through a s s i s t i v e care delivery: I draw on a lot of information and resources from other disciplines to focus on the client and I also use my nursing knowledge and expertise to enhance the nursing care of that client either through me directly or indirectly from or via the nursing staff. Participants believed that t r a d i t i o n a l l y nurses had assumed a subservient role with other health care team members, p a r t i c u l a r l y physicians. However, they thought that nurses i n ANP were partners on equal footing with a l l health providers: Nurses in Advanced Nursing Practice are valued partners with other members of the health care team. I mean you just have to look at the number of referrals that we get from physicians. It is good, the consulting back and forth. Thus, according to participants, nurses i n ANP developed strong and highly valued i n t e r d i s c i p l i n a r y collaborative relationships. Participants believed that although nurses i n ANP c l e a r l y recognized the s i g n i f i c a n t contribution that nurses make to c l i e n t care, c l i n i c a l issues could not be f u l l y met with d i s c i p l i n e s p e c i f i c approaches. To do so was thought to r e s u l t i n gaps, fragmentation and duplication p a r t i c u l a r l y from c l i e n t perspectives. Participants recognized that a l l nurses engaged i n practice with other d i s c i p l i n e s . However they believed that s t a f f nurses did not 105 f e e l comfortable i n routine collaboration with other d i s c i p l i n e s . Participants explained t h i s due to non-university education of most nurses who were thus not a r t i c u l a t e about, nor aware of the benefits of i n t e r d i s c i p l i n a r y collaboration. Participants thought there was a d i f f e r e n t degree or matter of knowledge between nurses i n ANP and s t a f f nurses related to i n t e r d i s c i p l i n a r y collaboration. Participants saw a role for nurses i n ANP to be the linkage between s t a f f nurses and other d i s c i p l i n e s for the o v e r a l l enhancement of c l i e n t care. They recognized that nurses i n ANP had a clear understanding and freedom of when to involve other d i s c i p l i n e s . Participants i d e n t i f i e d t h e i r c r e d i b i l i t y , legitimate access and acceptance from other d i s c i p l i n e s as factors related to t h e i r l e v e l of i n t e r d i s c i p l i n a r y collaboration. F i n a l l y , they believed that nurses i n ANP were on "equal footing" with a l l health care providers, including physicians. In summary, ANP was believed by participants to be a term that could be described. This description had as a basis or foundation what has been categorized as the minimal requirement t r i a d of ANP. The f i r s t element of t h i s t r i a d was graduate education. During t h i s education, participants believed that nurses were exposed to many important areas that resulted i n the competencies required for ANP. Participants struggled with whether graduate education should 106 be i n nursing and i f the education was i n another fa c u l t y how did that contribute to ANP. The second element of the minimal requirement t r i a d of ANP was thought to be a c l i n i c a l specialty focus. According to participants, t h i s focus needed to be combined with graduate education. A l l participants recognized themselves as "expert" nurses i n t h e i r c l i n i c a l area p r i o r to graduate education. They a l l believed that once they focused t h e i r studies with more indepth c l i n i c a l work, they graduated being able to practice at an advanced l e v e l . Strongly linked with the c l i n i c a l s p e c i a l i t y focus was the need for mentored practice and time for r e f l e c t i o n i n order to f u l l y develop as a nurse i n ANP. Participants described additional competencies that were acquired during graduate education linked with a c l i n i c a l s p e c i a l i t y focus. These competencies were believed by participants to enable nurses i n ANP to be able to be proactive rather than reactive i n a l l areas of practice. The t h i r d element of the minimal requirement t r i a d of ANP was thought to be research-based practice which was believed to be thinking about, p a r t i c i p a t i n g i n and u t i l i z a t i o n of research. Participants believed that nurses i n ANP worked hard at t r y i n g to have practice based on research. Toward that end, participants were active partners i n the conduct of research but believed that the p r i n c i p a l investigator role could not be assumed by the master's 107 prepared nurse. They believed that t r u l y d e f i n i t i v e research involved a partnership between a nurse i n ANP and a doctorally prepared nurse. The f i v e i d e n t i f i e d e ssential q u a l i t i e s of ANP were believed by participants to b u i l d on what has been categorized as the minimal requirement t r i a d of ANP. Participants believed that nurses i n ANP began development of these q u a l i t i e s while involved i n the t r i a d . In other words, while these nurses were attending graduate school, focusing on a c l i n i c a l s p e c i a l i t y and learning competencies related to research-based practice they were developing the essential q u a l i t i e s of ANP. These essential q u a l i t i e s were thought by participants to include an indepth a b i l i t y to think globally, an i n d i r e c t c l i n i c a l focus on c l i e n t s , a d i r e c t c l i n i c a l focus on s t a f f nurses, providing a high l e v e l of e f f e c t i v e leadership and f i n a l l y strong and highly valued i n t e r d i s c i p l i n a r y collaborative relationships. Possible Relationship Between Advanced Nursing Practice and C l i e n t Health Outcomes It was not easy for participants to c l e a r l y describe t h e i r practice i n r e l a t i o n to CHO. As they had a r t i c u l a t e d , nurses i n ANP had c l i e n t s as t h e i r i n d i r e c t c l i n i c a l focus, whereas s t a f f nurses were t h e i r d i r e c t c l i n i c a l focus. Since c l i e n t s were an i n d i r e c t focus, participants recognized the d i f f i c u l t i e s i n describing t h e i r practice, as representatives of ANP, i n r e l a t i o n to CHO. They thought that nurses i n ANP 108 were more the "conduit," i n that CHO came through them but not necessarily from them independently: In advanced nursing practice and in the preparation for that you are the conduit in a sense so the client outcomes come through you but not necessarily from you independently. Participants again r e i t e r a t e d that t r y i n g to make a linkage between ANP and CHO was "new" and "foreign." They believed that nurses i n ANP were just beginning to examine t h e i r input or contribution to CHO: I think we are just learning to recognize what we, how we contribute to outcomes. I think deep down we thought we have, but I don't think we have really empirically looked at relating our input or our contribution and what effect it has on outcomes. It is just fairly new. Once participants began to describe t h e i r practice i n r e l a t i o n to CHO, they described problems i n t r y i n g to a r t i c u l a t e CHO. They i d e n t i f i e d ways i n which nurses communicated the relat i o n s h i p between ANP and CHO, as well as th e o r e t i c a l problems i n t r y i n g to do so. Problems i n A r t i c u l a t i n g C l i e n t Health Outcomes Although participants knew that the researcher was interested i n learning about t h e i r practice i n r e l a t i o n to CHO, i n i t i a l l y participants focused on CHO as a term that required further discussion. They believed that CHO were a more recent area of intere s t than was ANP. They thought that CHO meant d i f f e r e n t things to d i f f e r e n t populations, including nurses i n ANP. Participants believed that CHO were d i f f i c u l t to define yet recognized that p o t e n t i a l l y many d e f i n i t i o n s were possible. They believed that there were 109 varying perceptions about CHO and there was d i f f i c u l t y i n t r y i n g to get agreement among interested p a r t i e s : I t i s good to raise this. We need to be looking at outcomes but what outcomes do we expect and who has done any research?... And so I think the whole world has just begun to really zero in on outcomes and start asking okay what does outcome mean to which population? What does it mean to CNSs? I guess there are a thousand definitions. It is very, very difficult to define. I think that at this point in time, there are so many perceptions out there as to what it is that it is pretty hard to get agreement. Participants discussed t h e i r interpretations of CHO as not being clear cut but rather open to many interpretations and influenced by values such as "healthy," "negative," "positive," "successful," "curative," "intended," "unintended" and "end results of interventions." They thought that i n nursing, i t was "only nurses i n ANP, researchers and academics" that were just beginning, and were therefore inexperienced, i n t r y i n g to explain a r e l a t i o n s h i p of nursing practice, l e t alone ANP, to CHO: I don't think that we as nursing practitioners have really looked at linking our practice to outcomes first of all so I think that very few of us have experience in it. I definitely think some of us are starting to look at outcomes more than others. I don't think the staff nurse at all looks at outcomes by and large. They look at surviving their day and finding the energy in getting through the day. But I think we, we are starting to look at outcomes and I think it is a new area for us. Participants thought that one reason for the lack of c l a r i t y around CHO was that they had not been a p r i o r i t y for nursing, p o l i c y makers or government up u n t i l recently. Participants 110 recognized that there was not s o l i d evidence that nurses had any d i r e c t e f f e c t on CHO: I t hasn't been a priority for nursing. It hasn't been a priority for government. There hasn't been much work done in that area so I can't say that nursing has an effect on long term outcomes that are specifically attributable to nursing. Participants believed that i t was important that c l i e n t s be involved i n looking at or measuring CHO. They thought that part of the d i f f i c u l t y i n a r t i c u l a t i n g CHO was that there had been very l i t t l e involvement of c l i e n t s i n determining or measuring CHO. Participants thought that health care had been t r a d i t i o n a l l y provider focused and that nurses and others had been tempted to define CHO. However, participants believed that a l l c l i e n t s were d i f f e r e n t and had very d i f f e r e n t expectations from and with the health care system, l e t alone s p e c i f i c d i s c i p l i n e s that may have been involved i n t h e i r care. Participants believed that c l i e n t s had the ri g h t to set goals or outcomes when i n t e r a c t i n g with health care providers as well as be involved i n the measurement of t h i s . It was however, a r e s p o n s i b i l i t y of the health care providers to ensure that c l i e n t s had s u f f i c i e n t information i n order to make decisions around t h e i r care: You're looking at client health outcomes from whose perspective? Our perspective or from the clients'? I tend to go with what a client would see as a health outcome as I don't necessarily think that my definition of a health outcome for a specific client has anything to do with that client. They are the ones that know what they want their health status to be and if they feel good, bad or in between. I believe really strongly that the person can define the I l l health outcomes for themselves. But I believe then the obligation is to give them the information to make decisions. I don't know if I am doing that well. But I think that ideally that is what health outcomes are. Thus, according to participants, CHO were thought to be a terra that was not well understood and therefore open to a variety of d e f i n i t i o n s and interpretations that could be influenced by values. They believed that nurses i n ANP, researchers and academics were the only nurses t r y i n g to make a l i n k between ANP and CHO. Up u n t i l the time of the research, participants thought that i n t e r e s t i n CHO had not been a p r i o r i t y for nursing, p o l i c y makers and/or government. F i n a l l y , participants believed that c l i e n t non-involvement i n looking at or measuring CHO was a factor related to problems in a r t i c u l a t i n g what they were. Communicating the Relationship Between Advanced Nursing Practice and C l i e n t Health Outcomes While participants were describing t h e i r practice i n r e l a t i o n to CHO, they spoke of t h e i r influence on CHO through the use of detailed c l i n i c a l s t o r i e s . They thought that nurses i n ANP influenced CHO from an i n d i r e c t and broad system perspective. Detailed C l i n i c a l Stories Throughout interviews, a l l participants frequently u t i l i z e d detailed c l i n i c a l stories as an inherent part of t h e i r discussions. These c l i n i c a l stories were used most while participants were attempting to describe t h e i r practice i n r e l a t i o n to CHO. The c l i n i c a l stories were descriptions 112 of how nurses i n ANP, through use of what had been categorized as essential q u a l i t i e s , influenced or impacted CHO. The following accounts are examples of these c l i n i c a l s t o r i e s . The f i r s t i l l u s t r a t e s p a r ticipant introduction of a controversial program where improvement i n CHO resulted: I have been working on a framework of care for a certain client group and it is extremely controversial. It really hits the heart of a lot of beliefs and attitudes that nursing and medical staff have. It goes directly against their grain. It is pain management in the chemically dependent client and includes a framework of care to recognize that you can't rescue or save that person from their addiction. Only they can do it and your focus should be on the pain management and comfort and the prevention of withdrawal. So in other words, you basically supply this person with a lot of drugs to satisfy their habit and their pain management. A lot of people have difficulty with that. But what is quite rewarding is that once staff have a few patients where this framework is implemented and they see the results it is like night and day. It has been very interesting because recently a number of staff have come to me and said that they just can't believe the decreased stress that they have surrounding working with those clients and seeing the difference in client outcomes. There are a lot less abusive interactions between the client and the nursing staff. The clients are out of here earlier and they appear to recover faster. The nurses are letting go of their guilt about not being able to cure the person of their addiction. They realize that they are not contributing towards the addiction and realize that they don't have to help them with the addiction. So that kind of framework and I mean it is modelling in some respects but it is also research utilization and also client advocacy. But really, I have really fought culture on that one and people are starting to see the results and people, nursing staff in particular, really see the value or see the effect on client outcomes that a CNS has. The second account refers to the general participant recognition of t h e i r ongoing influence with s t a f f to enhance CHO: The use of self is my philosophical underpinning of my 113 practice. You learn about the use of self with individuals and then as you develop you learn how to use yourself with groups of nurses as well. I know that the reason the Dementia Care Unit, not the only reason, but the fact that unit is a success and is maintained one year later as a thriving success, had to do with the relationship I have with the nursing staff. The encouragement that I give them as individuals and as groups that they are on the right track, they are doing the right thing, finding ways to celebrate the beauty of their work in making the end of l i f e with Alzheimer's disease good were important. Although the above accounts are f a i r l y broad i n nature and refer to c l i e n t groups, participants also described many other c l i e n t - s p e c i f i c d e tailed c l i n i c a l stories that consistently r e f l e c t e d t h e i r a c t i v i t i e s with s t a f f to enhance CHO. The following account i l l u s t r a t e s t h i s : We have a lady who is a long standing schizophrenic who is also diabetic and has multi-system problems. She developed severe gangrene on her feet. Of course, we did treat some of the gangrene but meanwhile there were some side effects. The gangrene on top of the diabetes and she developed septicemia and had refused for a long time any of her schizophrenic medications. The bottom line of it is that the Clinical Teacher tried to help the nurses with the skin care. I got involved because she was refusing any treatment on the foot or the leg, refusing to let them dress it at all, refusing to let them do anything, refusing to have surgery. The question is was she competent or not competent to make those decisions? I got involved in helping the staff make it through that one. Participants believed that use of detailed c l i n i c a l s tories was a routine and valued component of ANP. They seemed proud and confident about t h e i r a b i l i t y to make the stories meaningful. Participants were c l e a r l y able to a r t i c u l a t e why nurses i n ANP extensively used c l i n i c a l s tories throughout t h e i r practice, p a r t i c u l a r l y for education of a l l levels of health care providers and public. In 114 keeping with t h e i r focus on c l i n i c a l practice, they claimed that detailed c l i n i c a l stories were the embodiment of t h e i r r o l e : That i s the way the role has been historically enacted. I think that many CNSs feel that is the embodiment of their role. I think it is a natural learning....One of the reasons that we have clinical in front of our names is that it should be our focus. We represent the clinical area. Participants believed that detailed c l i n i c a l stories were useful as they r e f l e c t e d how nurses i n ANP thought, learned and mentored: That is exactly what the nature of our practice is....The only way I know how to talk about it is through clinical examples. Those are the things that make it real for me. I might make a generalization but then I will give you the stories to say well this is what it looks like. Because that is the very nature of the practice. I mean we tell paradigm cases, that is how we think, that is how we learn, that is how we mentor. Participants believed that s t a f f e a s i l y understood d e t a i l e d c l i n i c a l stories that were relevant and meaningful. Therefore, nurses i n ANP found the stories to be very useful i n education and practice to enhance CHO: A sign of advanced nursing practice is being able to explain to people with a clinical example that they can fully understand. Logically speaking, you can help people understand what you are talking about a lot easier if you give them, and maybe that is a sign of advanced practice too, if you give them something to work with, something that they can understand. Thus, according to participants, the use of det a i l e d c l i n i c a l stories was a way that nurses i n ANP described t h e i r practice i n r e l a t i o n to CHO. These c l i n i c a l s t o r i e s were c l i e n t and program focused and r e f l e c t e d what was thought to 115 be a routine and valued component of ANP. Participants saw the routine use of these detailed c l i n i c a l stories as the embodiment of ANP. They found them to be p a r t i c u l a r l y useful and meaningful when working with s t a f f to enhance CHO. Broad System Perspective Participants also described t h e i r practice i n r e l a t i o n to CHO from a broad system perspective. Through t h i s description, they provided s p e c i f i c examples that they believed were r e f l e c t i v e of nurses i n ANP p o s i t i v e l y influencing CHO. They explained t h e i r influence on CHO as a r e s u l t of global thinking that related to c l i n i c a l practice both i n t e r n a l and external to t h e i r employing agency. They believed that nurses i n ANP influenced CHO by way of t h e i r involvement i n programs that r e f l e c t e d a faster turnover of c l i e n t s therefore decreased wait l i s t s , c l i e n t s were discharged with an improved health status, and admissions and bed u t i l i z a t i o n were more appropriate: Well I can demonstrate to you, in a number of cases that my involvement has resulted in faster turnover of clients through here so there are decreased wait l i s t s for one thing. I can demonstrate very clearly and specifically that my interventions have caused people to be turned away from our doors. In other words, their care would be best met somewhere else than in an acute care setting so in terms of bed utilization, more appropriate bed utilization. I can fairly clearly demonstrate by some of the programs that I have been involved in, that I have coordinated or had probably the most significant input in. Those clients are out of here sooner, they are out of here healthier. They are not receiving some of the care that was inappropriately given to them before I was here. Participants believed that nurses i n ANP developed and 116 d i s t r i b u t e d innovative programs that assisted i n the advancement of nursing and i n t e r d i s c i p l i n a r y practice: You can measure the effectiveness not only fiscally but in terms of client outcomes and staff outcomes and public relations. In terms of the programs that we have developed here, some of them have become well known in the province and sometimes in the country. And sure they haven't been big money makers but they have advanced nursing practice and interdisciplinary practice in care of the elderly. Well that is big payoffs. You know that the bedside nurses could never have done that. Participants were confident that ANP p o s i t i v e l y influenced CHO i n both the s p e c i f i c and general sense. They i d e n t i f i e d themselves as being the "common thread or person" who influenced many agency broad system decisions. However, participants recognized that these influences were not hard indicators related to ANP: J think it is easy to demonstrate if you look at the various decisions that are made in an organization and identify the common person in all those decisions... that is the nurses in advanced nursing practice. But that is not a hard indicator. Participants thought that nurses i n ANP needed to be able to explain t h e i r practice i n r e l a t i o n to f i n a n c i a l issues around CHO. They thought that, due to current r e s t r a i n t s , i t was not enough to think about o v e r a l l improvements i n CHO without being able to demonstrate f i n a n c i a l savings: We are all increasingly looking at that, whether we are a CNS or not. How do we justify that we are here? It is really, really hard to quantify what you are doing....It is not enough to just be here, people need to know that you have helped to save perhaps this amount of money by your recommendations.... I try every day and it is not every day but the ideal is that I am sort of thinking about what I am doing, should I be doing it, is it, is it?...You won't be here anymore if you are not asking those questions. 117 Participants thought that to date, nurses i n ANP had not done well i n terms of proving t h e i r f i n a n c i a l worth v i a quantitative aspects of effectiveness related to CHO: I think that we haven't done really well in terms of proving our financial worth...in dollars and cents and unfortunately planners like quantitative aspects of effectiveness. However, participants believed that nurses i n ANP were far more responsible f i s c a l l y than were s t a f f nurses i n terms of operational management: Trying to make the most of the system which is what I think CNSs do. Trying to advance nursing, trying to advance the way in which we practice yet being fiscally responsible at the same time. You can't expect your bedside nurses, your people entrenched in client care, they are not going to do that. They are not going to analyze your system and find out that you are using too many drugs or you are calling in too many people or you know, making mistakes in time keeping or having too much sick time or whatever. Certainly management has some responsibility for that but Clinical Nurse Specialists can really assist in fiscal responsibility, in effective and efficient running of operations and that is where your best bang for your buck is. Thus, according to participants, ANP was linked with CHO from a broad system perspective. Participants were able to i l l u s t r a t e t h i s perspective through descriptions of t h e i r broad influences on care and CHO. , These same influences were thought to advance nursing as well as i n t e r d i s c i p l i n a r y practice. Participants saw nurses i n ANP as being the "common thread or person" that influenced many agency system decisions, however recognized that t h i s did not represent a hard indicator. Nurses i n ANP were thought to have not c l e a r l y demonstrated t h e i r effectiveness i n terms of f i s c a l 118 issues. However, participants believed that nurses i n ANP were f i s c a l l y responsible i n terms of operational management. Theoretical Problems i n Linking Advanced Nursing Practice With C l i e n t Health Outcomes Participants thought there were some t h e o r e t i c a l issues that explained t h e i r d i f f i c u l t i e s i n t r y i n g to describe t h e i r practice i n r e l a t i o n to CHO. These issues included the differences i n attempting to measure long term versus short term CHO and the strong influence of other variables. Long Term Versus Short Term Participants believed that there were major differences i n t r y i n g to examine and p o t e n t i a l l y measure the influence of ANP on long term versus short term CHO. They believed that short term CHO were easier to measure and done on a limited basis p a r t i c u l a r l y i n acute care settings: I would think i t is much easier for me to see client outcomes or demonstrate client outcomes in an acute care setting.... It i s easier to see the short term in an acute care setting. Participants gave examples of why short term CHO were easier to measure i n acute care settings. These were often related to s p e c i f i c interventions aimed at c l i n i c a l problems such as pain or wound management. They thought that since acute care c l i e n t s were generally quite i l l , r esults of interventions aimed at keeping them out of c r i s i s were easier to observe and measure: When I look at an outcome if I intervene with a client on a specific unit I can see that there is a better outcome say in terms of management of one of the 119 problems he or she is having whether it is pain or wound or whatever. So I can see an outcome there and that is great. People come in here generally because they are quite sick or require fairly significant interventions both from medicine and nursing. Their problems are so serious and even small interventions are often able to be demonstrated in terms of client outcomes.... Acute care interventions are basically to help the client over a crisis, through a crisis situation. Participants thought that nursing and medicine and other health care providers were not s k i l l e d at measuring long term CHO. Participants believed these to be the re a l indicators of health care provider involvement and/or effectiveness. Long term CHO described included coping strategies, improved health status and l i f e s t y l e changes. Participants recognized these measurements were unclear and d i f f i c u l t to i d e n t i f y and rate. They believed i t was because of these d i f f i c u l t i e s that long term CHO had not been a focus of attention: Long term outcomes I think are something that we haven't looked at that much in nursing and in medicine too....But if we look at really what our role is, it is to help the client cope, improve health status, l i f e style and I mean that is all based on long term outcomes. Are they clear and identifiable? I don't think so. That is probably part of the reason why we haven't focused on them because they might be so difficult to measure. Participants recognized that many long term CHO were associated with qua l i t y of l i f e issues and that some early e f f o r t s to address these were appearing i n the l i t e r a t u r e . Participants from g e r i a t r i c care environments were somewhat attuned to long term CHO and gave s p e c i f i c examples. These included aggressive c l i e n t behaviours, psychosocial 120 outcomes of adaptation to environment or chronic i l l n e s s , physical health outcomes such as skin break-down, i n f e c t i o n rates, management of constipation and peaceful deaths: In the long term care setting, I am very concerned about psychosocial outcomes of adaptation to the institutional environment or chronic illness care.... I am particularly-concerned about physical health outcomes like skin break-down, infection rates, management of constipation and the outcomes associated with that because that is such a big problem. The good deaths, I am very concerned about them too because 33 percent of our population die each year. Thus, according to participants, there were major differences i n t r y i n g to measure short term versus long term CHO. Short term CHO were thought to be easier to measure and done on a limited basis i n acute care settings. Long term CHO were thought to be the r e a l indicators of health care provider involvement with c l i e n t s , however were thought to be vague and d i f f i c u l t to measure. Participants recognized that some early e f f o r t s to address these issues were appearing i n the l i t e r a t u r e . Participants from g e r i a t r i c care environments seemed to focus more on what they described as long term CHO than did those from acute care. Strong Influence of Other Variables Participants recognized that many other variables influenced how nurses i n ANP could describe t h e i r practice i n r e l a t i o n to CHO. To begin with, participants questioned how any CHO could be d i r e c t l y and conclusively linked back to any s p e c i f i c d i s c i p l i n e , l e t alone nursing: If we want to get valid outcome measures, it is really hard to pull out what one person in a health care team 121 has done, to contribute to whatever outcomes the client has had and has experienced. Participants recognized that c l i e n t s were exposed to a multitude of health care providers. In addition, participants believed that c l i e n t s assumed varying le v e l s of r e s p o n s i b i l i t y related to personal education around t h e i r health concerns. Participants thought that t h i s c l i e n t education was also a factor related to CHO: Client health outcomes are just a neutral kind of thing that says whatever the outcome is of the interventions that any health professionals perform. And actually it doesn't even have to be health professionals, right? What about those clients that want to learn all they can about whatever it is that caused them to seek health care anyway? What about what they learn from friends and family let alone what they watch on television. Participants believed that many other variables influenced CHO and attempts to l i n k them back to nurses i n ANP p a r t i c u l a r l y i n the era of i n t e r d i s c i p l i n a r y collaboration would be problematic: If it is a true multidisciplinary approach and people are really, really administering care together with the client...it is harder to pull out what one person does....I think we are going to continue to struggle, even though we can focus on what we might call nursing outcomes or medical outcomes or occupational outcomes or social work outcomes. It is pretty blurry and I think we have a long way to go yet. The following account r e f l e c t s p a r ticipant e f f o r t s to i l l u s t r a t e what they viewed as f u t i l i t y i n t r y i n g to d i r e c t l y describe ANP i n r e l a t i o n to CHO: Unless you are in a situation where you are all by yourself with no other support systems, with nothing else going on and you are doing a laying on of hands and looking after this client in complete and total isolation. How would you know and I guess that is a 122 subject for researchers. How would you know that whatever outcome this client had was related to your intervention? And even at that, so you did do the laying on of hands and you did do a lot with this client, again how would you know that what you did wasn't related to some change in this client or something this client did as opposed to all your good intentions. The next account was a summary of a c l i n i c a l program that was thought to have demonstrated p o s i t i v e CHO, however again the participant c l e a r l y questioned how these could be linked back to her: If there are good clinical outcomes, positive clinical outcomes, how would you relate those to me as opposed to the Clinical Teacher who set up the education plan or one of the staff members that we took out of the rotation so that she could work on it and conduct education. I was involved in all that stuff, very much involved as a mentor...I took a leadership role in the development in that but how would you relate the positive outcomes to me? with much difficulty! On the other hand, participants thought i t s u f f i c i e n t to be able to describe the i n d i r e c t r e l a t i o n s h i p of t h e i r practice on CHO. They found i t useful to d i f f e r e n t i a t e how nurses i n ANP influenced CHO as compared to nurses at the bedside. They thought nurses, i n ANP influenced CHO for populations of c l i e n t s and s t a f f from a broad perspective: I think that ANP is really toward influencing in a number of arenas. So that it is much different from bedside nursing where really what you are influencing is the health outcome of the client you are looking after that day....We are influencing health outcomes for a population of clients and health outcomes for staff. They described t h i s perspective as "having a v i s i o n " and taking the time to develop i t with s i g n i f i c a n t input from i n t e r d i s c i p l i n a r y health care providers as well as c l i e n t s 123 and what they referred to as the appropriate "resource people." The participants described t h i s a b i l i t y to put a v i s i o n into action very rewarding: Clinical Nurse Specialists can have the vision and then they can actually take the time to develop that vision with the resource people they need....It is a vision that comes through the staff to us but we can make it happen. It is a big payoff. Participants believed that the h o l i s t i c , caring practice of nurses did not allow for easy measurement of CHO. Participants believed that nursing practice included decision making based on i n t u i t i o n and ways of knowing. Nursing practice was thought to be very encompassing i n r e l a t i o n to c l i e n t care. It was also thought to overlap and complement other health care providers which created issues about separating out the influence of nursing, l e t alone nurses i n ANP. Participants did not know how i t would be possible to measure t h e i r own i n t u i t i v e practice, ways of knowing and caring l e t alone that of other nurses: How do you measure intuitiveness and nurses ways of knowing and caring and so on and so forth? From a professional practice point of view, participants c i t e d the importance of standards i n r e l a t i o n to s e t t i n g and measuring CHO. Linked with t h e i r support for c l i e n t involvement i n care and determining CHO, participants thought that i f t h e i r professional standards did not provide d i r e c t i o n , then c l i e n t s should d i r e c t and determine t h e i r own outcomes: I suppose there are specific health outcomes that you've 124 got to look at from a professional point of view. I mean we have standards and obviously we have to follow them. But I guess the only thing to me, the only things you would have to look at defining in my perspective, the only things that I look at when I look at defining outcomes is what is my professional role? And if there is none mandated for me, if I don't have a standard to meet then as far as I am concerned the definition comes from the client. Whatever that client defines is the outcome that she/he wants that she/he is going to be happy with then that is the outcome. While discussing the rela t i o n s h i p of ANP to CHO, participants i d e n t i f i e d t h e i r b e l i e f that outcome measures from other d i s c i p l i n e s such as medicine had been t r a d i t i o n a l l y more valued than those of nursing. Reasons c i t e d for t h i s included the power base that medicine had t r a d i t i o n a l l y held and t h e i r focus on quantitative measures such as morbidity and mortality was much easier to capture. Participants thought that nursing played a major role i n these indicators but t h i s had not been acknowledged: It i s easier to place emphasis on outcomes from other disciplines, medicine in particular, simply because that is the way we have always looked at outcomes....Nursing is s t i l l struggling with hard indicators, concrete indicators of client outcomes that can be directly linked to nursing alone. Even when we look at morbidity and mortality we all know that nursing plays a role in those outcomes, a major role! Participants recognized that medical outcome indicators were a factor i n current i n i t i a t i v e s such as the development of p r o v i n c i a l c l i n i c a l practice guidelines. However, they also believed that outcome measures related to CHO needed to be i n t e r d i s c i p l i n a r y i n nature for a l l concerned p a r t i c u l a r l y c l i e n t s : Traditionally, we have been looking at medical care. 125 But I think there needs to be a balance to include the kinds of things that nursing values and thinks is important for clients and for health parameters. Thus, participants recognized that many other variables influenced the a b i l i t y of a nurse i n ANP describing her/his practice i n r e l a t i o n to CHO. Participants questioned how any CHO could be c l e a r l y linked back to the involvement of any s p e c i f i c d i s c i p l i n e . Participants believed that since c l i e n t s were exposed to-a multitude of health care providers, and assumed varying levels of r e s p o n s i b i l i t y towards personal education around t h e i r health concerns, attempts to l i n k CHO to nurses i n ANP was problematic. Participants believed that nurses i n ANP could describe an i n d i r e c t r e l a t i o n s h i p with CHO. Nurses i n ANP were thought to broadly influence CHO from a population of c l i e n t and s t a f f perspectives. These perspectives included having a v i s i o n to meet populations of c l i e n t needs and then taking a l l the required steps to ensure :action. Participants recognized that nurses were h o l i s t i c and caring i n t h e i r practice which again did not allow for ease i n measuring t h e i r influence on CHO. Participants recognized that nursing practice was often based on " i n t u i t i o n " and "ways of knowing" that could not be e a s i l y explained l e t alone measured. Participants stressed the importance of c l i e n t involvement i n CHO but at the same time recognized the need to determine whether or not professional nursing standards were a s s i s t i v e . 126 Participants recognized that although nursing played a major role i n CHO such as morbidity and mortality measures, th i s role had not been acknowledged. These measures had t r a d i t i o n a l l y been associated with medicine and were f a i r l y easy to capture quantitatively. Linked with t h i s , participants believed that current emphasis on medical outcome measures such as c l i n i c a l practice guidelines needed to be i n t e r d i s c i p l i n a r y i n nature. In summary, participant attempts to describe t h e i r practice i n re l a t i o n - t o CHO presented challenges. As participants did with ANP, they spent some time t r y i n g to define CHO. They believed that CHO were understood from many perspectives. They claimed that although i t was valuable to examine CHO, only nurses i n ANP, researchers and academics were doing so. This i n t e r e s t i n CHO was thought to be recent and therefore explained some of the lack of c l a r i t y . Participants believed that the exclusion of c l i e n t s i n defining CHO was problematic. In communicating the relat i o n s h i p between ANP and CHO, participants made extensive use of detailed c l i n i c a l stories which r e f l e c t e d influences on broad c l i e n t groups and s p e c i f i c c l i e n t s . The use of detailed c l i n i c a l s t o r i e s was believed by participants to be a routine, useful and valued aspect of ANP. Participants also believed that nurses i n ANP influenced CHO from a broad system perspective that included faster turnover of c l i e n t s , decreased wait l i s t s , discharges 127 with improved health status, more appropriate admissions and bed u t i l i z a t i o n , as well as development and d i s t r i b u t i o n of innovative programs. Participants believed that nurses i n ANP were often the "common thread or person" that influenced system changes. Participants recognized that nurses i n ANP had not c l e a r l y demonstrated t h e i r f i n a n c i a l worth, however believed that they were f i s c a l l y responsible i n terms of operational management. Participants believed that there were some f a i r l y clear t h e o r e t i c a l problems i n l i n k i n g ANP with CHO. These included short term CHO being easier to examine and p o t e n t i a l l y measure than were long term CHO. Participants also believed that other variables influenced how nurses i n ANP could describe t h e i r practice i n r e l a t i o n to CHO. Participants questioned how any CHO could be d i r e c t l y linked back to a s p e c i f i c health care provider, considering the m u l t i p l i c i t y of providers and the knowledge base of c l i e n t s . Participants did believe that nurses i n ANP p o s i t i v e l y influenced populations of c l i e n t s and s t a f f . In describing the nature of nursing practice and the overlapping scopes of nursing with other health care providers, participants believed that t h i s nature would be d i f f i c u l t to measure. Inherent i n the nature of nursing practice, participants believed i t important to determine i f nursing standards could a s s i s t i n looking at CHO. However, i f the standards did not provide d i r e c t i o n , then participants 128 believed that nurses i n ANP needed to take d i r e c t i o n from c l i e n t s . Chapter Summary In t h i s chapter, participant attempts to define ANP and describe t h e i r practice i n r e l a t i o n to CHO were presented. These d e f i n i t i o n s and descriptions were conceptualized from three broad categories. The f i r s t broad category related to d i f f i c u l t i e s participants had i n c l e a r l y defining ANP. This category consisted of two components: i n i t i a l attempts at defining ANP and reasons for lack of c l a r i t y about ANP. During i n i t i a l attempts to define ANP participants had d i f f i c u l t i e s i n tr y i n g to a r t i c u l a t e a clear and concise d e f i n i t i o n . Participants believed that ANP was a term that was inherently broad and vague i n nature. Participants were not concerned that many nurses i n ANP lacked c l a r i t y about ANP. In fact, participants supported t h i s as they claimed i t allowed for the continued f l e x i b i l i t y required for ANP. Participants believed that there were several v a l i d reasons related to the lack of c l a r i t y about ANP. The second broad category related to the descriptors of ANP. This category consisted of two components: minimal requirement t r i a d of ANP and essential q u a l i t i e s of ANP. Participants claimed that ANP had as i t s foundation three minimal requirements, namely graduate education, c l i n i c a l s pecialty focus and research-based practice. Participants 129 also believed that ANP included f i v e essential q u a l i t i e s that b u i l t on the minimal requirement t r i a d . These were believed to be global thinking, i n d i r e c t c l i n i c a l focus, a s s i s t i v e care delivery, e f f e c t i v e leadership and i n t e r d i s c i p l i n a r y collaboration. The t h i r d broad category related to possible rel a t i o n s h i p between ANP and CHO. This category consisted of three components: problems i n a r t i c u l a t i n g CHO, communicating the r e l a t i o n s h i p between ANP and CHO and t h e o r e t i c a l problems i n l i n k i n g ANP with CHO. Problems i n a r t i c u l a t i n g CHO were evident. Participants believed that CHO were a f a i r l y recent area of in t e r e s t and were understood from many perspectives. Participants believed that the most e f f e c t i v e way to communicate the relat i o n s h i p between ANP and CHO was through the use of detailed c l i n i c a l s t o r i e s . These stories r e f l e c t e d influences on CHO which ranged from an i n d i v i d u a l c l i e n t to broad, system perspectives. Participants claimed there were some f a i r l y clear t h e o r e t i c a l problems i n attempting to d i r e c t l y l i n k ANP with CHO. This chapter has presented the findings of t h i s study. In the next chapter, major findings that contribute to the knowledge base of ANP are discussed. 130 CHAPTER FIVE DISCUSSION of FINDINGS Findings from t h i s study reinforce many of the current views and research related to ANP. The exploration and description of how ANP influences CHO r e f l e c t s an area of study that has not been well documented i n the l i t e r a t u r e . Although a s i g n i f i c a n t body of l i t e r a t u r e challenges nurses i n ANP to recognize the impact of t h e i r practice on CHO, to date methodology to do so i s unclear. While participants i n t h i s study recognized the importance of being able to describe t h e i r practice i n r e l a t i o n to CHO, they were not accustomed to doing so. Considering that a l l participants were employed i n a major hospital society, hesitancy i n being able to e a s i l y a r t i c u l a t e ANP i n r e l a t i o n to CHO r e f l e c t s the "newness" of the o v e r a l l general emphasis on outcomes throughout Canadian health care. Despite the general consistency of t h i s study with ideas i n the available l i t e r a t u r e , there are three areas that may push us one step further i n developing c l a r i t y and richness about a description of ANP. These areas are: issues related to a d e f i n i t i o n of ANP; graduate education and ANP; and, ANP and i n t e r d i s c i p l i n a r y collaboration. The following discussion w i l l consider each of these within the context of e x i s t i n g knowledge. 131 Issues Related to a D e f i n i t i o n of Advanced Nursing Practice Participants were not able to a r t i c u l a t e a clear and concise d e f i n i t i o n of ANP and were aware of the vagueness associated with i t that was evident i n nursing l i t e r a t u r e . At the same time, participants were very confident i n t h e i r personal understanding of ANP and attempted to a s s i s t the researcher to b u i l d a common view of i t . Participant i n a b i l i t y to provide a clear d e f i n i t i o n of ANP i s not surprising. As was noted i n chapter two, nursing l i t e r a t u r e frequently incorporates the term ANP but authors r a r e l y define i t . Extensive use of the term ANP continues with regular a r t i c l e s and/or e d i t o r i a l s appearing i n nursing journals that emphasize a strong push for c l a r i t y about i t (eg. Forbes, 1995a). One j u s t i f i c a t i o n for the movement toward a clearer understanding of ANP i s the need to be able to a r t i c u l a t e i t to others. According to Giovannetti and Tenove (1995), t h i s i s p a r t i c u l a r l y important during current times of economic constraint and health reform. Although authors s t i l l recognize the need for a clear d e f i n i t i o n of ANP, there i s a growing trend to describe the ch a r a c t e r i s t i c s , attributes, competencies and behaviours of nurses i n ANP (eg. Davies & Hughes, 1995; Patterson & Haddad, 1992) . Three s p e c i f i c findings of t h i s study have raised important points for consideration about issues related to a d e f i n i t i o n of ANP. These points are either non-existent or 132 well developed i n the l i t e r a t u r e , or t h e i r treatment i n the l i t e r a t u r e raises further questions. They are: support for ANP remaining a broad and vague term; global thinking as an essential quality; and, the minimal requirement t r i a d as the foundation for ANP. Support For Advanced Nursing Practice Remaining A Broad And Vague Term Participants i n t h i s study were experienced CNSs who recognized that t h e i r role was l a b e l l e d ANP by professional associations, colleagues and nursing scholars. Participants c l e a r l y considered themselves to be advanced nursing p r a c t i t i o n e r s . They also c i t e d , without prompting, an indepth knowledge of a c t i v i t i e s by nursing scholars related to the development of a clear d e f i n i t i o n of ANP. However, i f there was any aspect related to a d e f i n i t i o n of ANP that participants emphasized above a l l others, i t was that they had a lack of concern related to t h e i r i n a b i l i t i e s to c l e a r l y and concisely define ANP and, i n fact, cautioned the researcher i n e f f o r t s to do so. I n i t i a l l y , participants attempted to provide a d e f i n i t i o n of ANP and said things such as "I should know t h i s . . . " This reaction can be t y p i c a l of CNSs and i s depicted i n the l i t e r a t u r e as an element of the "imposter phenomenon" (eg. Arena & Page, 1992). The imposter phenomenon, according to Arena and Page, describes individuals who may f e e l that they are f o o l i n g everyone, that 133 i s they are actually imposters i n t h e i r chosen profession. The t i t l e of CNS which includes the terra " s p e c i a l i s t " implies extensive expertise and the CNS may develop u n r e a l i s t i c expectations about her/his performance. As a r e s u l t , i t i s common for the CNS to think. "I should know t h i s . . . " However, soon aft e r beginning discussions, i t became obvious that participants lacked concern about t h e i r i n a b i l i t i e s to a r t i c u l a t e a clear and concise d e f i n i t i o n of ANP. Participants j u s t i f i e d t h e i r personal lack of concern on the minimal progress that credible and well known nursing scholars had made related to further understanding ANP. Participants were w i l l i n g to spend considerable time i n support of the researcher's e f f o r t s . However, i t was c l e a r l y evident that they did not f e e l that the phenomena of in t e r e s t were p r i o r i t i e s either for themselves or for ANP i n general. Participants were confident i n how they i n d i v i d u a l l y understood ANP. They f e l t comfortable i n t h e i r competencies related to ANP and considered these to be based on t h e i r personal and professional experiences, education and personality. Furthermore, participants thought that the requirements of busy day-to-day practice for nurses i n ANP required energy and focus related to nurses, c l i e n t s and i n t e r d i s c i p l i n a r y health care providers. Thus, t h i s precluded i n t e r e s t i n consideration of such issues as defining terms. It i s the researcher's opinion that nurses i n ANP 134 understand t h e i r practice and each other very well. They almost have an ingrained, i n t u i t i v e sense of i t . In day-to-day a c t i v i t i e s , p a r t i c u l a r l y where nurses i n ANP are autonomous and strongly supported by senior nursing administration, they are not accustomed to a r t i c u l a t i n g a description of t h e i r practice. Despite the pa r t i c i p a n t s ' confidence about t h e i r own practice, they are not necessarily able to communicate c l e a r l y t h e i r understanding of i t esp e c i a l l y to others who may not be i n an ANP ro l e . It would be most useful to observe participants i n t h e i r practice. The researcher i s l e f t with the questions: How do nurses i n ANP compare to each other i n the way they conduct t h e i r practice? Are some nurses "better" at ANP than others? What are the levels or stages of ANP? Participants viewed ANP as a term that was broad and vague i n nature. This nature was seen as b e n e f i c i a l as i t allowed for unlimited f l e x i b i l i t y associated with ANP. Participants highly valued t h i s f l e x i b i l i t y and believed i t was instrumental i n j u s t i f y i n g the in d i v i d u a l perspectives that nurses brought to ANP. In addition, participants recognized f l e x i b i l i t y as allowing them to consistently respond to changes as nursing evolved, organizational restructuring occurred and health reform continued. Literature generally r e f l e c t s varying interpretations of the unlimited f l e x i b i l i t y of ANP. Some nursing authors think that unlimited f l e x i b i l i t y can re s u l t i n the perception and 135 operationalization of ANP varying from nurse to nurse and from practice s e t t i n g to practice setting (eg. Alcock, 1995; Langford, 1995; Russell & Hezel, 1994). As a r e s u l t , some think t h i s causes confusion about ANP (eg. Patterson & Haddad, 1992), and others view i t as impeding implementation of ANP (eg. Davies & Eng, 1994). Confusion about ANP can re s u l t i n the public and professional colleagues not being clear about s p e c i f i c roles associated with ANP, unlike other d i s c i p l i n e s such as medicine where roles are clear (Alcock, 1995) . Vagueness about ANP leaves room for others to interpret the term based on t h e i r own needs, p a r t i c u l a r l y during health reform discussions. In some of these discussions, nursing authors are questioning i f senior nursing administrators, educators and researchers should also be c a l l e d advanced nursing p r a c t i t i o n e r s (eg. Ontario Ministry of Health, 1994; The Working Group for Registered Nurses i n Advanced Nursing Practice i n Rural/Remote Communities, 1994). The use of ANP within the context of these i n i t i a t i v e s again raises questions about the lack of c l a r i t y regarding ANP and the resultant implications. The idea that f l e x i b i l i t y could p o t e n t i a l l y r e s u l t i n practice inconsistencies with negative consequences for successful implementation of ANP was not a concern expressed by participants i n t h i s study. Other nursing authors recognize that unlimited f l e x i b i l i t y i n ANP i s b e n e f i c i a l as i t allows nurses i n the 136 role to be highly creative (eg. Sparacino, 1992), and increase t h e i r marketability p a r t i c u l a r l y during times of job in s e c u r i t y (eg. Prevost, 1995). Others see i t as an essential c h a r a c t e r i s t i c of ANP i f a goal of these nurses i s the development and exploration of new approaches and avenues i n an evolving health system (eg. Patterson & Haddad, 1992). These views c l o s e l y resemble those of the participants of t h i s study. Although participants supported the researcher i n t h i s study, they had strong cautions about e f f o r t s aimed at a clearer understanding of ANP. Participants were concerned about e f f o r t s to force a d e f i n i t i o n of ANP and believed i t should remain broad and vague i n nature. They thought a clear d e f i n i t i o n of ANP would p o t e n t i a l l y be r e s t r i c t i v e and thereby prove to be more negative than p o s i t i v e . This caution around e f f o r t s to more c l e a r l y understand ANP has not been documented by others. As the reader w i l l r e c a l l from chapter two, the opposite i s true. Although participants of t h i s study had cautions, i t may have been because they were secure and confident about t h e i r practice and supported to have unlimited f l e x i b i l i t y i n t h e i r r o l e s . As a r e s u l t , they viewed e f f o r t s towards developing a clear d e f i n i t i o n of ANP as negative. They did not support e f f o r t s that could r e s t r i c t t h e i r practice. For participants, ANP was "ever-changing" and therefore led to new areas of focus. Participants discussed the 137 increased administrative r e s p o n s i b i l i t i e s that they were assuming and j u s t i f i e d t h i s due to changing organizational needs. Again, they stressed the f l e x i b i l i t y they valued i n ANP as a factor to le g i t i m i z e an administrative focus. Participants understood the examination of various nursing roles as being an element of health reform. For these reasons, participants believed that to be able to continue employment, they needed to be open to an increasing administrative focus. A trend for CNSs to take on more administrative functions i s not surprising. In current times of f i s c a l r e s t r a i n t , nursing administrators and nurses i n ANP are often having to re-examine ANP roles (eg. Brunk, 1992; Houston & Green, 1993). With the elimination of many head nurse positions, often nurses i n ANP take on more administrative functions that are required for organizational e f f i c i e n c y . U n t i l recently, administrative functions have generally not been associated with ANP. However, t h i s i s changing. For example, a survey done by Davies and Eng (1995) related to CNS role implementation demonstrated that, "surprisingly, 19% of time was spent on administrative a c t i v i t i e s " (p. 26). Although the actual data c o l l e c t i o n time-frame i s not c l e a r l y outlined i n the a r t i c l e by Davies and Eng, the reader can assume that t h i s figure probably r e f l e c t s the s i t u a t i o n p r i o r to many recent eliminations of head nurse positions. Thus, participants as nurses i n ANP were confident i n 138 how they conducted t h e i r practice and valued the unlimited f l e x i b i l i t y inherent i n t h e i r roles. This legitimized changing role f o c i such as an increased administrative one. Participants believed that a clear d e f i n i t i o n of ANP would be r e s t r i c t i v e for nurses i n the r o l e . However, while participants of t h i s study did not f e e l that a d e f i n i t i o n of ANP was a p r i o r i t y , d e f i n i t i o n s continue to play an important role i n the health reform discourse. Global Thinking as an E s s e n t i a l Quality Participants valued global thinking that they believed was an essential q u a l i t y of ANP. Although global thinking i s only one of the essential q u a l i t i e s of ANP i d e n t i f i e d by participants, i t i s discussed here since t h i s q u a l i t y i s not well developed i n the l i t e r a t u r e . Global thinking was consistently evident i n the accounts and r e f l e c t e d p a r t i c i p a n t s ' knowledge of t h e i r agency and community, as well as p r o v i n c i a l , national and international i n i t i a t i v e s and trends. Participants could focus on an i n d i v i d u a l c l i e n t but would be consistently thinking about how that c l i e n t related to the whole of c l i e n t care. At the same time, participants would bring t h e i r competencies related to the health care system to any i n d i v i d u a l c l i e n t scenario. Participants stressed that global thinking enabled nurses i n ANP to be proactive so that they could p a r t i c i p a t e i n planning for programs/strategies p r i o r to occurrence of a 139 c r i s i s . According to participants, nurses i n ANP practiced i n a proactive manner, as opposed to s t a f f nurses who generally practiced i n a reactive manner. This reactive approach of s t a f f nurses was due to busy day-to-day demands of practice that precluded any long term planning or proactive strategies. Based on a proactive approach to c l i e n t care, nurses i n ANP assume a leadership role i n the improvement of c l i e n t care within t h e i r agency, as well as external agencies/groups. As noted above, the notion of global thinking as an essential q u a l i t y of ANP i s not prominent i n the l i t e r a t u r e . A linkage with t h i s q u a l i t y i s apparent, for example, i n the phrases "broad context" (Benner, Tanner & Chelsa, 1992), "broad perspective" (Davies & Hughes, 1995) and "whole picture" (Schaefer & Lucke, 1990). Although these phrases may r e f l e c t the same dimensions of practice, what i s not c l e a r l y described i n the l i t e r a t u r e i s how t h i s global thinking i s useful for nurses i n ANP to be proactive. This f i n d i n g i s important and worthy of future attention as t r a d i t i o n a l l y health care providers continue to be reactive and to "practice i n response to both the h i s t o r i c a l and current s o c i a l demands" (Patterson & Haddad, 1992, p. 18). In the era of health reform, the competencies of nurses i n ANP to a r t i c u l a t e global thinking to health p o l i c y decision makers could be very e f f e c t i v e not only for ensuring s u r v i v a l of ANP, but also for improving o v e r a l l health care. 140 Inherent i n t h e i r focus on global thinking, participants were able to describe through the use of detailed c l i n i c a l s t o r i e s , how they improved c l i e n t care, nursing s a t i s f a c t i o n with care, i n t e r d i s c i p l i n a r y collaboration and CHO. They also c l e a r l y a r t i c u l a t e d broad improvements i n care within t h e i r organizations. Participants stressed that s t a f f nurses were t h e i r c l i e n t s and consistently described ANP through c l i n i c a l stories within t h i s context. Literature often r e f l e c t s how nurses i n ANP focus on s t a f f nurses i n order to meet professional and c l i e n t needs (eg. Langford, 1995; Schaefer & Lucke, 1990). What i s not well developed i n the l i t e r a t u r e i s how nurses i n ANP c l e a r l y improve CHO and o v e r a l l health care within an organization. Literature i s beginning to appear that challenges nurses i n ANP to consider an organization as t h e i r c l i e n t (eg. Forbes, 1995b), rather than focusing d i r e c t l y on s t a f f nurses. This approach i s believed to be advantageous for ensuring the survival of the CNS position. Thus, according to participants, global thinking represented an essential q u a l i t y of ANP. Global thinking allowed nurses i n ANP to be proactive i n t h e i r practice and therefore assume a leadership role within t h e i r agency/organization to improve c l i e n t care. The a b i l i t y of nurses i n ANP to a r t i c u l a t e how global thinking and a proactive approach to care can benefit both the s u r v i v a l of ANP and improvements i n o v e r a l l health care can be 141 strengthened. Minimal Requirement Triad Participants c i t e d three minimum requirements as foundational for ANP. These have been conceptualized into the minimal requirement t r i a d of ANP, namely: graduate education, c l i n i c a l s pecialty focus, and research-based practice. Reasons why each element of the minimum requirement t r i a d was considered by participants as c r u c i a l for ANP were outlined i n chapter four. The purpose of discussion at t h i s point i s to focus on the minimal requirement t r i a d of ANP i n i t s entirety. It i s not just the three required elements of ANP, but rather the combination and int e r a c t i o n of them that provides the foundation of ANP. Within the l i t e r a t u r e , a baseline foundation of ANP remains contentious and nurses have not come to a consensus about i t . Authors of nursing l i t e r a t u r e related to CNS practice do not consistently focus on the above elements as providing a baseline or foundation for ANP. Although the elements are written about frequently, i t i s usually within the context of need for, implications and inconsistencies of one or more of these elements i n combination with others (eg. Calkin, 1994; Registered Nurses Association of B r i t i s h Columbia, 1994), and/or role functions and practice areas (eg. Patterson & Haddad, 1992). Is i t important to a r t i c u l a t e the need for a combination of minimum requirements as a foundation for ANP? How would the minimal requirement 142 t r i a d a s s i s t with a d e f i n i t i o n of ANP? Although the minimal requirement t r i a d discussed by participants i n t h i s study i s not apparent i n the l i t e r a t u r e , elements within the t r i a d have been discussed at length and can contribute to our interpretations of t h i s finding. The need for graduate education, at least at the master's l e v e l , was believed by participants to be required i n order to develop the competencies that contribute p o s i t i v e l y to ANP. This view i s well documented i n the l i t e r a t u r e (eg. Montemuro, 1987; Ray & Hardin, 1995; Synder, 1989) and more issues s p e c i f i c to graduate education are discussed l a t e r i n t h i s chapter. According to participants, a c l i n i c a l s p e c i a l t y focus i n graduate education, despite the faculty of study, was mandatory for ANP. Participants described themselves as expert p r a c t i t i o n e r s p r i o r to t h e i r graduate education. They believed that the combination of t h e i r expert practice i n a specialty area of nursing combined with graduate education resulted i n being to conduct ANP at a competent l e v e l . Davies and Hughes (1994) also note that ANP "builds upon c l i n i c a l expertise" and "experiential knowledge" (p. 158). This f i n d i n g may be explained by the knowledge that participants of t h i s study do not necessarily r e f l e c t the average nurse entering graduate education. That i s , many nurses entering graduate education may not be c l i n i c a l experts as were par t i c i p a n t s . When nurses enter graduate 143 studies, even i f they wish to focus on nursing c l i n i c a l practice, they may change the area i n which they have previously been p r a c t i s i n g . For example, a nurse with previous experience i n ped i a t r i c s may focus on community health i n her or his graduate studies. Participants viewed research-based practice as c r i t i c a l for ANP and thought i t was developed through research competencies gained through graduate education linked with a c l i n i c a l specialty focus. Participants referred to research-based practice as consistently thinking about, p a r t i c i p a t i n g i n , and u t i l i z i n g research. Participants thought that nurses i n ANP assumed a lead role i n r e l a t i o n to research-based practice within an organization. Participants viewed v a l i d and r e l i a b l e research as a useful strategy for nurses i n ANP to prompt s t a f f nurses to examine t h e i r i n d i v i d u a l and o v e r a l l practice. This f i n d i n g concurs with that of Nuccio and colleagues (1993), i n t h e i r study involving s t a f f nurse perceptions of the CNS r o l e . The convenience sample consisted of 636 registered nurses employed i n s t a f f positions i n three campuses of two a f f i l i a t e d medical centres i n the United States. Staff nurses believed that research-based nursing practice was important but thought they had i n s u f f i c i e n t time, knowledge and experience with i t themselves. Staff nurses reported a need for CNSs to be involved i n a l l aspects of the research process. 144 CNS l i t e r a t u r e regularly includes research as an important subrole of ANP (eg. Beecroft, 1992; Lusis, 1995; Montemuro, 1987; Sparacino, 1992). Nurses i n ANP are often seen as leaders i n the i d e n t i f i c a t i o n of research questions and the i n i t i a t i o n of studies i n order to advance nursing and i n t e r d i s c i p l i n a r y practice within an agency (eg. F i t z p a t r i c k et a l , 1991). However, there i s evidence that CNSs spend less time on research than on other nursing functions associated with the role (eg. Davies & Eng, 1995; Lusis, 1995; Williams & Valdivieso, 1994). Participants of t h i s study did not comment on the amount of time spent on research but, as the detailed c l i n i c a l stories r e f l e c t e d , they were i n various stages of being a c t i v e l y involved i n conducting research and a l l i d e n t i f i e d research u t i l i z a t i o n i n t h e i r practice. Participants recognized t h e i r own lim i t a t i o n s related to research and c l e a r l y valued partnerships with colleagues, i n t e r d i s c i p l i n a r y professionals and univer s i t y faculty for the conduct of research. Participants thought that t r u l y d e f i n i t i v e research involved a partnership between nurses i n ANP and doctorally prepared nurses. They believed that the doctorally prepared nurse should assume the p r i n c i p l e investigator r o l e . The nursing l i t e r a t u r e supports t h i s finding. Some authors hypothesize that nurses i n ANP spend lim i t e d time on research due to t h e i r graduate education. Some view a 145 master's l e v e l research course and the conduct of a thesis as preparing nurses to be consumers of research only (eg. C o l l i n s , 1992), to function as a research associate (eg. Stinson, F i e l d & Thibaudeau, 1988), or take "an active collaborative role i n such research a c t i v i t i e s as data c o l l e c t i o n and analysis" (Sharp & Hart, 1987, p. 38). Due to these factors, many support master's prepared nurses to partner with doctorally prepared nurses i n order to advance the science of nursing (eg. Arena & Page, 1992; C o l l i n s , 1992; Stinson, F i e l d & Thibaudeau, 1988). Thus, participants thought that ANP i s b u i l t on a minimal requirement foundation. This foundation included a t r i a d with the elements of graduate education, c l i n i c a l s pecialty focus and research-based practice. In summary, participants discussed important points related to e f f o r t s towards a d e f i n i t i o n of ANP. Overall, participants were not concerned about the general lack of c l a r i t y about ANP. They valued aspects of ANP that could be developed due to the broad and vague nature of i t . Global thinking represents one essential q u a l i t y of ANP that enables nurses i n the role to be proactive i n t h e i r practice which can r e s u l t i n o v e r a l l improvements to a l l levels of health care. Participants believed that-there are three minimum requirements of ANP. These aspects of ANP are of assistance i n understanding the complexities i n attempting to develop a d e f i n i t i o n of ANP. 146 Graduate Education and Advanced Nursing Practice According to participants, graduate education was a minimal requirement for ANP and provided a strong basis for many of the required competencies. A c r i t i c a l concern for participants was whether graduate education should be i n nursing or i n another faculty. While recognizing reasons why some nurses i n ANP undertook, non-nursing degrees, participants with nursing graduate education questioned i f th i s contributed p o s i t i v e l y to ANP. Participants with non-nursing graduate education were also sensitive and somewhat defensive about t h e i r preparation. They questioned the Registered Nurses Association of B r i t i s h Columbia (1994) support for nursing graduate education, related to ANP, when so many univer s i t y programs do not of f e r an associated c l i n i c a l s p e c i a l i z a t i o n . This d i v e r s i t y about graduate education for nursing, and for ANP, remains contentious amongst nurses. As participants i d e n t i f i e d and l i t e r a t u r e confirms, arguments centre around what education w i l l make the ultimate difference i n advancing and perfecting nursing knowledge, as well as nursing practice, education and research (eg. Stinson, F i e l d & Thibaudeau, 1988). It i s not surprising to f i n d that some participants undertook non-nursing graduate education. Non-nursing graduate education was the norm u n t i l recently i n Canada since there were very limited opportunities for graduate 147 education i n nursing (Kerr, 1991; Stinson, F i e l d & Thibaudeau, 1988). According to Kerr (1991), many nurses wishing to undertake non-nursing graduate education, did so due to a lack of: available programs, respect for nursing programs, and q u a l i f i e d f a c u l t y to teach these programs. By 1985, the majority of nurses who held master's degrees obtained non-nursing degrees although the precise breakdown i s not available (Stinson, F i e l d & Thibaudeau, 1988). Participants with non-nursing graduate education believed they were making valuable and s i g n i f i c a n t contributions to ANP, despite the focus of t h e i r graduate studies. Although graduate education i n other f a c u l t i e s may have served a purpose at one time, i t i s creating some problems now for nurses i n ANP. For example, during t h i s study, participants with non-nursing graduate education wondered c o l l o q u i a l l y i f some of the d i f f i c u l t i e s related to addressing the phenomena of inte r e s t was due to t h e i r educational preparation. However, from the researcher's perspective, there were no noticeable differences i n participant accounts that could be explained the f a c u l t y of t h e i r graduate educational preparation. Despite many nursing authors "best guess" that nursing graduate education i s required for ANP, what i s not clear i s how t h i s preparation c l e a r l y impacts practice and CHO. It i s not known for example, i f nurses are convinced that graduate education i n nursing i s mandatory for ANP p a r t i c u l a r l y i n an 148 era of i n t e r d i s c i p l i n a r y collaboration. It i s also not clear what differences there are i n the a c t i v i t i e s and outcomes of nurses i n ANP despite the fac u l t y of t h e i r graduate studies. At the present time, nursing professional bodies, although formally recognizing why some nurses i n ANP previously undertook non-nursing graduate education, are making i t clear that the preferred education for ANP i s a master's degree i n nursing (eg. Canadian C l i n i c a l Nurse S p e c i a l i s t Interest Group, 1994; Registered Nurses Association of B r i t i s h Columbia, 1994). This information can explain the s e n s i t i v i t y and defensiveness that participants with non-nursing graduate education are experiencing about t h e i r preparation for ANP. It also explains the support that participants with nursing graduate education have for t h i s s p e c i f i c preparation being a minimum requirement for ANP. Participants who had nursing graduate education viewed t h i s as c r i t i c a l l y important i n order to advance the science of nursing, and more s p e c i f i c a l l y ANP. Indeed, nursing graduate education i s often depicted i n the l i t e r a t u r e as being mandatory for ANP (eg. Bednash, Wulff & Haux, 1989; Canadian C l i n i c a l Nurse S p e c i a l i s t Interest Group, 1994; Hunsberger et a l , 1992; United States Department of Health and Human Services, 1990). Given t h i s knowledge, the strong support that these participants had for nursing graduate education related to ANP i s made more evident. A l l participants recognized the benefits of a strong 149 mentored c l i n i c a l s pecialty focus during graduate education, despite the faculty. A number of authors have s p e c i f i c a l l y reinforced the need for indepth mentored, c l i n i c a l experiences by way of practicums during graduate education i n order to develop competencies required for ANP (eg. Arena & Page, 1992; Bass, Rabbett & Siskind, 1993; Forbes, 1994; Hamric & Taylor, 1989). A l l participants of t h i s study were c l i n i c a l experts p r i o r to graduate education and experienced i n t h e i r ANP rol e s . In addition, a l l participants had obviously made s i g n i f i c a n t e f f o r t s to be informed about ANP as evidenced by t h e i r indepth knowledge, c i t e d without prompting, related to nursing scholars who had written extensively about ANP. There i s no description i n the l i t e r a t u r e as to how a mentored, c l i n i c a l s pecialty focus can be included i n non-nursing graduate education. The two participants with non-nursing graduate education took the i n i t i a t i v e during graduate studies to ensure a mentored, c l i n i c a l s pecialty focus, despite the faculty of t h e i r studies. It i s the researcher's opinion that t h i s approach may not be r e f l e c t i v e of the majority of nurses undertaking non-nursing graduate education. At the same time, participants with non-nursing graduate education questioned the increased support for nursing graduate education related to ANP, when many nursing programs did not contain a c l i n i c a l s p e c i a l i z a t i o n focus. They thought 150 t h i s represented one j u s t i f i c a t i o n that non-nursing graduate education was s t i l l very appropriate for ANP, p a r t i c u l a r l y i n an era of i n t e r d i s c i p l i n a r y collaborative practice. Participants recognized the importance of a strong c l i n i c a l background of the nurse p r i o r to graduate studies. These participants believed that a creative and motivated c l i n i c a l expert can maximize the benefits of non-nursing graduate education through strong linkages with nursing faculty. These findings were reinforced i n the l i t e r a t u r e i n the d i v e r s i t y that exists regarding c l i n i c a l s p e c i a l i z a t i o n requirements for graduate nursing programs i n Canada (eg. Synder, 1989), as well as i n t e r n a t i o n a l l y (eg. Starck, 1987). Although a specialized c l i n i c a l focus for ANP i s available at some u n i v e r s i t i e s , others o f f e r a focus on administration or education i n nursing programs. Programs also d i f f e r i n entrance requirements and course work related to c l i n i c a l experiences. Some programs require that the student have a defined number of years of c l i n i c a l practice i n a spe c i a l t y area while others do not require c l i n i c a l experience (Synder, 1989). Programs that do o f f e r c l i n i c a l s p e c i a l i z a t i o n also d i f f e r i n the amount and effectiveness of mentored c l i n i c a l practice that i s available (Anderson, 1994; Forbes, 1994). A lack of mentored c l i n i c a l practice was reported by Davies and Eng (1995). In t h e i r survey, 38 CNSs completed a s e l f administered questionnaire related to role implementation i n various health care agencies i n the Lower Mainland, B.C. 151 Participants of t h e i r study suggested the strong value of mentoring, p a r t i c u l a r l y for novice CNSs, however few CNSs reported having had the opportunity for t h i s experience. This may be a r e f l e c t i o n of the number of CNSs available for the purposes of mentoring and not an i n d i c a t i o n of the in t e r e s t of experienced CNSs i n t h i s a c t i v i t y . This information explains why participants with non-nursing graduate education questioned the focus on nursing graduate education as mandatory for ANP. They questioned nursing graduate education being so strongly advocated as mandatory for ANP given the inconsistencies of graduate preparation of nurses. Thus, although participants agreed that graduate education was a requirement for ANP, they had concerns related to whether or not t h i s education should be i n nursing. Those participants with nursing graduate education believed i t was c r i t i c a l i n order to advance nursing science and ANP. Participants with non-nursing graduate education questioned the support for nursing graduate education when so many inconsistencies and a lack of a c l i n i c a l s p e c i a l i t y focus existed i n nursing programs i n Canada. However, what i s not clear i s how varying graduate education influences the practice and outcomes of nurses i n ANP p a r t i c u l a r l y within an i n t e r d i s c i p l i n a r y collaborative care environment. Advanced Nursing Practice and I n t e r d i s c i p l i n a r y Collaboration As nurses i n ANP, participants c l e a r l y valued 152 i n t e r d i s c i p l i n a r y collaborative practice (ICP) that a c t i v e l y encouraged c l i e n t involvement. Participants thought that nurses i n ANP were more confident about ICP than were s t a f f nurses, and therefore promoted i t s benefits. According to participants, when nurses i n ANP embraced ICP, the a b i l i t y to determine any one health care provider's d i r e c t influence on CHO was challenging, and perhaps not possible. Recognition of the complexities related to t r y i n g to i s o l a t e the influence of any one provider, or the providers of any one d i s c i p l i n e on CHO i s a theme i n the l i t e r a t u r e (eg. Bond St Thomas, 1991; Hamric, 1983; Higgins, McCaughan, G r i f f i t h s & C a r r - H i l l , 1992; Hoeman, 1995; Pike et a l , 1993). Findings from t h i s study about ANP within the context of ICP warrant further consideration. Limited l i t e r a t u r e i s available that c l e a r l y demonstrates the influence of ANP on CHO within the context of ICP. Government health p o l i c y decision makers and authors are touting ICP as a p o t e n t i a l answer to current gaps and fragmentation i n health care, as well as to reducing costs of care (eg. Hastings, O'Keefe & Buckley, 1992; Seaton, 1991; Sebas, 1994; Velianoff, Neely & H a l l , 1993). Literature related to ICP has often focused on physician-nurse interactions or what was coined by Stein as early as 1967 as the "doctor-nurse game." Literature has focused on improving nurse-physician relationships (eg. Fagin, 1992; Kirchnoff, 1987; Prescott & Bowen, 1985; Sebas, 153 1994), and has maintained that collaboration i s esse n t i a l for c l i e n t care (eg. Michelson, 1988), and does lead to improved CHO (Baggs, Ryan, Phelps, Richeson & Johnson, 1992). Despite t h i s , the l i t e r a t u r e continues to r e f l e c t the d i f f i c u l t y that nurses and physicians have i n achieving true collaboration (eg. Wandel, 1991). Relations with other health care providers are less frequently mentioned i n the l i t e r a t u r e and are usually i n the context of an i n t e r d i s c i p l i n a r y team approach to care of s p e c i f i c populations of c l i e n t s . A r t i c l e s are appearing that describe the benefits of physicians working i n collaborative relationships with nurses in ANP (eg. Mundinger, 1994), however, l i t e r a t u r e related to CNS/physician collaboration i s minimal. According to Sparacino (1994), some physicians continue to view ANP as a true encroachment on the practice of medicine. Participants of t h i s study recognized the merits of a l l health care providers and did not i s o l a t e out physicians i n t h e i r discussions of ICP. In addition, they discussed p o s i t i v e relationships with a l l health care providers and did not refer to d i f f i c u l t i e s i n achieving collaboration. Participants highly valued and promoted ICP. They were confident i n t h e i r own competencies and therefore f e l t on equal footing with a l l members of the health care team. Participants saw nurses i n ANP as "partners" with other health care providers. Yet, participants also recognized that nursing offered unique perspectives to c l i e n t care. 154 Participants c l e a r l y saw e f f e c t i v e and e f f i c i e n t c l i e n t care as a p r i o r i t y for t h e i r practice. They were clear about when to involve other d i s c i p l i n e s i n c l i e n t care and who to consult. Participants recognized they had c r e d i b i l i t y with other health care providers. They attributed t h i s to: t h e i r broad university education, knowledge of other d i s c i p l i n e s ' competencies, demonstrated and recognized c l i n i c a l expertise, well-developed a b i l i t i e s to a r t i c u l a t e and t h e i r role within the organization. Literature r e f l e c t s the strong emphasis that nurses i n ANP place on ICP and some see i t as an i n t e g r a l part of ANP (eg. Hawkins & Thibodeau, 1989; Nugent, 1992; Spross, 1989). The notion of partnerships between nurses i n ANP and other health care providers i s viewed as ensuring successful ICP (eg. Fenton, 1995). According to Arslanian-Engoren (1995), nurses i n ANP are prepared by experience, education and role interpretation to advance ICP and w i l l enact very creative strategies to meet needs of s t a f f and c l i e n t s . Literature r e f l e c t s the strong influence of graduate l e v e l u n i v e r s i t y education i n terms of nurses i n ANP being accepted by other d i s c i p l i n e s , p a r t i c u l a r l y physicians (eg. Alcock, 1995; Arslanian-Engoren, 1995). It i s understandable, therefore, that participants highly valued ICP and f e l t they had to be active, contributory members and promoters of i t . Participants viewed nurses i n ANP as i n t e r a c t i n g more frequently, d i r e c t l y , appropriately and c o l l a b o r a t i v e l y with 155 i n t e r d i s c i p l i n a r y health care providers than did s t a f f nurses. They saw s t a f f nurses as hesitant and lacking confidence about ICP. This view concurs with that of Wise (1995) who recognized that s t a f f nurses lack confidence i n t h e i r nursing knowledge base despite t h e i r assessments of c l i e n t needs. Participants of t h i s study believed a contributing factor to t h i s was that many s t a f f nurses were educated i n non-university settings. This l i m i t e d s t a f f nurses' knowledge about the benefits of ICP. Staff nurse subservience with respect to ICP i s noted i n the l i t e r a t u r e and considered to be the re s u l t of basic nursing c u r r i c u l a encouraging t h i s approach (eg. Larson, 1995). Another noted trend i s that s t a f f nurses often defer c l i n i c a l decisions to other d i s c i p l i n e s and as a re s u l t imply that t h e i r knowledge i s less important than that of other d i s c i p l i n e s (eg. Wise, 1995). Therefore, i t appears that s t a f f nurse hesitancy and lack of confidence related to ICP i s common practice. Participants saw a key role for nurses i n ANP as that of a s s i s t i n g s t a f f nurses to increase t h e i r competencies about the benefits of ICP and to recognize t h e i r own l i m i t s i n regard to c l i e n t care. For participants, the description of t h e i r practice i n r e l a t i o n to CHO proved to be problematic. This was due to complexities inherent i n t h e i r role, such as being a s s i s t i v e to others, as well as being active members of ICP. Therefore, according to participants, nurses i n ANP have an 156 important but i n d i r e c t influence on CHO. Participants viewed nurses i n ANP as "the conduit" i n that many CHO came "through them" rather than "from them" d i r e c t l y . The fact that measuring CHO was a r e l a t i v e l y new emphasis i n health care i n B.C. further complicated p a r t i c i p a n t s ' attempts to make t h i s linkage e x p l i c i t . The trend demonstrated by participants to not i s o l a t e out t h e i r a c t i v i t i e s i n r e l a t i o n to CHO i s supported i n a study by Schaefer and Lucke (1990). Findings from that study indicated that CNSs consistently report that they perceive t h e i r work as part of a team and not occurring independent of others. Participants e a s i l y a r t i c u l a t e d the strong emphasis i n t h e i r practice related to c l i e n t involvement i n t h e i r own care. Participants worked with others to ensure a c l i e n t focus of care. The value and support that nurses i n ANP place on c l i e n t directed care i s evident i n the l i t e r a t u r e . For example, i n her discussion of'the CNS as case manager in a collaborative practice model, Nugent (1992) thinks that a CNS i s best suited to assume the case manager role on an i n t e r d i s c i p l i n a r y collaborative team. Nugent thinks that the CNS has the competencies required that ensure a t r u l y collaborative practice that keeps the c l i e n t as the f o c a l point. Others discuss how CHO should be viewed i n l i g h t of professional actions but also "viewed i n the l i g h t of i n d i v i d u a l patient's' needs and wishes" (Bond & Thomas, 1991, p. 1498). Therefore, the findings related to nurses i n ANP 157 promoting c l i e n t s being a c t i v e l y involved i n t h e i r own care are consistent with the t h e o r e t i c a l descriptions of i t i n the l i t e r a t u r e . Participants recognized the significance of being able to a r t i c u l a t e a j u s t i f i c a t i o n for t h e i r r o l e s . Despite a l l of the influencing variables, participants recognized that for many reasons i t would be advantageous to be able to quantita t i v e l y measure the influence of nurses i n ANP on CHO. The ANP l i t e r a t u r e continues to stress the importance of outcomes i n r e l a t i o n to ANP (eg. Harris & Warren, 1995; Sparacino, 1995; Spross, 1995; Waltz & Sylvia, 1991; Williams & Valdivieso, 1994). However, methodology to make the l i n k between ANP and CHO i s not well developed. Waltz and Sylvia (1991) word these challenges most accurately when they say "much remains to be accomplished with the thorny issues that s t i l l challenge those who seek to measure nursing outcomes" (p. 202). Participants thought that a tool that could measure an association between ANP and CHO would be useful but a re a l challenge to develop. Literature r e f l e c t s the need for research related to the development of tools to measure CNS outcomes (eg. Harris & Warren, 1995) i n order to substantiate c r e d i b i l i t y and worth of providers (eg. Moore, 1995; Waltz & Sylvia, 1991). How to do so remains unclear. For example, Munro (1993) asks "what [outcome] measures should we use? Certainly, i f we could agree on some, we would be able to 158 compare and contrast results across studies" (p. 246). Therefore, i t appears that the challenges associated with being able to quantify measures of the influence of ANP on CHO present common problems. Using detailed c l i n i c a l s t o r i e s , participants described how they p o s i t i v e l y influenced CHO as well as s t a f f and organizational outcomes within an ICP environment. Their a b i l i t i e s to be visionary and proactive about c l i e n t care were viewed as po s i t i v e influences on o v e r a l l CHO. Literature occasionally r e f l e c t s the need for nurses i n ANP to describe t h e i r practice through the use of c l i n i c a l examples (eg. Mantle, 1993; Mason et a l , 1992). Some authors are c a p i t a l i z i n g on t h i s approach (eg. Davies & Hughes, 1995). Their discussion indicates that nurses i n ANP describing t h e i r practice i n r e l a t i o n to CHO through the use of detailed c l i n i c a l stories might be very useful. Through t h i s process, nurses i n ANP may be able to more c l e a r l y a r t i c u l a t e which CHO they are i n a key position to influence. Thus, nurses i n ANP highly value and strongly promote ICP that includes an emphasis on active c l i e n t involvement i n th e i r own care. Given t h i s approach to care, methodology to make e x p l i c i t the influence of ANP on CHO i s d i f f i c u l t . Nurses i n ANP are often the "linkage" between s t a f f nurses and other health care providers i n order to enhance CHO. The use of detailed c l i n i c a l s t o r i e s , although perhaps not providing a quantifiable influence of ANP on CHO, may be the 159 avenue for these nurses to accurately describe t h e i r practice within an ICP environment. Chapter Summary In t h i s chapter, the findings of t h i s research were discussed i n r e l a t i o n to the findings of other researchers and views of nursing authors. The discussion was presented from three areas which relate to major findings from chapter four that contribute to the knowledge base of ANP. These findings are of assistance i n e f f o r t s to more c l e a r l y understand ANP and include: issues related to a d e f i n i t i o n of ANP, graduate education and ANP, and ANP and i n t e r d i s c i p l i n a r y collaboration. Participants of t h i s study were not able to a r t i c u l a t e a clear and concise d e f i n i t i o n of ANP. This finding i s consistent with that found i n the l i t e r a t u r e . Participants valued ANP being a broad and vague term and believed the unlimited f l e x i b i l i t y associated with i t allowed nurses i n ANP to adapt to ever-changing needs inherent i n health reform. Participants believed they understood t h e i r own practice well and were not concerned about the general lack of c l a r i t y about ANP. Participants cautioned the researcher i n e f f o r t s to more c l e a r l y define ANP. This finding i s not r e f l e c t e d i n the l i t e r a t u r e but may be explained by current autonomy and senior nursing administrative support enjoyed by pa r t i c i p a n t s . Participants viewed global thinking as an e s s e n t i a l 160 qu a l i t y of ANP. Although nursing authors discuss si m i l a r q u a l i t i e s , the l i t e r a t u r e does not c l e a r l y i d e n t i f y how nurses i n ANP are proactive i n t h e i r practice within the competency of global thinking. Participants also i d e n t i f i e d some minimal requirements of ANP that were conceptualized l a t e r as the minimal requirement t r i a d of ANP, namely: the combination of graduate education, c l i n i c a l s pecialty focus and research-based practice. In the l i t e r a t u r e , the combining of these three elements are not s p e c i f i c a l l y i d e n t i f i e d as a baseline or foundation but i n d i v i d u a l l y have been discussed at length. The need for graduate education as a c r i t i c a l requirement for ANP was described by a l l p a r t i c i p a n t s . What i s not clear from participant accounts and from the l i t e r a t u r e i s how graduate education from various f a c u l t i e s influences the process and outcomes related to ANP. Participants raised many questions about the influence of ANP on CHO within an ICP environment. Participants highly valued and promoted ICP that included c l i e n t s having active involvement i n t h e i r own care. Since t h i s was how participants approached t h e i r practice, they viewed i s o l a t i n g out the influence of ANP on CHO as being problematic. This fi n d i n g was supported i n the l i t e r a t u r e by the multitude of factors that influence CHO within an ICP environment. Although participants saw t h e i r role as working with s t a f f nurses and other health care providers to enhance CHO, they 161 were able to describe detailed c l i n i c a l stories that i l l u s t r a t e d how they did so. -These c l i n i c a l s t o r i e s are believed by some nursing authors to be a useful strategy for nurses i n ANP to be able to a r t i c u l a t e which CHO they can influence within an ICP environment. In t h i s chapter, a discussion of the research findings were presented. In the next chapter, the summary, conclusions and implications for nursing graduate education, p o l i c y and administration as well as research are presented. i 162 CHAPTER SIX SUMMARY, CONCLUSIONS and IMPLICATIONS Summary This study was designed to gain an understanding of how CNSs define ANP and describe t h e i r practice i n r e l a t i o n to CHO. The CNS participants were recognized as p r a c t i s i n g under the umbrella of ANP. The term ANP has been u t i l i z e d i n nursing l i t e r a t u r e and discussions for many years. However, ANP remains a term that i s not c l e a r l y defined nor consistently enacted. Although l i t e r a t u r e exists encouraging nurses i n ANP to be able to describe the impact of t h e i r practice on CHO, methodology to do so i s not clear. Any d i r e c t linkage between ANP and CHO i s d i f f i c u l t to measure due to the broad, global and a s s i s t i v e role that these nurses assume within an i n t e r d i s c i p l i n a r y collaborative environment. The e f f o r t s of nursing scholars to date have r e f l e c t e d a genuine urgency i n being able to a t t a i n further c l a r i t y about ANP and i t s influence on CHO. Although a wealth of l i t e r a t u r e exists that relates to the phenomena of in t e r e s t , minimal research-based l i t e r a t u r e i s available. In the push for c l a r i t y about ANP, l i t e r a t u r e r e f l e c t s attempts at d e f i n i t i o n s , descriptions, c h a r a c t e r i s t i c s , attributes and subroles. Literature related to ANP and i t s influence on CHO r e f l e c t s the early stages of nurses' attempts to l i n k t h e i r practice to outcomes of care. This approach i s further complicated by an era of ICP. Nurses and other health care 163 providers are questioning how any CHO can be d i r e c t l y linked to a s p e c i f i c provider and/or d i s c i p l i n e . No research-based l i t e r a t u r e asking nurses i n ANP to define and describe ANP i n r e l a t i o n to CHO was found. The exploratory descriptive method of q u a l i t a t i v e research was used for t h i s study. This method was p a r t i c u l a r l y suited to the question since there have not been indepth studies of the phenomena of inte r e s t (Brink & Wood, 1989), p a r t i c u l a r l y from a Canadian perspective. The researcher wanted to understand the d e f i n i t i o n of ANP and the rela t i o n s h i p of ANP on CHO from the perspectives of nurses i n ANP, within the B.C. health care environment. A purposive sample of Vancouver Island CNSs, employed i n a large hospital society, was chosen to p a r t i c i p a t e i n t h i s study. A l l participants who were approached for i n c l u s i o n consented to p a r t i c i p a t e . Seven participants of t h i s study, who met s p e c i f i c e l i g i b i l i t y c r i t e r i a , p a r t i c i p a t e d i n semi-structured interviews. A l l of the interviews, which were two to three one hour sessions with each participant, were audio-tape recorded and subsequently transcribed verbatim. Data analysis occurred concurrently with data c o l l e c t i o n . This q u a l i t a t i v e thematic analysis was done based on a n a l y t i c a l techniques and procedures i d e n t i f i e d by Strauss and Corbin (1990). Findings were c l a r i f i e d , elaborated upon and/or validated with participants to ensure accuracy, as well as 164 adding to the depth and richness of the data. There was not an available s p e c i f i c theory that could be linked with the phenomena of inter e s t and u t i l i z e d as a guide. The work of nursing scholars such as Fenton (1985), Benner (1984) and Calkin (1984), provided some conceptual background for t h i s study. A l l participants were very f a m i l i a r with, and c i t e d without prompting, the work of these nurses. Findings of t h i s study were presented according to three broad categories that resulted from thematic analysis. The f i r s t broad category related to d i f f i c u l t i e s i n c l e a r l y defining ANP. This category of data consisted of two components: i n i t i a l attempts at defining ANP and reasons for lack of c l a r i t y about i t . While participants were not able to provide a clear and concise d e f i n i t i o n of ANP, they were not at a l l concerned about t h i s and believed that they personally understood how t h e i r practice was that of ANP. They perceived the apparent lack of c l a r i t y about ANP as advantageous i n that i t allowed for the continued f l e x i b i l i t y that was required for ANP. They offered several reasons to explain the current vagueness associated with ANP such as role inconsistencies, imprecision regarding nursing, terminology changes and lack of time for r e f l e c t i o n about practice i n general. The second broad category related to the descriptors of ANP. This category consisted of two components: minimal requirement t r i a d of ANP and essential q u a l i t i e s of ANP. 165 Participants believed that there were three minimal requirements that were combined to provide the foundation for ANP: graduate education, c l i n i c a l s pecialty focus and research-based practice. Participants also i d e n t i f i e d f i v e essential q u a l i t i e s present i n ANP: global thinking, i n d i r e c t c l i n i c a l focus, a s s i s t i v e care delivery, e f f e c t i v e leadership and i n t e r d i s c i p l i n a r y collaboration. The t h i r d broad category related to p a r t i c i p a n t s ' ideas about a possible r e l a t i o n s h i p between ANP and CHO. This category consisted of three components: problems in a r t i c u l a t i n g CHO, communicating the r e l a t i o n s h i p between ANP and CHO, and the t h e o r e t i c a l problems i n l i n k i n g ANP with CHO. Participants recognized that measuring CHO was a f a i r l y new area of focus for health care providers i n B.C. They also recognized that the term CHO was understood from many perspectives and often did not involve the c l i e n t i n an active manner. Participants believed that nurses i n ANP influenced CHO i n an i n d i r e c t manner that was best explained through the use of detailed c l i n i c a l s t o r i e s . Such stories provided detailed c l i e n t - s p e c i f i c i l l u s t r a t i o n s of the application of ANP using a broad system perspective. Participants also i d e n t i f i e d t h e o r e t i c a l problems i n attempting to l i n k ANP with CHO, such as the i n d i r e c t r e l a t i o n s h i p that nurses i n ANP had with c l i e n t s , the differences i n t r y i n g to measure short term versus long term CHO, and the strong influence of other variables. In 166 pa r t i c u l a r , participants wondered how any CHO could be d i r e c t l y linked to any d i s c i p l i n e , l e t alone a s p e c i f i c provider, i n the current era of i n t e r d i s c i p l i n a r y collaboration. Participants valued ICP highly and thought that they had more d i r e c t access to and interacted with t h e i r colleagues i n other d i s c i p l i n e s very d i f f e r e n t l y than did st a f f nurses. Conclusions The research findings led to a number of conclusions about a d e f i n i t i o n of ANP and the relat i o n s h i p of ANP on CHO. These include: • ANP remains a term that i s not amenable to a clear and concise d e f i n i t i o n ; • nurses communicate about ANP through the use of detailed c l i n i c a l stories rather than d e f i n i t i o n s ; • the broad and vague nature of ANP i s valued i n that i t allows for unlimited f l e x i b i l i t y of the role as currently required i n health reform; • the a b i l i t y of nurses i n ANP to enact t h e i r roles i s strongly dependent upon the context of t h e i r practice; • an e x p l i c i t d e f i n i t i o n of ANP i s not a p r i o r i t y for nurses i n ANP. In fact, some believe that e f f o r t s to create such d e f i n i t i o n s could be counter-productive; • the s i g n i f i c a n t inconsistencies i n how nurses i n ANP enact t h e i r roles are viewed p o s i t i v e l y , as they allow for the unique personal and professional competencies 167 that nurses bring to ANP; • some nurses i n ANP tend not to have r e f l e c t i v e time to think, about terms such as ANP and CHO; • some nurses i n ANP believe that graduate education i s mandatory for ANP; • some nurses i n ANP believe that a nurse should be a c l i n i c a l expert p r i o r to graduate education for ANP; • some nurses i n ANP believe that graduate education for ANP should include a strong c l i n i c a l s pecialty focus; • some nurses i n ANP believe that research i s an important component of t h e i r role; • while there i s no consensus about the need for nursing or non-nursing graduate education for ANP, mentored c l i n i c a l experience i n graduate education i s thought to be c r u c i a l for nurses to develop into ANP; • some nurses i n ANP believe that ANP requires the a b i l i t y to think globally, that i s the a b i l i t y to translate i n d i v i d u a l c l i e n t scenarios into a whole or pattern, as well as bringing that whole or pattern to any in d i v i d u a l c l i e n t ; • some nurses i n ANP believe that t h e i r a b i l i t y to think globall y allow them to be proactive rather than reactive i n t h e i r practice; • some nurses i n ANP see t h e i r role as a s s i s t i v e to others i n order to enhance c l i e n t care; • some nurses i n ANP strongly support active involvement 168 of c l i e n t s i n determining meaningful CHO; • given current cost constraints, some nurses i n ANP are taking on more functions t y p i c a l l y associated with senior nursing administrators; • some nurses i n ANP strongly value i n t e r d i s c i p l i n a r y collaborative practice and recognize the contributions of a l l health care providers; and, • i t may not be possible to a r t i c u l a t e a d i r e c t rel a t i o n s h i p between ANP and CHO i n an i n t e r d i s c i p l i n a r y collaborative practice environment. Nursing Implications The findings of t h i s study have implications for graduate education, p o l i c y and administration as well as research. These w i l l now be presented. Graduate Education Participants of t h i s study believed that graduate education i s mandatory for ANP. However, as participants discussed and l i t e r a t u r e confirms, nurses i n ANP vary i n t h e i r support about the need for graduate education to be i n nursing. To date, t h i s issue remains contentious despite a lack of evidence that there are any differences i n the practice and outcomes of nurses i n ANP despite the f a c u l t y focus of t h e i r graduate studies. Of note, i n the interviews for t h i s study, although recognizing that there were only two participants with non-nursing graduate education, there were no noticeable differences i n how participants were able to 169 discuss ANP and describe t h e i r practice i n r e l a t i o n to CHO. Given the current era of ICP, discussions about the need for nursing versus non-nursing graduate education are very appropriate. Nurses, professional regulatory bodies and university educators need to consider how to best prepare nurses to assume r e s p o n s i b i l i t i e s for ANP and i t s influence on CHO. This i s p a r t i c u l a r l y important during health care reform. The above stakeholders need to determine and/or confirm concerns about the faculty of graduate study for ANP, p a r t i c u l a r l y i f a strong c l i n i c a l specialty focus and research expertise could be assured. Further dialogue about these issues w i l l a s s i s t i n determining whether current acceptance of non-nursing graduate education w i l l r e s u l t i n negative consequences for ANP and the science of nursing. Perhaps a primary graduate focus i n another fa c u l t y may be very useful i n an ICP environment es p e c i a l l y i f there was a strong l i n k with the nursing program to ensure some nursing courses as well as a mentored c l i n i c a l s p e c i a l i z a t i o n . These issues need to be debated, and i f required, appropriate changes should be made to graduate education. Nurses i n ANP believe that graduate education should include a strong c l i n i c a l specialty focus. Participants of t h i s study believed that nurses should be c l i n i c a l experts p r i o r to graduate education. The nursing community and educational i n s t i t u t i o n s have addressed the question of whether a nurse should be a c l i n i c a l expert p r i o r to graduate 170 education. However, as was noted i n chapter f i v e , nursing graduate educational programs vary i n t h i s requirement. If t h i s i s to continue, potential students need to make careful decisions about t h e i r selections for graduate education. They need to recognize that class discussions, assignments and other a c t i v i t i e s i n programs that do require c l i n i c a l experts may be very challenging to students without c l i n i c a l expertise. However, educators and students can further -develop creative i n d i v i d u a l ways to meet personal education goals. The i n d i v i d u a l student may require considerable additional e f f o r t s . Nurses i n ANP recognize the benefits of a mentored c l i n i c a l s pecialty focus during graduate education. Students and educators need to examine how c l i n i c a l practicums are structured and monitored i n order to ensure a mentored experience. Careful selection of preceptors who are keenly interested i n active p a r t i c i p a t i o n and partnership with students and educators i s c r i t i c a l . Strategies to ensure e f f e c t i v e communication between educators and preceptors can be strengthened, such as orientation, mentoring the mentor by faculty, and j o i n t evaluation of students. Nurses i n ANP seem to communicate about t h e i r practice, not through d e f i n i t i o n s , but through the use of detailed c l i n i c a l s t o r i e s . This approach can be further developed during graduate education through incorporation of c l i n i c a l s tories into assignments and class discussions. Students can 171 question preceptors about how they a r t i c u l a t e t h e i r practice with administrators and peers i n order to change and advance nursing practice. They can also engage i n discussions about a r t i c u l a t i n g the rel a t i o n s h i p of ANP on CHO. Outcomes from these can a s s i s t novice nurses i n ANP to become more a r t i c u l a t e about t h e i r practice and i t s influence on CHO. Nurses i n ANP value the f l e x i b i l i t y associated with t h e i r r o l e . This f l e x i b i l i t y was believed to be a factor that allowed nurses i n ANP to respond to changes inherent i n health reform. During graduate education, students should be exposed to a variety of nurses i n ANP and observe and question them about t h i s aspect of t h e i r p r a c t i c e . They could discuss the p o s i t i v e and negative effects of the d i v e r s i t y and f l e x i b i l i t y . Students could then have discussions with others about whether f l e x i b i l i t y was a p o s i t i v e aspect of ANP. Participants i n t h i s study believe that r e f l e c t i v e time i s required for discussing terms l i k e ANP and CHO. However, in busy day-to-day practice t h i s r e f l e c t i v e time i s not re a d i l y available. During graduate education, students regularly engage i n r e f l e c t i v e time i n order to prepare for class discussions and assignments. Graduate studies could be a platform to ensure that r e f l e c t i v e time i s b u i l t into practicums. Graduate nursing students and preceptors often engage i n r e f l e c t i v e thinking and discussions but perhaps other nurses could also p a r t i c i p a t e . Educators and students 172 could also promote the o v e r a l l benefits of the proactive approach of ANP which can be further developed by taking time for r e f l e c t i o n of practice. These strategies could provide a foundation for nurses i n ANP to believe that r e f l e c t i v e time i s mandatory for ANP and not a luxury. Nurses i n ANP strongly value research as an important component of t h e i r r o l e . Many nursing graduate programs do include a research course and the conduct of a thesis as a requirement. Others do not. Non-nursing f a c u l t i e s also vary i n t h e i r offerings of research courses. These inconsistencies influence the competencies of nurses i n ANP related to research. Nurses, professional regulatory bodies and educators need to examine the appropriate role for master's prepared nurses i n the conduct of research. The question as to whether c l i n i c a l l y based graduate education should include a research thesis experience also needs to be addressed. Although research i s generally recognized as an important component of ANP, participants of t h i s study believed they could best contribute to research by partnering with doctorally prepared nurses. Participants also believed that doing research accounted for the smallest proportion of t h e i r time i n t h e i r o v e r a l l practice, although research u t i l i z a t i o n permeated t h e i r practice. It i s important to r e v i s i t the general expectation of independent research on the part of a master's prepared nurse i n ANP. 173 F i n a l l y , nurses i n ANP highly value and inter a c t d i f f e r e n t l y with colleagues from other d i s c i p l i n e s than do s t a f f nurses. Currently, many nursing graduate programs are s o l e l y focused on nursing and r a r e l y involve other d i s c i p l i n e s through readings or class p a r t i c i p a t i o n . Students and educators need to question a f a c u l t y s p e c i f i c approach to graduate education. This i s p a r t i c u l a r l y important when a l l levels of health p o l i c y decision makers are suggesting ICP as a pot e n t i a l answer to current fragmentation, gaps and duplication i n health care. Students and educators could experiment with i n t e r d i s c i p l i n a r y education for courses early i n programs and at various stages throughout graduate education. During c l i n i c a l practicums, students need to observe and discuss how preceptors encourage ICP and how they perceive that influences CHO. Students could also involve c l i e n t s i n these discussions. Policy And Administration Nurses, health p o l i c y decision makers and administrators need to be more cognizant of the valuable contribution that nurses i n ANP can make to health reform. Participants of t h i s study described s i g n i f i c a n t contributions that they were making to i n d i v i d u a l , as well as o v e r a l l c l i e n t care within t h e i r organizations. Although participants alluded to being involved i n care with external agencies, t h i s seemed to be a minor focus. Findings from t h i s study reinforce that nurses i n ANP 174 have many of the competencies that could p o s i t i v e l y contribute to the enhancements of outcomes for c l i e n t s , i n t e r d i s c i p l i n a r y health care providers, as well as organizations. However, t h i s potential contribution does not seem to be promoted, recognized or sought. For example, i n current debates between "hospital and community" there i s a strong e f f o r t to determine "what nurses" should be providing care and i n "what context." Community nurses a c t i v e l y discourage hospital nurses from p r a c t i s i n g "outside" the hospital walls and vice-versa. However, i n the case of ANP, the health care community needs to ask i f t h i s i s appropriate. In many instances, nurses i n ANP should monitor and influence care across delivery settings more d i r e c t l y . Although i s o l a t e d examples of t h i s are occurring, i t i s not consistently encouraged and/or sanctioned. Nurses i n ANP could make s i g n i f i c a n t contributions i n discussions with health p o l i c y decision makers, including representatives from Community Health Councils and Regional Health Boards, concerning l o c a l and regional health care needs/plans. Participants of t h i s study described t h e i r increasing administrative focus. The outcomes of increased administrative r e s p o n s i b i l i t i e s for nurses i n ANP need further study. In the meantime, administrators need to ca r e f u l l y consider reasons for t h i s practice. If nurses i n ANP are educated to a c t i v e l y p a r t i c i p a t e with others i n order to improve c l i e n t care within an organization, administrators 175 need to determine i f that goal w i l l be met with nurses i n ANP taking on more of an administrative r o l e . It i s recognized that t h i s action may be the re s u l t of a " f i l l the gap" measure due to cost constraints and down-sizing of middle nursing management. However, administrators and nurses i n ANP need to c a r e f u l l y monitor how a decreasing focus on c l i e n t care w i l l impact c l i n i c a l practice within the organization. On the other hand, perhaps t h i s increased administrative focus could be viewed as an appropriate compromise that keeps ANP a l i v e during current times of economic r e s t r a i n t . Lastly, the nurse participants i n t h i s study p o s i t i v e l y view and encourage ICP. At the present time, there i s a heightened inte r e s t i n ICP with many d i s c i p l i n e s fearing yet others supporting i t . Nurses i n ANP can make use of t h i s i n t e r e s t and model to others how to a c t i v e l y p a r t i c i p a t e i n ICP. Nurses i n ANP can more f u l l y communicate t h e i r practice with others and encourage discussions about new and creative ways to improve CHO with an integrated care delivery mechanism. Research Findings from t h i s study can be used to i d e n t i f y further research topics related to ANP. The on-going exhaustive e f f o r t s to c l e a r l y define ANP need to be questioned. Nursing scholars s t r i v e for c l a r i t y about ANP because they know that these nurses make s i g n i f i c a n t and valuable contributions to 176 c l i e n t care, nursing practice and o v e r a l l health care. The nurse participants i n t h i s study share these views. However, d e f i n i t i o n s of ANP may not prove f r u i t f u l i n furthering the cause of ANP. Instead of t r y i n g to define ANP, e f f o r t s can be put toward applying current v i s i o n statements about i t toward meeting organizational, regional and p r o v i n c i a l health reform goals. Because nurses i n ANP do not f i n d i t important to spend energy t r y i n g to define a term equated with t h e i r practice, they caution against such e f f o r t s . Perhaps the above approach, related to v i s i o n statements, would enable nursing scholars and nurses i n ANP to be able to e f f e c t i v e l y communicate the valuable contribution they know nurses i n ANP make. There needs to be a clear and concise way to describe ANP so p o l i c y makers, government, other d i s c i p l i n e s and even nurses come to understand what ANP i s and are able to more f u l l y value i t . Participants i d e n t i f i e d some minimal requirements for ANP. Currently there a many nurses using a t i t l e linked with ANP from a variety of programs and backgrounds. Although others are a c t i v e l y exploring t h i s , i t may be useful to come to a consensus on minimal requirements for ANP. Research related to minimal requirements could explore any differences, and the resultant implications of how nurses i n ANP enact t h e i r roles, dependent upon whether they have nursing or non-nursing graduate education. Another question 177 worthy of further study relates to any differences between nurses who are c l i n i c a l experts versus those with minimal c l i n i c a l experiences p r i o r to graduate education. In t h i s study, participants were a l l from one major hospital society. Participants were quite consistent i n t h e i r approaches to the phenomena of in t e r e s t . It would be b e n e f i c i a l to investigate how nurses i n ANP i n other Canadian f a c i l i t i e s and c i t i e s describe t h e i r practice. A study of nurses i n ANP i n other centres might illuminate further the issues i n t r y i n g to define ANP and describe t h i s practice i n r e l a t i o n to CHO. Only two participants of t h i s study had undertaken non-nursing graduate education. Although generalizations cannot be made on the basis of these accounts, i t was obvious that both of these participants had made concerted e f f o r t s to ensure a c l i n i c a l s pecialty focus during t h e i r graduate studies. It would be useful to determine why nurses undertake non-nursing graduate education p a r t i c u l a r l y i f they wish to be a c t i v e l y involved i n nursing. Another question i s to determine the implications for ANP i f a nurse i s a graduate of a non-nursing graduate program that did not include a c l i n i c a l s pecialty focus. Participants of t h i s study attempted to define ANP and describe t h e i r practice i n r e l a t i o n to CHO. It would be most useful to follow these descriptions by observing nurses i n ANP as they conduct t h e i r practice. These observations would 178 shed more l i g h t on ANP. Nurses i n ANP strongly support c l i e n t active involvement i n decision making about t h e i r own care. These nurses also recognize the need for c l i e n t s to i d e n t i f y meaningful CHO from t h e i r own perspectives. Further research related to these areas could be of assistance i n the debates about health reform and evaluation of services both s p e c i f i c a l l y and generally. Perhaps asking c l i e n t s to a r t i c u l a t e the influence of nurses and nursing care on t h e i r CHO could a s s i s t i n our understanding of how to separate out the influence of nursing on CHO i n an ICP environment. It may also a s s i s t health p o l i c y decision makers, health care providers and nurses i n ANP to determine, j u s t i f y and/or eliminate programs that either r e s u l t i n p o s i t i v e or negative CHO. Lastly, the whole issue of the relat i o n s h i p of ANP to CHO requires further research. Participants described the complexities that they had i n t r y i n g to make a t h e o r e t i c a l linkage between t h e i r practice and CHO e x p l i c i t . Although participants were not accustomed to doing so, they described i n d i r e c t relationships between ANP and CHO. Although there i s general support for ANP, f a i l u r e to more c l e a r l y a r t i c u l a t e i t i n r e l a t i o n to CHO could prove to be problematic. Further questions need to be asked about the contribution that nurses i n ANP make to CHO, p a r t i c u l a r l y i n ICP environment. Perhaps the emphasis on c l i e n t s as 179 individuals has been problematic. Participants described the proactive, global perspective they brought to c l i e n t and ov e r a l l health care. An expansion on the contribution that nurses i n ANP make to an organization or to populations as c l i e n t could a s s i s t i n further understanding of how t h i s p o s i t i v e l y , a l b e i t i n d i r e c t l y , influences CHO. F i n a l l y , how other nurses i n ANP eg., nurse p r a c t i t i o n e r s address these issues could be useful i n e f f o r t s to further develop t h i s role i n Canada. Concluding Remarks In conclusion, t h i s report has outlined how CNSs define ANP and describe t h e i r practice i n r e l a t i o n to CHO. At the beginning of t h i s study, the researcher assumed that nurses whose role f e l l under the umbrella of ANP would be able to f a i r l y e a s i l y a s s i s t i n a r t i c u l a t i n g a d e f i n i t i o n of ANP as well as have an accurate sense of how t h e i r practice influenced CHO. This study has be an il l u m i n a t i n g experience that may have raised more questions than answers to the phenomena of in t e r e s t . However, i t i s the researcher's hope that despite the complexities associated with understanding ANP, nurses and others w i l l continue to recognize the valuable and s i g n i f i c a n t contributions that these nurses make to health care. Nurses, educators and researchers need to reassess the approach to understanding and describing ANP. 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Speci f i c name, t i t l e and address of potential participant Dear (name of CNS); As you may know, I am a student i n the Master's of Nursing Program at the University of B r i t i s h Columbia (UBC). I would l i k e to e n l i s t your help as a participant i n my proposed research that w i l l be conducted for the purposes of completing thesis research. The proposed research i s a q u a l i t a t i v e study related to advanced nursing practice and c l i e n t health outcomes. As you are aware, during times of economic r e s t r a i n t as i s facing our health care system now, health p o l i c y and economic decision makers may question your role as a C l i n i c a l Nurse S p e c i a l i s t . The outcome of t h i s study w i l l contribute to a knowledge base related to a clear d e f i n i t i o n of advanced nursing practice and how t h i s practice relates or contributes to c l i e n t health outcomes. I would l i k e to i n v i t e you to p a r t i c i p a t e i n t h i s research. Your involvement would include time for interviews, estimated to be a maximum of three, one hour interviews. This timing and frequency w i l l be determined based on our discussions and the subsequent findings of the interviews. The location and timing of these interviews can be mutually determined to accommodate your busy work schedule. Your privacy and c o n f i d e n t i a l i t y would be maintained. You would of course be free to withdraw from the proposed research at any time without jeopardy and would be free to refuse to discuss any s p e c i f i c topics. 195 If you have any questions and/or i f you would l i k e to volunteer to p a r t i c i p a t e i n the proposed research please contact me at home xxx-xxxx (machine), at work xxx-xxxx (phone) or by fax (xxx-xxxx). If I have not heard from you i n two weeks I w i l l give you a phone c a l l to ask you about your p a r t i c i p a t i o n decision and to answer any questions or issues that you may have. Dr. Sal l y Thorne, Chair of my Thesis Committee, i s available to answer any questions as well, and she can be contacted at UBC, telephone # xxx-xxxx. Thank you for your consideration and I look forward to hearing from you. Sincerely, Katherine Cox. APPENDIX B ELIGIBILITY CRITERIA AND DEMOGRAPHICS 1. Are you currently employed as a CNS? yes no 2. Have you been employed as a CNS for a minimum of one year? yes no 3. Do you have a Master's degree? yes no 4. What faculty i s your degree in? 5. Demographics: Age Gender F M Years employed as CNS Specialty 197 APPENDIX C Research Question: "How do C l i n i c a l Nurse S p e c i a l i s t s define advanced nursing practice and how do they describe t h e i r practice i n r e l a t i o n to c l i e n t health outcomes?" PROMPTS 1. Demographics, previous professional history, length of time employed as a C l i n i c a l Nurse S p e c i a l i s t and i n what department or area, what faculty master's degree i s i n . 2. Please t e l l me something about your practice. 3. So i t sounds l i k e t h i s could be c a l l e d "advanced" practice i n nursing. 4. It sounds l i k e you are d i f f e r e n t i a t i n g between expert practice and advanced nursing practice. 5. What you just noted there i s a c l i e n t health outcome, so to speak. I am interested i n that... 6. How do.you define c l i e n t health outcomes? So you seem to be making a l i n k to the immediate e f f e c t of your care on the c l i e n t ? Is there any benefit to examining or exploring long term effects? 7. You seem to be making a l i n k between advanced nursing practice and c l i e n t health outcomes. Can you elaborate on that...? 8. How do you see your practice as influencing c l i e n t health outcomes? 9. It sounds l i k e you think that things you do a f f e c t the client...(pause). Adapted from Patterson and Haddad, 1992. 198 APPENDIX D CONSENT FOR INTERVIEW In signing t h i s document, I am giving my consent to be interviewed by Katherine Cox, a Master of Science i n Nursing student from the University of B r i t i s h Columbia. I understand that I w i l l p a r t i c i p a t e i n data c o l l e c t i o n for research i n a nursing thesis. The research area of i n t e r e s t i s advanced nursing practice and c l i e n t health outcomes and w i l l involve one to three audio-taped interviews of approximately one hour i n length. There w i l l not be any f i n a n c i a l renumeration for any of the p a r t i c i p a n t s . I am aware that the tapes used during the interview w i l l be transcribed for the purposes of analysis by Katherine. The tape may be transcribed by a t y p i s t but the only other person (other than Katherine and the t y p i s t ) who may l i s t e n to them w i l l be three of Katherine's professors. I am assured of my c o n f i d e n t i a l i t y , i n that the tape and transcriptions w i l l not i d e n t i f y me personally. I understand that I was selected to p a r t i c i p a t e i n t h i s study because of my inte r e s t i n advanced nursing practice and the fact that I am employed as a C l i n i c a l Nurse S p e c i a l i s t . I have met the participant e l i g i b i l i t y c r i t e r i a as they have been explained to me by Katherine. I have been informed that the interview i s e n t i r e l y voluntary, and that at any point during the interview I can refuse to discuss any s p e c i f i c topics, and i n fact, can terminate the interview without j eopardy. This study has the potential to contribute to a d e f i n i t i o n of advanced nursing practice and the evaluation of how t h i s practice affects c l i e n t health outcomes, which to date i s lacking. I am aware that I am free to contact Katherine for any questions related to t h i s process or study and her telephone number i s on the bottom of t h i s consent. I understand that Dr. Sa l l y Thorne (Thesis Committee Chair: xxx-xxxx) or Dr. Anita Molzahn (xxx-xxxx), are the nursing faculty to contact i f I have any questions about t h i s process or study. I also understand that Katherine may contact me for more information i n the future. In addition, Katherine w i l l share the findings of t h i s study with me i f I am interested. Date Respondent's signature Acknowledgement that the participant has been given a copy of the consent form ( w i l l be / once signed by both the participant and researcher and a copy given to the p a r t i c i p a n t ) . 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