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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 H o s p i t a l , 1973 B.S.N., U n i v e r s i t y o f 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 o f Nursing  We accept t h i s t h e s i s as conforming t o the / r e q u i r e d 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  10:37  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  DE-6 (2/88)  QfMbll,  Ml?  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  P r a c t i c e and Describe T h e i r P r a c t i c e i n R e l a t i o n t o C l i e n t Health Outcomes Advanced n u r s i n g p r a c t i c e (ANP) i s a term w e l l u t i l i z e d i n the l i t e r a t u r e and i n n u r s i n g d i s c u s s i o n s , yet i s not c l e a r l y understood. Recently, n u r s i n g authors have been s t r o n g l y s u p p o r t i n g the need t o develop a c l e a r d e f i n i t i o n of ANP. The c u r r e n t focus on outcome measures throughout h e a l t h care has prompted e f f o r t s t o examine d i s c i p l i n e s p e c i f i c , as w e l l as broad i n f l u e n c e s on c l i e n t h e a l t h outcomes (CHO). The need f o r nurses i n ANP to be able to a r t i c u l a t e t h e i r p r a c t i c e i n r e l a t i o n t o CHO has been heightened d u r i n g the l a s t few y e a r s . This i s due to f a c t o r s such as the examination of v a r i o u s n u r s i n g r o l e s d u r i n g times of d e c r e a s i n g h e a l t h care resources i n h e r e n t i n h e a l t h reform. The purpose of t h i s study was to explore and d e s c r i b e how C l i n i c a l Nurse S p e c i a l i s t s (CNSs) d e f i n e ANP and d e s c r i b e t h e i r p r a c t i c e i n r e l a t i o n t o CHO. An e x p l o r a t o r y d e s c r i p t i v e q u a l i t a t i v e methodology was used f o r t h i s study. Data were c o l l e c t e d through s e m i - s t r u c t u r e d , audio-taped i n t e r v i e w s with 6 female and 1 male CNSs who had a master's degree and had been i n t h e i r r o l e f o r a mean of 6 . 3 y e a r s . From the thematic a n a l y s i s of the data, three broad c a t e g o r i e s or d e s c r i p t o r s t h a t were common to p a r t i c i p a n t s were i d e n t i f i e d and developed. Together these t h r e e broad c a t e g o r i e s r e p r e s e n t p a r t i c i p a n t attempts to d e f i n e ANP and d e s c r i b e t h e i r p r a c t i c e i n r e l a t i o n t o CHO. The f i r s t category r e l a t e s to d i f f i c u l t i e s i n c l e a r l y d e f i n i n g ANP. The second category r e l a t e s to d e s c r i p t o r s of ANP. The t h i r d category r e l a t e s to p o s s i b l e r e l a t i o n s h i p between ANP and CHO. These f i n d i n g s r e v e a l e d t h a t ANP i s a term t h a t i s broad and vague i n nature and not amenable to a c l e a r and c o n c i s e definition. Furthermore, i t was found t h a t i t may not be p o s s i b l e t o 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 c o l l a b o r a t i v e p r a c t i c e environment. The i m p l i c a t i o n s f o r graduate education, p o l i c y and a d m i n i s t r a t i o n as w e l l as r e s e a r c h are i d e n t i f i e d i n l i g h t of r e s e a r c h f i n d i n g s .  Ill  TABLE OF CONTENTS Chapter One -  Introduction  Introduction Background and S i g n i f i c a n c e of t h e Problem Conceptual Background Statement of t h e Problem Purpose of t h e Study. D e f i n i t i o n of Terms Assumptions Limitations Chapter Summary  1 1 5 10 11 11 13 13 14  Chapter Two - L i t e r a t u r e Review Introduction Advanced N u r s i n g P r a c t i c e Research-Based A r t i c l e s R e l a t e d t o Advanced N u r s i n g Practice Other L i t e r a t u r e R e l a t e d t o Advanced N u r s i n g P r a c t i c 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 H e a l t h Outcomes Research-Based A r t i c l e s R e l a t e d t o 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 H e a l t h Outcomes Other L i t e r a t u r e R e l a t e d t o 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 H e a l t h Outcomes F i n a l Word on the L i t e r a t u r e Review Chapter Summary  15 16 18 21 24 26 28 31 32  Chapter Three - Methodology Introduction Research Design S e l e c t i o n of P a r t i c i p a n t s Selection C r i t e r i a . . . . Procedure f o r Recruitment of P a r t i c i p a n t s C h a r a c t e r i s t i c s of P a r t i c i p a n t s Data C o l l e c t i o n Procedures Data A n a l y s i s E t h i c a l Considerations Chapter Summary  33 33 34 35 35 37 38 41 46 47  Chapter Four - F i n d i n g s Introduction D i f f i c u l t i e s i n C l e a r l y D e f i n i n g Advanced N u r s i n g Practice I n i t i a l Attempts a t D e f i n i n g Advanced N u r s i n g P r a c t i c e Broad and Vague Term Lack of Concern Cautions Around T r y i n g t o C l e a r l y Define  48 52 52 53 55 57  iv Reasons f o r Lack of C l a r i t y About Advanced N u r s i n g Practice 59 Role I n c o n s i s t e n c i e s 59 Imprecision Regarding Nursing 60 Terminology Changes 62 Lack of Time f o r R e f l e c t i o n 63 D e s c r i p t o r s of Advanced Nursing P r a c t i c e 66 •Minimal Requirement T r i a d of Advanced N u r s i n g Practice 66 Graduate Education . 67 C l i n i c a l S p e c i a l t y Focus 71 Research-Based P r a c t i c e 77 E s s e n t i a l Q u a l i t i e s of Advanced Nursing P r a c t i c e 80 Global.Thinking.. .... 80 I n d i r e c t C l i n i c a l Focus 86 A s s i s t i v e Care D e l i v e r y 92 E f f e c t i v e Leadership 96 Interdisciplinary Collaboration 100 P o s s i b l e R e l a t i o n s h i p Between Advanced Nursing P r a c t i c e and C l i e n 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 R e l a t i o n s h i p Between Advanced Nursing P r a c t i c e and C l i e n t Health Outcomes I l l Detailed C l i n i c a l Stories I l l Broad System P e r s p e c t i v e 115 T h e o r e t i c a l Problems i n L i n k i n g Advanced N u r s i n g P r a c t i c e With C l i e n t Health Outcomes 118 Long Term Versus Short Term 118 Strong I n f l u e n c e of Other V a r i a b l e s 120 Chapter Summary 128 Chapter F i v e - D i s c u s s i o n o f F i n d i n g s Introduction Issues R e l a t e d t o a D e f i n i t i o n of Advanced N u r s i n g Practice Support f o r Advanced Nursing P r a c t i c e Remaining a Broad and Vague Term. . . G l o b a l T h i n k i n g as an E s s e n t i a l Q u a l i t y Minimal Requirement T r i a d Graduate Education and Advanced N u r s i n g P r a c t i c e Advanced Nursing P r a c t i c e and I n t e r d i s c i p l i n a r y Collaboration Chapter Summary  130 131 132 138 141 146 151 159  Chapter S i x - Summary, C o n c l u s i o n s and I m p l i c a t i o n s Summary Conclusions Nursing I m p l i c a t i o n s Graduate Education P o l i c y and A d m i n i s t r a t i o n  162 166 168 168 173  V  Research  175  Concluding Remarks  179  References  181  Appendix Appendix Appendix Appendix  A B C D  -  L e t t e r of I n v i t a t i o n t o P a r t i c i p a n t s E l i g i b i l i t y C r i t e r i a and Demographics Prompts Consent f o r Interview  194 19 6 197 198  1 CHAPTER ONE INTRODUCTION Advanced n u r s i n g p r a c t i c e (ANP) i s a term u t i l i z e d throughout n u r s i n g l i t e r a t u r e and i n d i s c u s s i o n s y e t i s p o o r l y understood.  Over the course of the l a s t few y e a r s ,  t h e r e has been a heightened  i n t e r e s t by h e a l t h p o l i c y  d e c i s i o n makers and funders t o evaluate outcomes of h e a l t h care p r a c t i c e s .  T h i s i n t e r e s t has been prompted by c u r r e n t  h e a l t h care expenditures,  gaps i n primary  h e a l t h care and  awareness t h a t some h e a l t h care p r o f e s s i o n a l s , such as nurses,  a r e not able t o p r a c t i s e t o t h e i r f u l l  & Cox, 1993; M i n i s t r y of Health, Nurse S p e c i a l i s t s under the umbrella Columbia  1993; Roch 1992).  (CNSs) are nurses of ANP.  scope (Henning Clinical  r e c o g n i z e d as p r a c t i s i n g  Consultants- from the B r i t i s h  (B.C.) M i n i s t r y of Health, i n t e r - m i n i s t e r i a l h e a l t h  p o l i c y d e c i s i o n makers, p r o f e s s i o n a l r e g u l a t o r y bodies and n u r s i n g authors, g e n e r a l l y express a c l e a r understood  concern  t h a t t h e r e i s not  d e f i n i t i o n of ANP and how t h i s p r a c t i c e  l i n k s with c l i e n t h e a l t h outcomes (CHO). Background and S i g n i f i c a n c e o f the Problem The term ANP i s u t i l i z e d e x t e n s i v e l y i n n u r s i n g d i s c u s s i o n s and i n the l i t e r a t u r e , y e t nurses  a r e not a b l e t o  c l e a r l y a r t i c u l a t e what i t i s ( C a l k i n , 1984; Canadian Nurses A s s o c i a t i o n , 1992; Fenton, 1985; Haddad, 1992a; Schaefer & Lucke, 1990).  Despite t h i s l a c k of c l a r i t y , CNSs a r e  r e c o g n i z e d and i d e n t i f i e d as conducting ANP (American Nurses  2 A s s o c i a t i o n , 1985; 1985;  Canadian Nurses A s s o c i a t i o n , 1992;  Sparacino, 1992;  Spross & Baggerly, 1989).  nurses are a l s o r e c o g n i z e d as advanced  Fenton,  Other  nurse p r a c t i t i o n e r s ,  f o r 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 r e g i s t e r e d nurse a n e s t h e t i s t s Kjervik,  (Inglis &  1993).  In Canada, CNSs are g e n e r a l l y educated at the l e v e l and p r a c t i c e i n a v a r i e t y of s e t t i n g s t h a t hospitals, c l i n i c s , practice.  community h e a l t h u n i t s and  master's  include:  independent  CNSs are a c t i v e members of i n t e r d i s c i p l i n a r y teams  attempting t o meet c u r r e n t gaps i n primary h e a l t h c a r e . CNS  r o l e i s q u i t e w e l l e s t a b l i s h e d i n North American  care systems.  health  In Canada, t h e r e are approximately 220 CNSs  ( J e s s i e Mantle, p e r s o n a l communication, In B.C.,  The  September 7,  1993).  t h e r e are approximately 50 CNSs employed p r i m a r i l y  i n h o s p i t a l s i n the Lower Mainland and V i c t o r i a .  At the time  of t h i s r e s e a r c h , t h e r e were 3 community h e a l t h CNSs i n  B.C.:  2 employed i n the Vancouver Health Department and 1 i n Community Home Care N u r s i n g S e r v i c e s i n the M i n i s t r y of Health. During times of economic r e s t r a i n t , t h e r e i s a heightened need f o r nurses t o d e f i n e ANP develop a model of t h i s p r a c t i c e Nurses who  are i n ANP  and  subsequently  (Spross & Baggerly,  1989).  r o l e s are p a i d s a l a r i e s h i g h e r than  other nurses, and t h e r e f o r e are viewed as " c o s t i n g " the h e a l t h care system  "more" than other nurses  (Brunk,  1992;  3 Sparacino, 1992).  D e s p i t e s a l a r y i s s u e s , numerous a r t i c l e s  i d e n t i f y b e n e f i t s of employing advanced n u r s i n g p r a c t i t i o n e r s such as CNSs (Brunk, 1992; G i r o u a r d , 1989; Hawkins & Thibodeau, 1989).  Authors argue t h a t the system wide c l i e n t  care b e n e f i t s r e s u l t i n o v e r a l l c o s t savings t o the h e a l t h care system ( F r a l i c ,  1988; Gournic, 1989; K o e t t e r s ,  1989).  Despite these b e n e f i t s , - n u r s i n g r o l e s such as those of CNSs are b e i n g examined p a r t i c u l a r l y d u r i n g times of h e a l t h care budget crunches.  There i s a growing t r e n d t h a t CNSs are  b e i n g asked t o take on more a d m i n i s t r a t i v e i n t h e i r v a r i o u s agencies. the CNS  responsibilities  T h i s has the p o t e n t i a l t o spread  "too t h i n " or cause a l o s s of the c l i n i c a l  in their overall The CNS  emphasis  practice.  r o l e w i l l continue t o be c h a l l e n g e d as program  a d m i n i s t r a t o r s and managers are f o r c e d t o engage i n i n c r e a s i n g l y c o s t - e f f e c t i v e approaches t o h e a l t h 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 t o c l e a r l y a r t i c u l a t e and demonstrate the competencies skills, T h i s may  (knowledge,  a t t i t u d e s and judgements), i n h e r e n t i n t h e i r  roles.  a s s i s t administrators/managers t o continue  j u s t i f i c a t i o n and p o t e n t i a l expansion i n the employment of nurses i n ANP  (Spross & Baggerly, 1989).  C u r r e n t l y i n the B.C. i n t e r e s t i n e x p l o r i n g CHO  h e a l t h care system, t h e r e i s due t o an i n c r e a s e d focus on  self  care, h e a l t h promotion, c l i e n t advocacy and c o n t r a c t s between  c l i e n t s and p r o v i d e r s .  The  need f o r c o s t - e f f e c t i v e h e a l t h  care p r a c t i c e s , p l u s the a p p r o p r i a t e use of h e a l t h care p r o v i d e r s , have become c r i t i c a l concerns ( M i n i s t r y of 1993;  Seaton, 1991).  shift",  Health,  With the c u r r e n t " h o s p i t a l to community  i n t e r - m i n i s t e r i a l s t a f f are q u e s t i o n i n g "do we  more nurses  i n ANP?" and  "can nurses  i n ANP  need  demonstrate the  impact t h a t t h e i r p r a c t i c e has on CHO?" Minimal r e s e a r c h has been done with CNSs t o examine t h e i r a c t u a l p r a c t i c e (Amos-Taylor & E l b e r s o n , Sparacino,  1986).  Various n u r s i n g r e s e a r c h e r s have  i d e n t i f i e d i n t e r e s t i n examining ANP p e r s p e c t i v e ( B e e c r o f t , 1992; & Lucke, 1990).  1989;  from a q u a l i t a t i v e  Brown & Waybrant, 1988;  L i m i t e d e f f o r t s have been made to  Schaefer explore  the r i c h , d i r e c t , and unique c o n t r i b u t i o n t h a t nurses make to the h e a l t h outcomes of c l i e n t s .  Although  can  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 t o determine the e f f e c t i v e n e s s of these  on  c l i e n t l i f e s t y l e and h e a l t h (Brown & Waybrant, 1988), as w e l l as other outcome measures. I t was ANP,  the r e s e a r c h e r ' s b e l i e f t h a t CNSs, as nurses  d i d p o s i t i v e l y and  s i g n i f i c a n t l y i n f l u e n c e CHO  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 I t was  a l s o the r e s e a r c h e r ' s b e l i e f t h a t nurses  to maximize a c c o u n t a b i l i t y , and  continue and grow, two  somehow,  literature. i n ANP  do much to shape h e a l t h care d u r i n g h e a l t h reform. f o r nurses  in  f o r ANP  areas were worthy of f u r t h e r  could  In order to  5 e x p l o r a t i o n : nurses d e s c r i b i n g how  i n ANP  d e f i n i n g t h e i r p r a c t i c e and  i t r e l a t e s to Conceptual  CHO. Background  A s p e c i f i c theory or framework t h a t c o u l d c l e a r l y u t i l i z e d as a guide f o r t h i s study was Although  not  available.  t h e r e e x i s t e d an e x t e n s i v e amount of n u r s i n g  l i t e r a t u r e r e l a t e d to ANP  and  some with r e g a r d to CHO,  had been no comprehensive, systematic p e r s p e c t i v e of t h i s r e s e a r c h .  phenomena of  there  study done from the  Therefore,  e x p l o r a t o r y - d e s c r i p t i v e r e s e a r c h was  qualitative  a p p r o p r i a t e f o r the  interest.  There were t h r e e w e l l known n u r s i n g l e a d e r s developed  be  " t h e o r i e s " r e l a t e d to expert and ANP,  who namely  P a t r i c i a Benner (1984), Mary Fenton (1985) and Joy C a l k i n (1984).  Although  the work of these n u r s i n g s c h o l a r s d i d not  provide a s p e c i f i c s t r u c t u r a l  "theory"  f o r t h i s study, i t  formed both a b a s i s and a r a t i o n a l e f o r f u r t h e r study of the l i n k between ANP  and  CHO.  Benner (1984) conducted r e s e a r c h u s i n g an  interpretive  method, s p e c i f i c a l l y t h a t of hermeneutic phenomenology, i n her book From Novice  to Expert,  and,  i d e n t i f i e s f i v e l e v e l s of  p r o f e s s i o n a l n u r s i n g competency i n c l i n i c a l p r a c t i c e , namely: novice, advanced beginner,  competent, p r o f i c i e n t and  expert.  The h i g h e s t l e v e l of p r o f e s s i o n a l competency i s "expert." Although  expert p r a c t i c e has r e c e i v e d e x t e n s i v e s c r u t i n y  p r i m a r i l y because of Benner's work, what i s not c l e a r i s i f  6 t h e r e i s an i m p l i c a t i o n t h a t expert ANP or whether ANP i s a s i x t h  practice  i s the same as  level?  Benner began t o use the term ANP but does not d i f f e r e n t i a t e expert from advanced p r a c t i c e .  Often t h e r e i s  the use of the term "expert" i n c o n j u n c t i o n w i t h  "advanced,"  such as, the expert p r a c t i t i o n e r has not always been an e x p e r t . The nurse e n t e r i n g practice,, l i k e the person l e a r n i n g t o f l y an a i r p l a n e , r e q u i r e s a l l the guidance p o s s i b l e t o a v o i d mistakes so t h a t p a t i e n t s and nurses a l i k e s u r v i v e long enough t o develop advanced s k i l l s (p. 20) An a d d i t i o n a l example: "the exemplars taken from expert p r a c t i c e demonstrate the n o t i o n of good and the knowledge embedded i n advanced  l e v e l s of p r a c t i c e "  (Benner, 1989,  p. 21) . Benner's use of "exemplars" t o support her c o n c e p t u a l i z a t i o n s i s w e l l known.  She a l l u d e s t o the l i n k of  expert p r a c t i c e and CHO by p u b l i s h i n g only those  exemplars  "where the nurse made a p o s i t i v e d i f f e r e n c e i n the p a t i e n t ' s outcome" (Benner, 1984, p. x v i i ) . only immediately r e c o g n i z a b l e CHO.  These exemplars  illustrate  Benner's work does not  address long term CHO t h a t may d i r e c t l y r e s u l t from any of the f i v e l e v e l s of n u r s i n g competencies, nor does i t c o n s i d e r whether t h e r e may be d i f f e r e n c e s i n these outcomes upon the " l e v e l " of n u r s i n g p r a c t i c e . l e f t wondering nurse.  dependent  In a d d i t i o n , one i s  i f CHO can be d i r e c t l y l i n k e d back t o the  What about other i n f l u e n c i n g f a c t o r s i n c l i e n t care?  Benner  subsequently co-authored another book w i t h J u d i t h  7 Wrubel (1989), e n t i t l e d t h e Primacy  of  Caring.  The book i s  "devoted t o an i n t e r p r e t i v e t h e o r y of n u r s i n g p r a c t i c e as i t i s concerned with h e l p i n g people cope with the s t r e s s of illness"  (p. 7 ) . This work o u t l i n e s t h a t c a r i n g i s a c e n t r a l  component of e f f e c t i v e n u r s i n g p r a c t i c e and i s key f o r expert practice.  A component of c a r i n g i s concern and "within each  arena of concern a r e many d i f f e r e n t ways of c a r i n g " Wrubel,  1989, p. ,87).  (Benner &  I f nurses a r e concerned, they are  a l e r t e d t o the knowledge of the f e a t u r e s of t h e s i t u a t i o n t h a t make a d i f f e r e n c e and a r e attuned t o the cues t h a t s i g n a l a change i n s t a t u s  (Benner & Wrubel,  1989).  Is t h e r e  a d i f f e r e n c e i n the concern t h a t nurses i n ANP have i n t h e f e a t u r e s of t h e s i t u a t i o n they i d e n t i f y , and the cues t o which they a r e 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 c o l l e a g u e s who r e p r e s e n t expert p r a c t i c e i n n u r s i n g .  Often these nurses a r e h i g h l y  competent y e t may be educated a t the diploma l e v e l .  If,  t r a d i t i o n a l l y , nurses engaged i n ANP r e q u i r e a t l e a s t a master's degree, must t h e r e not be some d i f f e r e n c e i n ANP versus expert p r a c t i c e ?  I f not, then how can t h e r e be  j u s t i f i c a t i o n f o r the time and f i n a n c i a l c o s t s a s s o c i a t e d with e d u c a t i o n a l p r e p a r a t i o n f o r nurses a t the master's and doctoral  level?  Fenton  (1985) conducted an ethnographic study t h a t  i d e n t i f i e d common competencies  of master's prepared CNSs.  8 Using Benner's (1984) d e s c r i p t i o n of expert p r a c t i c e , confirmed t h a t CNSs are n u r s i n g e x p e r t s .  However,  Fenton  Fenton  i d e n t i f i e d some behaviours of CNSs t h a t had not been noted  by  Benner i n expert nurses, such as: o r g a n i z a t i o n a l and work r o l e competencies,  c o n s u l t i n g r o l e , m o n i t o r i n g and  the q u a l i t y of h e a l t h care p r a c t i c e s  (Fenton,  ensuring  1985).  She  a l s o found t h a t CNSs c l e a r l y i d e n t i f i e d the important b e i n g s u p p o r t i v e t o s t a f f nurses.  r o l e of  A d d i t i o n a l l y , CNSs o f t e n  "massage the system" f o r the goal of improvement i n c l i e n t / p a t i e n t and nurse s i t u a t i o n s  (Fenton, 1985).  This  l e a d e r s h i p f u n c t i o n i s o f t e n unrecognized by a d m i n i s t r a t o r s and t h e r e f o r e not t r a d i t i o n a l l y found i n job d e s c r i p t i o n s . Fenton's work r e p r e s e n t s a c l e a r e r attempt  t o address how  ANP  d i f f e r s from expert p r a c t i c e . Calkin  (1984) o u t l i n e s what she d e s c r i b e s as "a model  f o r advanced n u r s i n g p r a c t i c e . "  In t h i s model,  she  d i f f e r e n t i a t e s the p r a c t i c e of nurses a c c o r d i n g t o t h e i r experience i n r e l a t i o n t o human responses  t o h e a l t h problems.  She r e f e r s t o Benner (1984) and uses the same terms t o d e s c r i b e the nurses.  She attempts  t o d e f i n e ANP  but the  d e f i n i t i o n i s vague and a p p l i c a b l e t o a wide range of nurses. She r e c o g n i z e s t h a t " i t i s important t o t h i n k about the essence of advanced n u r s i n g p r a c t i c e "  ( C a l k i n , 1984,  p.  24).  A d d i t i o n a l l y , she notes t h a t "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  t o a c t u a l and p o t e n t i a l h e a l t h problems p r o v i d e s  nurses with h i g h - q u a l i t y outcomes or goals f o r n u r s i n g  9 interventions"  ( C a l k i n , 1984,  p. 27).  It i s i n t e r e s t i n g that  she uses the phrase " h i g h - q u a l i t y outcomes or g o a l s . " two  are not n e c e s s a r i l y the same, i n t h a t goals can  The  direct  n u r s i n g i n t e r v e n t i o n s but outcomes r e s u l t from n u r s i n g i n t e r v e n t i o n s and may In C a l k i n ' s  be more s p e c i f i c than g o a l  attainment.  (1988) d i s c u s s i o n on s p e c i a l i z a t i o n i n  n u r s i n g , she notes t h a t " f o r more than a decade I have used the term 'advanced nurse p r a c t i t i o n e r ' t o r e f e r to the master's prepared specialization"  nurse i n an attempt to a v o i d u s i n g the term  (p. 285).  She  a l s o recognizes  t h a t given  the  c u r r e n t trends  i n h e a l t h care i t i s not p o s s i b l e to keep a  command of the  "breadth  practice"  (p. 280).  Thus ' ' C l i n i c a l Nurse S p e c i a l i s t s  advanced knowledge and p. 280).  of knowledge needed f o r p r e c i s i o n i n  skill  are r e q u i r e d "  (Calkin,  I t i s i n t e r e s t i n g t o note t h a t the t i t l e  c o n t a i n s the word " s p e c i a l i s t . " s p e c i a l i s t and ANP  relate?  How  do the terms:  with 1988,  of the  CNS  expert,  C a l k i n claims t h a t nurses w i l l  need to come to terms with the e d u c a t i o n a l requirements t h a t are most a p p r o p r i a t e f o r ANP. All ANP  articulated.  yet none of these  key!  measured.  l i n k a g e s has been c l e a r l y  They a l l u d e to nurses i n f l u e n c i n g CHO,  t h i s i n f l u e n c e i s achieved  •  be  of these n u r s i n g s c h o l a r s have made a l i n k between  and CHO,  and CHO  This may  i s not d i s c u s s e d ,  yet  how  l e t alone  Nurses must be able to make the l i n k s between  ANP  i n order t o :  i n c r e a s e understanding  of the e f f e c t i v e n e s s of d i f f e r e n t  10 l e v e l s of n u r s i n g p r a c t i c e ; •  enhance d e c i s i o n making by themselves and with  •  develop standards  to guide n u r s i n g and h e a l t h  d e c i s i o n makers i n o p t i m i z i n g the use of ( E p s t e i n , 1990); •  clients; care  resources  and,  a r t i c u l a t e the value and b e n e f i t of graduate n u r s i n g education. Statement of the Problem The  l i t e r a t u r e r e v e a l s an i n c r e a s i n g l y important  c l e a r l y d e f i n e ANP  need to  as w e l l as t o a r t i c u l a t e the i n f l u e n c e  t h a t t h i s p r a c t i c e has  on CHO.  v i c t i m s of " s t a f f i n g c u t s " and  Nurses i n ANP  can be  the  e l i m i n a t i o n of p o s i t i o n s , or  change to a d m i n i s t r a t i v e r o l e s with o r g a n i z a t i o n s l e s s e n i n g the c l i n i c a l component emphasis. i n ANP  I t i s important  t o be able to c l e a r l y d i s c u s s the value  f o r nurses  and  s i g n i f i c a n c e of t h e i r r o l e p a r t i c u l a r l y d u r i n g h e a l t h reform.  Competencies t o do t h i s w i l l not o n l y be  care  of  a s s i s t a n c e i n the c o n t i n u a t i o n of c l i n i c a l l y based p o s i t i o n s w i t h i n o r g a n i z a t i o n s but w i l l . a l s o p r o v i d e o p p o r t u n i t i e s f o r nurses i n ANP  to p o s i t i v e l y shape h e a l t h care.  sought to answer the f o l l o w i n g q u e s t i o n :  "How  This do  study  Clinical  Nurse S p e c i a l i s t s d e f i n e advanced n u r s i n g p r a c t i c e and they d e s c r i b e t h e i r p r a c t i c e i n r e l a t i o n to c l i e n t outcomes?"  how  do  health  These phenomena remain not w e l l understood w i t h i n  the n u r s i n g community. For c l a r i f i c a t i o n ,  CNSs were not the o n l y  appropriate  11 source  to d e f i n e ANP  sources  and  i t s r e l a t i o n s h i p to CHO.  t h a t c o u l d have been contacted  educators,  nurse p r a c t i t i o n e r s ,  include  s t a f f nurses,  and h e a l t h p o l i c y decision-makers.  The  CHO  clients, nurse midwives  r e s e a r c h e r had  p e r s o n a l i n t e r e s t i n f u r t h e r understanding to  Other  ANP  and  from the p e r s p e c t i v e s of nurses i n the CNS  a  i t s links role.  Purpose of the Study The purpose of t h i s study was how  to explore and  describe  a group of CNSs as nurses f o r m a l l y r e c o g n i z e d  conducting  ANP,  a r t i c u l a t e d two  areas  as  of t h e i r p r a c t i c e :  •  How  d i d they d e f i n e ANP;  and,  •  How  d i d they d e s c r i b e t h e i r p r a c t i c e 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 study. who  s i m i l a r d e f i n i t i o n s of a CNS The  first  s t a t e s t h a t the CNS  were used f o r t h i s i s a r e g i s t e r e d nurse  i s an expert p r a c t i t i o n e r h o l d i n g a Master's or d o c t o r a l  degree i n n u r s i n g , having majored i n a c l i n i c a l s p e c i a l t y ( R e g i s t e r e d Nurses A s s o c i a t i o n of B r i t i s h Columbia, 1988). The  second s t a t e s t h a t a CNS  through study and  i s a r e g i s t e r e d nurse  s u p e r v i s e d p r a c t i c e at the graduate  (master's or d o c t o r a t e ) , has become expert  (American Nurses A s s o c i a t i o n , 1985).  d e f i n i t i o n r e f e r s to graduate education  level  i n a defined  of knowledge and p r a c t i c e i n a s e l e c t e d c l i n i c a l nursing"  "who,  area  area of  The  first  i n n u r s i n g whereas  the second does not s p e c i f y the f a c u l t y focus of graduate studies.  12 For t h i s study, was  i t would have been h e l p f u l i f "expert"  c l e a r l y d e f i n e d i n the l i t e r a t u r e .  e a r l i e r , although  As was  alluded to  Benner (1984) uses the term expert,  she  does not e x p l i c i t l y d e f i n e i t . Her work does not attempt to c l e a r l y d e f i n e the l e v e l s of n u r s i n g p r a c t i c e but d e s c r i b e s these  rather  l e v e l s from the p e r s p e c t i v e s of the nurses  i n t e r v i e w e d and observed (Benner, 1984). s e c t i o n of Benner's book From Novice "expertise" i s defined  In the g l o s s a r y  to Expert  (19 84)  as:  Developed only when the c l i n i c i a n t e s t s and r e f i n e s t h e o r e t i c a l and p r a c t i c a l knowledge i n a c t u a l c l i n i c a l situations. Expertise develops through a process of comparing whole s i m i l a r and d i s s i m i l a r c l i n i c a l s i t u a t i o n s with one another, so an expert has a deep background understanding of c l i n i c a l s i t u a t i o n s based upon many past paradigm cases. Expertise i s a h y b r i d 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) f u r t h e r develops the argument t h a t Benner  needs to d e f i n e expert nurse. t h i s r e s e a r c h , expert was  However, f o r the purposes of  d e f i n e d as the nurse who  not have an u n d e r l y i n g t h e o r e t i c a l education but l e s s c o n s i s t e n t l y accurate complex c l i e n t  and how  may  i s none-the-  judgements of  The  of t h i s study,  r e s e a r c h e r was  n e i t h e r ANP  them to t h e i r p r a c t i c e .  nor CHO  was  i n t e r e s t e d i n determining i f  p a r t i c i p a n t s d e f i n e d these terms and how  they r e l a t e d  In the l i t e r a t u r e s e c t i o n of t h i s  r e p o r t , some other d e f i n i t i o n s r e l a t e d t o t h i s study explored.  or  scenarios.  At the beginning pre-defined.  i n her/his c l i n i c a l  may  are  These were compared i n the a n a l y s i s of f i n d i n g s t o  p a r t i c i p a n t s ' own  ideas about the phenomena of  interest.  13 Assumptions The  following  assumptions were r e c o g n i z e d : a) i f the  p a r t i c i p a n t s were p r a c t i s i n g i n a CNS eligibility  criteria  r o l e and  met  the  (presented i n methodology s e c t i o n  of  t h i s r e p o r t ) they were p a r t i c i p a t i n g i n ANP;  b)  p a r t i c i p a n t s would be  t h i s would be  able to d e f i n e  ANP  and  the  f a m i l i a r t o p i c to them; c) the p a r t i c i p a n t s would be describe client  ANP  i n r e l a t i o n t o CHO  ( i n d i v i d u a l , family,  participants future  have an  despite  they  a b l e to  defined  group or community); and,  important and  of n u r s i n g and  how  health  a  d)  significant role in  the  care.  Limitations A l l p a r t i c i p a n t s were from one one  region  of B.C.  As  their consistencies the o r g a n i z a t i o n a l professional  CNSs, p a r t i c i p a n t s met  about ANP  and  CHO  may  regularly  had  and  c u l t u r e , p r e v i o u s e d u c a t i o n a l course work,  as a group.  described  t h a t they  had  In a d d i t i o n , a l l  themselves as b e i n g  experts p r i o r to t h e i r graduate education. p a r t i c i p a n t s who  in  have stemmed from  experiences as w e l l as d i s c u s s i o n s  with each other and participants  large hospital society  clinical  Even those  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 d u r i n g t h e i r  These f a c t o r s , p l u s the  small sample s i z e pose l i 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 r e p r e s e n t only one the umbrella of ANP.  studies.  study's f i n d i n g s .  F i n a l l y , CNSs  group of nurses t h a t are r e c o g n i z e d under This  study i s not  i n c l u s i v e of a l l  14 nurses  i n ANP.  F o r example, Nurse P r a c t i t i o n e r s have been  s t u d i e d e x t e n s i v e l y and have demonstrated many p o s i t i v e outcomes of t h e i r p r a c t i c e (Brunt, Health,  1988; O n t a r i o M i n i s t r y of  1993), which may be e x p l a i n e d by t h e i r emphasis on  d i r e c t c l i e n t care  (Williams & V a l d i v i e s o , 1994). Chapter Summary  T h i s chapter has presented  introductory information f o r  the study which sought t o answer the q u e s t i o n :  "How do  C l i n i c a l Nurse S p e c i a l i s t s d e f i n e advanced n u r s i n g p r a c t i c e and how do they d e s c r i b e t h e i r p r a c t i c e i n r e l a t i o n t o c l i e n t h e a l t h outcomes?"  In t h i s chapter, the r e s e a r c h problem was  d e s c r i b e d from a n u r s i n g p e r s p e c t i v e which p r o v i d e d r a t i o n a l e f o r t h e study.  The conceptual background t h a t was used as a  b a s i s f o r the study was d e s c r i b e d .  A d d i t i o n a l l y , terms  c e n t r a l t o the r e s e a r c h q u e s t i o n were e x p l o r e d and assumptions and l i m i t a t i o n s of t h e study were o u t l i n e d .  In  the f o l l o w i n g chapter, the e x i s t i n g l i t e r a t u r e p e r t i n e n t t o the i d e n t i f i e d r e s e a r c h problem i s reviewed.  15 CHAPTER  TWO  LITERATURE REVIEW The purpose  of t h i s chapter i s t o p r e s e n t an e x p l o r a t i o n  and a n a l y s i s of p e r t i n e n t l i t e r a t u r e r e l a t e d t o ANP r e l a t i o n s h i p t o CHO. for  the purposes  The  l i t e r a t u r e was  reviewed  and i t s initially  of g a i n i n g a p r e l i m i n a r y understanding of  what authors had d i s c u s s e d , as w e l l as what q u e s t i o n s were raised.  In q u a l i t a t i v e r e s e a r c h , the l i t e r a t u r e i s g e n e r a l l y  not reviewed to  e x t e n s i v e l y a t the b e g i n n i n g of a study i n order  e l i m i n a t e the r i s k of d e v e l o p i n g a sedimented  view  (Burns  & Grove, 1987), or f o r the r e s e a r c h e r t o be c o n s t r a i n e d and/or s t i f l e d i n c r e a t i v e e f f o r t s by the knowledge of i t (Strauss & Corbin, 1990). However, f o r t h i s i n e x p e r i e n c e d r e s e a r c h e r , an  initial  review of the l i t e r a t u r e a s s i s t e d i n having a more p r e c i s e understanding of the phenomena under study, as w e l l as the n o t i o n of what the r e s u l t s 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 & P i a n t a n i d a , 1988).  A d d i t i o n a l l y , r e v i e w i n g the l i t e r a t u r e a t t h a t p o i n t allowed for  the study t o " b u i l d on" e x i s t i n g work, r a t h e r than  p r o g r e s s i n g with r e s e a r c h t h a t had a l r e a d y been w e l l documented.  The  l i t e r a t u r e review i s o r g a n i z e d i n t o g e n e r a l  knowledge, research-based a r t i c l e s and other  literature  r e l a t e d t o ANP  and i t s r e l a t i o n s h i p t o CHO.  For  clarification,  l i t e r a t u r e r e l a t e d t o other nurses i n v o l v e d 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 r e s e a r c h e r was  i n t e r e s t e d i n the phenomena of i n t e r e s t  from  the p e r s p e c t i v e s of CNSs o n l y . Advanced Nursing P r a c t i c e Nursing but authors  l i t e r a t u r e f r e q u e n t l y i n c o r p o r a t e s the term r a r e l y d e f i n e i t (Brunk, 1992;  Hawkins & Thibodeau, 1989; 1990).  N i c h o l s , 1992;  Calkin,  use the term ANP,  y e t authors  Baggerly,  1989).  1990;  and  & Cooper,  frequently  of n u r s i n g l i t e r a t u r e  the need t o c l e a r l y d e f i n e i t (Fenton, Spross & Kozlowski,  1988;  Sparacino  In p r a c t i c e s e t t i n g s , nurses accept  1985;  identify  Forbes,  P a t t e r s o n & Haddad, 1992;  I f d e f i n i t i o n s of ANP  Rafson, Spross &  are given they  o f t e n vague, i n t h a t they c o u l d apply to many nurses, those prepared  at the diploma l e v e l .  these authors,  i s how  ANP  are such as  What i s not c l e a r ,  p r e p a r a t i o n at the master's i n n u r s i n g  l e v e l d i f f e r e n t i a t e s ANP  from other p r a c t i c e .  There i s a wealth of n u r s i n g l i t e r a t u r e r e l a t e d to CNS  r o l e s and  subroles.  These are o f t e n l i s t e d as  c o n s u l t a n t , expert p r a c t i t i o n e r and r e s e a r c h e r Calkin,  1984;  Hawkins & Thibodeau, 1989;  McCaffrey, 1991; Spross,  1989).  McGuire & Harwood, 1989;  Koetters, Priest,  and  1989;  interlinks  c l a r i f i e s t h e i r common g o a l  Although the term "advanced l e v e l " i s used i n i t i s not d e f i n e d , l e t alone  example, i t i s not c l e a r how  1989;  1989;  not been made ( P a t t e r s o n & Haddad, 1992).  definitions,  the  educator,  (Barron,  However, the common t h r e a d t h a t  the r o l e s a s s o c i a t e d with ANP has  from  clear.  For '  CNSs as advanced n u r s i n g  17 p r a c t i t i o n e r s d i f f e r from expert nurses, of  i f at a l l .  t h i s a r e t h e d e f i n i t i o n s of C a l k i n (1984) and King  Examples (1990).  C a l k i n ' s d e f i n i t i o n of ANP i s : Advanced n u r s i n g p r a c t i c e i s the d e l i b e r a t i v e d i a g n o s i s and treatment of a f u l l range of human responses to. a c t u a l and p o t e n t i a l h e a l t h problems. Advanced p r a c t i t i o n e r s can p r o v i d e a r a t i o n a l e f o r choosing d i a g n o s t i c and treatment processes. Advanced p r a c t i c e i s accompanied by s p e c i a l i z e d knowledge and s k i l l i n d e a l i n g with a human response t h a t cuts across h e a l t h problems (e.g. pain) o r with a c l u s t e r of human responses t o an i d e n t i f i a b l e a c t u a l or p o t e n t i a l problem (e.g. d i a b e t e s m e l l i t u s ) or a c l u s t e r of ages p e c i f i c human responses t o h e a l t h problems (e.g. i n f a n t s ) or a combination of these (e.g. changes i n s e l f - c o n c e p t i n pregnant a d o l e s c e n t s ) (p. 27). King  (1990) notes  that:  being an expert, a CNS p r a c t i t i o n e r p r o v i d e s p a t i e n t care from a n u r s i n g p e r s p e c t i v e a t an advanced l e v e l and i s a b l e t o model a n u r s i n g p r a c t i c e t h a t demonstrates a high degree of c l i n i c a l competence with s k i l l s i n p r o f e s s i o n a l judgement and the p o s s e s s i o n of a knowledge base (p. 174). The  f o l l o w i n g d e f i n i t i o n by Haddad (1992a) i s c l e a r e r but  some components present c h a l l e n g e s t o measure: An advanced nurse p r a c t i t i o n e r . . . m a y be d e s c r i b e d as a nurse with n u r s i n g p r e p a r a t i o n a t 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 p r a c t i c e s w i t h i n t h a t s p e c i a l i t y and i s committed t o ongoing l e a r n i n g , education, and development w i t h i n the d i s c i p l i n e of n u r s i n g . He/she a l s o maintains currency i n recent developments i n n u r s i n g and h e a l t h care, has a t t a i n e d and maintains a l e v e l of knowledge and s k i l l beyond t h a t of t h a t of s t a f f nurses, and u t i l i z e s t h a t knowledge and s k i l l t o develop and advance n u r s i n g p r a c t i c e through a c t i v e r o l e s i n education, c o n s u l t a t i o n and r e s e a r c h (p. 7 ) . There i s a f r e q u e n t l y noted assumptive leap with p r a c t i c e t o ANP i n the l i t e r a t u r e .  expert  The r e s e a r c h e r b e l i e v e s  t h a t t h e r e a r e d i f f e r e n c e s but i s not able t o c l e a r l y  18 a r t i c u l a t e what they are. ANP,  there  developing  the  lack, of c l a r i t y about  i s renewed i n t e r e s t i n f u r t h e r e x p l o r i n g  and  i t i n Canada (Canadian Nurses A s s o c i a t i o n ,  Haddad, 19 92a; Registered  Despite  Haddad, 1992b; P a t t e r s o n  & Haddad,  Nurses A s s o c i a t i o n of B r i t i s h Columbia,  Schroer, 1991;  Van  der Horst,  1992).  1992;  1992; 1990;  Is i t t h a t h e a l t h  p r o f e s s i o n a l s i n t u i t i v e l y know t h a t nurses i n ANP  offer  something t h a t i s unique and worth f u r t h e r development are j u s t not able to a r t i c u l a t e what i t i s ?  In order  decrease t h i s l a c k of c l a r i t y r e l a t e d to ANP,  care  but to  further  e x p l o r a t i o n can a s s i s t nurses to d e f i n e , continue to develop, and  explore ANP  i n ways t h a t meet some of the ongoing needs  of the n u r s i n g p r o f e s s i o n and  the c l i e n t s t h a t are  involved  in nurse/client interactions. Research-Based A r t i c l e s Related In a c u r s o r y  review of the  based r e p o r t s c o u l d be The  r e l a t e d ANP  l i t e r a t u r e , minimal  research-based l i t e r a t u r e was  p r a c t i c e as r e p o r t e d by p r a c t i s i n g CNSs. c o n s i s t e d of 17 Master's prepared CNSs who f o r a minimum of one  they used t h r e e recorded  The had  year.  methodology, the r e s e a r c h e r s  Using grounded  Schaefer  clinical sample functioned  in  Additionally,  case s t u d i e s found i n the  as a p a r t of the a n a l y s i s .  study.  reviewed to  r e p o r t e d with the study.  Lucke (1990) conducted a study to d e s c r i b e  the r o l e of a CNS  research-  found r e l a t e d d i r e c t l y t o t h i s  attempt t o l i n k what was and  t o Advanced Nursing P r a c t i c e  literature  theory  concluded t h a t s c i e n t i f i c  and  19 humanistic c a r i n g was of CNSs.  the c e n t r a l component t o the p r a c t i c e  The CNSs cared f o r c l i e n t s and t h e i r f a m i l i e s but  were a l s o of major support t o the s t a f f .  These f i n d i n g s were  subsequently v a l i d a t e d i n the l i t e r a t u r e .  Schaefer and Lucke  asked the q u e s t i o n : Does c a r i n g d i f f e r depending e d u c a t i o n a l p r e p a r a t i o n of the nurses?  upon the  They a l s o noted t h a t  t h e i r study d i d 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 t o the e x p l o r a t i o n of the r o l e of the CNS  in  community h e a l t h , Mason, Knight, T o u g h i l l , DeMaio, Beck and Christopher  (1992), conducted  a needs survey which c o n s i s t e d  of two q u e s t i o n n a i r e s : one t o assess the c u r r e n t and f u t u r e needs of community h e a l t h agencies f o r Master's-prepared nurses i n community h e a l t h n u r s i n g and the r o l e s i n which the agencies would use these nurses, and another t o assess the i n t e r e s t of b a c c a l a u r e a t e - p r e p a r e d nurses i n a t t e n d i n g a graduate program i n community h e a l t h n u r s i n g (Mason et a l . , 1992, p. 8). T h i s survey suggested t h a t  "community h e a l t h agencies may  be c l e a r about the b e n e f i t s of employing p r a c t i t i o n e r " nor how effectively 256  (p. 6).  t h i s advanced  t o use the community h e a l t h CNS  most  T h e i r sample i n c l u d e d 126 agencies  i n d i v i d u a l nurses.  not  and  F i n d i n g s of both groups r e f l e c t e d a  l a c k of understanding of the r o l e of the community h e a l t h CNS.  However, the f i n d i n g s a l s o demonstrated  t h a t community  h e a l t h agencies have great p r e s e n t and f u t u r e needs r e l a t e d to Master's prepared nurses.  Of i n t e r e s t , study p a r t i c i p a n t s  wanted t o put community h e a l t h educated CNSs i n t o management  20 roles. Mason and  colleagues  community h e a l t h CNS  (1992) i d e n t i f i e d t h a t  the  i s " d e s p e r a t e l y needed to advance  c l i n i c a l p r a c t i c e i n community h e a l t h n u r s i n g and t o promote the h e a l t h of communities.  This need w i l l only be  i f an adequate number of these educated but u t i l i z e d p r o p e r l y "  s p e c i a l i s t s are not (p. 12).  fulfilled only  They a l s o add  that  " i f n u r s i n g w i l l promote t h i s s p e c i a l i t y of n u r s i n g , i t w i l l a l s o be promoting the h e a l t h of communities" Although t h i s was f o r the B.C.  (p.  13).  an American study there are i m p l i c a t i o n s  and Canadian context given the c u r r e n t focus  on  community h e a l t h . The  r e s e a r c h e r b e l i e v e s t h a t Mason and  underscore the need f o r more nurses i n ANP the community i n B.C.  The  colleagues  to be employed i n  c u r r e n t " s h i f t " of c l i e n t s  h o s p i t a l t o home r e q u i r e s a p r e v i o u s l y undeveloped untapped e x p e r t i s e of community nurses.  support  i s mandatory.  The  from  and  For community nurses  t o develop t h i s e x p e r t i s e and be supported e f f o r t s , ANP  (1992)  i n t h e i r ongoing  r e s e a r c h e r wondered  i f the c u r r e n t study p a r t i c i p a n t s would i d e n t i f y t h e i r r o l e s i n r e l a t i o n t o the community as Benner, Tanner and Chesla  client. (1992) p u b l i s h e d a p o r t i o n of  a l a r g e r phenomenological study r e l a t e d t o s k i l l i n the p r a c t i c e of c r i t i c a l Dreyfus  Model of Skill  acquisition  care n u r s i n g through use of  Acquisition.  T h i s study was  the  another  attempt to c l a r i f y the f i v e l e v e l s of p r a c t i c e p r e v i o u s l y  21 i d e n t i f i e d by Benner (1984).  Although t h i s r e s e a r c h  i s only  p e r i p h e r a l l y l i n k e d with t h i s study, i t i s worth n o t i n g  since  the authors r e i n f o r c e d the need to d i f f e r e n t i a t e between expert  and  advanced n u r s i n g p r a c t i c e .  T h e i r sample c o n s i s t e d of 130 I n t e n s i v e Care U n i t s . baccalaureate  nurses who  Of these nurses, 98%  prepared.  Findings  practiced in  were  from t h e i r study f u r t h e r  develop the n o t i o n of p r a c t i c e from the c l i n i c a l worlds of nurses' v a r y i n g l e v e l s of experience.  The  d i s c u s s i o n i n the  a r t i c l e r e l a t e s to an i n d i v i d u a l nurse c a r i n g f o r an individual c r i t i c a l l y i l l  c l i e n t although the nurse  i n v o l v e the c l i e n t ' s f a m i l y i n t h a t care. 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 the medical model of p r a c t i c e .  Spross and  focus  strongly r e l a t e d to  practice.  t o Advanced Nursing P r a c t i c e  Baggerly (1989) i d e n t i f y two  concepts t h a t  they b e l i e v e are e s s e n t i a l to a model of advanced practice.  These are  e f f e c t i v e leadership" i s defined  i n the  This e x p e r i e n t i a l learning i s  c l e a r l y l i n k e d t o development of expert Other L i t e r a t u r e Related  The  may  "exquisite c l i n i c a l (p. 21).  judgement  Exquisite c l i n i c a l  nursing and judgement  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 i n c l u d e s : (1) d e c i s i o n s r e g a r d i n g what to observe i n a p a t i e n t s i t u a t i o n ; (2) i n f e r e n t i a l d e c i s i o n s , d e r i v i n g meaning from data observed ( d i a g n o s i s ) ; and (3) d e c i s i o n s r e g a r d i n g a c t i o n s t h a t should be taken which w i l l be of optimal b e n e f i t to the p a t i e n t (p. 21). E f f e c t i v e leadership i s defined  as:  22 uses communication processes to i n f l u e n c e 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 i n c l u d e s g u i d i n g 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, i n t e r p r e t i n g n u r s i n g p r a c t i c e t o nurses and non-nurses, d e v e l o p i n g i n n o v a t i v e approaches t o c l i n i c a l p r a c t i c e , promoting i n t e r d i s c i p l i n a r y c o l l a b o r a t i o n , and advancing the p r a c t i c e and p r o f e s s i o n of n u r s i n g (p.21). These authors note t h a t any incorporates  these two  advanced p r a c t i c e model t h a t  elements can a s s i s t CNSs to analyze  t h e i r advanced p r a c t i c e .  They add  however, t h a t  " c o n c e p t u a l i z i n g advanced p r a c t i c e and b e i n g  able  to  d i s c r i m i n a t e i t from the p r a c t i c e of a neophyte or an by experience i s v i t a l " English's  (Spross & Baggerly, 1989,  of e x p e r t i s e are d e s c r i b e d , (p. 387).  there  and  but  He  e x p e r t i s e i s not  at what stage one  i f there are b e t t e r experts  "aspects  clearly "according  becomes an  than o t h e r s ,  stages of e x p e r t i s e or i s 'expert'  state"  notes t h a t  In a d d i t i o n , he o u t l i n e s t h a t  to t h i s model i t i s u n c l e a r expert,  39).  (1993) c r i t i q u e of Benner's model prompts  another dimension f o r c o n s i d e r a t i o n .  defined"  p.  expert  i . e . are  a unique and  final  (p. 389)?  In order to e x p l a i n , j u s t i f y and  support d i f f e r e n t  l e v e l s of n u r s i n g p r a c t i c e , Spross and o u t l i n e the f o l l o w i n g models of ANP: Practice  (1989)  Benner's Model of Expert  (1984); Fenton's A p p l i c a t i o n of Benner's Model t o  CNSs (1985); Roy Practice  Baggerly  and M a r t i n e z '  Conceptual Framework For  (1983); H o l t ' s T h e o r e t i c a l Model For  CNS  Clinical  S p e c i a l i s t P r a c t i c e (1984); C a l k i n ' s Model of Advanced  '  23 Nursing P r a c t i c e (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 c r i t i q u e s of  these models done by Spross and Baggerly, is  they note t h a t " i t  c l e a r t h a t none a r e f u l l y developed i n terms of advanced  p r a c t i c e and the CNS" (p. 39). Having f u l l y reviewed models of ANP, the r e s e a r c h e r agreed with t h i s  these  conclusion.  P a t t e r s o n and Haddad (1992) add t o t h i s i n t h a t " i t i s our c o n t e n t i o n . . . t h a t  the a t t r i b u t e s and behaviours of  advanced p r 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 literature"  (p. 18). These authors  p o s s i b l e behaviours  presented  a list  of some  and a t t r i b u t e s a s s o c i a t e d with ANP.  are c l e a r t o p o i n t out t h a t t h i s l i s t and t h a t f u r t h e r refinement concepts a r e r e q u i r e d .  They  i s not a l l - i n c l u s i v e  and expansion of a l l of the  I n t e r e s t i n g l y enough, the l i s t  c o n t a i n s a t t r i b u t e s and some b e h a v i o u r s / i n d i c a t o r s t h a t a r e not c o n s i s t e n t l y found i n the l i t e r a t u r e .  Their  list  i n c l u d e s the f o l l o w i n g : Attributes  Some b e h a v i o u r s / i n d i c a t o r s  Risk Taker  * i d e n t i f y and develop a n u r s i n g p e r s p e c t i v e i n new areas of h e a l t h care * u t i l i z e and evaluate n u r s i n g r e s e a r c h t o guide c l i e n t care * p a r t i c i p a t e i n nursing research * i d e n t i f y and comment on c u r r e n t issues i n nursing * a r t i c u l a t e and disseminate n u r s i n g knowledge by i n f o r m a l and formal methods * demonstrate the use of t h e o r y based p r a c t i c e t o other nurses  Visionary I n q u i r i n g Mind Flexibility A b i l i t y to A r t i c u l a t e Leadership  Skills  Despite the i d e n t i f i c a t i o n of these a t t r i b u t e s and  24 behaviours/indicators, in  Patterson  and Haddad (1992) add  t h e i r review of the l i t e r a t u r e r e l a t e d t o ANP,  very  a t t e n t i o n has been p a i d to the c h a r a c t e r i s t i c s of i n d i v i d u a l t h a t would be necessary to f u l f i l an ANP  that, little  the  the demands of  role. 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  D e c i s i o n makers i n Canada's h e a l t h care system conduct an expensive business or plans  without any  outcome measurements, goals  ( R a c h l i s & Kushner, 1989).  q u a l i t y of h e a l t h care,  "outcomes matter most"  S e r v i c e s Research, 1992, M i n i s t r y of Health outcomes.  has  In attempts t o improve  p. 175).  focused  (Health  In recent years,  the  e f f o r t s on e v a l u a t i o n  There i s renewed i n t e r e s t i n e x p l a i n i n g  a n a l y z i n g c u r r e n t h e a l t h care p r a c t i c e s so t h a t d e c i s i o n s can be made on p o s i t i v e outcomes.  B.C.  and  and  funding  I t i s w e l l known  t h a t funding d e c i s i o n s have t r a d i t i o n a l l y not been c l e a r l y l i n k e d to CHO.  In the l a s t couple of years  in particular  there has been renewed i n t e r e s t i n attempting link  to make t h i s  explicit. I n c r e a s i n g l y , funding d e c i s i o n makers are  recognizing  the value of e v a l u a t i o n p r i o r t o c o n s i d e r a t i o n of funding budget i s s u e s  (Wood, 1989).  e s t a b l i s h e d ANP  1992).  Nurses p a r t i c i p a t i n g i n an  r o l e are a worry to h e a l t h care funders  they o f t e n secure  and  higher wages than most nurses  since  (Sparacino,  Yet these same nurses are educated to conduct  r e s e a r c h and  e v a l u a t i o n of t h e i r p r a c t i c e , as w e l l as outcome  25 measures of t h i s p r a c t i c e (Waltz & S y l v i a , 1991). Donabedian (1992; 1988) outcomes management and  incorporates  d e f i n e the q u a l i t y of care, process and  outcome.  i s a w e l l known l e a d e r a classic triad  Outcomes may  Some of the a t t r i b u t e s of q u a l i t y i n  l e g i t i m a c y and  be d e f i n e d as  i n d i v i d u a l s and p o p u l a t i o n s antecedent h e a l t h care" d e f i n i t i o n i s that  to  s p e c i f i c a l l y that of: structure,  h e a l t h care i n c l u d e : e f f e c t i v e n e s s , e f f i c i e n c y , acceptability,  of  equity  optimality,  (Donabedian, 1992).  " s t a t e s or c o n d i t i o n s  of  a t t r i b u t e d or a t t r i b u t a b l e to  (Donabedian, 1992,  "outcomes are the end  p. 356).  Another  r e s u l t s of care,  the  changes i n a p a t i e n t h e a l t h s t a t u s t h a t can be a t t r i b u t e d to the d e l i v e r y of h e a l t h care s e r v i c e s " (Naylor, Brooten, 1991,  p.  Munro &  210).  Nurses, are however, i n the e a r l y stages of  research  r e l a t e d to outcome measures t h a t can be  linked to  practice  McCaughan, G r i f f i t h s  (Bond & Thomas, 1991;  & Carr-Hill,  1992).  Higgins,  nursing  A d d i t i o n a l l y , CNSs are i n a p i v o t a l  p o s i t i o n to assure the d e l i v e r y of q u a l i t y n u r s i n g (Naylor, Munro & Brooten, 1991), and  care  have the p o t e n t i a l to  a s t r o n g v o i c e f o r care q u a l i t y , o f t e n l o s t i n the d i s c u s s i o n s of c o s t - e f f e c t i v e n e s s Yet  "research  (Redfern & Norman, 1990).  to date...has not adequately shown t h a t  n u r s i n g p r a c t i c e 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  the  be  26 p o s i t i v e outcomes.  Both unintended  and  unexpected  "consequences of n u r s i n g i n t e r v e n t i o n s are e q u a l l y v a l i d outcomes and indeed c o u l d be important Thomas, 1991,  p. 1494).  concerned, nurses CHO.  as  and r e v e a l i n g " (Bond &  As f a r as t h i s r e s e a r c h e r i s  need t o examine more t h a t j u s t  "immediate"  They need to begin e x p l o r a t i o n of "long term" n u r s i n g  care outcomes and CHO.  As  " i n c r e a s i n g numbers of  e x p l o r a t o r y , d e s c r i p t i v e , and c o r r e l a t i o n a l s t u d i e s l a y the groundwork f o r changes i n n u r s i n g p r a c t i c e , r e s e a r c h on  the  e f f e c t i v e n e s s of n u r s i n g i n t e r v e n t i o n s becomes more c r i t i c a l " 1  (Stewart  & Archbold,  1992,  p.  477).  Research-Based L i t e r a t u r e R e l a t e d t o 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  c o u l d be found r e l a t e d d i r e c t l y to t h i s r e s e a r c h . s t u d i e s which support  e f f o r t s of the r e s e a r c h were found.  F i t z p a t r i c k and c o l l e a g u e s experienced  The  (1991) conducted r e s e a r c h  CNSs u s i n g the D e l p h i technique  survey to capture  Two  and a  i n f o r m a t i o n r e l a t e d to r e s e a r c h  four-round priorities.  r e s u l t s , i n t e r e s t i n g l y enough, d i d not focus on  s p e c i f i c c l i n i c a l r e s e a r c h but r a t h e r o v e r a l l c l i n i c a l nursing research p r i o r i t i e s .  The  with  potential  general  results indicated  t h a t top p r i o r i t i e s f o r n u r s i n g r e s e a r c h are: "(1) f a c t o r s which i n f l u e n c e l o n g e v i t y i n c l i n i c a l n u r s i n g p r a c t i c e , p a t i e n t d e l i v e r y systems as r e l a t e d to nurse and  (2)  satisfaction,  (3) i n d i c a t o r s of q u a l i t y of n u r s i n g care"  (Fitzpatrick  27 et a l , 1991,  p. 94).  C l e a r l y t h e r e i s the r e c o g n i t i o n by  these CNSs of the value of outcomes from c l i e n t , p a t i e n t and p r o f e s s i o n a l domains. H i g g i n s , McCaughan, G r i f f i t h s and C a r r - H i l l conducted care.  The  (1992)  r e s e a r c h r e l a t e d to a s s e s s i n g outcomes of n u r s i n g r e s e a r c h e r s r e c o g n i z e d the d i f f i c u l t y  identifying  which outcome v a r i a b l e s c o u l d be a t t r i b u t e d to n u r s i n g alone. As a r e s u l t , they focused on immediate outcomes t h a t "would then r e f l e c t a r e s u l t t h a t c o u l d be r e l a t e d with some confidence to n u r s i n g i n t e r v e n t i o n v i a d i r e c t o b s e r v a t i o n " (p. 562).  This approach went beyond the t r a d i t i o n a l outcome  s t u d i e s such as those  " e x c l u s i v e l y concerned  with measuring  the c l i n i c a l outcomes of care such as changes i n p a t i e n t ' s symptoms and s u r v i v a l f o l l o w i n g d i a g n o s i s " (p. These authors  566).  c o l l e c t e d data from outcome measures i n  acute medical and s u r g i c a l wards at seven h o s p i t a l s i t e s . the same time, the Q u a l i t y of P a t i e n t Care Scale was  used.  At  (Qualpacs)  Measures focused on the outcomes of care d e l i v e r y .  The amended Qualpacs instrument was  used t o measure the  process of n u r s i n g care i n f i v e areas: p s y c h o s o c i a l care, p h y s i c a l care, g e n e r a l care, communication on b e h a l f of the p a t i e n t , and the p r o f e s s i o n a l i m p l i c a t i o n s of c a r e .  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 a n a l y s i s was  to t e s t f o r 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 r e s e a r c h e r s present t h e i r chosen outcome measures as a  28 p o s s i b l e way t o assess the outcomes of n u r s i n g care.  They  i d e n t i f y the l a c k of other s t u d i e s of n u r s i n g and outcomes, which r e s u l t s i n t h e i r i n a b i l i t y t o make comparisons.  This  work r e p r e s e n t s a good b e g i n n i n g e f f o r t t o l i n k n u r s i n g p r a c t i c e and CHO i n a g e n e r a l  way.  Other L i t e r a t u r e R e l a t e d t o 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 H e a l t h Outcomes Nurses, as p a r t i c i p a n t s i n t o t a l q u a l i t y management, have been d i r e c t e d t o evaluate programs and t o explore outcomes of c l i e n t care 1992).  ( B e e c r o f t , 1992; Stanhope & Lee,  However, t h i s t a s k i s o f t e n not p o s i t i v e l y r e c e i v e d  and can become the r e s p o n s i b i l i t y of a v a r i e t y of p e r s o n n e l . T o t a l q u a l i t y management has r o u t i n e l y examined s t r u c t u r e and some process, but r a r e l y outcomes of h e a l t h care p r a c t i c e s . General h e a l t h 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 i n t e r e s t f o r n u r s i n g and other h e a l t h care p r o f e s s i o n a l s (Bond & Thomas, 1991).  Waltz and S y l v i a  (1991) note: I t i s e s s e n t i a l t h a t v a l i d a t i o n of CNS e f f e c t on p a t i e n t outcomes be undertaken and t h a t s t u d i e s designed f o r t h i s purpose employ the most r e l e v a n t and a p p r o p r i a t e outcome v a r i a b l e s t o be s t u d i e d across p r a c t i c e s e t t i n g s and t h a t they be measured i n a manner t h a t allows f o r a p p l i c a b i l i t y and hence comparison across s t u d i e s , s e t t i n g s , and times (p. 203). Under the umbrella of ANP, CNS i s on c l i e n t - b a s e d p r a c t i c e .  the c o n s i s t e n t focus of the For any CNS, the u l t i m a t e  goal i s t o improve the o v e r a l l q u a l i t y of care d e l i v e r e d t o c l i e n t s / p a t i e n t s by nurses  (Sparacino & Cooper, 1990).  29 Despite t h i s g o a l , CNSs o f t e n l a c k formal education prepare them to partake  i n t o t a l q u a l i t y management.  and G i r a r d (1993) o u t l i n e the CNS U n i v e r s i t y of Texas Health i n San Antonio,  to  which has  Noll  c u r r i c u l u m from the  Science Center School  of  r e c e n t l y added a course  Nursing  in quality  assurance to f o r m a l l y prepare CNSs f o r t h i s major aspect t h e i r r o l e i n h e a l t h care.  This approach has  t r a d i t i o n a l l y been a r o u t i n e component of CNS  of  not graduate  education. If the CNS  i s t o be i n v o l v e d i n measuring the  e f f e c t i v e n e s s of n u r s i n g p r a c t i c e , what outcomes should i n c l u d e d and measured?  At the present  be  time i n n u r s i n g  there  i s a l a c k of c o n s i s t e n c y i n what i s measured and o f t e n  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 records.  A n e c d o t a l l y , 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 i n v o l v e d with someone whom the s t a f f has "difficult"  ( K o e t t e r s , 1989).  care  Moritz  becomes  identified  as  (1991) notes t h a t  "there i s c o n s i d e r a b l e r e s e a r c h work t o be done t o determine the best measures t o r e f l e c t the outcomes of practice"  (p.  nursing  114).  What about other outcome measures t h a t can c l e a r l y i n f l u e n c e d by n u r s i n g care?  Examples i n c l u d e : f u n c t i o n a l  s t a t u s , mental s t a t u s , s t r e s s , o v e r a l l s a t i s f a c t i o n with care  be  well-being,  (including accessibility, continuity,  thoroughness, humaneness, i n f o r m a t i v e n e s s  and e f f e c t i v e n e s s ) ,  30 burden of care, q u a l i t y of l i f e , 1992;  and c o s t of care  (Beecroft,  Donabedian, 1992; Naylor, Munro & Brooten, 1991; Roch,  1992).  Are these c u r r e n t l y being measured?  Very l i t t l e  And i f so, how?  e f f o r t t o date has been d i r e c t e d a t a s s e s s i n g the  e f f e c t of nurses' c o n t r i b u t i o n t o the outcomes of c l i e n t (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 p o s i t i o n i n t h a t they excellence  i n c l i e n t / p a t i e n t care.  recognize  They have c l e a r l y  d i s p l a y e d i n t e r e s t and enthusiasm f o r n u r s i n g care t h a t improve outcomes f o r c l i e n t s  care  (Beecroft,  1992; Kerr,  will  1991).  CNSs are a l s o keen t o develop and adopt "new ideas t o m a i n t a i n o r improve q u a l i t y p a t i e n t care i n a t i m e l y and c o s t - e f f e c t i v e manner" (King,  1990, p. 174).  Yet t h e i r r o l e  r e l a t e d t o t o t a l q u a l i t y management or q u a l i t y assurance has not been emphasized ( N o l l & G i r a r d , 1993).  Authors are  b e g i n n i n g t o make the l i n k between the CNS r o l e and outcomes via  t o t a l q u a l i t y management but the l i n k a g e i s not y e t w e l l  established. Beecroft outcomes.  (1992) supports the r o l e of CNSs i n r e l a t i o n t o  She says t h a t  on c l i n i c a l ,  " i n t h i s e r a of i n c r e a s e d  emphasis  f i n a n c i a l , and h e a l t h outcomes, I b e l i e v e the  time i s r i g h t f o r CNSs t o apply t h e i r r e s e a r c h  s k i l l s to  outcomes management and b r i n g themselves t o the f o r e f r o n t of the h e a l t h care arena" ( B e e c r o f t ,  1992, p. 175).  (1989) adds t o 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 r e l a t e d t o the advancement of the  Girouard  31 p r o f e s s i o n , working with others t o p l a n and e v a l u a t e h e a l t h programs f o r people a t r i s k and t o address h e a l t h care trends"  (p. 367).  S o c i e t a l trends and h e a l t h care p o l i c i e s  are d i r e c t l y l i n k e d t o h e a l t h - r e l a t e d outcomes and h e a l t h behaviours  (Girouard, 1989).  Waltz and S y l v i a  (1991) strengthen t h i s view by c l a i m i n g  t h a t , i n order t o document the worth of n u r s i n g programs and s e r v i c e s , i n v e s t i g a t i o n s must be undertaken  r e l a t e d t o the  r e l a t i o n s h i p between n u r s i n g process and outcomes.  Through  the process of l i n k i n g outcomes t o n u r s i n g p r a c t i c e s ,  "CNSs  w i l l more c l e a r l y d e f i n e those h e a l t h outcomes t h a t they are i n the b e s t p o s i t i o n t o i n f l u e n c e "  (Naylor, Munro & Brooten,  1991, p. 214). F i n a l Word on the L i t e r a t u r e Review A f t e r review of the l i t e r a t u r e , t h i s r e s e a r c h was t i m e l y .  i t became c l e a r t h a t  I t i s a p p r o p r i a t e t h a t nurses as  i n d i v i d u a l s and the n u r s i n g p r o f e s s i o n as a whole, have answers t o these key areas of i n q u i r y . To date, t h e r e has been a d e f i n i t e l a c k of knowledge r e l a t e d t o a c l e a r d e f i n i t i o n of ANP d e s p i t e i t s w i d e l y accepted use.  Nor has t h e r e been a c l e a r e f f o r t t o d i r e c t l y  l i n k ANP with CHO.  Given today's  h e a l t h care environment,  the r e s u l t a n t p r e s s u r e s f o r f i s c a l r e s t r a i n t , and the need f o r measurement  of CHO,  t h i s study p r o v i d e s f u r t h e r  about the phenomena of i n t e r e s t .  knowledge  I t also provides research  t h a t others can b u i l d on t o f u r t h e r explore r e l a t i o n s h i p s  32 between ANP  and  CHO. Chapter Summary  In t h i s chapter, p e r t i n e n t i t s r e l a t i o n s h i p t o CHO  was  l i t e r a t u r e r e l a t e d t o ANP  reviewed.  and  Although a wealth of  l i t e r a t u r e i s a v a i l a b l e r e l a t e d t o the phenomena of i n t e r e s t , minimal r e s e a r c h has been p u b l i s h e d t h a t  further  clarifies  these d e f i n i t i o n s and/or r e l a t i o n s h i p s .  Through t h i s  l i t e r a t u r e review p r o c e s s , the need f o r t h i s study has been validated. t h a t was  The f o l l o w i n g  chapter d e s c r i b e s the methodology  used f o r 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 i n q u i r y , i t was not p o s s i b l e t o d e f i n e the terms ANP and CHO and t h e i r relationship precisely.  Therefore,  f o r t h i s research a  q u a l i t a t i v e methodology was a p p r o p r i a t e so t h a t the r e s e a r c h p a r t i c i p a n t s c o u l d o f f e r t h e i r d e f i n i t i o n s and r e l a t i o n s h i p s among t h e phenomena of i n t e r e s t  (Ammon-Gaberson & P i a n t a n i d e ,  1988;  The study u t i l i z e d an  Strauss & Corbin, 1990).  e x p l o r a t o r y - d e s c r i p t i v e method t o generate  thematic a n a l y s i s  of the i n t e r v i e w s between t h e r e s e a r c h e r and p a r t i c i p a n t s . T h i s chapter commences with an overview of the r e s e a r c h design.  F o l l o w i n g t h a t , the s e l e c t i o n of p a r t i c i p a n t s ,  c o l l e c t i o n and data a n a l y s i s are d e s c r i b e d . concludes  with a d i s c u s s i o n of the study's  data  The chapter ethical  considerations. Research  Design  T h i s study d i d not c l e a r l y and d i r e c t l y t r a d i t i o n a l q u a l i t a t i v e r e s e a r c h methods.  "fit"  any of t h e  The use of an  e x p l o r a t o r y - d e s c r i p t i v e method was a p p r o p r i a t e s i n c e t h e l i t e r a t u r e r e f l e c t e d t h a t t h e r e have not been indepth s t u d i e s of t h e phenomena of i n t e r e s t  (Brink & Wood, 1989),  p a r t i c u l a r l y from a Canadian p e r s p e c t i v e . nurses  As a r e s u l t ,  have l i t t l e c l e a r t h e o r e t i c a l or f a c t u a l knowledge  about ANP, l e t alone i t s r e l a t i o n s h i p t o CHO ( C a r t e r , 1991). Because CNSs are understood  as a focused c u l t u r e i n  34 n u r s i n g (Morse, 1991), the use of ethnographic  methods would  have been i d e a l .  However, the r e s e a r c h p l a n i n c l u d e d  interviews only.  Although  i n t e r v i e w s are v a l u a b l e ,  r e p r e s e n t o n l y one  component of an a u t h e n t i c  study  Brink, 1989;  (Agar,  Atkinson, 1979).  1986;  1983;  Field,  L e i n i n g e r , 1970;  ethnographic  1982;  Hammersley &  Morse, 1991;  However, ethnography s t i l l p r o v i d e d  they  Spradley, considerable  guidance to the data c o l l e c t i o n and a n a l y s i s phases of t h i s research.  The r e s e a r c h r e p o r t w i l l d e s c r i b e how p a r t i c i p a n t s  knew, understood, world  and gave meaning to experiences  (Hunt, 1991).  These f i n d i n g s w i l l c o n t r i b u t e to the  development of n u r s i n g knowledge and ANP S p e c i f i c a l l y , the ethnographic  (Muecke, 1994).  t r a d i t i o n helped  r e s e a r c h e r to be c l e a r about the emic and data, as w e l l as how Every e f f o r t was nature,  of t h e i r  they were presented  the  e t i c sources  of  (Boyle, 1994).  made to have r e s e a r c h f i n d i n g s emic i n  i n t h a t they were d e r i v e d from the p a r t i c i p a n t s ' view  of t h e i r experiences  and p r a c t i c e s , as opposed to  i n f l u e n c e of the r e s e a r c h e r  any  ( F i e l d & Morse, 1985).  S e l e c t i o n of P a r t i c i p a n t s Using an e x p l o r a t o r y - d e s c r i p t i v e design,  the  p a r t i c i p a n t s become c o n t r i b u t o r s i n the g e n e r a t i o n of knowledge about t o p i c s where l i t t l e 1987).  A purposive  sample i s one  new  i s known (Burns & Grove,  sampling  d e s i g n used i n  q u a l i t a t i v e r e s e a r c h , whereby p a r t i c i p a n t s are s e l e c t e d because of t h e i r a b i l i t i e s t o d i s c u s s the phenomena of  35  i n t e r e s t knowledgeably  (Burns & Grove, 1987).  The  following  i s a d e s c r i p t i o n of the s e l e c t i o n c r i t e r i a , procedures f o r r e c r u i t m e n t of p a r t i c i p a n t s and the c h a r a c t e r i s t i c s of the CNSs who  p a r t i c i p a t e d i n t h i s study.  Selection  Criteria  The f o l l o w i n g c r i t e r i a f o r s e l e c t i o n of p a r t i c i p a n t s were developed f o r the purpose of e n s u r i n g a sampling of informants who were experienced i n an ANP  r o l e , and t h e r e f o r e  knowledgeable about the phenomena of i n t e r e s t . p a r t i c i p a n t was •  Each  required:  t o have a master's degree ( R e g i s t e r e d Nurses  Association  of B r i t i s h Columbia, 1988); and, •  t o be c u r r e n t l y employed and have been p r a c t i s i n g i n a CNS p o s i t i o n i n a c l i n i c a l year (Haddad,  s e t t i n g f o r a minimum of one  1992a; Sparacino, 1992).  R a t i o n a l e f o r the c r i t e r i o n of a master's degree i s p r o v i d e d i n the l i t e r a t u r e .  The r e s e a r c h e r made a c o n s c i o u s  d e c i s i o n not t o focus s o l e l y on p a r t i c i p a n t s who degrees i n n u r s i n g due t o the r e c o g n i t i o n  had master's  t h a t t h e r e are  c u r r e n t l y some nurses i n ANP w i t h non-nursing graduate degrees.  A minimum of one year i n the CNS  r o l e was viewed as  e n a b l i n g p a r t i c i p a n t s t o o f f e r " r e a l " or " e x p e r i e n t i a l knowledge"  r a t h e r than s o l e l y academic knowledge  to  discussions. Procedure f o r Recruitment of P a r t i c i p a n t s As was  noted above, a p u r p o s i v e sample was  used f o r the  36 research.  The Vancouver I s l a n d based CNSs, employed i n a  l a r g e h o s p i t a l s o c i e t y , were r e c o g n i z e d by t h e i r peers  and  t h e i r s u p e r v i s o r s as Advanced N u r s i n g P r a c t i t i o n e r s (P. F u l l e r t o n , p e r s o n a l communication,  October 9, 1992).  The  f i n a l number of p a r t i c i p a n t s needed f o r the r e s e a r c h was r e l a t e d t o s a t u r a t i o n of data c a t e g o r i e s (Sirnms,  1981;  Strauss & C o r b i n , 1990).  seven  participants in total. completed  T h i s was  achieved with  A p p r o p r i a t e documentation  and the proposed r e s e a r c h was  was  designed t o ensure  t h a t the p r i n c i p l e s of non-maleficence were maintained & Hungler,  1991).  The r e s e a r c h d e s i g n was  approved by The University Sciences  Screening  Involving  Human  of British  reviewed  Columbia  Committee For Research  (Polit  and  Behavioural  and Other  Studies  Subjects.  The Vancouver I s l a n d CNSs were sent a p e r s o n a l l y addressed l e t t e r the r e s e a r c h .  (Appendix A, p. 194) t h a t i n t r o d u c e d them t o  T h i s l e t t e r o u t l i n e d the type of r e s e a r c h and  the r e a s o n i n g 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 w e l l as c o n t a c t names and numbers.  In a d d i t i o n ,  the  l e t t e r o u t l i n e d t h a t , i f the p o t e n t i a l p a r t i c i p a n t d i d not c o n t a c t the r e s e a r c h e r w i t h i n two weeks, then the r e s e a r c h e r would e s t a b l i s h telephone c o n t a c t i n order t o i n q u i r e  about  i n t e r e s t and t o answer any q u e s t i o n s or address i s s u e s the p o t e n t i a l p a r t i c i p a n t may  have had.  At no time d i d the  r e s e a r c h e r use p r e s s u r e or c o e r c i o n with the p o t e n t i a l  37 participants.  A l l seven p a r t i c i p a n t s telephoned the  r e s e a r c h e r t o say they were i n t e r e s t e d i n p a r t i c i p a t i n g i n the study. When p o t e n t i a l p a r t i c i p a n t s c o n t a c t e d the r e s e a r c h e r f o r i n c l u s i o n i n the study, the r e s e a r c h e r asked q u e s t i o n s t o determine  i f the p a r t i c i p a n t s met  Appendix B,  the e l i g i b i l i t y  criteria.  (p. 196), l i s t s these q u e s t i o n s as w e l l as  o u t l i n i n g the demographic i n f o r m a t i o n t h a t was  collected.  the p a r t i c i p a n t s met  an i n t e r v i e w  was  the e l i g i b i l i t y c r i t e r i a ,  If  arranged.  C h a r a c t e r i s t i c s of P a r t i c i p a n t s A t o t a l of seven CNSs, s i x female and one male, p a r t i c i p a t e d i n the r e s e a r c h .  For the purposes  a l l w i l l be h e r e - a f t e r r e f e r r e d t o as females.  of anonymity, T h e i r ages  ranged from 40 t o 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 f o l l o w s : two two age 46, one age 49, one age 50 and one age A l l p a r t i c i p a n t s had a master's n u r s i n g , 1 i n h e a l t h s c i e n c e s and been employed i n the CNS  3.5,  years. 5.5,  7, 10.5  62.  1 i n science.  position in a c l i n i c a l  T h i s experience was and 13 y e a r s .  40,  degree with 5 b e i n g i n  minimum of one year, s p e c i f i c a l l y 2-13 6.3  age  They had a l l setting for a  years with a median of  d i s t r i b u t e d as f o l l o w s : 2,  3,  T h e i r s p e c i a l t y areas of  p r a c t i c e were: r e h a b i l i t a t i o n , maternal c h i l d , mental h e a l t h with a s u b - s p e c i a l t y i n gerontology, p a i n management, g e r i a t r i c p s y c h i a t r y and two  i n gerontology.  A l l were  38 employed i n a 1639  bed h o s p i t a l s o c i e t y which i n c l u d e s acute  and extended care beds. Data C o l l e c t i o n Once p a r t i c i p a n t s consented and i t was  found t h a t they met  Procedures to p a r t i c i p a t e i n the  eligibility  study  requirements,  i n t e r v i e w s were set up and data c o l l e c t i o n began.  Semi-  s t r u c t u r e d i n t e r v i e w s , which are a p p r o p r i a t e f o r e x p l o r a t o r y d e s c r i p t i v e design were h e l d (Brink, 1989; C o r b i n , 1986;  Hammersley, 1990;  Hunt, 1991).  interview i s purposefully f l e x i b l e for  Burns,  1989;  This type of  (Brink, 1989), and  allows  p a r t i c i p a n t s t o r e v e a l as much as they wish about the  t o p i c under d i s c u s s i o n .  The aim of the s e m i - s t r u c t u r e d  i n t e r v i e w i s t o " e l u c i d a t e the respondent's the world without  imposing  them" ( P o l i t & Hungler,  p e r c e p t i o n s of  any of the r e s e a r c h e r ' s views on  1991,  p. 279).  o u t l i n e s prompts t h a t guided the i n i t i a l  Appendix C (p. interviews.  197), These  prompts guided the r e s e a r c h e r i n attempting to o p e r a t i o n a l i z e the q u e s t i o n s d u r i n g the e a r l y phases of the i n t e r v i e w s (Swanson, 1986). Since the r e s e a r c h e r was to  i n e x p e r i e n c e d , i t was  c o n s u l t f r e q u e n t l y with the c h a i r of the t h e s i s  i n order t h a t : r e l e v a n t i n f o r m a t i o n was data was  important committee  captured; openness to  present without b e i n g clouded by n u r s i n g , medical  p s y c h o l o g i c a l l y o r i e n t e d viewpoints; r e s e a r c h e r  confidence  c o u l d develop d u r i n g v e r i f i c a t i o n of data; the r e s e a r c h e r c o u l d be reminded t h a t f l e x i b i l i t y  and ambiguity  were  or  39 i n t e g r a l p a r t s of t h e q u a l i t a t i v e r e s e a r c h process 1986); and, i n sense c o u l d be made of the data  (Corbin,  (Field &  Morse, 1985). The  s e t t i n g f o r the i n t e r v i e w s was determined  p a r t i c i p a n t s and a l l wished t o hold them i n t h e i r The  r e s e a r c h e r was prepared  offices.  t o request u n i n t e r r u p t e d time  d u r i n g i n t e r v i e w s but t h i s was not r e q u i r e d . put t h e i r phones on " c a l l  by the  forward"  doors without b e i n g asked.  Participants  and c l o s e d t h e i r  The r e s e a r c h e r accommodated the  p a r t i c i p a n t s ' c h o i c e of time.  This a s s i s t e d i n e f f o r t s f o r a  r e l a x e d atmosphere s i n c e p a r t i c i p a n t s d i d not f e e l should be somewhere e l s e a t t h a t p a r t i c u l a r Interviews were approximately P a r t i c i p a n t s a l l consented  office  they  time.  one hour long.  to interviews being  audio-taped.  If t a p i n g was not a c c e p t a b l e , then d e t a i l e d notes would have been taken.  The audio-tapes  made immediately  were supplemented by f i e l d  notes  a f t e r t h e i n t e r v i e w which i n c l u d e d  r e s e a r c h e r thoughts  and o b s e r v a t i o n s .  At the b e g i n n i n g of the i n i t i a l  i n t e r v i e w s , i n order t o  e s t a b l i s h a s h a r i n g r e l a t i o n s h i p , the r e s e a r c h e r again informed p a r t i c i p a n t s what was being s t u d i e d and why, as w e l l as what had aroused (Brink, 1989).  the r e s e a r c h e r ' s i n t e r e s t i n the t o p i c  Since t h e r e s e a r c h e r was a c o l l e a g u e of t h e  Vancouver I s l a n d CNSs, data c o l l e c t i o n became more q u i c k l y focussed and e f f i c i e n t than i f the r e s e a r c h e r were unknown ( F i e l d & Morse, 1985).  However, the r e s e a r c h e r was a l s o a  40 CNS 1994;  so r e f l e x i v i t y was  a f a c t o r i n data c o l l e c t i o n  Hammersley & Atkinson, During the i n t e r v i e w s  sharing,  i n t e r e s t , respect  (Boyle,  1983).  a tone was and  set t h a t encouraged  a p p r e c i a t i o n f o r the time  p a r t i c i p a n t s were t a k i n g to p a r t i c i p a t e i n the  research.  T h i s approach f u r t h e r promoted the r e l a t i o n s h i p and i n encouraging f o l l o w up i n t e r v i e w s Each p a r t i c i p a n t was and  an i n t e r v i e w number.  assigned As  (Chenitz,  the  assisted  1986).  an i d e n t i f i c a t i o n number  soon as p o s s i b l e a f t e r the  i n t e r v i e w , the audio-tapes were t r a n s c r i b e d by a t y p i s t , u s i n g wide margins on the r i g h t hand s i d e of the paper so that notations  and  codes c o u l d be entered  by the data.  The  l i n e s of the t r a n s c r i p t i o n s , as w e l l as the pages were numbered t o make r e t r i e v a l of data e a s i e r and organization.  A face sheet was  attached  to  to the  facilitate transcribed  i n t e r v i e w data t h a t a s s i s t e d 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 i n t e r v i e w s  (Swanson, 1986).  Accuracy of the verbatim t r a n s c r i p t i o n s was the r e s e a r c h e r transcripts.  checked  r e - l i s t e n i n g to the tapes w h i l e f o l l o w i n g The  researcher  or twice more so t h a t she  by the  l i s t e n e d to the audio-tapes once  could acquire  a sense of each  p a r t i c i p a n t ' s i m p l i e d or expressed meanings, changes i n tone or v o i c e 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  Morse, 1985;  P o l i t & Hungler, 1991).  (Field &  These were noted on  transcripts. As  soon as p o s s i b l e a f t e r the i n i t i a l a n a l y s i s of  the  the  41 first  i n t e r v i e w s , f i n d i n g s were c l a r i f i e d ,  and/or v a l i d a t e d with the p a r t i c i p a n t s . interviews  e l a b o r a t e d upon,  These a d d i t i o n a l  (arranged as noted e a r l i e r ) allowed f o r checking  the r e s e a r c h e r ' s o b s e r v a t i o n s and i n t e r p r e t a t i o n s , as w e l l as i n c r e a s i n g the depth and r i c h n e s s of data  (Corbin, 1986).  There were two t o t h r e e one hour v i s i t s between the r e s e a r c h e r and each p a r t i c i p a n t . Inherent i n q u a l i t a t i v e r e s e a r c h i s the i n t e r p e r s o n a l i n t e r a c t i o n between the r e s e a r c h e r and the p a r t i c i p a n t . r e s e a r c h e r was  The  aware of p e r s o n a l p r e c o n c e p t i o n s , v a l u e s  b e l i e f s and noted these i n a j o u r n a l .  and  These a s s i s t e d i n the  maintenance of r e s e a r c h e r awareness of the data and i t s meaning t o the p a r t i c i p a n t the r e s e a r c h e r was by way  (Hutchinson,  1986).  Anything t h a t  a p a r t of e i t h e r v e r b a l l y or n o n - v e r b a l l y  of experiences, f e e l i n g s , s i g h t and h e a r i n g , as w e l l  as g e n e r a l impressions d u r i n g i n t e r a c t i o n s , i n other words, the "dynamics of the s e t t i n g "  ( F i e l d & Morse, 1985,  were kept as a d d i t i o n a l f i e l d notes. immediately  p.  96),  These were w r i t t e n up  a f t e r the i n t e r v i e w , f u r t h e r c l a r i f i e d w h i l e r e -  l i s t e n i n g t o the tapes, and were i n c l u d e d with the taped interviews  ( F i e l d & Morse, 1985;  L i n c o l n & Guba,  1985;  Swanson, 1986) . Data A n a l y s i s The r e s e a r c h q u e s t i o n was  broad i n nature and i t  p r o g r e s s i v e l y narrowed and became more focused d u r i n g the research process.  The r e s e a r c h data a n a l y s i s  "requires a  42 fluid, 1989,  flexible,  somewhat i n t u i t i v e i n t e r a c t i o n "  (Brink,  p. 151), between the r e s e a r c h e r and the data.  In  a d d i t i o n t o the f l e x i b i l i t y  and i n t u i t i o n , data a n a l y s i s  requires researcher i n s i g h t  ( C a r t e r , 1991).  Q u a l i t a t i v e thematic  a n a l y s i s i s made up of two  coding t h a t f a c i l i t a t e d t h i s narrowing, and a x i a l coding.  types of  namely open coding  Data a n a l y s i s and data c o l l e c t i o n  occurred  s i m u l t a n e o u s l y and moved from i n d u c t i v e to d e d u c t i v e t h i n k i n g and back again 1990).  The  (Guba & Lincoln,. 1981;  researcher o f f e r e d f l e x i b i l i t y ,  i n s i g h t throughout Pollick,  Strauss & C o r b i n ,  a l l phases (Brink, 1989;  intuition Carter,  and 1991;  1991).  Open coding o c c u r r e d 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 p e r s i s t e n t words, phrases, identified.  by paragraph  concepts  so t h a t  and themes were  These were coded and developed  into categories.  T h i s ongoing a n a l y s i s allowed f o r the refinement  of prompts  so t h a t subsequent i n t e r v i e w s f u r t h e r e l a b o r a t e d emerging c a t e g o r i e s or themes. A x i a l coding f o l l o w e d and the c a t e g o r i e s were re-examined and re-connected  by use of a coding paradigm  i n v o l v i n g c o n d i t i o n s , context,  action/interactional  s t r a t e g i e s and consequences (Strauss & C o r b i n , 1990). r e s e a r c h e r was throughout thematic  The  c o n s t a n t l y a s k i n g questions of the data  a n a l y s i s (Corbin, 1986).  Significant  statements,  d e s c r i p t i o n s , and verbatim quotes were o r g a n i z e d  43 around each category or theme. Through ongoing data a n a l y s i s , concepts  and t h e i r  r e l a t i o n s h i p s were d i s c o v e r e d t o be r e l e v a n t or i r r e l e v a n t t o the r e s e a r c h q u e s t i o n  (Morse, 1994; Strauss & Corbin,  Phenomena were d i s c o v e r e d , developed  1990).  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 a n a l y s i s (Strauss & Corbin, 1990).  The r e s e a r c h e r developed  skill  r e l a t e d t o 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 s t e p p i n g back and a s k i n g  questions;  m a i n t a i n i n g an a t t i t u d e of s c e p t i c i s m ; and, f o l l o w i n g the r e s e a r c h procedures (Strauss & Corbin, The  with the guidance of her t h e s i s committee 1990)..  r e s e a r c h e r developed  a data f i l i n g  system t h a t  i n c l u d e d a f l e x i b l e storage system, as w e l l as procedures f o r r e t r i e v i n g the data  ( F i e l d & Morse, 1985).  r e s e a r c h e r ' s previous  l a c k of e x p e r t i s e i n q u a l i t a t i v e  a n a l y s i s , i t was c h a l l e n g i n g t o develop of  "filing"  or " o r g a n i z i n g " the data.  study progressed  Due t o the data  an a p p r o p r i a t e method T h i s u n f o l d e d as the  and the r e s e a r c h e r became more knowledgeable  about the c a p a c i t y of her computer, as w e l l as u t i l i z a t i o n of " c u t t i n g and p a s t i n g " t r a n s c r i p t i o n s . Throughout any phase of data a n a l y s i s the r e s e a r c h e r r e t u r n e d t o the f i e l d ,  through i n t e r v i e w , when t h e r e was a  need t o f u r t h e r c l a r i f y and/or v a l i d a t e data Strauss & Corbin, 1990).  (Corbin, 1986;  The i n f o r m a t i o n t h a t p a r t i c i p a n t s  shared was s i m i l a r i n b a s i c s t r u c t u r e t o what the r e s e a r c h e r  44 had generated  (Corbin, 1986).  p r o c e s s , the thematic  I f , through  verification  a n a l y s i s d i d not hold up, then i t was  d i s c a r d e d and the process began again L i t e r a t u r e was  the  reviewed  (Corbin, 1986).  throughout  data c o l l e c t i o n  a n a l y s i s i n order t o : s t i m u l a t e t h e o r e t i c a l  sensitivity,  s t i m u l a t e q u e s t i o n s , d i r e c t t h e o r e t i c a l sampling p r o v i d e supplementary v a l i d a t i o n The  l i t e r a t u r e was  and  and  to  (Strauss & C o r b i n , 1990).  used t o expand and c l a r i f y codes and  to  become s e n s i t i z e d to a d d i t i o n a l ways of e x p l o r i n g the emerging data a n a l y s i s (Charmaz, 1983).  A f t e r data a n a l y s i s  and the emergence of c a t e g o r i e s , the l i t e r a t u r e was reviewed  t o determine i f others had i d e n t i f i e d the same  c a t e g o r i e s and what they had 1987;  again  Strauss & Corbin,  s a i d about them (Burns  & Grove,  1990).  Once the conceptual c a t e g o r i e s and p r o p e r t i e s were e s t a b l i s h e d 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, r e s u l t a n t i n f o r m a t i o n was interest  (Simms, 1981;  the  used to d e s c r i b e the phenomena of  Strauss & C o r b i n , 1990).  The  d e s c r i p t i o n c o n s i s t s of c a t e g o r i e s t h a t are both dense with concepts  and s a t u r a t e d to the degree t h a t a range of  v a r i a t i o n was  accounted  f o r , hypothesis t e s t i n g v e r i f i e d  the c a t e g o r i e s i n t e g r a t e d (Corbin, 1986;  and  Strauss & C o r b i n ,  1990). Q u a l i t a t i v e r i g o r was •  assured through  t r u t h v a l u e - the theory developed  the f o l l o w i n g :  contains  faithful  d e s c r i p t i o n s or i n t e r p r e t a t i o n s of p a r t i c i p a n t s .  The  r e s e a r c h e r v e r i f i e d data with p a r t i c i p a n t s and t h a t i t was  "true" so they r e c o g n i z e d i t as t h e i r  (Guba & L i n c o l n , 1981; entries  Sandelowski, 1986).  ( f i e l d notes) documented how  were c l e a r l y separate  own  Journal  the r e s e a r c h e r  i n f l u e n c e d by p a r t i c i p a n t s so t h a t t h e i r  •  ensured  from those of the  was  experiences researcher.  a p p l i c a b i l i t y - f i n d i n g s from the r e s e a r c h  " f i t " the  data and are w e l l grounded i n the p a r t i c i p a n t s ' experiences.  T h i s was  confirmed  p a r t i c i p a n t s , and the checking  by v a l i d a t i o n  f o r the  r e p r e s e n t a t i v e n e s s of the data by way categories •.  (Guba & L i n c o l n , 1981;  of codes  was  ensured  t h e s i s committee review  inexperienced,  with having the c h a i r of the a s e c t i o n of the data t o ensure  t h e r e were c o n s i s t e n c i e s .in i n t e r p r e t a t i o n s . was  The  aim  t h a t the c h a i r a r r i v e d at the same or comparable  conclusions  (Guba & L i n c o l n , 1981;  A u d i t a b i l i t y was  ensured  Sandelowski, 1986).  by the r e s e a r c h e r d e s c r i b i n g ,  e x p l a i n i n g or j u s t i f y i n g a l l steps of the process 1981; •  and  Sandelowski, 1986).  c o n s i s t e n c y - s i n c e the r e s e a r c h e r was reliability  with  in this final  research  w r i t t e n r e p o r t (Guba & L i n c o l n ,  Sandelowski, 1986).  n e u t r a l i t y - freedom of r e s e a r c h e r b i a s i n the data ensured  by way  was  of the r e s e a r c h e r c a r e f u l l y t r a c k i n g and  documenting a l l phases of the r e s e a r c h .  This i s  r e f l e c t e d i n the r e s e a r c h r e p o r t (Guba & L i n c o l n ,  1981;  46 Sandelowski,  1986). E t h i c a l Considerations  At the b e g i n n i n g of the i n t e r v i e w s , the purpose r e s e a r c h was again reviewed with p a r t i c i p a n t s . r e s e a r c h e r confirmed the e l i g i b i l i t y  of the  The  c r i t e r i a and asked  p a r t i c i p a n t s i f they had any q u e s t i o n s or i s s u e s t h a t had not been addressed.  These were answered or r e s o l v e d t o the  s a t i s f a c t i o n of the p a r t i c i p a n t s . At the b e g i n n i n g of the i n i t i a l  i n t e r v i e w s , p r i o r t o any  data c o l l e c t i o n , d u p l i c a t e consent forms were signed by p a r t i c i p a n t s and the r e s e a r c h e r (Appendix  D, p. 198). The  s i g n i n g of the consent documents t h a t p a r t i c i p a n t s had been informed about adequate i n f o r m a t i o n and were w i l l i n g t o p a r t i c i p a t e i n the r e s e a r c h ( P o l i t & Hungler, 1986).  1991; Swanson,  Once the consent forms were signed, a copy was  r e t a i n e d by p a r t i c i p a n t s and the d u p l i c a t e was kept by the r e s e a r c h e r ( P o l i t & Hungler, f i n a n c i a l remuneration  1991).  There was not any  f o r the p a r t i c i p a n t s of t h i s r e s e a r c h .  P a r t i c i p a n t s were a l l informed t h a t they were f r e e t o : withdraw from the study a t any time without jeopardy and r e f u s e t o d i s c u s s any s p e c i f i c t o p i c s  (Munhall, 1988).  P a r t i c i p a n t s were assured of c o n f i d e n t i a l i t y .  T h i s was  a t t a i n e d through the use of codes known o n l y t o the r e s e a r c h e r t o i d e n t i f y p a r t i c i p a n t s on the i n t e r v i e w audiotapes and any of the w r i t t e n m a t e r i a l s f o r example t r a n s c r i p t s and/or j o u r n a l e n t r i e s .  P a r t i c i p a n t names and  47 s p e c i f i c work s e t t i n g s were not used a t any time.  Data was  s t o r e d i n a locked cupboard i n the r e s e a r c h e r ' s home and a c c e s s i b l e only t o t h e r e s e a r c h e r . p u b l i c a t i o n s of t h i s r e s e a r c h w i l l e i t h e r d i r e c t l y or i n d i r e c t l y .  Any r e s u l t a n t not i d e n t i f y p a r t i c i p a n t s  The data c o l l e c t e d d u r i n g a l l  i n t e r v i e w s was used only f o r the purposes of the r e s e a r c h and upon completion  of t h e study a l l audio-tapes  P a r t i c i p a n t s were informed  w i l l be erased.  t h a t f o r those i n t e r e s t e d a  summary of t h e r e s e a r c h f i n d i n g s would be made a v a i l a b l e . Chapter Summary T h i s chapter has d e s c r i b e d t h e methodology t h a t  guided  t h i s study i n i t s e x p l o r a t i o n of the d e f i n i t i o n of ANP and the r e l a t i o n s h i p of ANP t o CHO.  D i s c u s s i o n was i n c l u d e d t h a t  d e s c r i b e d the e x p l o r a t o r y - d e s c r i p t i v e r e s e a r c h  design,  p a r t i c i p a n t s e l e c t i o n , data c o l l e c t i o n , data a n a l y s i s and ethical considerations. study a r e presented.  In t h e next chapter,  f i n d i n g s of t h e  48 CHAPTER FOUR FINDINGS In t h i s chapter, the r e s e a r c h f i n d i n g s The  are presented.  r e s e a r c h area of i n t e r e s t generated t h o u g h t f u l and  r e f l e c t i v e discussions  by p a r t i c i p a n t s .  p a r t i c i p a n t s attempted t o d e f i n e  As nurses i n ANP,  ANP as w e l l as d e s c r i b e  t h e i r p r a c t i c e i n r e l a t i o n t o CHO. Although p a r t i c i p a n t s  e n t h u s i a s t i c a l l y began  discussions  about the r e s e a r c h phenomena of i n t e r e s t , i t q u i c k l y became obvious t h a t ANP was not a term t h a t was e a s i l y and c o n c i s e l y definable.  Initially,  "could you start thought  with an easier  about this  Participants  p a r t i c i p a n t s made comments such as question,"  a lot" and "I should  "I really  know  haven't  this."  thought ANP was a term t h a t was broad and vague  i n nature, however was a b l e t o be a r t i c u l a t e d through descriptors. Participants  found i t c h a l l e n g i n g  p r a c t i c e i n r e l a t i o n t o CHO.  to describe  Initially,  their  they focused on CHO,  again as a term t h a t needed a c l e a r e r understanding. too presented c h a l l e n g e s . clinical  Participants  thought t h a t t h e  focus f o r nurses i n ANP was s t a f f  Therefore, p a r t i c i p a n t s b e l i e v e d  nurses.  t h a t any i n f l u e n c e  might have had on CHO would be of an i n d i r e c t nature than a d i r e c t c o r r e l a t i o n .  Participants  ways t o a r t i c u l a t e t h e p o s s i b l e p r a c t i c e and CHO.  This  they rather  chose i n t e r e s t i n g  r e l a t i o n s h i p between t h e i r  49 A l l p a r t i c i p a n t s confirmed c o n f i d e n t l y t h a t c o n s i d e r e d themselves t o be advanced n u r s i n g They were able t o d e s c r i b e perspective  they  practitioners.  t h e i r p r a c t i c e from the  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 t h a t a l l p a r t i c i p a n t s c i t e d , without prompting, indepth knowledge of Joy C a l k i n and P a t r i c i a Benner's r e s e a r c h , professional as ANP.  nursing  r e l a t e d t o f i v e l e v e l s of  competency i n c l i n i c a l p r a c t i c e , as w e l l  P a r t i c i p a n t s made r e f e r e n c e  l i t e r a t u r e t h a t had been p u b l i s h e d to the CNS r o l e and ANP. formally  over s e v e r a l years r e l a t e d  They a l s o d e s c r i b e d  acknowledged by n u r s i n g  associations  t o the wealth of  scholars  how a CNS was  and p r o f e s s i o n a l  as b e i n g under t h e umbrella of ANP.  By way of s e t t i n g the stage f o r reader c o n s i d e r a t i o n of research  findings, information  i s presented now r e l a t e d t o  p a r t i c i p a n t context of p r a c t i c e . that despite  A l l participants  e f f o r t s t o understand, d e f i n e  recognized  or d e s c r i b e  ANP,  a b i l i t i e s t o enact t h e i r r o l e and any i n f l u e n c e they may have on CHO was s t r o n g l y dependent upon t h e context of p r a c t i c e . They saw t h i s as the s i n g l e 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 P a r t i c i p a n t s wanted the r e s e a r c h e r  to be c l e a r t h a t what  they might have b e l i e v e d d u r i n g t h i s study about ANP continue t o be r e a l i z e d due  t o many of the  i n v o l v e d i n h e a l t h care reform. research,  not  initiatives  During the time of  many n u r s i n g p o s i t i o n s were being  may  the  examined  and  p a r t i c i p a n t s were being asked to j u s t i f y t h e i r r o l e s , and take on more and more of what they considered administrative practice. was  to  to  be  f u n c t i o n s , as w e l l as broader scopes of  For these reasons, they s t r o n g l y b e l i e v e d t h a t  ever-changing and  r e q u i r e d a great d e a l of  ANP  flexibility:  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 how fast I can re-define my role.  flow.  Just  watch  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. P a r t i c i p a n t s recognized s i g n i f i c a n t l y impacting believed that inherent  t h a t h e a l t h reform  a l l h e a l t h care p r o v i d e r s i n ANP  was  was but  the c o n s i s t e n t and  ever-  NOTE: * The term c l i e n t w i l l continue to be used throughout the p r e s e n t a t i o n of r e s e a r c h f i n d i n g s . The p a r t i c i p a n t s used terms of client, patient, resident and consumer i n t h e i r discussions. However, f o r b r e v i t y , p a r t i c i p a n t anonymity as w e l l as c o n s i s t e n c y form the previous t h r e e chapters, client w i l l be i n s e r t e d wherever the p a r t i c i p a n t s spoke of the r e c i p i e n t s of, or p a r t i c i p a n t s i n n u r s i n g care.  51 changing context  of p r a c t i c e .  Thus, p a r t i c i p a n t s b e l i e v e d  t h a t they f r e q u e n t l y needed to provide value  to n u r s i n g The  s e r v i c e s and  researcher  has  evidence of  overall client  chosen to present  their  care.  findings  according  t o t h r e e broad c a t e g o r i e s , or d e s c r i p t o r s , t h a t r e s u l t e d from the thematic a n a l y s i s . difficulties  first  broad category r e l a t e s t o  i n c l e a r l y d e f i n i n g ANP.  c o n s i s t e d of two and  The  components: i n i t i a l  T h i s category of data attempts at d e f i n i n g  reasons f o r l a c k of c l a r i t y about ANP.  ANP  P a r t i c i p a n t s were  not concerned about t h e i r l a c k of c l a r i t y around a term t h a t was  r o u t i n e l y l i n k e d with t h e i r p r a c t i c e .  They i d e n t i f i e d  many f a c t o r s t h a t i n f l u e n c e d the vagueness a s s o c i a t e d  with  ANP. The  second broad category r e l a t e s to d e s c r i p t o r s of  T h i s category of data c o n s i s t e d of two requirement t r i a d of ANP  and  ANP.  components: minimal  e s s e n t i a l q u a l i t i e s of  ANP.  P a r t i c i p a n t s b u i l t on t h e i r attempts to d e f i n e ANP  and were  able to a r t i c u l a t e what they considered  foundation  for  ANP, The  to be the  as w e l l as e s s e n t i a l q u a l i t i e s . t h i r d broad category r e l a t e s t o p o s s i b l e  r e l a t i o n s h i p between ANP c o n s i s t e d of three  and  CHO.  This category of data  components: problems i n a r t i c u l a t i n g  communicating the r e l a t i o n s h i p between ANP t h e o r e t i c a l problems i n l i n k i n g ANP  and  with CHO.  CHO;  CHO;  and,  T h i s data  r e f l e c t s p a r t i c i p a n t attempts to d e s c r i b e t h e i r p r a c t i c e i n r e l a t i o n to CHO.  I t b u i l d s on the previous  c a t e g o r i e s by  way  52 of e x p l o r a t i o n and d e s c r i p t i o n of how nurses i n ANP r o l e s i n f l u e n c e CHO. Together these t h r e e broad c a t e g o r i e s  represent  p a r t i c i p a n t attempts t o d e f i n e ANP and t o d e s c r i b e p r a c t i c e i n r e l a t i o n t o CHO.  Throughout the p r e s e n t a t i o n ,  f i n d i n g s a r e i l l u s t r a t e d with verbatim participant  their  excerpts  from  accounts.  D i f f i c u l t i e s i n C l e a r l y D e f i n i n g Advanced Nursing In p r e s e n t i n g these  f i n d i n g s , i t i s important  Practice t o again  emphasize t h a t p a r t i c i p a n t s were CNSs who addressed the r e s e a r c h phenomena of i n t e r e s t from the p e r s p e c t i v e of t h e i r own r o l e s .  CNSs have been c o n s i s t e n t l y i d e n t i f i e d i n n u r s i n g  l i t e r a t u r e and i n n u r s i n g d i s c u s s i o n s as b e i n g advanced nursing p r a c t i t i o n e r s .  The assumption has been made f o r t h e  purposes of t h i s r e s e a r c h , t h a t s i n c e CNSs have been c l e a r l y l i n k e d with ANP, p a r t i c i p a n t s were able t o speak from t h a t perspective. P a r t i c i p a n t s had d i f f i c u l t y c l e a r l y d e f i n i n g ANP and i n i t i a l attempts t o do so r e f l e c t e d t h i s .  However,  p a r t i c i p a n t s o f f e r e d reasons f o r t h e i r l a c k of c l a r i t y ANP.  A d e s c r i p t i o n of t h e i r p e r c e p t i o n s  difficult  about  of what makes t h i s  w i l l p r o v i d e a context w i t h i n which t h e i r views  about ANP and CHO can be understood. I n i t i a l Attempts a t D e f i n i n g Advanced Nursing P r a c t i c e When p a r t i c i p a n t s i n i t i a l l y t r i e d t o a r t i c u l a t e a d e f i n i t i o n of ANP, they c o u l d not p r o v i d e a c l e a r or c o n c i s e  53 one.  The f o l l o w i n g 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 '  initial  l a c k of c l a r i t y r e g a r d i n g a d e f i n i t i o n of ANP.  recognized that a  d e f i n i t i o n of ANP  was  They  open t o many  interpretations: I don't know, I really define it.  don't know how  I am sure there is a basic core thing people mean when they use that term. different idea.  (pause) how  you  of what most But everyone has a  It is a concept that is not concrete nor easily (pause) there are not a lot of easy boundaries that concept you know.  defined around  A l l p a r t i c i p a n t s r e c o g n i z e d t h a t t h e i r r o l e as a CNS d i r e c t l y a s s o c i a t e d with ANP. t h a t ANP  was  However, they a l s o b e l i e v e d  a term t h a t remained  broad and vague i n nature.  They were not concerned about t h e i r l a c k of c l a r i t y ANP,  and as the data w i l l  her attempts  was  about  show, c a u t i o n e d the r e s e a r c h e r i n  towards a c l e a r e r understanding of i t .  Broad and Vague Term A l l p a r t i c i p a n t s were f a m i l i a r with n u r s i n g l i t e r a t u r e on ANP  and c i t e d v a r i o u s n u r s i n g s c h o l a r s such as C a l k i n  Benner's e f f o r t s at d e f i n i n g and/or d e s c r i b i n g ANP.  and  However,  p a r t i c i p a n t s thought t h a t these d e f i n i t i o n s and/or d e s c r i p t i o n s , although v a l u a b l e and a s s i s t i v e i n t h e i r  roles,  were not c l e a r or c o n s i s t e n t l y p r a c t i c e d . P a r t i c i p a n t s r e f e r r e d t o Benner's work and b e l i e v e d the l a c k of e x p l i c i t l i n k a g e between expert and ANP the l a c k of c l a r i t y about ANP. work d i d not f u l l y capture "ANP"  that  added t o  They thought t h a t Benner's although they knew she  54 r e f e r r e d t o , and used the term a l o n g with "expert." P a r t i c i p a n t s b e l i e v e d t h a t ANP was something more than the indepth c l i n i c a l knowledge t h a t was o f t e n a s s o c i a t e d 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. C o n t r i b u t o r s t o the o v e r a l l l a c k of c l a r i t y around ANP were thought t o i n c l u d e n u r s i n g l a n g u a g e / r h e t o r i c t h a t was not e a s i l y understood and/or meaningful w i t h i n n u r s i n g , alone o u t s i d e n u r s i n g .  P a r t i c i p a n t s 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 t h a t nurses had towards nursing education.  let  t h e v a r i o u s l e v e l s of  The f o l l o w i n g account summarizes these  c o n t r i b u t o r s and r e f l e c t s p a r t i c i p a n t awareness of t h e i n f l u e n c e of t h e i r p r a c t i c e r e l a t e d t o 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, a c c o r d i n g  to p a r t i c i p a n t s , ANP  broad and vague i n nature. work of n u r s i n g  scholars  a term t h a t  was  literature  and  They c i t e d n u r s i n g  such as C a l k i n and  thought t h a t c u r r e n t r e s e a r c h d i f f e r e n c e s between the expert  Benner but  d i d not adequately capture nurse and  P a r t i c i p a n t s b e l i e v e d t h a t there knowledge and  was  the nurse i n  i s more to ANP  t h a t p r o v i d i n g l e a d e r s h i p and  than  ANP. clinical  guidance to  others were an important p a r t of i n f l u e n c i n g them to meaningful  the  find  CHO.  Lack of Concern Not  one  of the p a r t i c i p a n t s was  of c l a r i t y around ANP.  concerned about her  A l l were very w i l l i n g to engage i n  d i s c u s s i o n f o r the purposes of the r e s e a r c h . obvious t o the r e s e a r c h e r was  lack  However, i t was  t h a t a c l e a r e r understanding of  ANP  not a p r i o r i t y area f o r p a r t i c i p a n t c o n s i d e r a t i o n .  O v e r a l l , although g r a c i o u s  i n taking part i n t h i s  study,  p a r t i c i p a n t s b e l i e v e d t h a t i n t h e i r day-to-day p r a c t i c e they had more important t h i n g s , such as program p l a n n i n g consultations to consider  and  r a t h e r than t r y i n g t o d e f i n e  ANP  more c l e a r l y : I know that ANP is not a clear more important things to think  term but about.  I have  other  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 p a r t i c i p a n t s were comfortable with t h e i r  own  understanding of ANP and v o i c e d c o n f i d e n c e i n how they d e f i n e d i t f o r themselves and how they enacted i t .  They were  not concerned i f t h e i r own understanding was not c l e a r t o others.  In f a c t , as the f o l l o w i n g account  demonstrates  p a r t i c i p a n t s got " f e d up" and " t i r e d " of what they p e r c e i v e d t o be exhaustive and f u t i l e e f f o r t s t o 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. P a r t i c i p a n t s e l a b o r a t e d on t h e i r own l a c k of concern by p o i n t i n g out t h a t v e r y c r e d i b l e and w e l l known n u r s i n g s c h o l a r s 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 t o f u r t h e r understand ANP, as w e l l as the i n d i v i d u a l r o l e s i n it,  but without much success.  Although p a r t i c i p a n t s v a l u e d  these e f f o r t s , the l a c k of success r e i n f o r c e d t h e i r own ideas about not needing t o be d i r e c t l y i n v o l v e d 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, p a r t i c i p a n t s were not concerned about t h e i r of c l a r i t y about ANP.  From t h e i r own  lack  p e r s p e c t i v e , they  understood i t w e l l enough t o be a b l e t o enact i t .  Although  p a r t i c i p a n t s supported the r e s e a r c h e r i n her e f f o r t s t o d e f i n e ANP,  c l e a r l y they d i d not share t h i s need.  Day-to-day  demands of p r a c t i c e were thought to be f a r more important areas f o r c o n s i d e r a t i o n .  P a r t i c i p a n t s r e c o g n i z e d the  exhaustive, but n o n - c o n c l u s i v e e f f o r t s of n u r s i n g l e a d e r s around v a r i o u s components of ANP.  Although  participants  found these e f f o r t s worthy of applause, they b e l i e v e d t h a t d e f i n i n g ANP time w i t h . t i r i n g and  was  not something  they needed t o spend any more  In f a c t , they thought e f f o r t s t o do so were futile.  Cautions Around T r y i n g t o C l e a r l y D e f i n e Not o n l y were p a r t i c i p a n t s not concerned about the l a c k of c l a r i t y about ANP,  they c a u t i o n e d the r e s e a r c h e r i n  e f f o r t s aimed a t a c l e a r e r understanding. i t was  b e n e f i c i a l f o r ANP  They b e l i e v e d t h a t  t o remain broad and vague.  allowed f o r the f l e x i b i l i t y r e q u i r e d f o r ANP evolve, l i k e the r e s t of n u r s i n g .  t o continue t o  Participants  the r i s k of what they r e f e r r e d t o as forcing  This  a  identified definition.  Although r e c o g n i z i n g t h a t some nurses wanted t h i n g s l i k e d e f i n i t i o n s t o be i n "black and white," p a r t i c i p a n t s  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 n e g a t i v e consequences nursing.  Given the ever-changing h e a l t h care  for  environments  and the r e s u l t a n t ambiguity i n n u r s i n g , p a r t i c i p a n t s  thought  58 ANP was understood w e l l enough.  The f o l l o w i n g 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! P a r t i c i p a n t s r e i n f o r c e d t h a t nurses knew enough about ANP y e t may never know enough t o have a c l e a r d e f i n i t i o n . They thought ANP was something t o be d e s c r i b e d  and these  d e s c r i p t i o n s allowed f o r ongoing changes and f l e x i b i l i t y f o r the r o l e .  The d e s c r i p t i o n s a l s o i n v o l v e d t e l l i n g  paradigm  stories: 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, p a r t i c i p a n t s b e l i e v e d t h a t n u r s i n g was e v o l v i n g and ANP needed t o be f l e x i b l e t o respond t o these  changes.  P a r t i c i p a n t s a l s o b e l i e v e d t h a t nurses understood ANP w e l l enough and may never know enough t o have a c l e a r d e f i n i t i o n . They thought ANP was something t o be d e s c r i b e d  i n paradigm  s t o r i e s , with the d e s c r i p t i o n s a l l o w i n g f o r ongoing changes to the enactment of the r o l e .  59 Reasons f o r Lack o f C l a r i t y About Advanced Nursing  Practice  As has been mentioned, p a r t i c i p a n t s had d i f f i c u l t y with a c l e a r d e f i n i t i o n of ANP.  Besides not b e i n g concerned,  p a r t i c i p a n t s could a r t i c u l a t e v a l i d e x p l a n a t i o n s f o r t h e i r l a c k of c l a r i t y i n attempting t o d e f i n e ANP. role inconsistencies;  imprecision  regarding  These  included:  nursing;  terminology changes; and, l a c k of time f o r r e f l e c t i o n . Role  Inconsistencies  P a r t i c i p a n t s r e c o g n i z e d t h a t 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 t o the enactment of t h a t practice.  This was b e l i e v e d  inconsistencies  to result i n o v e r a l l  r e l a t e d t o ANP.  Although r e c o g n i z e d as a  f a c t o r i n l a c k of c l a r i t y about ANP, p a r t i c i p a n t s thought these very i n c o n s i s t e n c i e s were v a l u a b l e , the  i n d i v i d u a l i t y of the nurse.  unique p e r s o n a l and p r o f e s s i o n a l  as they supported  P a r t i c i p a n t s supported the competencies* t h a t  each  nurse brought t o 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 different.  one of us is very different,  Participants believed very strong p e r s o n a l i t i e s .  very,  very  t h a t nurses who went i n t o ANP had These s t r o n g  personalities  combined with advanced education and experience r e s u l t e d i n NOTE: ^competencies - p a r t i c i p a n t s d e f i n e d competencies as the knowledge, s k i l l s , a t t i t u d e s and judgements t h a t nurses brought t o ANP.  60 unique, powerful competencies  which had the p o t e n t i a l t o  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 n u r s i n g and h e a l t h c a r e . P a r t i c i p a n t s a l s o b e l i e v e d t h a t d e s p i t e the v a r y i n g p e r s o n a l t i e s , nurses i n ANP were very s u p p o r t i v e of each other and would t r y hard t o embrace nurses new t o t h e r o l e . The f o l l o w i n g account r e f l e c t s p a r t i c i p a n t attempts t o e x p l a i n why ANP was not c l e a r l y d e f i n a b l e and how nurses i n ANP would support and mentor o t h e r s : 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, p a r t i c i p a n t s b e l i e v e d t h a t t h e r e were s i g n i f i c a n t d i f f e r e n c e s i n how nurses i n ANP enacted t h e i r r o l e s . d i f f e r e n c e s were supported as p a r t i c i p a n t s thought nurses who chose ANP brought  These  that  some s t r o n g p e r s o n a l i t i e s , as  w e l l as p r o f e s s i o n a l competencies  t h a t had the p o t e n t i a l t o  p o s i t i v e l y and s i g n i f i c a n t l y i n f l u e n c e n u r s i n g and h e a l t h care.  Nurses  i n ANP v a l u e d s u p p o r t i n g t h e i r peers.  Imprecision Regarding Nursing P a r t i c i p a n t s thought t h a t ANP, s i m i l a r t o so many other terms i n n u r s i n g , l a c k e d c l a r i t y . the focus w i t h i n n u r s i n g on ANP.  They t h e r e f o r e q u e s t i o n e d Participants believed that  d e s p i t e an apparent u n c l e a r understanding of s p e c i f i c most nurses were competently  able t o p r a c t i c e n u r s i n g .  terms, In  61 other words, although most nurses c o u l d competently  practice  n u r s i n g , they c o u l d n ' t c l e a r l y a r t i c u l a t e i t . P a r t i c i p a n t s r e c o g n i z e d the c o n t r o v e r s y concerning c l a r i t y of n u r s i n g i t s e l f , it.  As a r e s u l t , p a r t i c i p a n t s thought many f a c t o r s  i n f l u e n c e d attempts thought by  l e t alone s p e c i f i c r o l e s w i t h i n  a t c l e a r d e f i n i t i o n s of ANP.  the v a r i e t y of understandings  They  of ANP were i n f l u e n c e d  "hidden agendas" and " p r o t e c t i n g t u r f " of those t r y i n g t o  develop  definitions:  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  f o l l o w i n g account  r e f l e c t s these ideas as w e l l as  p a r t i c i p a n t views t h a t i t was "the experts" who were most concerned practice.  about c o n f u s i o n a s s o c i a t e d with a l l of n u r s i n g However, d e s p i t e o v e r a l l l a c k of c l a r i t y ,  p a r t i c i p a n t s thought ANP was a u s e f u l 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, a c c o r d i n g t o p a r t i c i p a n t s , p a r t of the l a c k of  62 c l a r i t y a s s o c i a t e d 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 p a r t i c i p a n t s  b e l i e v e d t h a t most nurses c o u l d q u i t e competently  practice  n u r s i n g , these same nurses had d i f f i c u l t y t r y i n g t o articulate their practice.  Participants d i d believe that  f a c t o r s such as "hidden agendas" and  "protecting turf"  i n f l u e n c e d the v a r y i n g understandings of ANP. disagreement  D e s p i t e expert  on the d e f i n i t i o n s and p r a c t i c e of n u r s i n g ,  p a r t i c i p a n t s b e l i e v e d t h a t ANP  was  a useful  term.  Terminology Changes P a r t i c i p a n t s thought t h a t ANP " r e l a t i v e l y new"  was  a complex and  y e t ever-changing term.  Participants  b e l i e v e d t h a t one p o s s i b l e i n f l u e n c i n g f a c t o r as t o whether a nurse c o u l d t a l k about ANP was  i n d e t a i l was whether or not i t  a t o p i c i n the l i t e r a t u r e d u r i n g attendance a t graduate  school.  I f i t was,  p a r t i c i p a n t s b e l i e v e d i t would then have  been i n c l u d e d i n t h e i r course work.  Even though  participants  r e c o g n i z e d the scope of n u r s i n g l i t e r a t u r e i n c i r c u l a t i o n d u r i n g the time of t h i s r e s e a r c h r e l a t e d t o ANP, t h a t t o t r u l y understand ANP  they thought  i t might have been u s e f u l t o  have "the l u x u r y of graduate student time" f o r indepth discussion.  They b e l i e v e d t h a t once nurses  completed  graduate education, they would be u n l i k e l y t o have the time to  f u l l y e x p l o r e terms  such as ANP.  T h i s l a c k of time  thought t o be p r i m a r i l y due t o the e x t e n s i v e day-to-day demands of p r a c t i c e :  was  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, p a r t i c i p a n t s r e c o g n i z e d the v a l u e of b e i n g a b l e t o f u l l y e x p l o r e terms  such as ANP  i n graduate s c h o o l .  extent t h a t a nurse c o u l d d i s c u s s ANP  was  r e f l e c t i v e of whether or not the term was  thought t o be i n the  and t h e r e f o r e p a r t of education, w h i l e the nurse a t t e n d i n g graduate s c h o o l .  The  literature, was  I f not, once the nurse was i n  day-to-day demands of p r a c t i c e , time r e q u i r e d f o r f u l l e x p l o r a t i o n of ANP  was  not a v a i l a b l e .  Lack of Time f o r R e f l e c t i o n P a r t i c i p a n t s b e l i e v e d t h a t t o understand terms ANP,  c r i t i c a l t h i n k i n g about p r a c t i c e was  such as  required.  P a r t i c i p a n t s r e f e r r e d t o t h i s as " r e f l e c t i v e time." d e f i n e d r e f l e c t i v e time as time when nurses i n ANP  They could  "step back" and spend q u a l i t y time c r i t i c a l l y t h i n k i n g  about  a v a r i e t y of terms and/or concepts t h a t were l i n k e d w i t h their practice. sought, was  This r e f l e c t i v e time, although h i g h l y  r e f e r r e d t o as "a l u x u r y " and  u n a t t a i n a b l e due t o workload p r e s s u r e s .  basically However,  p a r t i c i p a n t s i d e n t i f i e d t h a t when r e f l e c t i v e time i s not b u i l t i n t o n u r s i n g p r a c t i c e , i t c o u l d be an important  factor  64 r e l a t e d t o the o v e r a l l l a c k 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 f o l l o w i n g account f u r t h e r e x e m p l i f i e s t h a t  this  r e f l e c t i v e t h i n k i n g would o n l y be done when the nurse i n ANP was i n v o l v e d i n r e s e a r c h .  Otherwise p a r t i c i p a n t s  thought  t h a t , i n day-to-day p r a c t i c e , they were not r e q u i r e d t o be " p r a c t i c e d 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, a c c o r d i n g t o p a r t i c i p a n t s , r e f l e c t i v e time was r e q u i r e d f o r nurses i n ANP t o understand terms  such as ANP.  They r e a l i z e d t h a t due t o day-to-day workload p r e s s u r e s i n t h e i r p r a c t i c e , they c o u l d 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 t o be a l u x u r y t h a t was u s u a l l y o n l y engaged i n when p a r t i c i p a n t s were i n v o l v e d i n r e s e a r c h . In summary, ANP was a term t h a t d i d not a l l o w f o r a c l e a r or c o n c i s e d e f i n i t i o n but r a t h e r was thought t o be i n h e r e n t l y broad and vague i n nature.  T h i s nature was  thought t o be i n f l u e n c e d by the l a c k of understanding t h a t n u r s i n g s c h o l a r s had between expert and ANP, n u r s i n g l a n g u a g e / r h e t o r i c and s e n s i t i v i t y of i s s u e s r e l a t e d t o nursing education. P a r t i c i p a n t s were not concerned about t h e i r l a c k of  65 c l a r i t y about ANP  and b e l i e v e d t h a t t h e i r  understanding was  s u f f i c i e n t to adequately conduct t h e i r  practice.  Out  personal  of support t o the r e s e a r c h e r ,  participants  attempted to address the phenomena of i n t e r e s t . they b e l i e v e d t h a t i f n u r s i n g ANP,  then nurses i n ANP  However,  s c h o l a r s were not c l e a r about  had more important and  pressing  issues for consideration. Although s u p p o r t i v e cautious  of the r e s e a r c h ,  p a r t i c i p a n t s were  around e f f o r t s t o c l e a r l y d e f i n e ANP.  t h a t nurses i n ANP  They b e l i e v e d  c o u l d adequately d e s c r i b e t h e i r p r a c t i c e  u s i n g paradigm s t o r i e s t h a t would a l l o w f o r the  flexibility  r e q u i r e d f o r on-going changes t h a t i n f l u e n c e d the of  evolvement  ANP. P a r t i c i p a n t s o f f e r e d reasons f o r the general  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 i n c o n s i s t e n c i e s i n how although t h i s v a r i a t i o n was encouraged. n u r s i n g was  The  l a c k of  they enacted t h e i r  s t r o n g l y supported  and  l a c k of p r e c i s i o n or d e f i n i t i o n  another reason c i t e d .  role,  Participants  regarding recognized  t h a t most nurses c o u l d competently p r a c t i c e n u r s i n g but not c l e a r l y a r t i c u l a t e t h e i r p r a c t i c e . as the general  Despite  could  f a c t o r s such  disagreement around many d e f i n i t i o n s  a s s o c i a t e d with n u r s i n g and  the i n f l u e n c e t h a t  agendas and  i n t r y i n g to develop a c l e a r e r  t u r f i s s u e s had  understanding about ANP,  various  p a r t i c i p a n t s thought t h a t ANP  u s e f u l term e s p e c i a l l y to represent  a concept or  idea.  was  a  66 P a r t i c i p a n t s a l s o b e l i e v e d t h a t graduate s c h o o l was s e t t i n g where concepts or terms such as ANP explored.  c o u l d be  They b e l i e v e d t h a t i f a term such as ANP  p a r t of a nurse's graduate education, then busy  a  fully was  not  day-to-day  p r a c t i c e would p r e c l u d e time r e q u i r e d t o be a b l e t o c l e a r l y articulate a definition. F i n a l l y , time f o r r e f l e c t i o n i n p r a c t i c e was be a c r u c i a l f a c t o r f o r understanding ANP.  thought t o  Although b e l i e v e d  to be c r u c i a l , p a r t i c i p a n t s r e c o g n i z e d r e f l e c t i v e time as a luxury t h a t was  u s u a l l y o n l y p o s s i b l e d u r i n g the process of  a s s i s t i n g others i n r e s e a r c h . D e s c r i p t o r s of Advanced Nursing P r a c t i c e Although p a r t i c i p a n t s c o u l d not c l e a r l y and d e f i n e ANP, description. f i r s t was  they b e l i e v e d i t was Two  a term t h a t was  concisely amenable t o  main d e s c r i p t o r s were i d e n t i f i e d .  what p a r t i c i p a n t s b e l i e v e d t o be  requirements of ANP  The  minimal  namely: graduate education, c l i n i c a l  s p e c i a l t y focus and research-based p r a c t i c e . the e s s e n t i a l q u a l i t i e s of  The second  was  ANP.  Minimal Requirement T r i a d of Advanced Nursing P r a c t i c e P a r t i c i p a n t s o u t l i n e d what.they b e l i e v e d t o be the b a s i c s , the f o u n d a t i o n or minimal requirements of ANP.  These  have been c a t e g o r i z e d as the t h r e e minimal requirements of ANP,  namely graduate education, c l i n i c a l  s p e c i a l t y focus and  research-based p r a c t i c e .  A c c o r d i n g t o p a r t i c i p a n t s , each  of  thought t o be e q u a l l y c r u c i a l f o r  these requirements was  one  67 ANP.  However, i t was  the combination of the t h r e e t h a t  formed a t r i a d of minimal requirements f o r ANP. Graduate E d u c a t i o n A l l p a r t i c i p a n t s s t r o n g l y supported the need f o r graduate e d u c a t i o n .  Graduate  education formed the  element of the minimal requirement t r i a d of  first  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  and p o s i t i v e l y t o ANP.  thought t o c o n t r i b u t e  significantly  Participants believed that, during  graduate education, nurses developed many competencies were v i t a l f o r ANP.  These competencies  were thought t o be  i n f l u e n c e d by an exposure t o indepth p e r t i n e n t r e s e a r c h methodologies and i n t e r p e r s o n a l  that  theories,  communication  skills: 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, p a r t i c i p a n t s b e l i e v e d 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 p r a c t i c e and a h i g h e r l e v e l of o v e r a l l a n a l y s i s of n u r s i n g p r a c t i c e : 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. P a r t i c i p a n t s b e l i e v e d t h a t graduate education a l s o p r o v i d e d a l i b e r a l education i n domains of s o c i a l s c i e n c e s and the o v e r a l l h e a l t h care system..  P a r t i c i p a n t s thought  this  r e s u l t e d i n a f o u n d a t i o n f o r ongoing l e a r n i n g r e l a t e d t o 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 a l s o s i g n i f i c a n t l y enhanced  critical  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 p a r t i c i p a n t s c l e a r l y supported  graduate  education, they had s t r o n g and d i f f e r i n g views on what f a c u l t y the graduate degree  should be from.  Participants  were graduates of v a r y i n g programs and had d e f i n i t e o p i n i o n s on t h i s matter.  Graduate  n u r s i n g education was s t r o n g l y  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 p a r t i c i p a n t s a l s o understood why some nurses chose t o undertake non-nursing graduate e d u c a t i o n .  Reasons c i t e d  i n c l u d e d p r o x i m i t y t o a u n i v e r s i t y and whether or not t h e nurse had r e s p e c t f o r the n u r s i n g graduate program. P a r t i c i p a n t s with n u r s i n g graduate degrees were s e n s i t i v e t o the i s s u e of some of t h e i r c o l l e a g u e s having non-nursing graduate e d u c a t i o n .  O b v i o u s l y wanting t o be s u p p o r t i v e ,  these p a r t i c i p a n t s s t i l l q u e s t i o n e d whether or not nonn u r s i n g graduate e d u c a t i o n c o n t r i b u t e d p o s i t i v e l y t o ANP. They d i d not t h i n k i t d i d : 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, p a r t i c i p a n t s who had non-nursing graduate degrees v i g o r o u s l y q u e s t i o n e d the ongoing support f o r n u r s i n g graduate e d u c a t i o n as a b a s i c requirement f o r CNS p r a c t i c e and ANP: There is a lot of discrepancy degree that should be.  then over...what  kind of  These p a r t i c i p a n t s seemed as s e n s i t i v e as p a r t i c i p a n t s with n u r s i n g graduate degrees t o the i s s u e of e d u c a t i o n , y e t b e l i e v e d they were making a s i g n i f i c a n t and v a l u a b l e c o n t r i b u t i o n t o ANP.  They based some of t h e i r q u e s t i o n i n g  about t h e support f o r n u r s i n g graduate e d u c a t i o n on t h e f a c t  70 t h a t many of these n u r s i n g programs d i d not c o n t a i n a clinical  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, o c c a s i o n a l l y these p a r t i c i p a n t s q u e s t i o n e d i f p a r t of t h e i r d i f f i c u l t y r e l a t e d t o a d d r e s s i n g aspects of the r e s e a r c h phenomena was  due t o t h e i r non-nursing graduate  education: Some of us may have difficulty in defining client outcomes because we don't have a nursing master's. don't know...  health I  D e s p i t e s t r o n g l y i d e n t i f y i n g the need f o r graduate education, p a r t i c i p a n t s b e l i e v e d t h a t t h i s education alone d i d not r e s u l t i n ANP.  Although r e c o g n i z e d as a v i t a l  minimal requirement, they b e l i e v e d graduate e d u c a t i o n o n l y formed the f i r s t element of what has been c o n c e p t u a l i z e d as the minimal requirement t r i a d of ANP. education was l e d t o ANP,  Although graduate  thought t o p r o v i d e v a l u a b l e competencies  that  p a r t i c i p a n t s thought most graduate n u r s i n g  education programs d i d not s i g n i f i c a n t l y c o n t r i b u t e t o advanced  clinical  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 programs. They are not designed to define  educational expertise.  71 Thus, a c c o r d i n g t o p a r t i c i p a n t s , graduate e d u c a t i o n was thought t o be a c r u c i a l minimum requirement of ANP.  During  graduate education, nurses l e a r n e d : indepth p e r t i n e n t t h e o r i e s , r e s e a r c h methodologies, i n t e r p e r s o n a l  communication  skills,  a broader knowledge base, enhanced problem  skills,  research-based p r a c t i c e and a h i g h e r l e v e l o f o v e r a l l  analysis i n nursing practice.  solving  They a l s o developed a constant  q u e s t i o n i n g of, and l e a r n i n g , r e l a t e d t o p r a c t i c e and the broader h e a l t h care system, as w e l l as enhanced thinking.  A l l of these competencies  c o n t r i b u t e p o s i t i v e l y t o ANP.  critical  were thought t o  The i s s u e o f whether graduate  education needed t o be i n n u r s i n g o r another f a c u l t y contentious.  However, p a r t i c i p a n t s r e c o g n i z e d t h a t  remained graduate  education alone d i d not r e s u l t i n ANP. C l i n i c a l Specialty  Focus  P a r t i c i p a n t s b e l i e v e d t h a t nurses i n ANP must combine graduate education with a c l i n i c a l  s p e c i a l t y focus.  focus formed the second element o f the minimal t r i a d o f ANP.  This  requirement  Even those p a r t i c i p a n t s with non-nursing  graduate e d u c a t i o n b e l i e v e d t h a t , d e s p i t e the graduate program, nurses who wanted t o p r a c t i c e ANP needed t o combine t h e i r graduate e d u c a t i o n with an indepth n u r s i n g  clinical  s p e c i a l t y 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 setting.  that specialty  knowledge in a  clinical  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  reflected  their c l i n i c a l practice  on t h e i r own  experience about  p r i o r t o graduate e d u c a t i o n .  They  d e s c r i b e d themselves as having been "expert" c l i n i c a l practitioners  p r i o r t o t h e i r graduate work.  d e s c r i b e d how  they brought t h e i r i n d i v i d u a l  They c l e a r l y specialty  n u r s i n g t o graduate education and then d u r i n g t h e i r focused on more indepth c l i n i c a l of t h e i r programs, p a r t i c i p a n t s their practice  competencies.  studies  On completion  could e a s i l y describe  had changed by way  area of  how  of p e r s o n a l growth and  enhancement of t h e i r o v e r a l l c l i n i c a l  specialization:  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. D e s p i t e b e i n g an expert p r i o r t o graduate e d u c a t i o n ,  73 p a r t i c i p a n t s thought t h a t the c l i n i c a l t h i s education mentored.  s p e c i a l t y focus of  needed t o i n c l u d e c l i n i c a l p r a c t i c e t h a t was  They b e l i e v e d t h i s t o be c r i t i c a l i f nurses were  t o r e a l l y develop i n t o ANP.  P a r t i c i p a n t s b e l i e v e d the mentor  needed t o be a r o l e model t h a t t h e nurse c o u l d r e s p e c t challenged  by.  and be  Again, p a r t i c i p a n t s b e l i e v e d t h a t t h e  mentoring system needed t o i n c l u d e d e d i c a t e d  time so t h a t  r e f l e c t i v e p r a c t i c e d i d 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. P a r t i c i p a n t s b e l i e v e d t h a t the c l i n i c a l combined with graduate education couple of reasons.  s p e c i a l t y focus  was b e n e f i c i a l f o r ANP f o r a  F i r s t l y , they thought t h a t i t enhanced  the a b i l i t y of nurses i n ANP t o l i n k academic experience w i t h practice.  T h i s l i n k a g e was thought t o enable nurses i n ANP  t o draw from a number of v a l i d t h e o r i e s whether i n f a m i l i a r or n o n - f a m i l i a r  scenarios  related to client  P a r t i c i p a n t s b e l i e v e d t h i s t o be very  care.  e f f e c t i v e i n problem  s o l v i n g complex c l i n i c a l p r a c t i c e c h a l l e n g e s  t h a t nurses i n  ANP were presented with on a day-to-day b a s i s : 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, it 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, p a r t i c i p a n t s thought the c l i n i c a l s p e c i a l t y focus  l i n k e d with graduate education  developing  was a s s i s t i v e i n  d i f f e r e n t approaches t o the ongoing e v a l u a t i o n of  actions: Advanced clinical practice and the with that forces you to consistently in a different way.  education analyze  that goes what you do  T h i s a n a l y s i s began a process t h a t developed i n t o what p a r t i c i p a n t s described  as a constant  questioning  They b e l i e v e d t h a t the process of graduate  education  supported and encouraged behaviours i n h e r e n t t h i n k i n g such as c h a l l e n g i n g c o l l e a g u e s as q u e s t i o n i n g  everything  nurses i n ANP had the confidence all  practice  Participants believed to question  l e v e l s of h e a l t h care p r o v i d e r s ,  makers.  in critical  and f a c u l t y , as w e l l  from b a s i c c l i n i c a l  p r o t o c o l s t o broad h e a l t h p o l i c y .  of p r a c t i c e .  the p r a c t i c e of  as w e l l as p o l i c y  P a r t i c i p a n t s saw t h e i r l e v e l and frequency of  questioning  that  p r a c t i c e as being very d i f f e r e n t from t h a t of  75 other nurses: We are constantly questioning and whether we can do things  the practices differently.  that  We are the ones that are not afraid to ask the questions. We are always questioning.  we have stupid  P a r t i c i p a n t s a l s o v a l u e d t h e i r a b i l i t y t o prompt others t o begin t o q u e s t i o n p r a c t i c e 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. P a r t i c i p a n t s r e c o g n i z e d t h a t by a s k i n g q u e s t i o n s of s t a f f nurses, r a t h e r than p r o v i d i n g answers, they c o u l d f u r t h e r develop competencies s t a f f nurses might a l r e a d y 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. P a r t i c i p a n t s b e l i e v e d t h e confidence of nurses i n ANP t o c o n s i s t e n t l y q u e s t i o n p r a c t i c e , combined with other competencies noted above, enabled nurses i n ANP t o be " p r o a c t i v e " r a t h e r than  "reactive" to c l i n i c a l  practice  s c e n a r i o s and o v e r a l l h e a l t h c a r e : As a profession, nursing can't progress if we can only manage client needs. That is one big nursing practice.• Those of us proactive and try to influence The f o l l o w i n g account  actively participate and to keep up to day-to-day influence of advanced in the role can be overall health care.  r e f l e c t s a combination  of the  competencies of o v e r a l l system a n a l y s i s , q u e s t i o n i n g of p r a c t i c e and p r o a c t i v e approaches t o care r e l a t e d t o 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, a c c o r d i n g t o p a r t i c i p a n t s , an indepth  clinical  s p e c i a l t y focus combined with n u r s i n g or non-nursing  graduate  education were minimal requirements  f o r ANP.  d e s c r i b e d how they entered graduate  education having been  r e c o g n i z e d as a c l i n i c a l  Participants  expert i n t h e i r f i e l d .  Once they  focused t h e i r s t u d i e s with more indepth c l i n i c a l work, they thought  they graduated  being able to p r a c t i c e at a d i f f e r e n t  and advanced l e v e l of n u r s i n g . i n h e r e n t i n graduate  Participants believed that  s t u d i e s was the need f o r mentors and  r e f l e c t i v e time i n order t o f u l l y develop as a nurse i n ANP. A clinical  s p e c i a l t y focus combined with  graduate  education was b e l i e v e d t o have many p o s i t i v e outcomes such as use of v a l i d t h e o r i e s f o r d e c i s i o n making, a b i l i t y t o e f f e c t i v e l y problem s o l v e complex c l i n i c a l  practice  c h a l l e n g e s , development of an awareness of and a b i l i t y t o i n f l u e n c e the broad h e a l t h care system and development of d i f f e r e n t approaches t o a n a l y s i s of p r a c t i c e which i n c l u d e d a constant q u e s t i o n i n g of p r a c t i c e .  P a r t i c i p a n t s saw t h i s  q u e s t i o n i n g of p r a c t i c e as b e i n g d i f f e r e n t from t h a t of other nurses.  P a r t i c i p a n t s a l s o b e l i e v e d these  competencies  77 enabled nurses i n ANP t o be p r o a c t i v e r a t h e r than r e a c t i v e t o c l i n i c a l p r a c t i c e i s s u e s and o v e r a l l h e a l t h care.  Of  i n t e r e s t i s t h e f a c t the p a r t i c i p a n t s were q u i t e c l e a r about what d i f f e r e n t i a t e d expert  from ANP, y e t they were unable t o  a r t i c u l a t e t h a t i n response t o being asked t o d e f i n e ANP. Research-Based P r a c t i c e P a r t i c i p a n t s b e l i e v e d t h a t another v i t a l requirement of ANP was research-based p r a c t i c e .  T h i s formed t h e t h i r d  element of t h e minimal requirement t r i a d of ANP.  When  p a r t i c i p a n t s r e f e r r e d t o research-based p r a c t i c e , they meant the r e s e a r c h  competencies gained through graduate  l i n k e d with a c l i n i c a l  s p e c i a l t y focus.  education  Participants cited  research-based p r a c t i c e from the p e r s p e c t i v e s  of c o n s i s t e n t l y  t h i n k i n g 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 r e s e a r c h as c r u c i a l f o r 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. P a r t i c i p a n t s believed that research foundation  needed t o be t h e  of a l l n u r s i n g p r a c t i c e when t h a t was p o s s i b l e .  They recognized  t h a t a great d e a l of n u r s i n g p r a c t i c e was not  based on r e s e a r c h .  However, they s t r o n g l y b e l i e v e d t h a t when  v a l i d and r e l i a b l e r e s e a r c h  r e l a t e d t o p r a c t i c e had been  done, nurses i n ANP o f t e n l e d the way i n t o i n c o r p o r a t i n g 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. P a r t i c i p a n t s b e l i e v e d t h a t the wealth of i n f o r m a t i o n c o n t a i n e d i n r e s e a r c h l i t e r a t u r e was extremely u s e f u l i n l e a r n i n g about, understanding and i n f l u e n c i n g n u r s i n g practice.  P a r t i c i p a n t s thought t h a t t h i s l i t e r a t u r e  assisted  them t o work, with and educate s t a f f about p r a c t i c e from a v a r i e t y of p e r s p e c t i v e s .  I t was a l s o thought t o p r o v i d e a  s t r a t e g y f o r nurses i n ANP t o get s t a f f nurses t o q u e s t i o n t h e i r own p r a c t i c e : 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. P a r t i c i p a n t s c l e a r l y v a l u e d p a r t n e r s h i p s with c o l l e a g u e s , i n t e r d i s c i p l i n a r y p r o f e s s i o n a l s and u n i v e r s i t y educators i n the conduct of r e s e a r c h and/or d i s s e m i n a t i o n 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 p a r t i c i p a n t s thought t h e conduct of r e s e a r c h t o be important and r e c o g n i z e d the v a l u e of p a r t n e r s h i p s w i t h others toward t h i s aim, an important area of t h e i r c o n s i d e r a t i o n was whether the master's prepared nurse i n ANP  79 c o u l d adequately assume the p r i n c i p l e i n v e s t i g a t o r r o l e i n research.  P a r t i c i p a n t s b e l i e v e d they p l a y e d a s i g n i f i c a n t  r o l e i n research-based p r a c t i c e but t h a t r e a l l y  definitive  r e s e a r c h i n v o l v e d a p a r t n e r s h i p between a nurse i n ANP d o c t o r a l l y prepared nurse.  and a  They b e l i e v e d the d o c t o r a l l y  prepared nurse should be the p r i n c i p l e  investigator:  I'm not actually committed to the master's practitioner as the principle researcher.  level  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, a c c o r d i n g t o p a r t i c i p a n t s , research-based by way  of r e s e a r c h competencies,  education l i n k e d with a c l i n i c a l c r i t i c a l minimum requirement  gained through  practice  graduate  s p e c i a l t y focus, was  of ANP.  They saw  a  research-based  p r a c t i c e as i n c l u s i v e of t h i n k i n g 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 r e s e a r c h . of  n u r s i n g p r a c t i c e was  P a r t i c i p a n t s r e c o g n i z e d t h a t much not based on r e s e a r c h , however they  b e l i e v e d t h a t when v a l i d and r e l i a b l e r e s e a r c h had been done, nurses i n ANP  needed t o make s t r o n g e f f o r t s t h a t i t be  incorporated into nursing practice. w i t h i n r e s e a r c h l i t e r a t u r e was nurses i n ANP,  Information c o n t a i n e d  thought t o be u s e f u l f o r  i n order t o a s s i s t them i n e f f o r t s with  nurses about o v e r a l l examination of p r a c t i c e .  staff  Participants  a l s o v a l u e d p a r t n e r s h i p s with others f o r the conduct  of  80 research  and/or d i s s e m i n a t i o n of f i n d i n g s .  Participants  questioned i f master's prepared nurses i n ANP  could  adequately assume the p r i n c i p l e i n v e s t i g a t o r r o l e i n research. research  According to p a r t i c i p a n t s , t r u l y d e f i n i t i v e involved partnerships  between a nurse i n ANP and a  d o c t o r a l l y prepared nurse. E s s e n t i a l Q u a l i t i e s o f Advanced Nursing Participants believed  Practice  t h a t t h e r e were a number of  e s s e n t i a l q u a l i t i e s t h a t were c h a r a c t e r i s t i c of ANP. P a r t i c i p a n t s thought t h a t nurses i n ANP i n c o r p o r a t e d t h e competencies mastered i n r e l a t i o n t o the minimal requirement t r i a d and combined these with experience and time.  This  r e s u l t e d i n what p a r t i c i p a n t s b e l i e v e d were the e s s e n t i a l q u a l i t i e s of ANP: g l o b a l t h i n k i n g ;  indirect clinical  focus;  a s s i s t i v e care d e l i v e r y ; e f f e c t i v e l e a d e r s h i p ; and, interdisciplinary Global  collaboration.  Thinking  A l l participants strongly believed  t h a t ANP i n v o l v e d an  indepth a b i l i t y t o c o n s i s t e n t l y t h i n k g l o b a l l y . t h i n k i n g r e p r e s e n t e d the f i r s t was mentioned f r e q u e n t l y  global  e s s e n t i a l q u a l i t y of ANP.  It  and thought t o be p a r t of the "world  view" and "system" p e r s p e c t i v e . global thinking included  This  According to p a r t i c i p a n t s ,  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  g l o b a l views of the n u r s i n g  p r a c t i c e 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.  G l o b a l t h i n k i n g was b e l i e v e d by p a r t i c i p a n t s t o be t h i n k i n g about t h e "bigger p i c t u r e . " I t was f r e q u e n t l y obvious t o t h e r e s e a r c h e r  that  p a r t i c i p a n t s were c o n s i s t e n t l y t r a n s l a t i n g i n f o r m a t i o n global perspective.  into a  In other words, they were f r e q u e n t l y  t h i n k i n g 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 s c e n a r i o had relevance c l i e n t care. was  f o r understanding t h e whole of  They b e l i e v e d t h e i r a b i l i t y t o t h i n k g l o b a l l y  extremely b e n e f i c i a l f o r n u r s i n g ,  interdisciplinary practice.  as w e l l as f o r  P a r t i c i p a n t s thought t h a t nurses  i n ANP were aware of i s s u e s i n the worlds of n u r s i n g and i n h e a l t h care and had made some p e r s o n a l  stands about  these.  T h i s was viewed as u s e f u l i n i n t e r a c t i o n s with s t a f f , t e l l i n g s t a f f what was going on i n other what kinds  of t h i n g s they should  areas,  such as  as w e l l as  have been c o n s i d e r i n g  for  t h e i r own areas of p r a c t i c e : 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 one  how they never i n t e r a c t e d w i t h  c l i e n t without t h i n k i n g about the i m p l i c a t i o n s t h a t t h e  care of t h a t p a r t i c u l a r c l i e n t would have f o r other as w e l l as o v e r a l l p r a c t i c e :  clients  82 Care is not just for one client but for other clients that will do better because of that one scenario. The f o l l o w i n g accounts exemplify p a r t i c i p a n t s ' a b i l i t i e s t o t r a n s l a t e i n d i v i d u a l c l i e n t s c e n a r i o s i n t o a whole o r pattern.  The f i r s t demonstrates r e c o g n i t i o n of " p a t t e r n s "  r e l a t e d t o p r a c t i c e and r e s u l t a n t a n a l y s i s of p r a c t i c e : 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 r e f e r s t o r e c o g n i t i o n of p a t t e r n s but assurance t h a t d e c i s i o n s 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 t h e same time, p a r t i c i p a n t s r e c o g n i z e d t h e b e n e f i t of b r i n g i n g "the whole" t o any one c l i e n t s c e n a r i o f o r an improvement i n c l i n i c a l  s t a t u s of i n d i v i d u a l s / g r o u p s through  working w i t h 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. T h i s t h i n k i n g was i n f l u e n c e d by s y n t h e s i s of competencies i n nurses i n ANP l i n k e d w i t h t h e i r awareness  of agency,  community, p r o v i n c i a l , n a t i o n a l and i n t e r n a t i o n a l h e a l t h care  83 trends,  i s s u e s and i n i t i a t i v e s .  Participants believed this  t h i n k i n g could have an impact on t h e i r communities, as w e l l as e t h i c a l d e c i s i o n 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 r e s e a r c h ,  a l l p a r t i c i p a n t s were a v a i l a b l e  f o r c o n s u l t a t i o n t o t h e i r e n t i r e agency. geographical  This  large  r e s p o n s i b i l i t y was b e l i e v e d t o be u s e f u l i n  i d e n t i f y i n g and m o n i t o r i n g trends and s h a r i n g between u n i t s , as w e l l as a l l o w i n g  information  global thinking to  i n f l u e n c e and be a p a r t of c l i n i c a l p r a c t i c e : 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. P a r t i c i p a n t s b e l i e v e d t h e r e were many b e n e f i t s 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 a s s i s t e d i n t h e i r e f f o r t s t o p o s i t i v e l y i n f l u e n c e the "bedside" or " s t a f f " nurse and thus enhance o v e r a l l p r a c t i c e : 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 i n f l u e n c e s t a f f nurses was thought t o be extremely important.  O v e r a l l , p a r t i c i p a n t s thought t h a t t h e  84 m a j o r i t y of nurses t r a d i t i o n a l l y p r a c t i c e d from a "narrow" focus and were subsequently g e n e r a l l y  "reactive" to c l i e n t  care and o v e r a l l h e a l t h care and thus were c o n s i s t e n t l y managing c r i s i s .  They e x p l a i n e d t h a t , due t o  day-to-day  p r e s s u r e s and r e s p o n s i b i l i t i e s , most nurses were " b a r e l y able to  keep up" d u r i n g t h e i r s h i f t s , and o f t e n ended up b e i n g  only a b l e t o p r a c t i c e i n the " r e a c t i v e " mode. p a r t i c i p a n t s a l s o r e c o g n i z e d t h a t , due t o restrictions,  i t may  However,  system  have been i m p o s s i b l e f o r s t a f f nurses t o  do a n y t h i n g but r e a c t : 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. P a r t i c i p a n t s b e l i e v e d t h a t one r e s p o n s i b i l i t y of nurses i n ANP  was  to b r i n g t h e i r global t h i n k i n g to  clinical  p r a c t i c e and thus t r y t o work with nurses i n e f f o r t s t o move them from a l e s s r e a c t i v e and c r i s i s management mode t o one of  being proactive.  However, p a r t i c i p a n t s r e c o g n i z e d t h a t  t h e i r r o l e enabled them t o be  "once removed" from the  t h e r e f o r e a b l e t o see i s s u e s t h a t many nurses saw, more o b j e c t i v i t y . ability  client,  but w i t h  P a r t i c i p a n t s b e l i e v e d t h i s enhanced the  of nurses i n ANP  t o be p r o a c t i v e :  When you are in it you sometimes don't generate as many questions as when you The beauty of my job is that I am once is going on, from the actual work, the of the nurse. So I look at it through but I look at it more objectively, not emotion of the job, the stress and the  know...you don't are once removed. removed from what day-to-day work a nurse's eyes caught up in the pressure of the  85 tasks. Secondly, p a r t i c i p a n t s b e l i e v e d many c l i e n t needs went un-met i n an agency t h a t d i d not have a nurse i n ANP.  The  f o l l o w i n g account r e f l e c t s p a r t i c i p a n t attempts t o e x p l a i n the v a l u e they saw i n b r i n g i n g the g l o b a l t h i n k i n g t o c l i n i c a l p r a c t i c e 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 global thinking, proactive  nurses i n ANP u t i l i z e d  s t r a t e g i e s and m o n i t o r i n g of  trends t o make changes t o the h e a l t h agency and t h e r e f o r e  improve  client  of c l i e n t s i n t h e i r 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 w e l l as w i t h i n t h e i r agency, p a r t i c i p a n t s a l s o  believed  t h a t nurses i n ANP needed t o expand/extend g l o b a l t h i n k i n g t o 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, a c c o r d i n g t o p a r t i c i p a n t s , ANP i n v o l v e d a b i l i t y to think g l o b a l l y .  Global  an i n d e p t h  t h i n k i n g was b e l i e v e d t o  be the nurse's a b i l i t y t o t h i n k b r o a d l y about the l i n k s  86 between i n d i v i d u a l c l i e n t s and o v e r a l l health  care.  groups/populations as w e l l  Nurses i n ANP  were thought to have  competencies to t r a n s l a t e i n d i v i d u a l c l i e n t s c e n a r i o s whole or p a t t e r n any  practice.  I t was  believed  clinical  t o be a p o s i t i v e i n f l u e n c e when  P a r t i c i p a n t s recognized that  staff  nurses p r a c t i c e d i n the r e a c t i v e mode, p r i m a r i l y due system c o n s t r a i n t s .  Participants believed  p r a c t i c e d from a p r o a c t i v e r e s p o n s i b i l i t y to use  mode, and  to  t h a t nurses i n  i t was  ANP  their  t h e i r g l o b a l t h i n k i n g 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. t h a t i f an agency d i d not  c l i e n t needs would go un-met. thinking, proactive  to  P a r t i c i p a n t s i d e n t i f i e d a number of  of b r i n g i n g t h e i r g l o b a l t h i n k i n g to  working with s t a f f .  believed  into a  as w e l l as b r i n g i n g t h a t whole or p a t t e r n  individual client.  benefits  as  Participants  have a nurse i n ANP,  Another b e n e f i t of  s t r a t e g i e s and  many  global  m o n i t o r i n g of trends  was  t h a t they were thought to be a s s i s t i v e f o r nurses i n ANP  to  make changes to the h e a l t h w e l l as e x t e r n a l  of c l i e n t s w i t h i n  t h e i r agency,  as  agencies.  I n d i r e c t 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 nurses i n ANP This  one  had  of the p a r t i c i p a n t s i d e n t i f i e d t h a t  an i n d i r e c t c l i n i c a l  focus on  i n d i r e c t c l i n i c a l focus r e p r e s e n t e d the  q u a l i t y of ANP.  clients.  second e s s e n t i a l  P a r t i c i p a n t s 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 r e c i p i e n t s of care, whereas nurses i n ANP 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  P a r t i c i p a n t s thought t h a t nurses i n ANP  clinically  focused  clients.  used l e a d e r s h i p  m o d e l l i n g with nurses to i n d i r e c t l y i n f l u e n c e safe  and  client  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. P a r t i c i p a n t s b e l i e v e d t h a t the a n t i c i p a t e d outcome from directly clinically c l i e n t s was  f o c u s i n g on s t a f f and  improvement i n p r a c t i c e and  outcomes f o r both nurses and others i n v o l v e d i n care.  indirectly  on  enhancement of h e a l t h  c l i e n t s , as w e l l as  appropriate  P a r t i c i p a n t s spoke very h i g h l y of  s t a f f nurses and d e s c r i b e d them as the  "most v a l u a b l e  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  p a r t i c i p a n t had a somewhat d i f f e r e n t s l a n t on  direct c l i n i c a l  focus i n t h a t she i d e n t i f i e d i t as c l i e n t s  groups of c l i e n t s , r a t h e r than s t a f f nurses. she was  somewhat unique i n t h i s approach.  f o l l o w i n g account demonstrates, she s t i l l  She  or  believed  However, as  the  d e s c r i b e d working  d i r e c t l y with the n u r s i n g s t a f f to f a c i l i t a t e outcomes:  her  c l i e n t care  and  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. P a r t i c i p a n t s very strongly valued t h e i r  indirect  r e l a t i o n s h i p with c l i e n t s and had a great d e a l of p e r s o n a l s a t i s f a c t i o n i n s o l v i n g s t a f f / c l i e n t c h a l l e n g e s 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 t o an i n d i r e c t r e l a t i o n s h i p , p a r t i c i p a n t s  believed  t h a t i t was almost i m p o s s i b l e t o d i r e c t l y l i n k t h e i r to CHO.  practice  Due t o t h e i r o v e r a l l a s s i s t i v e care d e l i v e r y  q u a l i t i e s , p a r t i c i p a n t s thought t h a t t h e i r i n f l u e n c e on CHO was a c t u a l l y from the broader p e r s p e c t i v e , 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. P a r t i c i p a n t s r e c o g n i z e d t h a t i t would be advantageous t o  89 be a b l e t o measure the i n f l u e n c e of t h e i r p r a c t i c e on CHO, even i n as a s s o c i a t i v e type way.  However, they saw t h a t as  b e i n g v e r y d i f f i c u l t due t o 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 clients: 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 p a r t i c i p a n t s had made informed d e c i s i o n s t o remain c l o s e t o c l i n i c a l p r a c t i c e thus c l o s e t o s t a f f nurses and c l i e n t s , as opposed  to pursuing careers i n administration.  P a r t i c i p a n t s b e l i e v e d t h a t a l l nurses i n ANP were v e r y c l e a r about the p e r s o n a l v a l u e they p l a c e d on c l i n i c a l Clinical Nurse away from what care or direct something that  practice:  Specialists have never wanted to move is referred to as bedside care, client client contact. This has always been is highly prized.  P a r t i c i p a n t s b e l i e v e d t h a t although a d m i n i s t r a t o r s were very important and p l a y e d a key r o l e , nurses i n ANP found  real  meaning and c h a l l e n g e i n working with s t a f f nurses and clients.  The f o l l o w i n g account demonstrates  participant  p a s s i o n about nurses i n ANP involvement i n c l i n i c a l  practice:  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 important t o p a r t i c i p a n t s .  focus with c l i e n t s was i n c r e d i b l y So much so t h a t , d e s p i t e t h e  90 ongoing f l e x i b i l i t y  required i n t h e i r roles,  participants  thought t h a t i f t h e r e was ever a s i g n i f i c a n t t h r e a t t o t h e i r focus, they would r e s i g n 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. P a r t i c i p a n t s b e l i e v e d t h a t an i s s u e a s s o c i a t e d with ANP was whether or not nurses i n these r o l e s should assume r e s p o n s i b i l i t y f o r d i r e c t c l i e n t care.  Participants  believed  t h a t nurses i n ANP should not assume r e s p o n s i b i l i t y f o r d i r e c t c l i e n t care as t h i s was c o n t r a d i c t o r y t o the very essence of ANP, as w e l l as not b e i n g c o s t  effective:  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. P a r t i c i p a n t s o c c a s i o n a l l y had some minor p e r s o n a l s t r u g g l e s with t h i s s i n c e they enjoyed d i r e c t c l i e n t c a r e .  However,  another reason they i d e n t i f i e d f o r nurses i n ANP not assuming r e s p o n s i b i l i t y f o r d i r e c t c l i e n t care was because get  one would  " b u r i e d " and then not be a b l e t o continue t o 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. P a r t i c i p a n t s a l s o b e l i e v e d t h a t i f nurses i n ANP  d i d assume  r e s p o n s i b i l i t y f o r d i r e c t c l i e n t care, i t would be counterproductive f o r nursing s t a f f .  P a r t i c i p a n t s were very  s e n s i t i v e t o the p o t e n t i a l of g i v i n g the impression t h a t they were " b e t t e r than" s t a f f .  Instead they wanted t o work, w i t h  s t a f f i n order t o a s s i s t them t o continue t o l e a r n and t o r e c o g n i z e t h e i r own  competencies  in solving  clinical  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, a c c o r d i n g t o p a r t i c i p a n t s , s i n c e 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 i n f l u e n c e t h a t nurses i n ANP an i n d i r e c t nature.  had on CHO  was  of  P a r t i c i p a n t s r e c o g n i z e d the b e n e f i t s of  b e i n g a b l e t o measure t h i s i n f l u e n c e , even i n an a s s o c i a t i v e manner, but thought t h i s t o be  difficult.  P a r t i c i p a n t s b e l i e v e d t h a t nurses i n ANP nurses as a d i r e c t c l i n i c a l enhance CHO.  had  staff  focus and worked with them t o  P a r t i c i p a n t s b e l i e v e d t h a t nurses i n ANP  made  very informed d e c i s i o n s t o remain i n v o l v e d i n c l i n i c a l practice.  T h i s involvement was  h i g h l y v a l u e d and  p a r t i c i p a n t s found meaning and c h a l l e n g e working with nurses and c l i e n t s .  I f t h i s was  staff  ever s e r i o u s l y t h r e a t e n e d ,  p a r t i c i p a n t s thought they would r e s i g n from t h e i r agency.  92 P a r t i c i p a n t s thought t h a t , although the temptation was strong,  i t was i n a p p r o p r i a t e  f o r nurses i n ANP t o assume  r e s p o n s i b i l i t y f o r d i r e c t c l i e n t care. be  contradictory  They b e l i e v e d  this to  t o the very essence of ANP as w e l l as not  being c o s t - e f f e c t i v e .  In a d d i t i o n , p a r t i c i p a n t s  expressed  s e n s i t i v i t y about s t a f f nurses, i n t h a t i t was important they continue t o l e a r n and r e c o g n i z e t h e i r own competencies t o solve c l i n i c a l  scenarios.  A s s i s t i v e Care  Delivery  C l o s e l y a l i g n e d with the i n d i r e c t c l i n i c a l participants believed  t h a t nurses i n ANP had a primary  r e s p o n s i b i l i t y t o be of a s s i s t a n c e delivery.  focus,  t o "others"  i n care  A s s i s t i v e care d e l i v e r y r e p r e s e n t e d the t h i r d  e s s e n t i a l q u a l i t y of ANP.  "Others" p r i m a r i l y r e f e r r e d t o  s t a f f nurses but p a r t i c i p a n t s a l s o spoke of a s s i s t i n g interdisciplinary professionals,  as w e l l 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 t o enhance CHO.  Participants believed  t h i s a s s i s t i v e r o l e t o be c r u c i a l  f o r ANP and thus c l i e n t care, nursing  and o v e r a l l h e a l t h  as w e l l as advancement of  care.  d e a l of p e r s o n a l and p r o f e s s i o n a l a s s i s t i n g others t o d e l i v e r  P a r t i c i p a n t s gained a great s a t i s f a c t i o n by way of  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 P a r t i c i p a n t s c i t e d indepth use of c o n s u l t a t i o n education as s t r a t e g i e s t o a s s i s t care d e l i v e r y .  and  The  f o l l o w i n g account r e f l e c t s p a r t i c i p a n t d e s c r i p t i o n s of via  the a s s i s t i v e care d e l i v e r y p e r s p e c t i v e .  ANP  As i s  i l l u s t r a t e d i n the account, p a r t i c i p a n t s d e s c r i b e d b e i n g a b l e to  r e l a t e t o and v a l i d a t e both c l i e n t and s t a f f e x p e r i e n c e s ,  b e i n g a b l e t o a s s i s t them t o take a c t i o n and t o f e e l  positive  about t h e i r d e c i s i o n s and t o use a p a r t i c u l a r experience as an o p p o r t u n i t y t o i n c r e a s e s t a f f competencies.  Participants  s t r o n g l y b e l i e v e d i n the "use of s e l f " with others r a t h e r than demonstrating advanced  clinical  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 d e l i v e r y , p a r t i c i p a n t s were  p a r t i c u l a r l y i n t r i g u e d and c h a l l e n g e d by complex  clinical  practice scenarios.  were  They b e l i e v e d nurses i n ANP  predominantly i n v o l v e d i n those s c e n a r i o s . account i l l u s t r a t e s how  The  following  p a r t i c i p a n t s thought nurses i n  ANP,  u s i n g Joy C a l k i n ' s model as a r e f e r e n c e , t a r g e t e d complex, r e a l l y unusual c l i n i c a l  s c e n a r i o s and were a b l e t o be  a s s i s t i v e t o others t o s o l v e 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. P a r t i c i p a n t s b e l i e v e d t h a t nurses i n ANP,  through b e i n g  i n v o l v e d i n an a s s i s t i v e care d e l i v e r y , u t i l i z e d many s t r a t e g i e s r e l a t e d t o empowerment of s t a f f .  They a l s o  b e l i e v e d t h a t these s t r a t e g i e s needed t o be so e f f e c t i v e t h a t o f t e n s t a f f nurses.would not remember who P a r t i c i p a n t s thought t h i s was e f f e c t i v e empowerment. "started things,"  i n i t i a t e d an i d e a .  a t r u e r e f l e c t i o n of r e a l l y  They thought t h a t nurses i n ANP  "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 d e l i v e r y c o u l d get the s t a f f t o the p o i n t 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 had some come to to look at their thinking that it doing it. I like  nurses look at care delivery. I have me and say on one unit, they would like care delivery system. They are is not very effective, the way they are 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. P a r t i c i p a n t s were so committed s t a f f competencies  t o improving and/or  t h a t they aimed towards working  enhancing 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, a t the same time, p a r t i c u l a r l y i f p a r t i c i p a n t s had spent a great d e a l of time and e f f o r t on a complex  clinical  s c e n a r i o , they o c c a s i o n a l l y had some p e r s o n a l c h a l l e n g e s a s s o c i a t e d with not b e i n g given c r e d i t f o r i t .  These  r e a c t i o n s were b r i e f and p a r t i c i p a n t s were able t o overcome t h e i r p e r s o n a l f e e l i n g s and o b t a i n s a t i s f a c t i o n about the o v 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 o t h e r s , p a r t i c i p a n t s b e l i e v e d t h a t nurses i n ANP a l s o wanted t o educate and empower c l i e n t s a t the same time as other h e a l t h care p r o v i d e r s .  They d e s c r i b e d  l e a r n i n g s c e n a r i o s where education was aimed a t both nurses and c l i e n t s .  The g o a l was t h a t 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 o n l y d u r i n g t h a t  particular  s c e n a r i o but they would be a b l e "to r e c a l l " t h e l e a r n i n g and use i t e f f e c t i v e l y the next time.  Participants  consistently  aimed a t an i n c r e a s e d l e v e l of knowledge, d e c i s i o n making and a c t i o n s r e l a t e d t o care f o r both s t a f f and c l i e n t s :  96 If the nurses learn, the next time.  clicks  will  go off  in their  head  That client will have seen it happen...and clients question next time and they will have a better experience the next time. Thus, a c c o r d i n g  to p a r t i c i p a n t s , nurses- i n ANP  will  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 p r o f e s s i o n a l s , c l i e n t s and delivery. education  f a m i l i e s / s i g n i f i c a n t others  of  care  Participants extensively u t i l i z e d consultation as s t r a t e g i e s f o r t h i s approach.  nurses i n ANP  to s o l v e .  scenarios  and  They thought t h a t  were p a r t i c u l a r l y i n t r i g u e d , c h a l l e n g e d  s a t i s f i e d by complex c l i n i c a l  s t a f f was  by way  and  t h a t they were able  P a r t i c i p a n t s a l s o b e l i e v e d t h a t the empowerment of c r u c i a l even to the p o i n t of w i l l i n g n e s s to work  themselves out of t h e i r , jobs.  This empowerment was  by the f a c t t h a t although nurses i n ANP  may  have i n i t i a t e d  idea/program, they were f u l l y able to a l l o w other assume ownership of these.  reflected  nurses to  Often t h i s r e s u l t e d i n s t a f f  remembering t h a t the nurse i n ANP  initiated  an  not  these  i d e a s / a c t i o n s but p a r t i c i p a n t s were s a t i s f i e d with obvious improvement i n c l i e n t care and b e l i e v e d i n education  and  outcomes.  Participants also  empowering c l i e n t s w h i l e working  with nurses aiming f o r the o v e r a l l goal of an i n c r e a s e d of care f o r both s t a f f and  level  clients.  E f f e c t i v e Leadership P a r t i c i p a n t s b e l i e v e d t h a t nurses i n ANP l e v e l of e f f e c t i v e l e a d e r s h i p . represented  provided  E f f e c t i v e leadership  the f o u r t h e s s e n t i a l q u a l i t y of  ANP.  a  high  97 P a r t i c i p a n t s b e l i e v e d t h a t 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 a u t h o r i t y t o shape c l i n i c a l p r a c t i c e . P a r t i c i p a n t s valued agencies.  the c o n t r i b u t i o n t h a t they made t o t h e i r  The f o l l o w i n g account r e f l e c t s p a r t i c i p a n t b e l i e f s  t h a t nurses i n ANP were on the " c u t t i n g edge" of c l i n i c a l nursing p r a c t i c e : I think we are the cutting edge of the practice discipline and I think we are the clinical conscience the organization... I think that is the greatest contribution that we make. P a r t i c i p a n t s b e l i e v e d there were l e a d e r s h i p inherent modelling indepth,  i n ANP.  of  traits  These i n c l u d e d p r o v i d i n g d i r e c t i o n and r o l e  t o s t a f f t h a t were based on nurses i n ANP having an 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 l e a d e r s h i p t r a i t s were being for excellence  high a c h i e v e r s  who s t r o v e  i n c l i n i c a l p r a c t i c e 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 t o p o s i t i v e l y i n f l u e n c e h e a l t h care, a b i t p e r f e c t i o n i s t i c and not wanting t o m a i n t a i n the s t a t u s 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 l e a d e r s h i p t r a i t s were being  interested i n radical,  98 although a p p r o p r i a t e change, demonstrated i n i t i a t i v e and c r e a t i v i t y , as w e l l as p o s s e s s i n g a high t o l e r a n c e f o r conflict: 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 t o address problem s o l v i n g and/or l e a r n i n g  situations:  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 i n c l u d e d b e i n g change agents, r i s k t a k e r s and extremely d e d i c a t e d t o n u r s i n g .  F o r p a r t i c i p a n t s , t h e r e was  a f i n e l i n e from b e i n g d e d i c a t e d t o n u r s i n g t o b e i n g consumed by n u r s i n g : 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. R e l a t e d t o d e d i c a t i o n , p a r t i c i p a n t s b e l i e v e d t h a t nurses i n ANP were " r e a l l y hard workers."  P a r t i c i p a n t s thought t h a t  nurses i n ANP put a great d e a l of time i n over and above t h e i r r e g u l a r l y 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  t h a t nurses i n ANP needed t o work c l o s e l y , i n a complementary manner, with s e n i o r n u r s i n g a d m i n i s t r a t i o n . partnership  was seen as c r i t i c a l  This r e s u l t a n t  f o r 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 administration. P a r t i c i p a n t s a l s o b e l i e v e d t h a t nurses i n ANP needed administrative did  support.  that to strong  They thought t h a t i f nurses i n ANP  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 That is incredibly important. Thus, a c c o r d i n g  t o p a r t i c i p a n t s , nurses i n ANP  a high l e v e l of e f f e c t i v e l e a d e r s h i p .  c l i n i c a l p r a c t i c e and c l i e n t care.  care.  based on an  P a r t i c i p a n t s thought nurses i n ANP  who c o n s t a n t l y  i n c l u s i v e of education  provided  i n ANP which  i n c l u d e d p r o v i d i n g d i r e c t i o n and r o l e m o d e l l i n g advanced competency base.  role.  Participants believed  there were many l e a d e r s h i p t r a i t s i n h e r e n t  were high a c h i e v e r s  for the  strove f o r excellence i n They a l s o saw ANP as  aimed a t p o s i t i v e l y i n f l u e n c i n g h e a l t h  P a r t i c i p a n t s thought nurses i n ANP were p e r f e c t i o n i s t s  who were i n t e r e s t e d i n r a d i c a l but a p p r o p r i a t e  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 w e l l as p o s s e s s i n g a high t o l e r a n c e  forconflict.  Other l e a d e r s h i p  i n c l u d e d advanced group f a c i l i t a t i o n s k i l l s , r i s k takers  and extremely d e d i c a t e d  traits  change agents,  to nursing.  Participants  b e l i e v e d t h a t nurses i n ANP were hard workers who put i n very long hours.  F i n a l l y , p a r t i c i p a n t s thought t h a t f o r the  successful continuation  and e f f e c t i v e n e s s of ANP, nurses i n  ANP needed t o have complementary r e l a t i o n s h i p s with, as s t r o n g support from s e n i o r n u r s i n g Interdisciplinary  as w e l l  administration.  Collaboration  A l l p a r t i c i p a n t s had developed strong,  highly  valued  i n t e r d i s c i p l i n a r y c o l l a b o r a t i v e r e l a t i o n s h i p s and c l e a r l y recognized team.  the merits  of other members of the h e a l t h  I n t e r d i s c i p l i n a r y c o l l a b o r a t i o n represented  e s s e n t i a l q u a l i t y of ANP.  care  the f i f t h  P a r t i c i p a n t s a r t i c u l a t e d t h e very  s i g n i f i c a n t c o n t r i b u t i o n t h a t nurses made t o c l i e n t care but s e r i o u s l y questioned a d i s c i p l i n e s p e c i f i c approach. recognized  that  They  " 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  p r a c t i c e " were i s s u e s of concern and debate f o r many h e a l t h care p r o v i d e r s .  Providers  were thought t o be concerned about  "unique" aspects of t h e i r d i s c i p l i n e ' s p r a c t i c e and wanting to "protect t u r f . "  However, p a r t i c i p a n t s b e l i e v e d t h a t as a  r e s u l t , h e a l t h care was o f t e n d i s j o i n t e d which r e s u l t e d i n gaps, fragmentation and d u p l i c a t i o n p a r t i c u l a r l y from t h e client's  perspective.  P a r t i c i p a n t s b e l i e v e d t h a t they had much t o o f f e r  101 c l i n i c a l p r a c t i c e and c l i e n t care from a n u r s i n g  perspective,  but t h a t n u r s i n g was u s u a l l y not a l l t h a t was r e q u i r e d . P a r t i c i p a n t s valued  approaching c l i e n t care s c e n a r i o s not  from a s i n g u l a r n u r s i n g p e r s p e c t i v e , context  but i n s t e a d from the  of i n t e r d i s c i p l i n a r y c o l l a b o r a t i o n and p r a c t i c e .  P a r t i c i p a n t s recognized  t h a t when care was approached by  s p e c i f i c d i s c i p l i n e s , o f t e n d e c i s i o n s were made i n i s o l a t i o n . Instead,  p a r t i c i p a n t s thought t h a t nurses i n ANP approached  c l i e n t care r e c o g n i z i n g t h a t other d i s c i p l i n e s had much t o offer: 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. P a r t i c i p a n t s s t r o n g l y b e l i e v e d t h a t i n order t o enhance c l i e n t care, a l l nurses needed t o p r a c t i c e more c l o s e l y and c o l l a b o r a t i v e l y w i t h other d i s c i p l i n e s . t h a t s t a f f nurses worked w i t h other  Although  h e a l t h care  recognizing  providers,  p a r t i c i p a n t s thought s t a f f nurses d i d not r o u t i n e l y c o l l a b o r a t e with other d i s c i p l i n e s , doing so.  nor f e e l  comfortable  P a r t i c i p a n t s b e l i e v e d t h a t one c o n t r i b u t i n g f a c t o r  was t h a t the m a j o r i t y  of nurses were educated i n non-  u n i v e r s i t y s e t t i n g s , t h e r e f o r e were not as a r t i c u l a t e about, nor aware t h a t they c o u l d b e n e f i t from, and thus  value  interdisciplinary 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 P a r t i c i p a n t s b e l i e v e d t h a t t h e i r acceptance  of,  c o n s u l t a t i o n with, and c o l l a b o r a t i v e r e l a t i o n s h i p s w i t h other d i s c i p l i n e s was nurses.  q u i t e unique  t o ANP,  P a r t i c i p a n t s thought  as compared t o other  nurses i n ANP  were more aware  and a b l e t o a c t i v e l y p a r t i c i p a t e i n c o l l a b o r a t i v e p r a c t i c e and r e s e a r c h , as w e l l as r e c o g n i z e t h a t no one h e a l t h care p r o v i d e r c o u l d "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" r e l a t e d t o i n t e r d i s c i p l i n a r y c o l l a b o r a t i o n when comparing nurses i n ANP  with s t a f f nurses.  Participants  b e l i e v e d t h a t a major f u n c t i o n of nurses i n ANP  was  t o 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 t o enhance c l i e n t care. and nurses i n ANP  They r e c o g n i z e d t h a t both s t a f f  sought  nurses  resources needed f o r c l i e n t care,  however these resources might be d i f f e r e n t based on l e v e l s of expertise.  P a r t i c i p a n t s b e l i e v e d t h a t nurses i n ANP  had a  higher l e v e l of e x p e r t i s e t o draw from compared t o s t a f f nurses.  P a r t i c i p a n t s expressed hopes t h a t s t a f f nurses would  be able t o r e c o g n i z e t h e i r own i n ANP  l i m i t a t i o n s and c a l l  when they reached t h e i r p e r s o n a l  i n nurses  limits:  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. P a r t i c i p a n t s b e l i e v e d t h a t nurses i n ANP had a c l e a r understanding of when t o i n v o l v e o t h e r d i s c i p l i n e s and a freedom t o then approach and communicate with them: In my role there are no bounds to basically communicate with.  who I can  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. P a r t i c i p a n t s b e l i e v e d t h a t t h e i r education, demonstrated and r e c o g n i z e d c l i n i c a l e x p e r t i s e , c o n f i d e n c e , a b i l i t y t o a r t i c u l a t e and t h e i r t i t l e gave them a d d i t i o n a l  credibility  and l e g i t i m a t e access t o and acceptance from other disciplines.  This c r e d i b i l i t y ,  access and acceptance was  thought t o be enhanced by t h e f a c t t h a t nurses i n ANP u s u a l l y had a broader competency base than s o l e l y from n u r s i n g .  This  base came from formal and i n f o r m a l education with and from other d i s c i p l i n e s .  T h i s was thought t o be a s s i s t i v e i n  a p p r o p r i a t e c o n s u l t a t i o n and p r e v e n t i o n of t u r f  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. P a r t i c i p a n t s b e l i e v e d t h a t they r o u t i n e l y used t h e i r s t r o n g n u r s i n g competency base, a l o n g with i n f o r m a t i o n and from other d i s c i p l i n e s t o enhance c l i e n t care  resources  through  a s s i s t i v e care d e l i v e r y : I draw on a lot of information and disciplines to focus on the client nursing knowledge and expertise to care of that client either through indirectly from or via the nursing  resources from other and I also use my enhance the nursing me directly or staff.  P a r t i c i p a n t s b e l i e v e d t h a t t r a d i t i o n a l l y nurses  had  assumed a s u b s e r v i e n t r o l e w i t h other h e a l t h care team members, p a r t i c u l a r l y p h y s i c i a n s . nurses i n ANP  However, they thought  that  were p a r t n e r s on equal f o o t i n g w i t h a l l h e a l t h  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, a c c o r d i n g t o p a r t i c i p a n t s , nurses i n ANP s t r o n g and h i g h l y v a l u e d i n t e r d i s c i p l i n a r y relationships. ANP  developed  collaborative  P a r t i c i p a n t s b e l i e v e d t h a t although nurses i n  c l e a r l y r e c o g n i z e d the s i g n i f i c a n t c o n t r i b u t i o n t h a t  nurses make t o c l i e n t care, c l i n i c a l f u l l y met thought  i s s u e s c o u l d not  with d i s c i p l i n e s p e c i f i c approaches.  t o r e s u l t i n gaps, fragmentation and  p a r t i c u l a r l y from c l i e n t p e r s p e c t i v e s .  be  To do so  was  duplication  Participants  r e c o g n i z e d t h a t a l l nurses engaged i n p r a c t i c e with other disciplines.  However they b e l i e v e d t h a t s t a f f nurses d i d not  105 f e e l comfortable i n r o u t i n e c o l l a b o r a t i o n with other disciplines.  P a r t i c i p a n t s e x p l a i n e d t h i s due t o non-  u n i v e r s i t y education of most nurses who were thus not a r t i c u l a t e about, nor aware of the b e n e f i t s of interdisciplinary  collaboration.  P a r t i c i p a n t s thought  t h e r e was a d i f f e r e n t degree o r  matter of knowledge between nurses i n ANP and s t a f f related to i n t e r d i s c i p l i n a r y collaboration.  nurses  P a r t i c i p a n t s saw  a r o l e f o r nurses i n ANP t o be the l i n k a g e between s t a f f nurses and other d i s c i p l i n e s f o r t h e o v e r a l l enhancement of c l i e n t care.  They r e c o g n i z e d t h a t nurses i n ANP had a c l e a r  understanding and freedom of when t o i n v o l v e other disciplines.  Participants identified their  l e g i t i m a t e access and acceptance  credibility,  from other d i s c i p l i n e s as  f a c t o r s r e l a t e d t o 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 b e l i e v e d t h a t nurses i n ANP  were on "equal f o o t i n g " with a l l h e a l t h care p r o v i d e r s , including physicians. In summary, ANP was b e l i e v e d by p a r t i c i p a n t s t o be a term t h a t c o u l d be d e s c r i b e d .  T h i s d e s c r i p t i o n had as a  b a s i s or foundation what has been c a t e g o r i z e d as t h e minimal requirement was graduate  t r i a d of ANP. education.  The f i r s t  element of t h i s  triad  During t h i s education, p a r t i c i p a n t s  b e l i e v e d t h a t nurses were exposed t o many important  areas  t h a t r e s u l t e d i n the competencies r e q u i r e d f o r ANP. P a r t i c i p a n t s s t r u g g l e d with whether graduate  education should  106 be i n n u r s i n g and i f the education was d i d that contribute to  i n another f a c u l t y  how  ANP.  The second element of the minimal requirement t r i a d of ANP  was  thought t o be a c l i n i c a l  s p e c i a l t y focus.  According  t o p a r t i c i p a n t s , t h i s focus needed t o be combined with graduate e d u c a t i o n .  A l l p a r t i c i p a n t s r e c o g n i z e d 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 t o graduate education.  They a l l b e l i e v e d t h a t once they focused t h e i r  s t u d i e s with more indepth c l i n i c a l work, they graduated b e i n g a b l e t o p r a c t i c e a t an advanced the c l i n i c a l  level.  s p e c i a l i t y focus was  Strongly linked with  the need f o r mentored  p r a c t i c e and time f o r r e f l e c t i o n i n order t o f u l l y develop as a nurse i n ANP. competencies  Participants described  additional  t h a t were a c q u i r e d d u r i n g graduate education  l i n k e d with a c l i n i c a l  s p e c i a l i t y focus.  These  competencies  were b e l i e v e d by p a r t i c i p a n t s t o enable nurses i n ANP  t o be  a b l e t o be p r o a c t i v e r a t h e r than r e a c t i v e 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 t o be research-based p r a c t i c e which  was  b e l i e v e d t o be t h i n k i n g 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 r e s e a r c h . i n ANP  P a r t i c i p a n t s b e l i e v e d t h a t nurses  worked hard a t t r y i n g t o have p r a c t i c e based on  research.  Toward t h a t end, p a r t i c i p a n t s were a c t i v e p a r t n e r s  i n the conduct of r e s e a r c h but b e l i e v e d t h a t the p r i n c i p a l i n v e s t i g a t o r r o l e c o u l d not be assumed by the master's  107 prepared nurse.  They b e l i e v e d t h a t t r u l y d e f i n i t i v e  i n v o l v e d a p a r t n e r s h i p between a nurse i n ANP  and  research  a  d o c t o r a l l y prepared nurse. The  f i v e i d e n t i f i e d e s s e n t i a l q u a l i t i e s of ANP  b e l i e v e d by p a r t i c i p a n t s to b u i l d on what has categorized  been  as the minimal requirement t r i a d of  P a r t i c i p a n t s b e l i e v e d t h a t nurses i n ANP  on a c l i n i c a l  s p e c i a l i t y and  focusing  l e a r n i n g competencies r e l a t e d t o the e s s e n t i a l  These e s s e n t i a l q u a l i t i e s were thought  p a r t i c i p a n t s to i n c l u d e an indepth an i n d i r e c t c l i n i c a l focus  In other words,  graduate s c h o o l ,  research-based p r a c t i c e they were developing q u a l i t i e s of ANP.  ANP.  began development of  these q u a l i t i e s w h i l e i n v o l v e d i n the t r i a d . w h i l e these nurses were a t t e n d i n g  were  focus  by  a b i l i t y to t h i n k g l o b a l l y ,  on c l i e n t s , a d i r e c t c l i n i c a l  on s t a f f nurses, p r o v i d i n g a high l e v e l of e f f e c t i v e  l e a d e r s h i p and  finally  s t r o n g and  highly  valued  interdisciplinary collaborative relationships. P o s s i b l e R e l a t i o n s h i p Between Advanced Nursing P r a c t i c e C l i e n t Health I t was  Outcomes  not easy f o r p a r t i c i p a n t s t o c l e a r l y  t h e i r p r a c t i c e i n r e l a t i o n to CHO. nurses i n ANP  had  describe  As they had a r t i c u l a t e d ,  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  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,  focus.  c l i e n t s were an i n d i r e c t focus, p a r t i c i p a n t s r e c o g n i z e d difficulties of ANP,  i n d e s c r i b i n g t h e i r p r a c t i c e , as  i n r e l a t i o n to CHO.  and  Since the  representatives  They thought t h a t nurses i n  ANP  108 were more the "conduit,"  i n t h a t CHO came through them but  not n e c e s s a r i l y 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. P a r t i c i p a n t s again  r e i t e r a t e d t h a t t r y i n g t o make a l i n k a g e  between ANP and CHO was "new" and " f o r e i g n . "  They b e l i e v e d  t h a t nurses i n ANP were j u s t b e g i n n i n g t o examine t h e i r  input  or c o n t r i b u t i o n t o 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 p a r t i c i p a n t s began t o d e s c r i b e t h e i r p r a c t i c e i n r e l a t i o n t o CHO, they d e s c r i b e d problems i n t r y i n g t o 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 r e l a t i o n s h i p between ANP and CHO, as w e l l as t h e o r e t i c a l problems i n t r y i n g t o 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 p a r t i c i p a n t s knew t h a t the r e s e a r c h e r  was  i n t e r e s t e d i n l e a r n i n g about t h e i r p r a c t i c e i n r e l a t i o n t o CHO, i n i t i a l l y p a r t i c i p a n t s focused required further discussion. more recent  on CHO as a term t h a t  They b e l i e v e d t h a t CHO were a  area of i n t e r e s t than was ANP.  They thought t h a t  CHO meant d i f f e r e n t t h i n g s t o d i f f e r e n t p o p u l a t i o n s , i n c l u d i n g nurses i n ANP.  P a r t i c i p a n t s b e l i e v e d t h a t CHO were  d i f f i c u l t to define yet recognized d e f i n i t i o n s were p o s s i b l e .  t h a t p o t e n t i a l l y many  They b e l i e v e d t h a t t h e r e were  109 v a r y i n g p e r c e p t i o n s about CHO  and t h e r e was  t r y i n g t o get agreement among i n t e r e s t e d  difficulty in  parties:  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 It  are a thousand  is very, very  difficult  to  definitions. 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. P a r t i c i p a n t s d i s c u s s e d t h e i r i n t e r p r e t a t i o n s of CHO  as  not b e i n g c l e a r cut but r a t h e r open t o many i n t e r p r e t a t i o n s and i n f l u e n c e d by values such as "healthy," "negative," "positive,"  "successful,"  "unintended"  and  "curative,"  "intended,"  "end r e s u l t s of i n t e r v e n t i o n s . "  thought t h a t i n n u r s i n g , i t was r e s e a r c h e r s and academics"  "only nurses i n  They ANP,  t h a t were j u s t b e g i n n i n g , 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  n u r s i n g p r a c t i c e , 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. P a r t i c i p a n t s thought t h a t one reason f o r the l a c k of around  CHO  was  t h a t they had not been a p r i o r i t y  p o l i c y makers or government up u n t i l  recently.  clarity  f o r nursing, Participants  110 recognized any  t h a t t h e r e was not s o l i d evidence t h a t nurses had  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. P a r t i c i p a n t s b e l i e v e d t h a t i t was important t h a t  be  i n v o l v e d i n l o o k i n g a t o r measuring CHO.  clients  They thought  t h a t p a r t of t h e 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 t h a t there had been very  little  involvement of c l i e n t s i n  determining o r measuring CHO.  P a r t i c i p a n t s thought t h a t  h e a l t h care had been t r a d i t i o n a l l y p r o v i d e r nurses and others  focused  had been tempted t o d e f i n e CHO.  and t h a t However,  p a r t i c i p a n t s b e l i e v e d t h a t a l l c l i e n t s were d i f f e r e n t very d i f f e r e n t  expectations  from and with the h e a l t h  and had 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 t h a t may have been i n v o l v e d i n t h e i r care. had  P a r t i c i p a n t s believed that  the r i g h t t o s e t goals  clients  or outcomes when i n t e r a c t i n g  with  h e a l t h care p r o v i d e r s  as w e l l as be i n v o l v e d i n t h e  measurement of t h i s .  I t was however, a r e s p o n s i b i l i t y of the  h e a l t h care p r o v i d e r s  t o ensure t h a t c l i e n t s had s u f f i c i e n t  information  i n order  t o make d e c i s i o n s 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  Ill 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, a c c o r d i n g  t o p a r t i c i p a n t s , CHO were thought t o be  a terra t h a t was not w e l l understood and t h e r e f o r e open t o a v a r i e t y of d e f i n i t i o n s and i n t e r p r e t a t i o n s t h a t c o u l d be i n f l u e n c e d by v a l u e s . researchers  They b e l i e v e d t h a t nurses i n ANP,  and academics were the only nurses t r y i n g t o make  a l i n k between ANP and CHO. research,  Up u n t i l the time of the  p a r t i c i p a n t s thought t h a t i n t e r e s t i n CHO had not  been a p r i o r i t y f o r n u r s i n g ,  p o l i c y makers and/or government.  F i n a l l y , p a r t i c i p a n t s b e l i e v e d t h a t c l i e n t non-involvement i n l o o k i n g a t o r measuring CHO was a f a c t o r r e l a t e d t o problems i n a r t i c u l a t i n g what they were. Communicating t h e R e l a t i o n s h i p Between Advanced Nursing P r a c t i c e and C l i e n t Health  Outcomes  While p a r t i c i p a n t s were d e s c r i b i n g t h e i r p r a c t i c e i n r e l a t i o n t o CHO, they spoke of t h e i r i n f l u e n c e on CHO through the use of d e t a i l e d c l i n i c a l  stories.  They thought t h a t  nurses i n ANP i n f l u e n c e d 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 i n t e r v i e w s , utilized detailed c l i n i c a l their discussions.  a l l participants frequently s t o r i e s as an i n h e r e n t p a r t of  These c l i n i c a l  s t o r i e s were used most  w h i l e p a r t i c i p a n t s were attempting t o d e s c r i b e t h e i r p r a c t i c e i n r e l a t i o n t o CHO.  The c l i n i c a l  s t o r i e s were d e s c r i p t i o n s  112 of how nurses i n ANP, through use of what had been categorized CHO.  as e s s e n t i a l q u a l i t i e s ,  The f o l l o w i n g  stories.  The f i r s t  influenced  or impacted  accounts are examples of these c l i n i c a l i l l u s t r a t e s participant introduction  c o n t r o v e r s i a l program where improvement i n CHO  of a  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 r e f e r s t o the g e n e r a l p a r t i c i p a n t recognition  of t h e i r ongoing i n f l u e n c e  with s t a f f t o 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 r e f e r t o c l i e n t groups, p a r t i c i p a n t s a l s o d e s c r i b e d many other c l i e n t - s p e c i f i c d e t a i l e d c l i n i c a l  stories  that  c o n s i s t e n t l y 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 t o enhance CHO.  The f o l l o w i n g account i l l u s t r a t e s  this:  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. P a r t i c i p a n t s b e l i e v e d t h a t use of d e t a i l e d s t o r i e s was  clinical  a r o u t i n e and v a l u e d component of ANP.  They  seemed proud and c o n f i d e n t about t h e i r a b i l i t y t o make the s t o r i e s meaningful. a r t i c u l a t e why  P a r t i c i p a n t s were c l e a r l y a b l e t o  nurses i n ANP  e x t e n s i v e l y used  clinical  s t o r i e s throughout t h e i r p r a c t i c e , p a r t i c u l a r l y f o r e d u c a t i o n of  a l l l e v e l s of h e a l t h care p r o v i d e r s and p u b l i c .  In  114 keeping with t h e i r focus on c l i n i c a l p r a c t i c e , they claimed that d e t a i l e d c l i n i c a l  s t o r i e s were the embodiment of t h e i r  role: 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  s t o r i e s were  u s e f u l as they r e f l e c t e d how nurses i n ANP thought, l e a r n e d 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. P a r t i c i p a n t s b e l i e v e d t h a t s t a f f e a s i l y understood clinical  detailed  s t o r i e s t h a t were r e l e v a n t and meaningful.  T h e r e f o r e , nurses i n ANP found the s t o r i e s t o be v e r y u s e f u l i n education and p r a c t i c e t o 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, a c c o r d i n g t o p a r t i c i p a n t s , the use of d e t a i l e d clinical  s t o r i e s was a way t h a t nurses i n ANP d e s c r i b e d t h e i r  p r a c t i c e i n r e l a t i o n t o 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 t o  115 be a r o u t i n e and v a l u e d component of ANP.  Participants  the r o u t i n e use of these d e t a i l e d c l i n i c a l  s t o r i e s as the  embodiment of ANP.  They found them t o be p a r t i c u l a r l y  and meaningful when working with s t a f f t o enhance Broad System  useful  CHO.  Perspective  Participants also described t o CHO  saw  their practice in relation  from a broad system p e r s p e c t i v e .  d e s c r i p t i o n , they p r o v i d e d  Through t h i s  s p e c i f i c examples t h a t they  b e l i e v e d 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 i n f l u e n c i n g CHO.  They e x p l a i n e d  t h e i r i n f l u e n c e on CHO  as a  r e s u l t of g l o b a l t h i n k i n g t h a t r e l a t e d t o c l i n i c a l p r a c t i c e both i n t e r n a l and e x t e r n a l t o t h e i r employing b e l i e v e d t h a t nurses i n ANP  i n f l u e n c e d CHO  agency.  by way  They  of t h e i r  involvement i n programs t h a t r e f l e c t e d a f a s t e r t u r n o v e r of c l i e n t s t h e r e f o r e decreased wait l i s t s , discharged  w i t h an improved  bed u t i l i z a t i o n were more  c l i e n t s were  h e a l t h s t a t u s , and admissions  and  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. P a r t i c i p a n t s b e l i e v e d t h a t nurses i n ANP  developed  and  116 d i s t r i b u t e d i n n o v a t i v e programs  t h a t a s s i s t e d i n the  advancement of n u r s i n g 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. P a r t i c i p a n t s were c o n f i d e n t t h a t ANP p o s i t i v e l y i n f l u e n c e d CHO i n both t h e s p e c i f i c and g e n e r a l sense.  They  i d e n t i f i e d themselves as b e i n g the "common t h r e a d or person" who i n f l u e n c e d many agency broad system d e c i s i o n s .  However,  p a r t i c i p a n t s r e c o g n i z e d t h a t these i n f l u e n c e s were not hard i n d i c a t o r s r e l a t e d t o 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. P a r t i c i p a n t s thought t h a t nurses i n ANP needed t o be a b l e t o e x p l a i n t h e i r p r a c t i c e i n r e l a t i o n t o f i n a n c i a l i s s u e s around CHO.  They thought t h a t , due t o c u r r e n t r e s t r a i n t s ,  not enough t o t h i n k about o v e r a l l improvements b e i n g a b l e t o demonstrate f i n a n c i a l  i t was  i n CHO without  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 P a r t i c i p a n t s thought t h a t t o date, nurses i n ANP  had not done  w e l l i n terms of p r o v i n g t h e i r f i n a n c i a l worth v i a q u a n t i t a t i v e aspects of e f f e c t i v e n e s s r e l a t e d t o  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, p a r t i c i p a n t s b e l i e v e d t h a t nurses i n ANP  were f a r  more r e s p o n s i b l e f i s c a l l y than were s t a f f nurses i n terms of o p e r a t i o n a l 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, a c c o r d i n g t o p a r t i c i p a n t s , ANP from a broad system p e r s p e c t i v e .  was  l i n k e d with  CHO  P a r t i c i p a n t s were a b l e t o  i l l u s t r a t e t h i s p e r s p e c t i v e through d e s c r i p t i o n s of t h e i r broad i n f l u e n c e s on care and CHO.  , These same i n f l u e n c e s were  thought t o advance n u r s i n g as w e l l as practice.  interdisciplinary  P a r t i c i p a n t s saw nurses i n ANP  as b e i n g the  "common t h r e a d or person" t h a t i n f l u e n c e d many agency  system  d e c i s i o n s , however r e c o g n i z e d t h a t t h i s d i d not r e p r e s e n t a hard i n d i c a t o r .  Nurses i n ANP  c l e a r l y demonstrated  were thought t o have not  t h e i r e f f e c t i v e n e s s i n terms of  fiscal  118 issues.  However, p a r t i c i p a n t s b e l i e v e d t h a t nurses i n ANP  were f i s c a l l y r e s p o n s i b l e  i n terms of o p e r a t i o n a l management.  T h e o r e t i c a l Problems i n L i n k i n g Advanced Nursing P r a c t i c e With C l i e n t Health  Outcomes  P a r t i c i p a n t s thought t h e r e were some t h e o r e t i c a l i s s u e s that explained  their difficulties  p r a c t i c e i n r e l a t i o n t o CHO.  i n t r y i n g to describe  their  These i s s u e s i n c l u d e d the  d i f f e r e n c e s i n attempting t o measure long term versus  short  term CHO and the s t r o n g i n f l u e n c e of other v a r i a b l e s . Long Term Versus Short  Term  P a r t i c i p a n t s b e l i e v e d t h a t t h e r e were major d i f f e r e n c e s i n t r y i n g t o examine and p o t e n t i a l l y measure the i n f l u e n c e of ANP on long term versus short term CHO.  They b e l i e v e d  that  short term CHO were e a s i e r t o measure and done on a l i m i t e d b a s i s p a r t i c u l a r l y i n acute care s e t t i n g s : I would think i t is much easier outcomes or demonstrate client setting.... I t i s easier to see acute care setting.  for me to see client outcomes in an acute care the short term in an  P a r t i c i p a n t s gave examples of why short term CHO were e a s i e r to measure i n acute care s e t t i n g s .  These were o f t e n r e l a t e d  t o s p e c i f i c i n t e r v e n t i o n s aimed a t c l i n i c a l problems such as p a i n or wound management.  They thought t h a t s i n c e acute  c l i e n t s were g e n e r a l l y q u i t e i l l ,  care  r e s u l t s of i n t e r v e n t i o n s  aimed a t keeping them out of c r i s i s were e a s i e r t o observe and  measure: When I look on a specific outcome say  at  an outcome if I intervene with unit I can see that there is a in terms of management of one of  a client better 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. P a r t i c i p a n t s thought t h a t n u r s i n g and medicine and o t h e r h e a l t h care p r o v i d e r s were not s k i l l e d a t measuring long term CHO.  P a r t i c i p a n t s b e l i e v e d these t o be the r e a l  of h e a l t h care p r o v i d e r involvement and/or  indicators  effectiveness.  Long term CHO d e s c r i b e d i n c l u d e d c o p i n g s t r a t e g i e s , h e a l t h s t a t u s and l i f e s t y l e changes.  Participants  improved recognized  these measurements were u n c l e a r and d i f f i c u l t t o i d e n t i f y and rate.  They b e l i e v e d i t was because of these d i f f i c u l t i e s  t h a t long term CHO had not been a focus of a t t e n t i o n : 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, life 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. P a r t i c i p a n t s r e c o g n i z e d t h a t many long term CHO were a s s o c i a t e d w i t h q u a l i t y of l i f e i s s u e s and t h a t some e a r l y e f f o r t s t o address these were appearing i n the l i t e r a t u r e . P a r t i c i p a n t s from g e r i a t r i c care environments were somewhat attuned t o long term CHO and gave s p e c i f i c  examples.  These i n c l u d e d a g g r e s s i v e c l i e n t behaviours, p s y c h o s o c i a l  120 outcomes of a d a p t a t i o n to environment or c h r o n i c i l l n e s s , p h y s i c a l h e a l t h outcomes such as s k i n break-down, i n f e c t i o n r a t e s , management of c o n s t i p a t i o n and p e a c e f u l  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 particularlyconcerned 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, a c c o r d i n g t o p a r t i c i p a n t s , t h e r e were major d i f f e r e n c e s i n t r y i n g t o measure s h o r t term versus long term CHO.  Short term CHO  were thought  t o be e a s i e r t o measure and  done on a l i m i t e d b a s i s i n acute care s e t t i n g s . CHO  were thought  to be the r e a l i n d i c a t o r s of h e a l t h care  p r o v i d e r involvement  with c l i e n t s , however were thought  vague and d i f f i c u l t to measure. some e a r l y e f f o r t s t o address the l i t e r a t u r e .  Long term  to be  P a r t i c i p a n t s recognized that  these i s s u e s were appearing i n  P a r t i c i p a n t s from g e r i a t r i c  care  environments seemed to focus more on what they d e s c r i b e d as long term CHO  than d i d those from acute  care.  Strong I n f l u e n c e of Other V a r i a b l e s P a r t i c i p a n t s r e c o g n i z e d t h a t many other v a r i a b l e s i n f l u e n c e d how  nurses  r e l a t i o n to CHO. any CHO  i n ANP  could describe t h e i r p r a c t i c e i n  To begin with, p a r t i c i p a n t s questioned  c o u l d be d i r e c t l y and c o n c l u s i v e l y l i n k e d back t o  specific discipline,  how any  l e t alone n u r s i n g :  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 has  done, to contribute to whatever had and has experienced.  P a r t i c i p a n t s recognized multitude  outcomes the  client  t h a t c l i e n t s were exposed to a  of h e a l t h care p r o v i d e r s .  In a d d i t i o n ,  p a r t i c i p a n t s b e l i e v e d t h a t c l i e n t s assumed v a r y i n g l e v e l s of r e s p o n s i b i l i t y r e l a t e d to personal h e a l t h concerns. education  was  education  around t h e i r  P a r t i c i p a n t s thought t h a t t h i s  also a f a c t o r r e l a t e d to  client  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. P a r t i c i p a n t s b e l i e v e d t h a t many other v a r i a b l e s i n f l u e n c e d CHO ANP  and  attempts to l i n k them back to nurses i n  p a r t i c u l a r l y i n the era of  c o l l a b o r a t i o n would be  interdisciplinary  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  f o l l o w i n g account r e f l e c t s p a r t i c i p a n t 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 e s c r i b e ANP  i n r e l a t i o n to  directly  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 looking after this client in complete and total isolation. How would you know and I guess that is a  and  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 t h a t  thought t o have demonstrated  p o s i t i v e CHO,  p a r t i c i p a n t c l e a r l y q u e s t i o n e d how  was  however again the  these c o u l d be l i n k e d 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, p a r t i c i p a n t s thought i t s u f f i c i e n t t o be a b l e t o d e s c r i b e 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 p r a c t i c e on CHO. nurses i n ANP bedside.  They found i t u s e f u l t o d i f f e r e n t i a t e  i n f l u e n c e d CHO  how  as compared t o nurses at the  They thought nurses, i n ANP  i n f l u e n c e d CHO  for  p o p u l a t i o n s of c l i e n t s and s t a f f from a broad p e r s p e c t i v e : 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 d e s c r i b e d t h i s p e r s p e c t i v e as "having a v i s i o n "  and  t a k i n g the time t o develop i t with s i g n i f i c a n t i n p u t from i n t e r d i s c i p l i n a r y h e a l t h care p r o v i d e r s as w e l l as  clients  123 and  what they r e f e r r e d to as the a p p r o p r i a t e  people."  The  p a r t i c i p a n t s described  "resource  t h i s a b i l i t y to put  a  v i s i o n i n t o a c t i o n 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 of nurses d i d not  t h a t the h o l i s t i c ,  caring  a l l o w f o r easy measurement of  Participants believed  that nursing  p r a c t i c e was  separating ANP.  decision  Nursing  thought to be very encompassing i n r e l a t i o n to  c l i e n t care. other h e a l t h  CHO.  practice included  making based on i n t u i t i o n and ways of knowing.  practice  I t was  a l s o thought to o v e r l a p  care p r o v i d e r s  out the  i n f l u e n c e of nursing,  P a r t i c i p a n t s d i d not  measure t h e i r own  which c r e a t e d  know how  and  issues  complement about  l e t alone nurses i n  i t would be p o s s i b l e  i n t u i t i v e p r a c t i c e , ways of knowing  to  and  c a r i n g l e t alone t h a t of other nurses: How do you measure intuitiveness knowing and caring and so on and  and so  nurses forth?  ways of  From a p r o f e s s i o n a l p r a c t i c e p o i n t of view, p a r t i c i p a n t s c i t e d the  importance of standards i n r e l a t i o n t o s e t t i n g  measuring CHO.  and  L i n k e d with t h e i r support f o r c l i e n t  involvement i n care and  d e t e r m i n i n g CHO,  that i f t h e i r professional  p a r t i c i p a n t s thought  standards d i d not  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  provide  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 d i s c u s s i n g the r e l a t i o n s h i p of ANP  to  CHO,  p a r t i c i p a n t s i d e n t i f i e d t h e i r b e l i e f t h a t 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 v a l u e d than those of n u r s i n g .  Reasons  c i t e d f o r t h i s i n c l u d e d the power base t h a t medicine  had  t r a d i t i o n a l l y h e l d and t h e i r focus on q u a n t i t a t i v e measures such as m o r b i d i t y and m o r t a l i t y was  much e a s i e r t o capture.  P a r t i c i p a n t s thought t h a t n u r s i n g p l a y e d a major r o l e i n these i n d i c a t o r s but t h i s had not been acknowledged: I t i s e a s i e r 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! P a r t i c i p a n t s r e c o g n i z e d t h a t medical outcome i n d i c a t o r s were a f a c t o r i n c u r r e n t i n i t i a t i v e s such as the development of provincial c l i n i c a l practice guidelines.  However, they a l s o  b e l i e v e d t h a t outcome measures r e l a t e d t o CHO  needed t o be  i n t e r d i s c i p l i n a r y i n nature f o r a l l concerned  particularly  clients: Traditionally,  we have been looking  at medical  care.  125 But I think there needs to be a balance to include kinds of things that nursing values and thinks is important for clients and for health parameters. Thus, p a r t i c i p a n t s r e c o g n i z e d  the  t h a t many other v a r i a b l e s  i n f l u e n c e d the a b i l i t y of a nurse i n ANP d e s c r i b i n g h e r / h i s p r a c t i c e i n r e l a t i o n t o CHO.  P a r t i c i p a n t s questioned  how any  CHO c o u l d be c l e a r l y l i n k e d back t o the involvement of any specific discipline.  Participants believed that since  c l i e n t s were exposed t o - a m u l t i t u d e  of h e a l t h care p r o v i d e r s ,  and assumed v a r y i n g l e v e l s of r e s p o n s i b i l i t y towards p e r s o n a l education  around t h e i r h e a l t h concerns,  to nurses i n ANP was  attempts t o l i n k CHO  problematic.  P a r t i c i p a n t s b e l i e v e d t h a t nurses i n ANP c o u l d an i n d i r e c t r e l a t i o n s h i p with CHO.  describe  Nurses i n ANP were  thought t o b r o a d l y i n f l u e n c e CHO from a p o p u l a t i o n of c l i e n t and  staff perspectives.  These p e r s p e c t i v e s i n c l u d e d having a  v i s i o n t o meet p o p u l a t i o n s  of c l i e n t needs and then t a k i n g  a l l the r e q u i r e d steps t o ensure a c t i o n . :  P a r t i c i p a n t s r e c o g n i z e d t h a t nurses were h o l i s t i c and c a r i n g i n t h e i r p r a c t i c e which again d i d not allow f o r ease i n measuring t h e i r i n f l u e n c e on CHO.  P a r t i c i p a n t s recognized  t h a t n u r s i n g p r a c t i c e was o f t e n based on " i n t u i t i o n " and "ways of knowing" t h a t c o u l d not be e a s i l y e x p l a i n e d l e t alone measured.  P a r t i c i p a n t s s t r e s s e d the importance of  c l i e n t involvement i n CHO but a t the same time r e c o g n i z e d the need t o determine whether or not p r o f e s s i o n a l n u r s i n g standards  were a s s i s t i v e .  126 P a r t i c i p a n t s recognized  t h a t although n u r s i n g p l a y e d a  major r o l e i n CHO such as m o r b i d i t y t h i s r o l e had not been acknowledged.  and m o r t a l i t y measures, These measures had  t r a d i t i o n a l l y been a s s o c i a t e d with medicine and were f a i r l y easy t o capture q u a n t i t a t i v e l y .  Linked with t h i s ,  p a r t i c i p a n t s b e l i e v e d t h a t c u r r e n t emphasis on medical outcome measures such as c l i n i c a l p r a c t i c e g u i d e l i n e s 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, p a r t i c i p a n t attempts t o d e s c r i b e  their  p r a c t i c e i n r e l a t i o n - t o CHO presented c h a l l e n g e s .  As  p a r t i c i p a n t s d i d with ANP, they spent some time t r y i n g t o d e f i n e CHO.  They b e l i e v e d t h a t CHO were understood from many  perspectives.  They claimed  t h a t although i t was v a l u a b l e t o  examine CHO, only nurses i n ANP, r e s e a r c h e r s were doing so. and  and academics  T h i s i n t e r e s t i n CHO was thought t o be recent  therefore explained  some of the l a c k of c l a r i t y .  P a r t i c i p a n t s b e l i e v e d t h a t the e x c l u s i o n of c l i e n t s i n d e f i n i n g CHO was  problematic.  In communicating the r e l a t i o n s h i p between ANP and CHO, p a r t i c i p a n t s made e x t e n s i v e  use of d e t a i l e d c l i n i c a l s t o r i e s  which r e f l e c t e d i n f l u e n c e s on broad c l i e n t groups and specific clients.  The use of d e t a i l e d c l i n i c a l  s t o r i e s was  b e l i e v e d by p a r t i c i p a n t s t o be a r o u t i n e , u s e f u l and v a l u e d aspect  of ANP.  P a r t i c i p a n t s a l s o b e l i e v e d t h a t nurses i n ANP  i n f l u e n c e d CHO from a broad system p e r s p e c t i v e f a s t e r turnover  that  of c l i e n t s , decreased wait l i s t s ,  included discharges  127 with improved h e a l t h s t a t u s , more a p p r o p r i a t e bed  u t i l i z a t i o n , as w e l l as development and  i n n o v a t i v e programs. ANP  were o f t e n the  system changes. had  admissions  and  d i s t r i b u t i o n of  P a r t i c i p a n t s b e l i e v e d t h a t nurses i n  "common thread  or person" t h a t  P a r t i c i p a n t s recognized  influenced  t h a t nurses i n  ANP  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  b e l i e v e d t h a t they were f i s c a l l y  responsible  i n terms of  o p e r a t i o n a l management. P a r t i c i p a n t s b e l i e v e d t h a t there were some f a i r l y t h e o r e t i c a l problems i n l i n k i n g ANP short term CHO  being  with CHO.  Participants also believed  t h a t other v a r i a b l e s i n f l u e n c e d how  nurses i n ANP  d e s c r i b e t h e i r p r a c t i c e i n r e l a t i o n to CHO. any  CHO  did  and  Participants  c o n s i d e r i n g the  multiplicity  the knowledge base of c l i e n t s .  b e l i e v e t h a t nurses i n ANP  populations  could  c o u l d be d i r e c t l y l i n k e d back to a  s p e c i f i c h e a l t h care p r o v i d e r , of p r o v i d e r s  of c l i e n t s and  Participants  p o s i t i v e l y influenced  staff.  In d e s c r i b i n g the nature of n u r s i n g p r a c t i c e and overlapping  included  e a s i e r to examine and p o t e n t i a l l y  measure than were long term CHO.  questioned how  These  clear  scopes of n u r s i n g with other h e a l t h  the  care  p r o v i d e r s , p a r t i c i p a n t s b e l i e v e d t h a t t h i s nature would difficult  to measure.  Inherent i n the nature of  be  nursing  p r a c t i c e , p a r t i c i p a n t s b e l i e v e d i t important to determine i f nursing  standards c o u l d a s s i s t i n l o o k i n g at CHO.  i f the standards d i d not p r o v i d e  However,  d i r e c t i o n , then p a r t i c i p a n t s  128 b e l i e v e d t h a t nurses i n ANP needed t o take d i r e c t i o n  from  clients. Chapter Summary In t h i s chapter, p a r t i c i p a n t attempts t o d e f i n e ANP and d e s c r i b e t h e i r p r a c t i c e i n r e l a t i o n t o CHO were p r e s e n t e d . These d e f i n i t i o n s and d e s c r i p t i o n s were c o n c e p t u a l i z e d from t h r e e broad  categories.  The f i r s t  broad category r e l a t e d t o d i f f i c u l t i e s  p a r t i c i p a n t s had i n c l e a r l y d e f i n i n g ANP. c o n s i s t e d of two components: i n i t i a l  T h i s category  attempts  and reasons f o r l a c k of c l a r i t y about ANP.  a t d e f i n i n g ANP  During  initial  attempts t o d e f i n e ANP p a r t i c i p a n t s had d i f f i c u l t i e s i n t r y i n g t o a r t i c u l a t e a c l e a r and c o n c i s e d e f i n i t i o n . P a r t i c i p a n t s b e l i e v e d t h a t ANP was a term t h a t was i n h e r e n t l y broad and vague i n nature.  P a r t i c i p a n t s were not concerned  t h a t many nurses i n ANP l a c k e d c l a r i t y  about ANP.  In f a c t ,  p a r t i c i p a n t s supported t h i s as they claimed i t allowed f o r the continued f l e x i b i l i t y r e q u i r e d f o r ANP.  Participants  b e l i e v e d t h a t t h e r e were s e v e r a l v a l i d reasons r e l a t e d t o t h e l a c k of c l a r i t y about ANP. The second broad category r e l a t e d t o the d e s c r i p t o r s of ANP.  T h i s category c o n s i s t e d of two components: minimal  requirement t r i a d of ANP and e s s e n t i a l q u a l i t i e s of ANP. P a r t i c i p a n t s claimed t h a t ANP had as i t s f o u n d a t i o n t h r e e minimal requirements, namely graduate education, c l i n i c a l s p e c i a l t y focus and research-based p r a c t i c e .  Participants  129 a l s o b e l i e v e d t h a t ANP i n c l u d e d f i v e e s s e n t i a l 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 b e l i e v e d  to be g l o b a l t h i n k i n g , 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 d e l i v e r y , e f f e c t i v e l e a d e r s h i p 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 r e l a t e d t o p o s s i b l e  r e l a t i o n s h i p between ANP and CHO.  T h i s category c o n s i s t e d of  t h r e e 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. evident.  Problems i n a r t i c u l a t i n g CHO were  P a r t i c i p a n t s b e l i e v e d t h a t CHO were a f a i r l y  area of i n t e r e s t and were understood from many  recent  perspectives.  P a r t i c i p a n t s b e l i e v e d t h a t the most e f f e c t i v e way t o communicate the r e l a t i o n s h i p between ANP and CHO was through the use of d e t a i l e d c l i n i c a l  stories.  These s t o r i e s  r e f l e c t e d i n f l u e n c e s on CHO which ranged from an i n d i v i d u a l c l i e n t t o broad, system p e r s p e c t i v e s .  Participants  claimed  t h e r e were some f a i r l y c l e a r t h e o r e t i c a l problems i n attempting t o d i r e c t l y l i n k ANP with CHO. T h i s chapter has presented the f i n d i n g s of t h i s In the next chapter,  study.  major f i n d i n g s t h a t c o n t r i b u t e t o the  knowledge base of ANP are d i s c u s s e d .  130 CHAPTER FIVE DISCUSSION of FINDINGS F i n d i n g s from t h i s study r e i n f o r c e many of the c u r r e n t views and r e s e a r c h r e l a t e d to ANP. d e s c r i p t i o n of how  ANP  The  i n f l u e n c e s CHO  e x p l o r a t i o n and  r e f l e c t s an area of  study t h a t has not been w e l l documented i n the Although i n ANP  literature.  a s i g n i f i c a n t body of l i t e r a t u r e c h a l l e n g e s  nurses  to r e c o g n i z e the impact of t h e i r p r a c t i c e on CHO,  to  date methodology to do so i s u n c l e a r . While p a r t i c i p a n t s i n t h i s study r e c o g n i z e d  the  importance of b e i n g a b l e to d e s c r i b e t h e i r p r a c t i c e i n r e l a t i o n to CHO,  they were not accustomed to doing  so.  C o n s i d e r i n g t h a t a l l p a r t i c i p a n t s were employed i n a major h o s p i t a l s o c i e t y , h e s i t a n c y i n b e i n g able t o 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 g e n e r a l emphasis on outcomes throughout Canadian health care. Despite the general c o n s i s t e n c y of t h i s study with  ideas  i n the a v a i l a b l e l i t e r a t u r e , t h e r e are t h r e e areas t h a t push us one  step f u r t h e r i n d e v e l o p i n g c l a r i t y and  about a d e s c r i p t i o n of ANP. t o a d e f i n i t i o n of ANP; and  richness  These areas are: i s s u e s r e l a t e d  graduate education and ANP;  interdisciplinary collaboration.  and,  ANP  The f o l l o w i n g  d i s c u s s i o n w i l l c o n s i d e r each of these w i t h i n the context e x i s t i n g knowledge.  may  of  131 Issues Related t o a D e f i n i t i o n o f Advanced Nursing P r a c t i c e P a r t i c i p a n t s were not able t o a r t i c u l a t e a c l e a r and c o n c i s e d e f i n i t i o n of ANP and were aware of the vagueness a s s o c i a t e d with i t t h a t was evident i n n u r s i n g  literature.  At the same time, p a r t i c i p a n t s were very c o n f i d e n t i n t h e i r p e r s o n a l understanding  of ANP and attempted t o a s s i s t the  r e s e a r c h e r t o b u i l d a common view of i t . P a r t i c i p a n t i n a b i l i t y t o p r o v i d e a c l e a r d e f i n i t i o n of ANP i s not s u r p r i s i n g .  As was noted i n chapter  two, n u r s i n g  l i t e r a t u r e f r e q u e n t l y i n c o r p o r a t e s the term ANP but authors r a r e l y d e f i n e i t . E x t e n s i v e use of the term ANP with r e g u l a r a r t i c l e s and/or e d i t o r i a l s appearing  continues i n nursing  j o u r n a l s t h a t emphasize a s t r o n g push f o r 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 f o r the movement  toward a c l e a r e r understanding to a r t i c u l a t e i t t o o t h e r s .  of ANP i s the need t o be able  According  t o G i o v a n n e t t i and  Tenove (1995), t h i s i s p a r t i c u l a r l y important  during  times of economic c o n s t r a i n t and h e a l t h reform. authors  still  current  Although  r e c o g n i z e the need f o r a c l e a r d e f i n i t i o n of  ANP, there i s a growing t r e n d t o d e s c r i b e the c h a r a c t e r i s t i c s , a t t r i b u t e s , competencies and behaviours  of  nurses i n ANP (eg. Davies & Hughes, 1995; P a t t e r s o n & Haddad, 1992) . Three s p e c i f i c f i n d i n g s of t h i s study have r a i s e d important  p o i n t s f o r c o n s i d e r a t i o n about i s s u e s r e l a t e d t o a  d e f i n i t i o n of ANP.  These p o i n t s a r e e i t h e r non-existent or  132 w e l l developed i n the  l i t e r a t u r e , or t h e i r treatment i n  l i t e r a t u r e raises further questions. ANP  remaining a broad and  e s s e n t i a l q u a l i t y ; and, foundation f o r  They are:  the  support f o r  vague term; g l o b a l t h i n k i n g as  the minimal requirement t r i a d as  an the  ANP.  Support For Advanced Nursing P r a c t i c e Remaining A Broad And  Vague Term  P a r t i c i p a n t s i n t h i s study were experienced CNSs r e c o g n i z e d t h a t t h e i r r o l e was associations,  colleagues  and  l a b e l l e d ANP  nursing  by  practitioners.  professional  scholars.  c l e a r l y c o n s i d e r e d themselves to be advanced  Participants nursing  They a l s o c i t e d , without prompting,  indepth knowledge of a c t i v i t i e s by n u r s i n g  any  an  scholars  t o the development of a c l e a r d e f i n i t i o n of ANP. t h e r e was  related  However, i f  aspect r e l a t e d to a d e f i n i t i o n of ANP  p a r t i c i p a n t s emphasized above a l l others,  who  i t was  that  that  they  had  a l a c k of concern r e l a t e d 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  c o n c i s e l y d e f i n e ANP  and,  r e s e a r c h e r i n e f f o r t s to do  i n f a c t , cautioned  the  so.  I n i t i a l l y , p a r t i c i p a n t s attempted to p r o v i d e a d e f i n i t i o n of ANP this..." depicted  and  said things  such as  "I should know  This r e a c t i o n can be t y p i c a l of CNSs and i n the  l i t e r a t u r e as an element of the  phenomenon" (eg. Arena & Page, 1992). phenomenon, a c c o r d i n g t o Arena and i n d i v i d u a l s who  may  The  Page,  is  "imposter  imposter describes  f e e l t h a t they are f o o l i n g everyone,  that  133 i s they are a c t u a l l y imposters i n t h e i r chosen p r o f e s s i o n . The  t i t l e of CNS which i n c l u d e s the terra " s p e c i a l i s t "  extensive  implies  e x p e r t i s e and the CNS may develop u n r e a l i s t i c  expectations  about h e r / h i s performance.  common f o r the CNS t o think. "I should  As a r e s u l t ,  i t is  know t h i s . . . "  However, soon a f t e r b e g i n n i n g d i s c u s s i o n s , i t became obvious t h a t p a r t i c i p a n t s lacked concern about t h e i r i n a b i l i t i e s t o a r t i c u l a t e a c l e a r and c o n c i s e d e f i n i t i o n of ANP.  P a r t i c i p a n t s j u s t i f i e d t h e i r personal  l a c k of concern  on the minimal progress t h a t c r e d i b l e and w e l l known n u r s i n g s c h o l a r s had made r e l a t e d t o f u r t h e r understanding ANP. P a r t i c i p a n t s were w i l l i n g t o spend c o n s i d e r a b l e support of the r e s e a r c h e r ' s evident  efforts.  time i n  However, i t was  clearly  t h a t they d i d not f e e l t h a t the phenomena of i n t e r e s t  were p r i o r i t i e s e i t h e r f o r themselves or f o r ANP i n g e n e r a l . P a r t i c i p a n t s were c o n f i d e n t understood ANP.  They f e l t comfortable i n t h e i r  r e l a t e d t o ANP and considered personal  i n how they i n d i v i d u a l l y  these t o be based on t h e i r  and p r o f e s s i o n a l experiences,  personality.  competencies  education  and  Furthermore, p a r t i c i p a n t s thought t h a t the  requirements of busy day-to-day p r a c t i c e f o r nurses i n ANP r e q u i r e d energy and focus  r e l a t e d t o 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 h e a l t h care p r o v i d e r s . precluded  Thus, t h i s  i n t e r e s t i n c o n s i d e r a t i o n of such i s s u e s as  d e f i n i n g terms. I t i s the r e s e a r c h e r ' s  o p i n i o n t h a t nurses i n ANP  134 understand  t h e i r p r a c t i c e and each other very w e l l .  almost have an i n g r a i n e d , i n t u i t i v e sense of i t . 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  They  In day-to-  i n ANP a r e  autonomous and s t r o n g l y supported by s e n i o r n u r s i n g a d m i n i s t r a t i o n , they a r e not accustomed t o a r t i c u l a t i n g a d e s c r i p t i o n of t h e i r p r a c t i c e .  D e s p i t e the p a r t i c i p a n t s '  confidence about t h e i r own p r a c t i c e , they a r e not n e c e s s a r i l y a b l e t o communicate c l e a r l y t h e i r understanding of i t e s p e c i a l l y t o others who may not be i n an ANP r o l e . be most u s e f u l t o observe p a r t i c i p a n t s i n t h e i r  I t would  practice.  The r e s e a r c h e r i s l e f t w i t h the q u e s t i o n s : How do nurses i n ANP compare t o each other i n the way they conduct practice?  Are some nurses  their  " b e t t e r " a t ANP than others?  What  are the l e v e l s or stages of ANP? P a r t i c i p a n t s viewed ANP as a term t h a t was broad and vague i n nature.  T h i s nature was seen as b e n e f i c i a l as i t  allowed f o r u n l i m i t e d f l e x i b i l i t y  a s s o c i a t e d w i t h ANP.  P a r t i c i p a n t s h i g h l y valued t h i s f l e x i b i l i t y  and b e l i e v e d i t  was i n s t r u m e n t a l i n j u s t i f y i n g the i n d i v i d u a l p e r s p e c t i v e s t h a t nurses brought  t o ANP.  recognized f l e x i b i l i t y  In a d d i t i o n ,  participants  as a l l o w i n g them t o c o n s i s t e n t l y  respond t o changes as n u r s i n g evolved, o r g a n i z a t i o n a l r e s t r u c t u r i n g o c c u r r e d and h e a l t h reform  continued.  L i t e r a t u r e g e n e r a l l y r e f l e c t s v a r y i n g i n t e r p r e t a t i o n s of the u n l i m i t e d f l e x i b i l i t y that unlimited f l e x i b i l i t y  of ANP.  Some n u r s i n g authors t h i n k  can r e s u l t i n the p e r c e p t i o n and  135 o p e r a t i o n a l i z a t i o n of ANP v a r y i n g from nurse t o nurse and from p r a c t i c e s e t t i n g t o p r a c t i c e s e t t i n g Langford,  1995; R u s s e l l & Hezel, 1994).  (eg. A l c o c k , 1995; As a r e s u l t , some  t h i n k t h i s causes c o n f u s i o n about ANP (eg. P a t t e r s o n & Haddad, 1992), and others view i t as impeding of  ANP (eg. Davies  & Eng, 1994).  implementation  Confusion about ANP can  r e s u l t i n the p u b l i c and p r o f e s s i o n a l c o l l e a g u e s not b e i n g c l e a r about s p e c i f i c r o l e s a s s o c i a t e d w i t h ANP, u n l i k e other d i s c i p l i n e s such as medicine  where r o l e s a r e c l e a r  (Alcock,  1995) . Vagueness about ANP leaves room f o r others t o i n t e r p r e t the term based on t h e i r own needs, p a r t i c u l a r l y d u r i n g h e a l t h reform d i s c u s s i o n s .  In some of these d i s c u s s i o n s , n u r s i n g  authors a r e q u e s t i o n i n g i f s e n i o r n u r s i n g a d m i n i s t r a t o r s , educators  and r e s e a r c h e r s should a l s o be c a l l e d advanced  nursing p r a c t i t i o n e r s  (eg. O n t a r i o M i n i s t r y of Health, 1994;  The Working Group f o r R e g i s t e r e d Nurses i n Advanced  Nursing  P r a c t i c e i n Rural/Remote Communities, 1994).  The use of ANP  w i t h i n the context of these i n i t i a t i v e s again  raises  questions about the l a c k of c l a r i t y r e g a r d i n g ANP and the resultant implications.  The i d e a t h a t 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 p r a c t i c e i n c o n s i s t e n c i e s with consequences f o r s u c c e s s f u l implementation concern  expressed by p a r t i c i p a n t s i n t h i s  negative  of ANP was not a study.  Other n u r s i n g authors r e c o g n i z e t h a t u n l i m i t e d flexibility  i n ANP i s b e n e f i c i a l as i t allows nurses  i n the  136 r o l e t o be h i g h l y c r e a t i v e  (eg. Sparacino, 1992), and  i n c r e a s e t h e i r m a r k e t a b i l i t y p a r t i c u l a r l y d u r i n g times of job insecurity  (eg. P r e v o s t , 1995).  e s s e n t i a l c h a r a c t e r i s t i c of ANP  Others see i t as an i f a goal of these nurses i s  the development and e x p l o r a t i o n of new  approaches  and avenues  i n an e v o l v i n g h e a l t h system  (eg. P a t t e r s o n & Haddad, 1992).  These views c l o s e l y resemble  those of the p a r t i c i p a n t s of  this  study. Although p a r t i c i p a n t s supported the r e s e a r c h e r i n t h i s  study, they had s t r o n g c a u t i o n s about c l e a r e r understanding of ANP. about  e f f o r t s aimed at a  P a r t i c i p a n t s were  e f f o r t s t o f o r c e a d e f i n i t i o n of ANP  should remain broad and vague i n nature. c l e a r d e f i n i t i o n of ANP  concerned  and b e l i e v e d i t They thought  a  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 t o be more n e g a t i v e than p o s i t i v e . T h i s c a u t i o n around ANP  e f f o r t s t o more c l e a r l y  has not been documented by o t h e r s .  r e c a l l from chapter two,  understand  As the reader w i l l  the o p p o s i t e i s t r u e .  p a r t i c i p a n t s of t h i s study had c a u t i o n s , i t may  Although have been  because they were secure and c o n f i d e n t about t h e i r and supported t o have u n l i m i t e d f l e x i b i l i t y As a r e s u l t , they viewed d e f i n i t i o n of ANP  in their  roles.  e f f o r t s towards d e v e l o p i n g a c l e a r  as n e g a t i v e .  that could r e s t r i c t t h e i r For p a r t i c i p a n t s , ANP l e d t o new  practice  areas of f o c u s .  They d i d not support  efforts  practice. was  "ever-changing"  and t h e r e f o r e  P a r t i c i p a n t s d i s c u s s e d the  137 increased  a d m i n i s t r a t i v e r e s p o n s i b i l i t i e s t h a t they were  assuming and j u s t i f i e d t h i s due t o changing needs. ANP  organizational  Again, they s t r e s s e d the f l e x i b i l i t y they v a l u e d i n  as a f a c t o r t o l e g i t i m i z e an a d m i n i s t r a t i v e  focus.  P a r t i c i p a n t s understood the examination of v a r i o u s r o l e s as b e i n g an element  of h e a l t h reform.  nursing  For these  reasons, p a r t i c i p a n t s b e l i e v e d t h a t t o be able t o continue employment, they needed t o be open t o an i n c r e a s i n g administrative  focus.  A t r e n d f o r CNSs t o take on more a d m i n i s t r a t i v e functions  i s not s u r p r i s i n g .  In c u r r e n t times of  r e s t r a i n t , nursing administrators having t o re-examine ANP Green,  1993).  and nurses i n ANP  r o l e s (eg. Brunk, 1992;  Houston &  take on more a d m i n i s t r a t i v e  f u n c t i o n s t h a t are r e q u i r e d f o r o r g a n i z a t i o n a l U n t i l recently, administrative been a s s o c i a t e d with ANP.  efficiency.  f u n c t i o n s have g e n e r a l l y not  However, t h i s i s changing.  example, a survey done by Davies and Eng r o l e implementation demonstrated  of time was  are o f t e n  With the e l i m i n a t i o n of many head nurse  p o s i t i o n s , o f t e n nurses i n ANP  CNS  fiscal  For  (1995) r e l a t e d t o  that,  " s u r p r i s i n g l y , 19%  spent on a d m i n i s t r a t i v e a c t i v i t i e s "  Although the a c t u a l data c o l l e c t i o n time-frame  (p. 26). i s not  clearly  o u t l i n e d i n the a r t i c l e by Davies and Eng, the reader can assume t h a t t h i s f i g u r e 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  e l i m i n a t i o n s of head nurse p o s i t i o n s .  Thus, p a r t i c i p a n t s as nurses i n ANP  were c o n f i d e n t i n  138 how  they conducted t h e i r p r a c t i c e and valued  f l e x i b i l i t y inherent  in their roles.  the  unlimited  This l e g i t i m i z e d  changing r o l e f o c i such as an i n c r e a s e d  administrative  P a r t i c i p a n t s b e l i e v e d t h a t a c l e a r d e f i n i t i o n of ANP r e s t r i c t i v e f o r nurses i n the r o l e .  one.  would  However, w h i l e  p a r t i c i p a n t s of t h i s study d i d not f e e l t h a t a d e f i n i t i o n ANP  was  a p r i o r i t y , d e f i n i t i o n s continue to p l a y an  r o l e i n the h e a l t h reform Global Thinking  g l o b a l t h i n k i n g t h a t they b e l i e v e d Although g l o b a l t h i n k i n g i s  of the e s s e n t i a l q u a l i t i e s of ANP  p a r t i c i p a n t s , i t i s discussed w e l l developed i n the  identified  by  here s i n c e t h i s q u a l i t y i s not  literature.  G l o b a l t h i n k i n g was and  important  discourse.  an e s s e n t i a l q u a l i t y of ANP.  only one  of  as an E s s e n t i a l Q u a l i t y  P a r t i c i p a n t s valued was  be  c o n s i s t e n t l y evident  i n the  accounts  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 w e l l as p r o v i n c i a l , n a t i o n a l and i n t e r n a t i o n a l i n i t i a t i v e s and  trends.  P a r t i c i p a n t s c o u l d focus on  i n d i v i d u a l c l i e n t but would be how  an  c o n s i s t e n t l y t h i n k i n g about  t h a t c l i e n t r e l a t e d t o the whole of c l i e n t care.  same time, p a r t i c i p a n t s would b r i n g t h e i r r e l a t e d t o the h e a l t h care system to any  At  the  competencies individual client  scenario. P a r t i c i p a n t s s t r e s s e d t h a t g l o b a l t h i n k i n g enabled nurses i n ANP i n planning  t o be p r o a c t i v e so t h a t they c o u l d p a r t i c i p a t e  f o r programs/strategies  p r i o r to occurrence of a  139 crisis.  According  to p a r t i c i p a n t s , nurses i n ANP  practiced  i n a p r o a c t i v e manner, as opposed to s t a f f nurses g e n e r a l l y p r a c t i c e d i n a r e a c t i v e manner. approach of s t a f f nurses was of p r a c t i c e t h a t precluded proactive strategies.  due  any  who  This r e a c t i v e  to busy day-to-day demands  long term p l a n n i n g  or  Based on a p r o a c t i v e approach to  c l i e n t care, nurses i n ANP  assume a l e a d e r s h i p r o l e i n the  improvement of c l i e n t care w i t h i n t h e i r agency, as w e l l external  as  agencies/groups.  As noted above, the n o t i o n of g l o b a l t h i n k i n g as e s s e n t i a l q u a l i t y of ANP  i s not prominent i n the  an  literature.  A l i n k a g e with t h i s q u a l i t y i s apparent, f o r example, i n the phrases "broad context" "broad p e r s p e c t i v e " picture" may  (Schaefer  (Benner, Tanner & Chelsa,  (Davies & Hughes, 1995) & Lucke, 1990).  and  1992),  "whole  Although these phrases  r e f l e c t the same dimensions of p r a c t i c e , 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 n k i n g i s u s e f u l f o r nurses i n ANP  this  global  to be p r o a c t i v e .  This  f i n d i n g i s important and worthy of f u t u r e a t t e n t i o n as t r a d i t i o n a l l y h e a l t h care p r o v i d e r s and  continue t o be  reactive  to " p r a c t i c e i n response to both the h i s t o r i c a l  current  s o c i a l demands" (Patterson  & Haddad, 1992,  and p.  18).  In the era of h e a l t h reform, the competencies of nurses i n ANP  to a r t i c u l a t e g l o b a l t h i n k i n g to h e a l t h p o l i c y d e c i s i o n  makers c o u l d be very of ANP,  e f f e c t i v e not only f o r e n s u r i n g  but a l s o f o r improving o v e r a l l h e a l t h  care.  survival  140 Inherent i n t h e i r focus  on g l o b a l t h i n k i n g , p a r t i c i p a n t s  were able t o d e s c r i b e through the use s t o r i e s , how with care,  of d e t a i l e d c l i n i c a l  they improved c l i e n t care, n u r s i n g  i n t e r d i s c i p l i n a r y c o l l a b o r a t i o n and  satisfaction CHO.  They  a l s o c l e a r l y a r t i c u l a t e d broad improvements i n care t h e i r organizations.  P a r t i c i p a n t s stressed that s t a f f  were t h e i r c l i e n t s and clinical  c o n s i s t e n t l y d e s c r i b e d ANP  stories within this  s t a f f nurses i n order (eg. Langford, 1995;  through  nurses i n ANP  to meet p r o f e s s i o n a l and  focus  What i s not  nurses i n ANP  o v e r a l l h e a l t h care w i t h i n an  to c o n s i d e r  clearly  organization.  L i t e r a t u r e i s b e g i n n i n g to appear t h a t c h a l l e n g e s ANP  on  c l i e n t needs  Schaefer & Lucke, 1990).  w e l l developed i n the l i t e r a t u r e i s how and  nurses  context.  L i t e r a t u r e o f t e n r e f l e c t s how  improve CHO  within  an o r g a n i z a t i o n as t h e i r c l i e n t  nurses i n  (eg. Forbes,  1995b), r a t h e r than f o c u s i n g d i r e c t l y on s t a f f nurses. approach i s b e l i e v e d t o be advantageous f o r e n s u r i n g s u r v i v a l of the CNS  to p a r t i c i p a n t s , g l o b a l t h i n k i n g  an e s s e n t i a l q u a l i t y of ANP.  allowed nurses i n ANP  t o be p r o a c t i v e  nurses i n ANP  Global  and  their  to improve c l i e n t care.  to a r t i c u l a t e how  thinking  in their practice  t h e r e f o r e assume a l e a d e r s h i p r o l e w i t h i n agency/organization  the  position.  Thus, a c c o r d i n g represented  This  The  ability  g l o b a l t h i n k i n g and  of  a  p r o a c t i v e approach to care can b e n e f i t both the s u r v i v a l of ANP  and  improvements i n o v e r a l l h e a l t h care can  be  141 strengthened. Minimal Requirement  Triad  P a r t i c i p a n t s c i t e d t h r e e minimum requirements as f o u n d a t i o n a l f o r ANP.  These have been c o n c e p t u a l i z e d i n t o  the minimal requirement t r i a d of ANP, education, c l i n i c a l practice.  s p e c i a l t y f o c u s , and research-based  Reasons why  requirement t r i a d was f o r ANP  namely: graduate  each element of the minimum c o n s i d e r e d by p a r t i c i p a n t s as c r u c i a l  were o u t l i n e d i n chapter f o u r .  The purpose of  d i s c u s s i o n a t t h i s p o i n t i s t o focus on the minimal requirement t r i a d of ANP  in i t s entirety.  t h r e e r e q u i r e d elements of ANP,  I t i s not j u s t the  but r a t h e r the combination  and i n t e r a c t i o n of them t h a t p r o v i d e s the f o u n d a t i o n of W i t h i n the l i t e r a t u r e , a b a s e l i n e f o u n d a t i o n of remains c o n t e n t i o u s and nurses have not come t o a about i t .  ANP.  ANP  consensus  Authors of n u r s i n g l i t e r a t u r e r e l a t e d t o  CNS  p r a c t i c e do not c o n s i s t e n t l y focus on the above elements p r o v i d i n g a b a s e l i n e or f o u n d a t i o n f o r ANP.  as  Although the  elements are w r i t t e n about f r e q u e n t l y , i t i s u s u a l l y w i t h i n the context of need f o r , i m p l i c a t i o n s and i n c o n s i s t e n c i e s of one or more of these elements C a l k i n , 1994; Columbia,  i n combination with others (eg.  R e g i s t e r e d Nurses A s s o c i a t i o n of B r i t i s h  1994), and/or r o l e f u n c t i o n s and p r a c t i c e areas  (eg. P a t t e r s o n & Haddad, 1992).  Is i t important t o  a r t i c u l a t e the need f o r a combination of minimum requirements as a f o u n d a t i o n f o r 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 t h e minimal  requirement t r i a d d i s c u s s e d by p a r t i c i p a n t s i n t h i s study i s not  apparent i n t h e l i t e r a t u r e ,  elements w i t h i n t h e t r i a d  have been d i s c u s s e d a t l e n g t h and can c o n t r i b u t e t o our i n t e r p r e t a t i o n s of t h i s  finding.  The need f o r graduate education, a t l e a s t a t t h e master's  l e v e l , was b e l i e v e d by p a r t i c i p a n t s t o be r e q u i r e d  i n order t o develop the competencies p o s i t i v e l y t o ANP. literature 1989)  that  contribute  T h i s view i s w e l l documented i n t h e  (eg. Montemuro, 1987; Ray & Hardin, 1995; Synder,  and more i s s u e s s p e c i f i c t o graduate e d u c a t i o n a r e  d i s c u s s e d l a t e r i n t h i s chapter. According to p a r t i c i p a n t s , a c l i n i c a l  s p e c i a l t y focus i n  graduate education, d e s p i t e t h e f a c u l t y of study, was mandatory f o r ANP.  P a r t i c i p a n t s d e s c r i b e d themselves as  expert p r a c t i t i o n e r s p r i o r t o t h e i r graduate e d u c a t i o n .  They  b e l i e v e d t h a t the combination of t h e i r expert p r a c t i c e i n a s p e c i a l t y area of n u r s i n g combined with graduate e d u c a t i o n r e s u l t e d i n b e i n g t o conduct ANP a t a competent  level.  Davies and Hughes (1994) a l s o note t h a t ANP " b u i l d s upon clinical  e x p e r t i s e " and " e x p e r i e n t i a l knowledge" (p.  158).  T h i s f i n d i n g may be e x p l a i n e d by the knowledge t h a t p a r t i c i p a n t s of t h i s study do not n e c e s s a r i l y r e f l e c t t h e average nurse e n t e r i n g graduate e d u c a t i o n .  That i s , many  nurses e n t e r i n g graduate e d u c a t i o n may not be c l i n i c a l experts as were p a r t i c i p a n t s .  When nurses e n t e r graduate  143 s t u d i e s , even i f they wish t o focus on n u r s i n g c l i n i c a l p r a c t i c e , they may  change the area i n which they have  p r e v i o u s l y been p r a c t i s i n g .  For example, a nurse with  p r e v i o u s experience i n p e d i a t r i c s may h e a l t h i n her or h i s graduate P a r t i c i p a n t s viewed f o r ANP  and thought  competencies clinical  focus on community  studies.  research-based p r a c t i c e as c r i t i c a l  i t was  developed through r e s e a r c h  gained through graduate education l i n k e d with a  s p e c i a l t y focus.  Participants referred to research-  based p r a c t i c e as c o n s i s t e n t l y t h i n k i n g about, i n , and u t i l i z i n g i n ANP  research.  participating  P a r t i c i p a n t s thought t h a t  nurses  assumed a l e a d r o l e i n r e l a t i o n t o research-based  p r a c t i c e w i t h i n an o r g a n i z a t i o n . P a r t i c i p a n t s viewed  v a l i d and r e l i a b l e r e s e a r c h as a  u s e f u l s t r a t e g y f o r nurses i n ANP  t o prompt s t a f f nurses t o  examine t h e i r i n d i v i d u a l and o v e r a l l p r a c t i c e .  This f i n d i n g  concurs with t h a t of Nuccio and c o l l e a g u e s (1993), i n t h e i r study i n v o l v i n g s t a f f nurse p e r c e p t i o n s of the CNS convenience  sample c o n s i s t e d of 636 r e g i s t e r e d  role.  The  nurses  employed i n s t a f f p o s i t i o n s i n t h r e e campuses of a f f i l i a t e d medical c e n t r e s i n the U n i t e d S t a t e s .  two Staff  nurses b e l i e v e d t h a t research-based n u r s i n g p r a c t i c e  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.  S t a f f nurses r e p o r t e d a  need f o r CNSs t o be i n v o l v e d i n a l l aspects of the r e s e a r c h process.  144 CNS l i t e r a t u r e r e g u l a r l y i n c l u d e s r e s e a r c h as an important  s u b r o l e of ANP (eg. B e e c r o f t , 1992; L u s i s , 1995;  Montemuro, 1987; Sparacino, 1992).  Nurses i n ANP a r e o f t e n  seen as l e a d e r s i n t h e i d e n t i f i c a t i o n of r e s e a r c h q u e s t i o n s and the i n i t i a t i o n of s t u d i e s i n order t o advance n u r s i n g and i n t e r d i s c i p l i n a r y p r a c t i c e w i t h i n an agency (eg. F i t z p a t r i c k et a l , 1991).  However, t h e r e i s evidence t h a t CNSs spend  l e s s time on r e s e a r c h than on other n u r s i n g f u n c t i o n s a s s o c i a t e d with the r o l e 1995;  (eg. Davies & Eng, 1995; L u s i s ,  Williams & V a l d i v i e s o ,  1994).  P a r t i c i p a n t s of t h i s  study d i d not comment on the amount of time spent on r e s e a r c h but, as the d e t a i l e d c l i n i c a l  s t o r i e s r e f l e c t e d , they were i n  v a r i o u s stages of b e i n g a c t i v e l y i n v o l v e d i n conducting r e s e a r c h and a l l i d e n t i f i e d r e s e a r c h u t i l i z a t i o n i n t h e i r practice. P a r t i c i p a n t s r e c o g n i z e d t h e i r own l i m i t a t i o n s r e l a t e d t o r e s e a r c h and c l e a r l y v a l u e d p a r t n e r s h i p s with c o l l e a g u e s , i n t e r d i s c i p l i n a r y p r o f e s s i o n a l s and u n i v e r s i t y f a c u l t y f o r the conduct  of r e s e a r c h .  P a r t i c i p a n t s thought  that t r u l y  d e f i n i t i v e r e s e a r c h i n v o l v e d a p a r t n e r s h i p between nurses i n ANP and d o c t o r a l l y prepared nurses.  They b e l i e v e d t h a t t h e  d o c t o r a l l y prepared nurse should assume the p r i n c i p l e investigator  role.  The n u r s i n g l i t e r a t u r e supports t h i s f i n d i n g .  Some  authors hypothesize t h a t nurses i n ANP spend l i m i t e d time on r e s e a r c h due t o t h e i r graduate  education.  Some view a  145 master's  l e v e l r e s e a r c h course and the conduct of a t h e s i s as  p r e p a r i n g nurses t o be consumers of r e s e a r c h o n l y (eg. Collins,  1992), t o f u n c t i o n as a r e s e a r c h a s s o c i a t e (eg.  S t i n s o n , F i e l d & Thibaudeau,  1988), o r take "an a c t i v e  c o l l a b o r a t i v e r o l e i n such r e s e a r c h a c t i v i t i e s as data c o l l e c t i o n and a n a l y s i s "  (Sharp & Hart, 1987, p. 38).  these f a c t o r s , many support master's  Due t o  prepared nurses t o  p a r t n e r with d o c t o r a l l y prepared nurses i n order t o advance the s c i e n c e of n u r s i n g (eg. Arena & Page, 1992; C o l l i n s , 1992;  S t i n s o n , F i e l d & Thibaudeau,  1988).  Thus, p a r t i c i p a n t s thought t h a t ANP i s b u i l t on a minimal  requirement  foundation.  t r i a d with the elements  This foundation included a  of graduate education,  s p e c i a l t y focus and research-based  clinical  practice.  In summary, p a r t i c i p a n t s d i s c u s s e d important p o i n t s r e l a t e d t o e f f o r t s towards a d e f i n i t i o n of ANP. p a r t i c i p a n t s were not concerned c l a r i t y about ANP.  Overall,  about the g e n e r a l l a c k of  They v a l u e d aspects of ANP t h a t c o u l d be  developed due t o the broad and vague nature of i t .  Global  t h i n k i n g r e p r e s e n t s one e s s e n t i a l q u a l i t y of ANP t h a t  enables  nurses i n the r o l e t o be p r o a c t i v e i n t h e i r p r a c t i c e which can r e s u l t i n o v e r a l l improvements t o a l l l e v e l s of h e a l t h care.  P a r t i c i p a n t s b e l i e v e d t h a t - t h e r e are t h r e e minimum  requirements  of ANP.  These aspects of ANP are of a s s i s t a n c e  i n understanding the c o m p l e x i t i e s i n attempting t o develop a d e f i n i t i o n of ANP.  146 Graduate Education and Advanced Nursing A c c o r d i n g t o p a r t i c i p a n t s , graduate minimal  requirement  education was a  f o r ANP and p r o v i d e d a s t r o n g b a s i s f o r  many of the r e q u i r e d competencies. p a r t i c i p a n t s was whether graduate n u r s i n g o r i n another f a c u l t y .  A critical  concern f o r  education should be i n  While  r e c o g n i z i n g reasons why  some nurses i n ANP undertook, non-nursing p a r t i c i p a n t s with n u r s i n g graduate t h i s c o n t r i b u t e d p o s i t i v e l y t o ANP. n u r s i n g graduate  Practice  degrees,  education questioned i f P a r t i c i p a n t s with non-  education were a l s o s e n s i t i v e and somewhat  d e f e n s i v e about t h e i r p r e p a r a t i o n .  They questioned the  R e g i s t e r e d Nurses A s s o c i a t i o n of B r i t i s h Columbia support f o r n u r s i n g graduate  (1994)  education, r e l a t e d t o ANP, when  so many u n i v e r s i t y programs do not o f f e r an a s s o c i a t e d clinical  specialization.  T h i s d i v e r s i t y about graduate  education f o r n u r s i n g , and  f o r ANP, remains c o n t e n t i o u s amongst nurses.  As p a r t i c i p a n t s  i d e n t i f i e d and l i t e r a t u r e confirms, arguments c e n t r e around what education w i l l make the u l t i m a t e d i f f e r e n c e i n advancing and p e r f e c t i n g n u r s i n g knowledge, as w e l l as n u r s i n g p r a c t i c e , education and r e s e a r c h (eg. S t i n s o n , F i e l d & Thibaudeau, 1988). I t i s not s u r p r i s i n g t o f i n d t h a t some p a r t i c i p a n t s undertook non-nursing graduate  graduate  education.  Non-nursing  education was the norm u n t i l r e c e n t l y i n Canada  s i n c e t h e r e were very l i m i t e d o p p o r t u n i t i e s f o r graduate  147 education  i n nursing  Thibaudeau, 1988).  (Kerr, 1991; According  Stinson, F i e l d &  to Kerr  (1991), many nurses  w i s h i n g to undertake non-nursing graduate education, due  d i d so  to a l a c k o f : a v a i l a b l e programs, r e s p e c t f o r n u r s i n g  programs, and q u a l i f i e d f a c u l t y to teach these programs. 1985,  the m a j o r i t y of nurses who  By  h e l d master's degrees  obtained non-nursing degrees although  the p r e c i s e breakdown  i s not a v a i l a b l e ( S t i n s o n , F i e l d & Thibaudeau, 1988). P a r t i c i p a n t s with non-nursing graduate b e l i e v e d they were making v a l u a b l e and c o n t r i b u t i o n s t o ANP, studies.  have served a purpose at one  study,  significant  d e s p i t e the focus of t h e i r graduate  Although graduate education  problems now  education  i n other f a c u l t i e s  may  time, i t i s c r e a t i n g some  f o r nurses i n ANP.  For example, d u r i n g  p a r t i c i p a n t s with non-nursing graduate  this  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 r e l a t e d t o a d d r e s s i n g the phenomena of i n t e r e s t was educational preparation.  due  However, from the  to t h e i r researcher's  p e r s p e c t i v e , there were no n o t i c e a b l e d i f f e r e n c e s i n p a r t i c i p a n t accounts t h a t c o u l d be e x p l a i n e d the f a c u l t y of t h e i r graduate e d u c a t i o n a l  preparation.  Despite many n u r s i n g authors graduate education how  "best guess" t h a t  i s r e q u i r e d f o r ANP,  nursing  what i s not c l e a r i s  t h i s p r e p a r a t i o n c l e a r l y impacts p r a c t i c e and CHO.  not known f o r example, i f nurses are convinced education  i n n u r s i n g i s mandatory f o r ANP  It i s  t h a t graduate  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 c o l l a b o r a t i o n .  I t i s a l s o not c l e a r  what d i f f e r e n c e s there are i n the a c t i v i t i e s and outcomes of nurses i n ANP d e s p i t e the f a c u l t y of t h e i r graduate s t u d i e s . At the present although  time, n u r s i n g p r o f e s s i o n a l bodies,  f o r m a l l y r e c o g n i z i n g why some nurses i n ANP  p r e v i o u s l y undertook non-nursing graduate education, a r e making i t c l e a r t h a t the p r e f e r r e d education master's degree i n n u r s i n g Specialist  f o r ANP i s a  (eg. Canadian C l i n i c a l Nurse  I n t e r e s t Group, 1994; R e g i s t e r e d Nurses  A s s o c i a t i o n of B r i t i s h Columbia, 1994).  T h i s i n f o r m a t i o n can  e x p l a i n t h e s e n s i t i v i t y and defensiveness with non-nursing graduate education t h e i r p r e p a r a t i o n f o r ANP.  that p a r t i c i p a n t s  are e x p e r i e n c i n g about  I t a l s o e x p l a i n s the support  p a r t i c i p a n t s with n u r s i n g graduate education  that  have f o r t h i s  s p e c i f i c p r e p a r a t i o n b e i n g a minimum requirement f o r ANP. P a r t i c i p a n t s who had n u r s i n g graduate education t h i s as c r i t i c a l l y important  i n order t o advance the s c i e n c e  of n u r s i n g , and more s p e c i f i c a l l y ANP. graduate education  viewed  Indeed, n u r s i n g  i s o f t e n d e p i c t e d i n the l i t e r a t u r e as  b e i n g mandatory f o r 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 I n t e r e s t Group, 1994; Hunsberger e t a l , 1992; U n i t e d and Human S e r v i c e s , 1990). support  States Department of Health  Given t h i s knowledge, the s t r o n g  t h a t these p a r t i c i p a n t s had f o r n u r s i n g graduate  education  r e l a t e d t o ANP i s made more e v i d e n t .  A l l p a r t i c i p a n t s r e c o g n i z e d the b e n e f i t s of a s t r o n g  149 mentored c l i n i c a l  s p e c i a l t y focus d u r i n g graduate  d e s p i t e the f a c u l t y .  education,  A number of authors have s p e c i f i c a l l y  r e i n f o r c e d t h e need f o r indepth mentored,  clinical  experiences by way of practicums d u r i n g graduate  education i n  order t o develop competencies r e q u i r e d f o r ANP (eg. Arena & Page, 1992; Bass, Rabbett Hamric & T a y l o r , 1989). clinical  & S i s k i n d , 1993; Forbes, 1994; A l l p a r t i c i p a n t s of t h i s study were  experts p r i o r t o graduate  i n t h e i r ANP r o l e s .  education and experienced  In a d d i t i o n , a l l p a r t i c i p a n t s had  o b v i o u s l y made s i g n i f i c a n t e f f o r t s t o be informed about ANP as evidenced by t h e i r indepth knowledge, c i t e d prompting,  without  r e l a t e d t o n u r s i n g s c h o l a r s who had w r i t t e n  e x t e n s i v e l y about ANP. There i s no d e s c r i p t i o n i n the l i t e r a t u r e as t o how a mentored, c l i n i c a l  s p e c i a l t y focus can be i n c l u d e d i n non-  n u r s i n g graduate  education.  n u r s i n g graduate  education took the i n i t i a t i v e  graduate  The two p a r t i c i p a n t s with nonduring  s t u d i e s t o ensure a mentored, c l i n i c a l  focus, d e s p i t e the f a c u l t y of t h e i r s t u d i e s .  specialty  I t i s the  r e s e a r c h e r ' s o p i n i o n t h a t t h i s approach may not be r e f l e c t i v e of  the m a j o r i t y of nurses undertaking non-nursing  graduate  education. At t h e same time, p a r t i c i p a n t s with non-nursing  graduate  education questioned the i n c r e a s e d support f o r n u r s i n g graduate did  education r e l a t e d t o ANP, when many n u r s i n g programs  not c o n t a i n a c l i n i c a l  s p e c i a l i z a t i o n f o c u s . They  thought  150 t h i s represented one education was  j u s t i f i c a t i o n t h a t non-nursing  s t i l l very a p p r o p r i a t e f o r ANP,  graduate  particularly in  an era of i n t e r d i s c i p l i n a r y c o l l a b o r a t i v e p r a c t i c e . P a r t i c i p a n t s r e c o g n i z e d the importance of a s t r o n g background of the nurse p r i o r t o graduate  clinical  studies.  These  p a r t i c i p a n t s b e l i e v e d t h a t a c r e a t i v e and motivated expert can maximize the b e n e f i t s of non-nursing education through  clinical  graduate  s t r o n g l i n k a g e s with n u r s i n g f a c u l t y .  These f i n d i n g s were r e i n f o r c e d 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 requirements  f o r graduate  specialization  n u r s i n g programs i n Canada (eg.  Synder, 1989), as w e l l as i n t e r n a t i o n a l l y Although  a specialized c l i n i c a l  (eg. Starck, 1987).  focus f o r ANP  i s a v a i l a b l e at  some u n i v e r s i t i e s , others o f f e r a focus on a d m i n i s t r a t i o n or education i n n u r s i n g programs. entrance requirements experiences.  Programs a l s o d i f f e r i n  and course work r e l a t e d t o  clinical  Some programs r e q u i r e t h a t the student have a  d e f i n e d number of years of c l i n i c a l p r a c t i c e i n a s p e c i a l t y area w h i l e others do not r e q u i r e c l i n i c a l 1989).  Programs t h a t do o f f e r c l i n i c a l  experience  specialization also  d i f f e r i n the amount and e f f e c t i v e n e s s of mentored practice that i s available  (Anderson,  l a c k of mentored c l i n i c a l p r a c t i c e was Eng  (1995).  In t h e i r survey,  (Synder,  1994;  Forbes,  clinical 1994).  r e p o r t e d by Davies  and  38 CNSs completed a s e l f  a d m i n i s t e r e d q u e s t i o n n a i r e r e l a t e d to r o l e implementation v a r i o u s h e a l t h care agencies  A  i n the Lower Mainland,  B.C.  in  151 P a r t i c i p a n t s of t h e i r study suggested the s t r o n g v a l u e of mentoring,  p a r t i c u l a r l y f o r novice CNSs, however few CNSs  r e p o r t e d having had the o p p o r t u n i t y f o r t h i s T h i s may  be a r e f l e c t i o n of the number of CNSs a v a i l a b l e f o r  the purposes  of mentoring  and not an i n d i c a t i o n of the  i n t e r e s t of experienced CNSs i n t h i s T h i s i n f o r m a t i o n e x p l a i n s why n u r s i n g graduate graduate  experience.  activity.  p a r t i c i p a n t s with  non-  education questioned the focus on n u r s i n g  education as mandatory f o r ANP.  n u r s i n g graduate  They q u e s t i o n e d  education b e i n g so s t r o n g l y advocated  mandatory f o r ANP  given the i n c o n s i s t e n c i e s of  as  graduate  p r e p a r a t i o n of nurses. Thus, although p a r t i c i p a n t s agreed t h a t education was  a requirement  f o r ANP,  graduate  they had  concerns  r e l a t e d t o whether or not t h i s education should be i n nursing.  Those p a r t i c i p a n t s with n u r s i n g graduate  b e l i e v e d i t was and ANP.  critical  education  i n order t o advance n u r s i n g s c i e n c e  P a r t i c i p a n t s with non-nursing  graduate  questioned the support f o r n u r s i n g graduate  education  education when so  many i n c o n s i s t e n c i e s and a l a c k of a c l i n i c a l  speciality  focus e x i s t e d i n n u r s i n g programs i n Canada.  However, what  i s not c l e a r i s how  v a r y i n g graduate  education i n f l u e n c e s the  p r a c t i c e and outcomes of nurses i n ANP  p a r t i c u l a r l y w i t h i n an  i n t e r d i s c i p l i n a r y c o l l a b o r a t i v e care environment. Advanced Nursing P r a c t i c e and As nurses i n ANP,  Interdisciplinary Collaboration  p a r t i c i p a n t s 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 c o l l a b o r a t i v e p r a c t i c e (ICP) encouraged c l i e n t involvement. nurses i n ANP nurses,  were more c o n f i d e n t about ICP than were s t a f f  and t h e r e f o r e promoted i t s b e n e f i t s .  determine any was  one  embraced ICP,  According  one  d i s c i p l i n e on CHO Thomas, 1991;  Findings  Recognition  r e l a t e d t o t r y i n g to i s o l a t e  the  p r o v i d e r , or the p r o v i d e r s of any  i s a theme i n the l i t e r a t u r e  Hamric, 1983;  1992;  one  (eg. Bond St  Higgins, McCaughan, G r i f f i t h s &  Hoeman, 1995;  Pike et a l , 1993).  from t h i s study about ANP  ICP warrant f u r t h e r c o n s i d e r a t i o n .  w i t h i n the context  w i t h i n the context  d e c i s i o n makers and  of ICP.  Buckley, 1992; Hall,  on  Government h e a l t h p o l i c y  authors are t o u t i n g ICP as a p o t e n t i a l  answer t o c u r r e n t gaps and w e l l as to r e d u c i n g  of  Limited l i t e r a t u r e i s  a v a i l a b l e t h a t c l e a r l y demonstrates the i n f l u e n c e of ANP CHO  to  h e a l t h care p r o v i d e r ' s d i r e c t i n f l u e n c e on  of the c o m p l e x i t i e s i n f l u e n c e of any  to  the a b i l i t y  c h a l l e n g i n g , and perhaps not p o s s i b l e .  Carr-Hill,  actively  P a r t i c i p a n t s thought t h a t  p a r t i c i p a n t s , when nurses i n ANP  CHO  that  fragmentation  c o s t s of care  Seaton, 1991;  i n h e a l t h care,  (eg. Hastings,  Sebas, 1994;  as  O'Keefe &  V e l i a n o f f , Neely &  1993). L i t e r a t u r e r e l a t e d to ICP has  physician-nurse e a r l y as 1967 focused Fagin,  o f t e n focused  i n t e r a c t i o n s or what was  as the  "doctor-nurse  game."  on improving n u r s e - p h y s i c i a n 1992;  K i r c h n o f f , 1987;  on  coined by S t e i n as L i t e r a t u r e has  r e l a t i o n s h i p s (eg.  P r e s c o t t & Bowen, 1985;  Sebas,  153 1994), and has maintained t h a t c o l l a b o r a t i o n i s e s s e n t i a l f o r c l i e n t care (eg. Michelson,  1988), and does l e a d t o 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 t o r e f l e c t the d i f f i c u l t y t h a t nurses and p h y s i c i a n s have i n a c h i e v i n g t r u e c o l l a b o r a t i o n (eg. Wandel, 1991).  R e l a t i o n s with other h e a l t h care  p r o v i d e r s are l e s s f r e q u e n t l y mentioned i n the l i t e r a t u r e and are u s u a l l y 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 t o care of s p e c i f i c p o p u l a t i o n s of c l i e n t s . A r t i c l e s a r e appearing t h a t d e s c r i b e the b e n e f i t s of p h y s i c i a n s working i n c o l l a b o r a t i v e r e l a t i o n s h i p s with  nurses  i n ANP (eg. Mundinger, 1994), however, l i t e r a t u r e r e l a t e d t o CNS/physician Sparacino  c o l l a b o r a t i o n i s minimal.  (1994),  According to  some p h y s i c i a n s continue t o view ANP as a  t r u e encroachment on the p r a c t i c e of medicine.  Participants  of t h i s study r e c o g n i z e d the m e r i t s of a l l h e a l t h care p r o v i d e r s and d i d not i s o l a t e out p h y s i c i a n s i n t h e i r d i s c u s s i o n s of ICP.  In a d d i t i o n , they d i s c u s s e d p o s i t i v e  r e l a t i o n s h i p s with a l l h e a l t h care p r o v i d e r s and d i d not refer to d i f f i c u l t i e s  i n achieving collaboration.  P a r t i c i p a n t s h i g h l y v a l u e d and promoted ICP.  They were  c o n f i d e n t i n t h e i r own competencies and t h e r e f o r e f e l t on equal f o o t i n g with a l l members of the h e a l t h care team. P a r t i c i p a n t s saw nurses i n ANP as " p a r t n e r s " with other h e a l t h care p r o v i d e r s .  Yet, p a r t i c i p a n t s a l s o r e c o g n i z e d  t h a t n u r s i n g o f f e r e d unique p e r s p e c t i v e s t o c l i e n t  care.  154 P a r t i c i p a n t s 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  as a p r i o r i t y f o r t h e i r p r a c t i c e .  They were c l e a r about when  t o i n v o l v e other d i s c i p l i n e s i n c l i e n t care and who consult.  care  to  P a r t i c i p a n t s r e c o g n i z e d they had c r e d i b i l i t y with  other h e a l t h care p r o v i d e r s .  They a t t r i b u t e d t h i s t o : t h e i r  broad u n i v e r s i t y education, knowledge of other d i s c i p l i n e s ' competencies,  demonstrated and r e c o g n i z e d c l i n i c a l e x p e r t i s e ,  w e l l - d e v e l o p e d a b i l i t i e s t o a r t i c u l a t e and t h e i r r o l e w i t h i n the o r g a n i z a t i o n . L i t e r a t u r e r e f l e c t s the s t r o n g emphasis t h a t nurses i n ANP  p l a c e on ICP and some see i t as an i n t e g r a l p a r t of  (eg. Hawkins & Thibodeau,  1989;  Nugent, 1992;  Spross,  The n o t i o n of p a r t n e r s h i p s between nurses i n ANP  and  ANP  1989). other  h e a l t h care p r o v i d e r s i s viewed as e n s u r i n g s u c c e s s f u l ICP (eg. Fenton, nurses i n ANP  1995).  According to Arslanian-Engoren  (1995),  are prepared by experience, education and  role  i n t e r p r e t a t i o n t o advance ICP and w i l l enact very c r e a t i v e s t r a t e g i e s t o 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 s t r o n g i n f l u e n c e of graduate  university  education i n terms of nurses  i n ANP  level  b e i n g 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 p h y s i c i a n s (eg. Alcock, Arslanian-Engoren,  1995).  1995;  I t i s understandable, t h e r e f o r e ,  t h a t p a r t i c i p a n t s h i g h l y v a l u e d ICP and f e l t they had t o be a c t i v e , c o n t r i b u t o r y members and promoters of i t . P a r t i c i p a n t s viewed nurses i n ANP  as i n t e r a c t i n g more  f r e q u e n t l y , d i r e c t l y , a p p r o p r i a t e l y and c o l l a b o r a t i v e l y w i t h  155 i n t e r d i s c i p l i n a r y h e a l t h care p r o v i d e r s than d i d s t a f f nurses.  They saw s t a f f nurses as h e s i t a n t and l a c k i n g  confidence  about ICP.  T h i s view concurs with t h a t of Wise  (1995) who r e c o g n i z e d t h a t s t a f f nurses l a c k confidence i n t h e i r n u r s i n g knowledge base d e s p i t e t h e i r assessments of c l i e n t needs.  P a r t i c i p a n t s of t h i s study b e l i e v e d a  c o n t r i b u t i n g f a c t o r t o t h i s was t h a t many s t a f f nurses were educated i n n o n - u n i v e r s i t y s e t t i n g s . nurses'  This l i m i t e d  staff  knowledge about t h e b e n e f i t s of ICP.  S t a f f nurse subservience  with r e s p e c t t o ICP i s noted i n  the l i t e r a t u r e and c o n s i d e r e d t o be t h e r e s u l t of b a s i c n u r s i n g c u r r i c u l a encouraging t h i s approach (eg. 1995).  Larson,  Another noted t r e n d i s t h a t s t a f f nurses o f t e n d e f e r  c l i n i c a l d e c i s i o n s t o other d i s c i p l i n e s and as a r e s u l t t h a t t h e i r knowledge i s l e s s important disciplines  (eg. Wise, 1995).  than t h a t of other  Therefore,  i t appears t h a t  s t a f f nurse h e s i t a n c y and l a c k of confidence i s common p r a c t i c e .  imply  r e l a t e d t o ICP  P a r t i c i p a n t s saw a key r o l e f o r nurses  i n ANP as t h a t of a s s i s t i n g s t a f f nurses t o i n c r e a s e  their  competencies about t h e b e n e f i t s of ICP and t o r e c o g n i z e own l i m i t s i n regard t o c l i e n t  their  care.  For p a r t i c i p a n t s , the d e s c r i p t i o n of t h e i r p r a c t i c e i n r e l a t i o n t o CHO proved t o be p r o b l e m a t i c . complexities  T h i s was due t o  i n h e r e n t i n t h e i r r o l e , such as b e i n g  assistive  t o o t h e r s , as w e l l as b e i n g a c t i v e members of ICP. Therefore,  a c c o r d i n g t o p a r t i c i p a n t s , nurses i n ANP have an  156 important but  i n d i r e c t i n f l u e n c e on CHO.  nurses i n ANP  as  "the conduit"  P a r t i c i p a n t s viewed  i n t h a t many CHO  them" r a t h e r than "from them" d i r e c t l y . measuring CHO B.C.  was  a r e l a t i v e l y new  f u r t h e r complicated  linkage e x p l i c i t .  The  The  came "through  fact  that  emphasis i n h e a l t h care i n  p a r t i c i p a n t s ' attempts to make t h i s  t r e n d demonstrated by p a r t i c i p a n t s 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  is  supported i n a study by Schaefer and  Findings  Lucke (1990).  from t h a t study i n d i c a t e d t h a t CNSs c o n s i s t e n t l y r e p o r t they p e r c e i v e independent of  t h e i r work as p a r t of a team and  not  that  occurring  others.  P a r t i c i p a n t s e a s i l y a r t i c u l a t e d the s t r o n g emphasis i n t h e i r p r a c t i c e r e l a t e d t o c l i e n t involvement i n t h e i r care. focus  P a r t i c i p a n t s worked with others of care.  The  value  and  own  to ensure a c l i e n t  support t h a t nurses i n  p l a c e on c l i e n t d i r e c t e d care i s evident For example, i n her d i s c u s s i o n o f ' t h e CNS  i n the  ANP  literature.  as case manager i n  a c o l l a b o r a t i v e p r a c t i c e model, Nugent (1992) t h i n k s t h a t a CNS  i s best  s u i t e d to assume the case manager r o l e on  i n t e r d i s c i p l i n a r y c o l l a b o r a t i v e team. CNS  has  Nugent t h i n k s t h a t  Others d i s c u s s how  CHO  should  i n d i v i d u a l patient's' needs and wishes" 1498).  Therefore,  focal  be viewed i n l i g h t  p r o f e s s i o n a l a c t i o n s but a l s o "viewed i n the  p.  the  the competencies r e q u i r e d t h a t ensure a t r u l y  c o l l a b o r a t i v e p r a c t i c e t h a t keeps the c l i e n t as the point.  an  light  of  of  (Bond & Thomas,  the f i n d i n g s r e l a t e d to nurses i n  1991, ANP  157 promoting  c l i e n t s being a c t i v e l y i n v o l v e d i n t h e i r own care  are c o n s i s t e n t with the t h e o r e t i c a l d e s c r i p t i o n s of i t i n the literature. P a r t i c i p a n t s r e c o g n i z e d the s i g n i f i c a n c e of b e i n g a b l e 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 f o r t h e i r r o l e s .  Despite a l l  of the i n f l u e n c i n g v a r i a b l e s , p a r t i c i p a n t s r e c o g n i z e d t h a t f o r many reasons  i t would be advantageous t o be a b l e t o  q u a n t i t a t i v e l y measure the i n f l u e n c e of nurses i n ANP on CHO. The ANP l i t e r a t u r e continues t o s t r e s s the importance of outcomes i n r e l a t i o n t o ANP (eg. H a r r i s & Warren, 1995; Sparacino, 1995; Spross, 1995; Waltz & S y l v i a , & Valdivieso,  1994).  1991; W i l l i a m s  However, methodology t o make the l i n k  between ANP and CHO i s not w e l l developed.  Waltz and S y l v i a  (1991) word these c h a l l e n g e s most a c c u r a t e l y when they say "much remains t o be accomplished still  with the thorny i s s u e s t h a t  c h a l l e n g e those who seek t o measure n u r s i n g outcomes"  (p. 202). P a r t i c i p a n t s thought  t h a t a t o o l t h a t c o u l d measure an  a s s o c i a t i o n between ANP and CHO would be u s e f u l but a r e a l c h a l l e n g e t o develop.  L i t e r a t u r e r e f l e c t s the need f o r  r e s e a r c h r e l a t e d t o the development of t o o l s t o measure CNS outcomes (eg. H a r r i s & Warren, 1995) i n order t o s u b s t a n t i a t e c r e d i b i l i t y and worth of p r o v i d e r s (eg. Moore, 1995; Waltz & Sylvia,  1991).  How t o do so remains u n c l e a r .  Munro (1993) asks  For example,  "what [outcome] measures should we use?  C e r t a i n l y , i f we c o u l d agree on some, we would be a b l e t o  158 compare and c o n t r a s t r e s u l t s across Therefore, being  studies"  i t appears t h a t the c h a l l e n g e s  (p.  246).  associated  with  able t o q u a n t i f y measures of the i n f l u e n c e of ANP on  CHO present  common problems.  Using d e t a i l e d c l i n i c a l  s t o r i e s , p a r t i c i p a n t s described  how they p o s i t i v e l y i n f l u e n c e d CHO as w e l l as s t a f f and o r g a n i z a t i o n a l outcomes w i t h i n an ICP environment. abilities  Their  t o be v i s i o n a r y and p r o a c t i v e about c l i e n t  care  were viewed as p o s i t i v e i n f l u e n c e s on o v e r a l l CHO. L i t e r a t u r e o c c a s i o n a l l y r e f l e c t s the need f o r nurses i n ANP t o d e s c r i b e t h e i r p r a c t i c e through t h e use of c l i n i c a l examples (eg. Mantle, 1993; Mason e t 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).  T h e i r d i s c u s s i o n i n d i c a t e s t h a t nurses i n ANP  d e s c r i b i n g t h e i r p r a c t i c e i n r e l a t i o n t o CHO through the use of d e t a i l e d c l i n i c a l t h i s process,  s t o r i e s might be very u s e f u l .  Through  nurses i n ANP may be able t o more c l e a r l y  a r t i c u l a t e which CHO they a r e i n a key p o s i t i o n t o i n f l u e n c e . Thus, nurses i n ANP h i g h l y value  and s t r o n g l y promote  ICP t h a t i n c l u d e s an emphasis on a c t i v e c l i e n t involvement i n t h e i r own care.  Given t h i s approach t o care, methodology t o  make e x p l i c i t the i n f l u e n c e of ANP on CHO i s d i f f i c u l t . Nurses i n ANP are o f t e n t h e " l i n k a g e " between s t a f f and  other  h e a l t h care p r o v i d e r s  use  of d e t a i l e d c l i n i c a l  nurses  i n order t o enhance CHO.  The  s t o r i e s , although perhaps not  p r o v i d i n g a q u a n t i f i a b l e i n f l u e n c e of ANP on CHO, may be t h e  159 avenue f o r these nurses to a c c u r a t e l y d e s c r i b e t h e i r p r a c t i c e w i t h i n an  ICP  environment. Chapter Summary  In t h i s chapter, discussed  the f i n d i n g s of t h i s r e s e a r c h  i n r e l a t i o n to the f i n d i n g s of other  and views of n u r s i n g authors.  The  were  researchers  d i s c u s s i o n was  presented  from t h r e e areas which r e l a t e to major f i n d i n g s from chapter f o u r t h a t c o n t r i b u t e t o the knowledge base of ANP. f i n d i n g s are of a s s i s t a n c e understand ANP ANP,  and  These  i n e f f o r t s t o more c l e a r l y  i n c l u d e : i s s u e s r e l a t e d to a d e f i n i t i o n  graduate education  and ANP,  and ANP  of  and  interdisciplinary collaboration. P a r t i c i p a n t s of t h i s study were not able to a r t i c u l a t e a c l e a r and  c o n c i s e d e f i n i t i o n of ANP.  c o n s i s t e n t with t h a t found i n the valued  ANP  being a broad and  This f i n d i n g i s  literature.  Participants  vague term and b e l i e v e d  the  u n l i m i t e d f l e x i b i l i t y a s s o c i a t e d with i t allowed nurses i n ANP  to adapt to ever-changing needs i n h e r e n t  reform.  i n health  P a r t i c i p a n t s b e l i e v e d they understood t h e i r  own  p r a c t i c e w e l l and were not concerned about the general of c l a r i t y about ANP.  P a r t i c i p a n t s cautioned  i n e f f o r t s to more c l e a r l y d e f i n e ANP. r e f l e c t e d i n the l i t e r a t u r e but may autonomy and  the  lack  researcher  T h i s f i n d i n g i s not  be e x p l a i n e d  senior nursing administrative  by  current  support enjoyed  participants. P a r t i c i p a n t s viewed g l o b a l t h i n k i n g as an e s s e n t i a l  by  160 q u a l i t y of ANP.  Although n u r s i n g authors d i s c u s s s i 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 a r e p r o a c t i v e i n t h e i r p r a c t i c e w i t h i n the competency of g l o b a l  thinking.  P a r t i c i p a n t s a l s o i d e n t i f i e d some minimal of  requirements  ANP t h a t were c o n c e p t u a l i z e d 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 practice. elements  s p e c i a l t y focus and research-based  In the l i t e r a t u r e , the combining  of these t h r e e  a r e 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 b a s e l i n e or  f o u n d a t i o n but i n d i v i d u a l l y have been d i s c u s s e d a t l e n g t h . The need f o r graduate education as a c r i t i c a l requirement f o r ANP was d e s c r i b e d by a l l p a r t i c i p a n t s .  What  i s not c l e a r from p a r t i c i p a n t accounts and from the l i t e r a t u r e i s how graduate education from v a r i o u s f a c u l t i e s i n f l u e n c e s the process and outcomes r e l a t e d t o ANP. P a r t i c i p a n t s r a i s e d many q u e s t i o n s about the i n f l u e n c e of  ANP on CHO w i t h i n an ICP environment.  Participants  highly  v a l u e d and promoted ICP t h a t i n c l u d e d c l i e n t s having a c t i v e involvement i n t h e i r own c a r e . p a r t i c i p a n t s approached  Since t h i s was how  t h e i r p r a c t i c e , they viewed  isolating  out the i n f l u e n c e of ANP on CHO as b e i n g p r o b l e m a t i c .  This  f i n d i n g was supported i n the l i t e r a t u r e by the m u l t i t u d e of f a c t o r s t h a t i n f l u e n c e CHO w i t h i n an ICP environment. Although p a r t i c i p a n t s saw t h e i r r o l e as working with  staff  nurses and other h e a l t h care p r o v i d e r s t o enhance CHO, they  161 were a b l e t o d e s c r i b e d e t a i l e d c l i n i c a l  stories that  i l l u s t r a t e d how they d i d so. -These c l i n i c a l b e l i e v e d by some n u r s i n g authors nurses  s t o r i e s are  t o be a u s e f u l s t r a t e g y f o r  i n ANP t o be able t o a r t i c u l a t e which CHO they can  i n f l u e n c e w i t h i n an ICP environment. In t h i s chapter, were presented.  a d i s c u s s i o n of the r e s e a r c h f i n d i n g s  In the next chapter,  the summary,  c o n c l u s i o n s and i m p l i c a t i o n s f o r n u r s i n g graduate  education,  p o l i c y and a d m i n i s t r a t i o n as w e l l as r e s e a r c h are presented.  i  162 CHAPTER  SIX  SUMMARY, CONCLUSIONS and  IMPLICATIONS  Summary This  study was  CNSs d e f i n e CHO.  The  ANP  CNS  and  designed t o g a i n an understanding of describe  n u r s i n g l i t e r a t u r e and ANP  enacted.  nurses i n ANP  d i r e c t linkage  i s not  The  has  practising been u t i l i z e d  f o r many y e a r s .  c l e a r l y defined  in  However,  nor  Although l i t e r a t u r e e x i s t s encouraging  methodology to do between ANP  and  to the broad, g l o b a l and  assume w i t h i n  term ANP  to be a b l e to d e s c r i b e  p r a c t i c e on CHO,  due  The  discussions  remains a term t h a t  consistently  t h e i r p r a c t i c e i n r e l a t i o n to  p a r t i c i p a n t s were r e c o g n i z e d as  under the umbrella of ANP.  how  CHO  the  impact of t h e i r  so i s not  clear.  Any  i s d i f f i c u l t to measure  a s s i s t i v e r o l e t h a t these nurses  an i n t e r d i s c i p l i n a r y c o l l a b o r a t i v e  e f f o r t s of n u r s i n g s c h o l a r s  environment.  to date have r e f l e c t e d a  genuine urgency i n being a b l e to a t t a i n f u r t h e r 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 e x i s t s t h a t r e l a t e s to the phenomena of i n t e r e s t , minimal research-based l i t e r a t u r e i s a v a i l a b l e . f o r c l a r i t y about ANP,  characteristics, attributes  L i t e r a t u r e r e l a t e d to ANP  r e f l e c t s the  push  l i t e r a t u r e r e f l e c t s attempts at  definitions, descriptions, subroles.  In the  and  i t s influence  and on  CHO  e a r l y stages of nurses' attempts t o l i n k t h e i r  p r a c t i c e t o outcomes of c a r e .  This  approach i s  complicated by an era of ICP.  Nurses and  further  other h e a l t h  care  163 p r o v i d e r s are q u e s t i o n i n g how to  any  CHO  can be d i r e c t l y l i n k e d  a s p e c i f i c p r o v i d e r and/or d i s c i p l i n e .  l i t e r a t u r e a s k i n g nurses i n ANP r e l a t i o n to CHO The  was  research-based  to d e f i n e and d e s c r i b e ANP  found.  used f o r t h i s study.  T h i s method  p a r t i c u l a r l y s u i t e d to the q u e s t i o n  was  s i n c e there have not been  s t u d i e s of the phenomena of i n t e r e s t  (Brink & Wood,  1989), p a r t i c u l a r l y from a Canadian p e r s p e c t i v e .  The  r e s e a r c h e r wanted to understand the d e f i n i t i o n of ANP r e l a t i o n s h i p of ANP ANP,  in  e x p l o r a t o r y d e s c r i p t i v e method of q u a l i t a t i v e  r e s e a r c h was  indepth  No  on CHO  w i t h i n the B.C.  and  the  from the p e r s p e c t i v e s of nurses i n  h e a l t h care environment.  A  purposive  sample of Vancouver I s l a n d CNSs, employed i n a l a r g e h o s p i t a l s o c i e t y , was  chosen t o p a r t i c i p a t e i n t h i s study.  p a r t i c i p a n t s who  All  were approached f o r i n c l u s i o n consented to  participate. Seven p a r t i c i p a n t s of t h i s study, who eligibility criteria, interviews. one  participated in  met  semi-structured  A l l of the i n t e r v i e w s , which were two  hour s e s s i o n s with each p a r t i c i p a n t , were  recorded  specific  and  subsequently  t r a n s c r i b e d verbatim.  to t h r e e  audio-tape Data  a n a l y s i s o c c u r r e d c o n c u r r e n t l y with data c o l l e c t i o n . q u a l i t a t i v e thematic techniques (1990).  a n a l y s i s was  done based on  analytical  and procedures i d e n t i f i e d by Strauss and  F i n d i n g s were c l a r i f i e d ,  This  Corbin  e l a b o r a t e d upon and/or  v a l i d a t e d with p a r t i c i p a n t s to ensure accuracy,  as w e l l as  164 adding t o the depth and r i c h n e s s of the data. There was  not an a v a i l a b l e s p e c i f i c t h e o r y t h a t c o u l d be  l i n k e d with the phenomena of i n t e r e s t and u t i l i z e d as a guide.  The work of n u r s i n g s c h o l a r s such as Fenton  Benner (1984) and C a l k i n  (1984), p r o v i d e d some conceptual  background f o r t h i s study.  A l l p a r t i c i p a n t s were very  f a m i l i a r with, and c i t e d without prompting, nurses.  the work of these  F i n d i n g s of t h i s study were presented a c c o r d i n g t o  t h r e e broad c a t e g o r i e s t h a t r e s u l t e d from thematic The  analysis.  f i r s t broad category r e l a t e d t o d i f f i c u l t i e s i n  c l e a r l y d e f i n i n g ANP.  T h i s category of data c o n s i s t e d of  components: i n i t i a l attempts l a c k of c l a r i t y about i t .  at d e f i n i n g ANP  not a t a l l concerned p e r s o n a l l y understood  two  and reasons f o r  While p a r t i c i p a n t s were not able  to p r o v i d e a c l e a r and c o n c i s e d e f i n i t i o n of ANP,  they were  about t h i s and b e l i e v e d t h a t they how  t h e i r p r a c t i c e was  They p e r c e i v e d the apparent  t h a t of  l a c k of c l a r i t y about ANP  advantageous i n t h a t i t allowed f o r the continued t h a t was  (1985),  r e q u i r e d f o r ANP.  ANP. as  flexibility  They o f f e r e d s e v e r a l reasons  e x p l a i n the c u r r e n t vagueness a s s o c i a t e d with ANP  to  such as  role inconsistencies, imprecision regarding nursing, terminology changes and  l a c k of time f o r r e f l e c t i o n about  practice i n general. The ANP.  second broad category r e l a t e d t o the d e s c r i p t o r s of  T h i s category c o n s i s t e d of two  requirement  t r i a d of ANP  components:  minimal  and e s s e n t i a l q u a l i t i e s of  ANP.  165 Participants  believed  that  t h e r e were t h r e e minimal  requirements t h a t were combined to p r o v i d e the ANP:  graduate education, c l i n i c a l  research-based p r a c t i c e .  s p e c i a l t y focus  Participants  e s s e n t i a l q u a l i t i e s present i n ANP: clinical and  global  thinking,  effective  r e l a t i o n s h i p between ANP  a r t i c u l a t i n g CHO,  leadership  CHO,  and  communicating the  This  r e l a t i o n s h i p between  r e c o g n i z e d t h a t measuring CHO  area of focus f o r h e a l t h  p e r s p e c t i v e s and a c t i v e manner. CHO  through the  CHO.  the t h e o r e t i c a l problems i n l i n k i n g ANP  Participants  influenced  and  often  d i d not  was  was  Participants  of ANP  an  that  nurses i n  ANP  stories.  best  Such s t o r i e s  the  the  a l s o i d e n t i f i e d t h e o r e t i c a l problems i n  r e l a t i o n s h i p that  and  explained  u s i n g a broad system p e r s p e c t i v e .  attempting to l i n k ANP  differences  They  client in  i n d i r e c t manner t h a t was  of d e t a i l e d c l i n i c a l  fairly  the  p r o v i d e d d e t a i l e d 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 application  a  understood from many  involve  believed  ANP  with  care p r o v i d e r s i n B.C.  term CHO  Participants i n an  use  ideas  of t h r e e components: problems i n  a l s o r e c o g n i z e d t h a t the  CHO,  indirect  t h i r d broad category r e l a t e d t o p a r t i c i p a n t s '  category c o n s i s t e d  new  and  also i d e n t i f i e d f i v e  focus, a s s i s t i v e care d e l i v e r y ,  about a p o s s i b l e  CHO.  for  interdisciplinary collaboration. The  and  foundation  with CHO,  nurses i n ANP  such as the had  indirect  with c l i e n t s , the  i n t r y i n g to measure s h o r t term versus l o n g term strong influence  of other v a r i a b l e s .  In  166 particular,  participants  d i r e c t l y linked  wondered how any CHO c o u l d be  t o any d i s c i p l i n e ,  l e t alone a s p e c i f i c  p r o v i d e r , i n the c u r r e n t e r a of i n t e r d i s c i p l i n a r y collaboration.  Participants  t h a t they had more d i r e c t  v a l u e d ICP h i g h l y and thought  access t o and i n t e r a c t e d with  c o l l e a g u e s i n other d i s c i p l i n e s staff  their  very d i f f e r e n t l y than d i d  nurses. Conclusions The  r e s e a r c h f i n d i n g s l e d t o a number of c o n c l u s i o n s  about a d e f i n i t i o n of ANP and the r e l a t i o n s h i p  of ANP on CHO.  These i n c l u d e : •  ANP remains a term t h a t i s not amenable t o a c l e a r and concise  •  nurses communicate about ANP through the use of d e t a i l e d clinical  •  definition;  stories  r a t h e r than  definitions;  the broad and vague nature of ANP i s v a l u e d i n t h a t i t allows f o r u n l i m i t e d f l e x i b i l i t y of the r o l e as c u r r e n t l y r e q u i r e d i n h e a l t h reform;  •  the a b i l i t y of nurses i n ANP t o enact t h e i r r o l e s i s s t r o n g l y dependent upon the context of t h e i r  •  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 f o r nurses i n ANP.  In f a c t ,  c r e a t e such d e f i n i t i o n s •  practice;  the s i g n i f i c a n t  some b e l i e v e t h a t e f f o r t s t o c o u l d be c o u n t e r - p r o d u c t i v e ;  i n c o n s i s t e n c i e s i n how nurses i n ANP  enact t h e i r r o l e s  are viewed p o s i t i v e l y ,  f o r the unique p e r s o n a l and p r o f e s s i o n a l  as they a l l o w competencies  167 t h a t nurses b r i n g t o ANP; •  some nurses i n ANP tend not t o have r e f l e c t i v e time t o think, about terms such as ANP and CHO;  •  some nurses i n ANP b e l i e v e t h a t graduate e d u c a t i o n i s mandatory f o r ANP;  •  some nurses i n ANP b e l i e v e t h a t a nurse should be a c l i n i c a l expert p r i o r t o graduate e d u c a t i o n f o r ANP;  •  some nurses i n ANP b e l i e v e t h a t graduate e d u c a t i o n f o r ANP should i n c l u d e a s t r o n g c l i n i c a l  •  some nurses i n ANP b e l i e v e t h a t r e s e a r c h i s an important component of t h e i r  •  s p e c i a l t y focus;  role;  w h i l e t h e r e i s no consensus about the need f o r n u r s i n g or non-nursing graduate e d u c a t i o n f o r ANP, mentored c l i n i c a l experience i n graduate e d u c a t i o n i s thought t o be c r u c i a l f o r nurses t o develop i n t o ANP;  •  some nurses i n ANP b e l i e v e t h a t ANP r e q u i r e s the a b i l i t y to t h i n k g l o b a l l y , t h a t i s the a b i l i t y t o t r a n s l a t e i n d i v i d u a l c l i e n t s c e n a r i o s i n t o a whole or p a t t e r n , as w e l l as b r i n g i n g t h a t whole or p a t t e r n t o any i n d i v i d u a l client;  •  some nurses i n ANP b e l i e v e t h a t t h e i r a b i l i t y t o t h i n k g l o b a l l y a l l o w them t o be p r o a c t i v e r a t h e r than r e a c t i v e in their  •  practice;  some nurses i n ANP see t h e i r r o l e as a s s i s t i v e t o o t h e r s i n order t o enhance c l i e n t care;  •  some nurses i n ANP s t r o n g l y support a c t i v e  involvement  168 of c l i e n t s i n d e t e r m i n i n g meaningful •  given  CHO;  c u r r e n t c o s t c o n s t r a i n t s , some nurses i n ANP  t a k i n g on more f u n c t i o n s t y p i c a l l y a s s o c i a t e d senior nursing •  some nurses i n ANP  s t r o n g l y value  interdisciplinary  recognize  of a l l h e a l t h care p r o v i d e r s ; i t may  with  administrators;  c o l l a b o r a t i v e p r a c t i c e and  •  are  the  contributions  and,  not be p o s s i b l e t o 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  interdisciplinary  c o l l a b o r a t i v e p r a c t i c e environment. Nursing The  f i n d i n g s of t h i s study have i m p l i c a t i o n s f o r  graduate education, research.  Implications  p o l i c y and  These w i l l now  be  administration  as w e l l  as  presented.  Graduate Education P a r t i c i p a n t s of t h i s study b e l i e v e d t h a t graduate education  i s mandatory f o r ANP.  discussed  and  However, as p a r t i c i p a n t s  l i t e r a t u r e confirms,  nurses i n ANP  vary  t h e i r support about the need f o r graduate education nursing.  To date, t h i s i s s u e remains c o n t e n t i o u s  l a c k of evidence t h a t there are any p r a c t i c e and focus  t o be i n  despite  d e s p i t e the f a c u l t y  Of note, i n the  interviews  f o r t h i s study, although r e c o g n i z i n g t h a t t h e r e were o n l y p a r t i c i p a n t s with non-nursing graduate education, no n o t i c e a b l e d i f f e r e n c e s i n how  a  d i f f e r e n c e s i n the  outcomes of nurses i n ANP  of t h e i r graduate s t u d i e s .  in  two  t h e r e were  p a r t i c i p a n t s were able  to  169 d i s c u s s ANP  and d e s c r i b e t h e i r p r a c t i c e i n r e l a t i o n t o  Given the c u r r e n t era of ICP, f o r n u r s i n g versus appropriate. university  d i s c u s s i o n s about the need  non-nursing graduate education  are  Nurses, p r o f e s s i o n a l r e g u l a t o r y bodies  educators  need to c o n s i d e r how  nurses to assume r e s p o n s i b i l i t i e s f o r ANP on CHO.  T h i s i s p a r t i c u l a r l y important  reform.  The  above s t a k e h o l d e r s  to best prepare and  i t s influence  during health  specialty  r e s e a r c h e x p e r t i s e c o u l d be assured.  focus  Further dialogue  a s s i s t i n determining  consequences f o r ANP  for  ANP,  and about  whether c u r r e n t  acceptance of non-nursing graduate education w i l l negative  care  need to determine and/or  p a r t i c u l a r l y i f a strong c l i n i c a l  issues w i l l  very and  c o n f i r m concerns about the f a c u l t y of graduate study  these  CHO.  and the s c i e n c e of  result in nursing.  Perhaps a primary graduate focus i n another f a c u l t y may very u s e f u l i n an ICP environment e s p e c i a l l y  be  i f there was  a  s t r o n g l i n k with the n u r s i n g program to ensure some n u r s i n g courses  as w e l l as a mentored c l i n i c a l  i s s u e s need to be debated, and  i f required,  changes should be made to graduate Nurses i n ANP  specialization. appropriate  education.  b e l i e v e t h a t graduate education  include a strong c l i n i c a l  specialty  focus.  The  should  P a r t i c i p a n t s of  t h i s study b e l i e v e d t h a t nurses should be c l i n i c a l p r i o r to graduate education.  These  experts  n u r s i n g community  e d u c a t i o n a l i n s t i t u t i o n s have addressed the q u e s t i o n whether a nurse should be a c l i n i c a l  and of  expert p r i o r to graduate  170 education. graduate  However, as was  noted i n chapter f i v e ,  nursing  e d u c a t i o n a l programs vary i n t h i s requirement.  If  t h i s i s t o continue, p o t e n t i a l students need t o make c a r e f u l d e c i s i o n s about t h e i r s e l e c t i o n s f o r graduate  education.  They need t o r e c o g n i z e t h a t c l a s s d i s c u s s i o n s , assignments and other a c t i v i t i e s i n programs t h a t do r e q u i r e c l i n i c a l experts may  be very c h a l l e n g i n g t o students without  expertise.  However, educators and students can  clinical  further  -develop c r e a t i v e i n d i v i d u a l ways t o meet p e r s o n a l education goals.  The  additional  i n d i v i d u a l student may efforts.  Nurses i n ANP clinical  require considerable  r e c o g n i z e the b e n e f i t s of a mentored  s p e c i a l t y focus d u r i n g graduate  and educators need t o examine how s t r u c t u r e d and monitored experience.  education.  Students  c l i n i c a l practicums  are  i n order t o ensure a mentored  C a r e f u l s e l e c t i o n of p r e c e p t o r s who  are keenly  i n t e r e s t e d i n a c t i v e p a r t i c i p a t i o n and p a r t n e r s h i p w i t h students and educators i s c r i t i c a l .  S t r a t e g i e s to  ensure  e f f e c t i v e communication between educators and p r e c e p t o r s can be strengthened, f a c u l t y , and  such as o r i e n t a t i o n , mentoring  the mentor by  j o i n t e v a l u a t i o n of students.  Nurses i n ANP  seem t o 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 d e t a i l e d clinical  stories.  d u r i n g graduate  T h i s approach can be f u r t h e r  education through  developed  i n c o r p o r a t i o n of  s t o r i e s i n t o assignments and c l a s s d i s c u s s i o n s .  clinical  Students  can  171 q u e s t i o n p r e c e p t o r s about how  they a r t i c u l a t e t h e i r  practice  w i t h a d m i n i s t r a t o r s and peers i n order t o change and nursing practice.  advance  They can a l s o engage i n d i s c u s s i o n s about  a r t i c u l a t i n g the r e l a t i o n s h i p of ANP  on CHO.  these can a s s i s t novice nurses i n ANP  Outcomes from  t o become more  a r t i c u l a t e about t h e i r p r a c t i c e and i t s i n f l u e n c e on Nurses i n ANP their role.  v a l u e the f l e x i b i l i t y  T h i s f l e x i b i l i t y was  t h a t allowed nurses i n ANP h e a l t h reform.  CHO.  a s s o c i a t e d with  b e l i e v e d t o be a f a c t o r  t o respond t o changes i n h e r e n t i n  During graduate  education, students should be  exposed t o a v a r i e t y of nurses i n ANP  and observe  and  q u e s t i o n them about t h i s aspect of t h e i r p r a c t i c e .  They  c o u l d d i s c u s s the p o s i t i v e and negative e f f e c t s of the d i v e r s i t y and f l e x i b i l i t y .  Students  c o u l d then have  d i s c u s s i o n s with others about whether f l e x i b i l i t y was p o s i t i v e aspect of  a  ANP.  P a r t i c i p a n t s i n t h i s study b e l i e v e t h a t r e f l e c t i v e i s r e q u i r e d f o r d i s c u s s i n g terms l i k e ANP  and CHO.  time  However,  i n busy day-to-day p r a c t i c e t h i s r e f l e c t i v e time i s not readily available.  During graduate  education,  students  r e g u l a r l y engage i n r e f l e c t i v e time i n order t o prepare f o r c l a s s d i s c u s s i o n s and assignments.  Graduate s t u d i e s c o u l d be  a p l a t f o r m t o ensure t h a t r e f l e c t i v e time i s b u i l t practicums.  into  Graduate n u r s i n g students and p r e c e p t o r s o f t e n  engage i n r e f l e c t i v e t h i n k i n g and d i s c u s s i o n s but perhaps other nurses c o u l d a l s o p a r t i c i p a t e .  Educators and  students  172 c o u l d a l s o promote the o v e r a l l b e n e f i t s of the p r o a c t i v e approach of ANP for  which can be f u r t h e r developed  r e f l e c t i o n of p r a c t i c e .  foundation f o r nurses i s mandatory f o r ANP Nurses i n ANP  i n ANP  by t a k i n g time  These s t r a t e g i e s c o u l d p r o v i d e a to b e l i e v e t h a t r e f l e c t i v e time  and not a l u x u r y .  s t r o n g l y v a l u e r e s e a r c h as an  component of t h e i r r o l e .  important  Many n u r s i n g graduate programs do  i n c l u d e a r e s e a r c h course and the conduct of a t h e s i s as a requirement.  Others do not.  Non-nursing f a c u l t i e s a l s o vary  i n t h e i r o f f e r i n g s of r e s e a r c h courses.  These  i n c o n s i s t e n c i e s i n f l u e n c e the competencies of nurses r e l a t e d to r e s e a r c h . and educators  in  ANP  Nurses, p r o f e s s i o n a l r e g u l a t o r y bodies  need to examine the a p p r o p r i a t e r o l e f o r  master's prepared  nurses  i n the conduct of r e s e a r c h .  q u e s t i o n as t o whether c l i n i c a l l y based graduate should i n c l u d e a r e s e a r c h t h e s i s experience  The  education  a l s o needs to be  addressed. Although important  r e s e a r c h i s g e n e r a l l y r e c o g n i z e d as  component of ANP,  p a r t i c i p a n t s of t h i s  an study  b e l i e v e d they c o u l d best c o n t r i b u t e to r e s e a r c h by p a r t n e r i n g with d o c t o r a l l y prepared  nurses.  Participants also believed  t h a t doing r e s e a r c h accounted f o r the s m a l l e s t p r o p o r t i o n of t h e i r time i n t h e i r o v e r a l l p r a c t i c e , although u t i l i z a t i o n permeated t h e i r p r a c t i c e .  research  I t i s important  r e v i s i t the g e n e r a l e x p e c t a t i o n of independent r e s e a r c h the p a r t of a master's prepared  nurse i n  ANP.  to on  173 F i n a l l y , nurses  i n ANP  h i g h l y value and  interact  d i f f e r e n t l y with c o l l e a g u e s from other d i s c i p l i n e s than s t a f f nurses.  do  C u r r e n t l y , many n u r s i n g graduate programs are  s o l e l y focused on n u r s i n g and r a r e l y i n v o l v e other d i s c i p l i n e s through readings or c l a s s Students  participation.  and educators need t o q u e s t i o n a f a c u l t y  approach t o graduate  education.  specific  This i s p a r t i c u l a r l y  important when a l l l e v e l s of h e a l t h p o l i c y d e c i s i o n makers are s u g g e s t i n g ICP as a p o t e n t i a l answer t o c u r r e n t fragmentation, gaps and d u p l i c a t i o n i n h e a l t h c a r e . and educators c o u l d experiment  with  Students  interdisciplinary  education f o r courses e a r l y i n programs and at v a r i o u s stages throughout  graduate  education.  students need t o observe ICP and how  During c l i n i c a l  and d i s c u s s how  practicums,  p r e c e p t o r s encourage  they p e r c e i v e t h a t i n f l u e n c e s CHO.  Students  c o u l d a l s o i n v o l v e c l i e n t s i n these d i s c u s s i o n s . P o l i c y And A d m i n i s t r a t i o n Nurses,  h e a l t h p o l i c y d e c i s i o n makers and a d m i n i s t r a t o r s  need t o be more cognizant of the v a l u a b l e c o n t r i b u t i o n t h a t nurses i n ANP  can make t o h e a l t h reform.  P a r t i c i p a n t s of  t h i s study d e s c r i b e d s i g n i f i c a n t c o n t r i b u t i o n s t h a t they were making t o i n d i v i d u a l , as w e l l as o v e r a l l c l i e n t care w i t h i n their organizations.  Although p a r t i c i p a n t s a l l u d e d t o b e i n g  i n v o l v e d i n care with e x t e r n a l agencies, t h i s seemed t o be a minor f o c u s . F i n d i n g s from t h i s study r e i n f o r c e t h a t nurses i n  ANP  174 have many of the competencies t h a t c o u l d p o s i t i v e l y c o n t r i b u t e t o the enhancements of outcomes f o r c l i e n t s , i n t e r d i s c i p l i n a r y h e a l t h care p r o v i d e r s , as w e l l as organizations.  However, t h i s p o t e n t i a l c o n t r i b u t i o n does not  seem t o be promoted, r e c o g n i z e d  or sought.  F o r example, i n  c u r r e n t debates between " h o s p i t a l and community" t h e r e i s a s t r o n g e f f o r t t o determine "what nurses" care and i n "what context." discourage  should be p r o v i d i n g  Community nurses a c t i v e l y  h o s p i t a l nurses from p r a c t i s i n g  h o s p i t a l w a l l s and v i c e - v e r s a .  " o u t s i d e " the  However, i n t h e case of ANP,  the h e a l t h care community needs t o ask i f t h i s i s appropriate. and  In many i n s t a n c e s , nurses i n ANP should monitor  i n f l u e n c e care across d e l i v e r y s e t t i n g s 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 o c c u r r i n g , i t i s not c o n s i s t e n t l y encouraged and/or s a n c t i o n e d .  Nurses i n ANP  c o u l d make s i g n i f i c a n t c o n t r i b u t i o n s i n d i s c u s s i o n s with h e a l t h p o l i c y d e c i s i o n makers, i n c l u d i n g r e p r e s e n t a t i v e s from Community Health C o u n c i l s and Regional concerning  Health  Boards,  l o c a l and r e g i o n a l h e a l t h care needs/plans.  P a r t i c i p a n t s of t h i s study d e s c r i b e d t h e i r i n c r e a s i n g administrative focus.  The outcomes of i n c r e a s e d  a d m i n i s t r a t i v e r e s p o n s i b i l i t i e s f o r nurses i n ANP need f u r t h e r study.  In the meantime, a d m i n i s t r a t o r s need t o  c a r e f u l l y c o n s i d e r reasons f o r t h i s p r a c t i c e .  I f nurses i n  ANP a r e educated t o a c t i v e l y p a r t i c i p a t e with others i n order t o improve c l i e n t care w i t h i n an o r g a n i z a t i o n ,  administrators  175 need t o determine  i f t h a t g o a l w i l l be met with nurses  t a k i n g on more of an a d m i n i s t r a t i v e r o l e .  I t i s recognized  t h a t t h i s a c t i o n may be the r e s u l t of a " f i l l  the gap"  measure due t o c o s t c o n s t r a i n t s and down-sizing n u r s i n g management.  organization.  of middle  However, a d m i n i s t r a t o r s and nurses i n  ANP need t o c a r e f u l l y monitor c l i e n t care w i l l  i n ANP  impact  how a d e c r e a s i n g focus on  c l i n i c a l p r a c t i c e w i t h i n the  On the other hand, perhaps t h i s i n c r e a s e d  a d m i n i s t r a t i v e focus c o u l d be viewed as an a p p r o p r i a t e compromise t h a t keeps ANP a l i v e d u r i n g c u r r e n t times of economic r e s t r a i n t . L a s t l y , the nurse p a r t i c i p a n t s i n t h i s study view and encourage ICP. heightened  positively  At the present time, t h e r e i s a  i n t e r e s t i n ICP with many d i s c i p l i n e s f e a r i n g y e t  others s u p p o r t i n g i t .  Nurses i n ANP can make use of t h i s  i n t e r e s t and model t o others how t o 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 d i s c u s s i o n s about new and c r e a t i v e ways t o improve CHO with an i n t e g r a t e d care d e l i v e r y mechanism. Research F i n d i n g s from t h i s study can be used t o i d e n t i f y r e s e a r c h t o p i c s r e l a t e d t o ANP.  The on-going  exhaustive  e f f o r t s t o c l e a r l y d e f i n e ANP need t o be questioned. scholars s t r i v e f o r c l a r i t y  further  Nursing  about ANP because they know t h a t  these nurses make s i g n i f i c a n t and v a l u a b l e c o n t r i b u t i o n s t o  176 c l i e n t care, n u r s i n g p r a c t i c e and o v e r a l l h e a l t h c a r e . nurse p a r t i c i p a n t s i n t h i s study share these views. d e f i n i t i o n s of ANP may not prove f r u i t f u l  The  However,  i n f u r t h e r i n g the  cause of ANP. Instead of t r y i n g t o d e f i n e ANP, e f f o r t s can be put toward a p p l y i n g c u r r e n t v i s i o n statements about  i t toward  meeting o r g a n i z a t i o n a l , r e g i o n a l and p r o v i n c i a l h e a l t h reform goals.  Because nurses i n ANP do not f i n d i t important t o  spend energy t r y i n g t o d e f i n e a term equated w i t h t h e i r p r a c t i c e , they c a u t i o n a g a i n s t such e f f o r t s . above approach,  Perhaps the  r e l a t e d t o v i s i o n statements, would enable  n u r s i n g s c h o l a r s and nurses i n ANP t o be a b l e t o e f f e c t i v e l y communicate the v a l u a b l e c o n t r i b u t i o n they know nurses i n ANP make.  There needs t o be a c l e a r and c o n c i s e way t o d e s c r i b e  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 t o understand what ANP i s and a r e a b l e t o more f u l l y value i t . P a r t i c i p a n t s i d e n t i f i e d some minimal requirements f o r ANP.  C u r r e n t l y t h e r e a many nurses u s i n g a t i t l e  ANP from a v a r i e t y of programs and backgrounds.  l i n k e d with Although  others a r e a c t i v e l y e x p l o r i n g t h i s , i t may be u s e f u l t o come to  a consensus  on minimal requirements f o r ANP.  Research  r e l a t e d t o minimal requirements c o u l d e x p l o r e any d i f f e r e n c e s , and the r e s u l t a n t i m p l i c a t i o n s of how nurses i n ANP enact t h e i r r o l e s , dependent upon whether they have n u r s i n g o r non-nursing graduate e d u c a t i o n .  Another q u e s t i o n  177 worthy of f u r t h e r study r e l a t e s t o any d i f f e r e n c e s between nurses who a r e c l i n i c a l clinical  experts versus those w i t h minimal  experiences p r i o r t o graduate e d u c a t i o n .  In t h i s study, p a r t i c i p a n t s were a l l from one major hospital society. t h e i r approaches  P a r t i c i p a n t s were q u i t e c o n s i s t e n t i n t o the phenomena of i n t e r e s t .  I t would be  b e n e f i c i a l t o i n v e s t i g a t e how nurses i n ANP i n other f a c i l i t i e s and c i t i e s  describe their practice.  nurses i n ANP i n other c e n t r e s might  Canadian  A study of  i l l u m i n a t e f u r t h e r the  i s s u e s i n t r y i n g t o d e f i n e ANP and d e s c r i b e t h i s p r a c t i c e i n r e l a t i o n t o CHO. Only two p a r t i c i p a n t s of t h i s study had undertaken nonn u r s i n g graduate e d u c a t i o n .  Although g e n e r a l i z a t i o n s  cannot  be made on the b a s i s of these accounts, i t was obvious t h a t both of these p a r t i c i p a n t s had made c o n c e r t e d e f f o r t s t o ensure a c l i n i c a l studies.  s p e c i a l t y focus d u r i n g t h e i r  graduate  I t would be u s e f u l t o determine why nurses  undertake non-nursing graduate education p a r t i c u l a r l y i f they wish t o be a c t i v e l y i n v o l v e d i n n u r s i n g . to  Another q u e s t i o n i s  determine the i m p l i c a t i o n s f o r ANP i f a nurse i s a  graduate of a non-nursing graduate program t h a t d i d not include a c l i n i c a l  s p e c i a l t y focus.  P a r t i c i p a n t s of t h i s study attempted  t o d e f i n e ANP and  d e s c r i b e t h e i r p r a c t i c e i n r e l a t i o n t o CHO.  I t would be most  u s e f u l t o f o l l o w these d e s c r i p t i o n s by o b s e r v i n g nurses i n ANP as they conduct t h e i r p r a c t i c e .  These o b s e r v a t i o n s would  178 shed more l i g h t on ANP. Nurses i n ANP s t r o n g l y support  c l i e n t a c t i v e involvement  i n d e c i s i o n making about t h e i r own care.  These nurses a l s o  r e c o g n i z e t h e need f o r c l i e n t s t o i d e n t i f y meaningful CHO from t h e i r own p e r s p e c t i v e s . these areas  Further research r e l a t e d to  c o u l d be of a s s i s t a n c e i n the debates about  h e a l t h reform  and e v a l u a t i o n of s e r v i c e s both  and g e n e r a l l y .  specifically  Perhaps a s k i n g c l i e n t s t o a r t i c u l a t e the  i n f l u e n c e of nurses and n u r s i n g care on t h e i r CHO c o u l d a s s i s t i n our understanding  of how t o separate  out the  i n f l u e n c e of n u r s i n g on CHO i n an ICP environment. a l s o a s s i s t h e a l t h p o l i c y d e c i s i o n makers, h e a l t h  I t may care  p r o v i d e r s and nurses i n ANP t o determine, j u s t i f y and/or e l i m i n a t e programs t h a t e i t h e r r e s u l t i n p o s i t i v e or negative CHO. L a s t l y , the whole i s s u e of t h e r e l a t i o n s h i p of ANP t o CHO r e q u i r e s f u r t h e r r e s e a r c h .  P a r t i c i p a n t s d e s c r i b e d the  c o m p l e x i t i e s t h a t they had i n t r y i n g t o make a t h e o r e t i c a l l i n k a g e between t h e i r p r a c t i c e and CHO e x p l i c i t .  Although  p a r t i c i p a n t s were not accustomed t o doing so, they i n d i r e c t r e l a t i o n s h i p s between ANP and CHO. i s g e n e r a l support  described  Although  there  f o r ANP, f a i l u r e t o 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 t o CHO c o u l d prove t o be problematic.  F u r t h e r questions  need t o be asked about the  c o n t r i b u t i o n t h a t nurses i n ANP make t o 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 i n d i v i d u a l s has been p r o b l e m a t i c . proactive, global perspective o v e r a l l h e a l t h care.  P a r t i c i p a n t s described the  they brought t o c l i e n t and  An expansion on the c o n t r i b u t i o n t h a t  nurses i n ANP make t o an o r g a n i z a t i o n or t o p o p u l a t i o n s  as  c l i e n t c o u l d a s s i s t i n f u r t h e r understanding of how t h i s positively, albeit indirectly, other  i n f l u e n c e s CHO.  F i n a l l y , how  nurses i n ANP eg., nurse p r a c t i t i o n e r s address these  i s s u e s c o u l d be u s e f u l i n e f f o r t s t o f u r t h e r develop t h i s r o l e i n Canada. Concluding Remarks In c o n c l u s i o n ,  t h i s r e p o r t has o u t l i n e d how CNSs d e f i n e  ANP and d e s c r i b e t h e i r p r a c t i c e i n r e l a t i o n t o CHO. b e g i n n i n g of t h i s study, the r e s e a r c h e r  At the  assumed t h a t nurses  whose r o l e f e l l under t h e umbrella of ANP would be able t o 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 w e l l as have an accurate i n f l u e n c e d CHO.  sense of how t h e i r p r a c t i c e  T h i s study has be an i l l u m i n a t i n g experience  t h a t may have r a i s e d more questions phenomena of i n t e r e s t .  than answers t o t h e  However, i t i s the r e s e a r c h e r ' s  that despite the complexities  hope  a s s o c i a t e d with understanding  ANP, nurses and others w i l l continue t o recognize the valuable  and s i g n i f i c a n t c o n t r i b u t i o n s t h a t these nurses make  t o h e a l t h care. reassess  Nurses, educators and r e s e a r c h e r s  need t o  the approach t o understanding and d e s c r i b i n g ANP.  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Spross (Eds.), The C l i n i c a l Nurse S p e c i a l i s t i n theory and p r a c t i c e ( 2 n d , ed.)(pp. 325-342). P h i l a d e l p h i a : W.B. Saunders Company. The Working Group f o r R e g i s t e r e d Nurses i n Advanced Nursing P r a c t i c e i n Rural/Remote Communities (1994). G u i d e l i n e s f o r r e g i s t e r e d nurses i n advanced n u r s i n g p r a c t i c e p r o v i d i n g primary h e a l t h care s e r v i c e s i n u n d e r - s e r v i c e d communities i n A l b e r t a . Edmonton, A l b e r t a : Author. U n i t e d States Department of Health and Human S e r v i c e s (1990). Seventh' r e p o r t t o the p r e s i d e n t and congress on the s t a t u s of h e a l t h personnel i n the U n i t e d S t a t e s . Washington, D.C: P u b l i c Health S e r v i c e , Health Resources Administration. Van  der h o r s t , M.L. (1992). Canada's h e a l t h care system provides lessons f o r NPs. Nurse P r a c t i t i o n e r , 17, 44,50,52-53,57,60.  V e l i a n o f f , G.D., Neely, C. & H a l l , S. (1993). Developmental l e v e l s of i n t e r d i s c i p l i n a r y c o l l a b o r a t i v e p r a c t i c e committees. J o u r n a l of Nursing A d m i n i s t r a t i o n , 23(7/8), 26-29. Waltz, C F . & S y l v i a , B.M. (1991). A c c o u n t a b i l i t y and outcome measurement: Where do we go from here? C l i n i c a l Nurse S p e c i a l i s t , 5, 202-203.  193 Wandel, J.C. (1991). Moral outrage and moral d i s c o u r s e i n n u r s e - p h y s i c i a n c o l l a b o r a t i o n . J o u r n a l of P r o f e s s i o n a l Nursing, 1 ( 6 ) , 351-163. W i l l i a m s , C A . & V a l d i v i e s o , G.C (1994). Advanced p r a c t i c e models: A comparison of c l i n i c a l nurse s p e c i a l i s t and nurse p r a c t i t i o n e r a c t i v i t i e s . C l i n i c a l Nurse S p e c i a l i s t , 8(6), 311-318. Wise, P.S.Y. (1995). Leading and managing i n n u r s i n g . Toronto: Mosby Year Book, Inc. Wood, M.J. (1989). E v a l u a t i n g d e s i g n s . In P.J. B r i n k & M.J. Wood (Eds.), Advanced d e s i g n i n n u r s i n g r e s e a r c h (pp. 223237). Newbury Park, CA: Sage P u b l i c a t i o n s .  194 APPENDIX A LETTER OF INVITATION TO PARTICIPANTS Address of Researcher Date. . S p e c i f i c name, t i t l e and address of p o t e n t i a l p a r t i c i p a n t Dear (name of CNS); As you may know, I am a student i n the Master's of Nursing Program a t t h e U n i v e r s i t y of B r i t i s h Columbia (UBC). I would l i k e t o e n l i s t your help as a p a r t i c i p a n t i n my proposed r e s e a r c h t h a t w i l l be conducted f o r t h e purposes of completing t h e s i s r e s e a r c h . The proposed r e s e a r c h i s a q u a l i t a t i v e study r e l a t e d t o advanced n u r s i n g p r a c t i c e and c l i e n t h e a l t h outcomes. As you are aware, d u r i n g times of economic r e s t r a i n t as i s f a c i n g our h e a l t h care system now, h e a l t h p o l i c y and economic d e c i s i o n makers may q u e s t i o n your r o l e as a C l i n i c a l Nurse Specialist. The outcome of t h i s study w i l l c o n t r i b u t e t o a knowledge base r e l a t e d t o a c l e a r d e f i n i t i o n of advanced n u r s i n g p r a c t i c e and how t h i s p r a c t i c e r e l a t e s o r c o n t r i b u t e s t o c l i e n t h e a l t h outcomes. I would l i k e t o i n v i t e you t o p a r t i c i p a t e i n t h i s r e s e a r c h . Your involvement would i n c l u d e time f o r i n t e r v i e w s , estimated t o be a maximum of t h r e e , one hour i n t e r v i e w s . This t i m i n g and frequency w i l l be determined based on our d i s c u s s i o n s and the subsequent f i n d i n g s of t h e i n t e r v i e w s . The l o c a t i o n and t i m i n g of these i n t e r v i e w s can be mutually determined t o accommodate your busy work schedule. Your p r i v a c y and c o n f i d e n t i a l i t y would be maintained. You would of course be f r e e t o withdraw from t h e proposed r e s e a r c h a t any time without jeopardy and would be f r e e t o r e f u s e t o d i s c u s s any s p e c i f i c t o p i c s .  195 I f you have any questions and/or i f you would l i k e to v o l u n t e e r to p a r t i c i p a t e i n the proposed r e s e a r c h p l e a s e c o n t a c t me at home xxx-xxxx (machine), at work xxx-xxxx (phone) or by fax (xxx-xxxx). I f I have not heard from you i n two weeks I w i l l g i v e 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 d e c i s i o n and to answer any q u e s t i o n s or i s s u e s t h a t you may have. Dr. S a l l y Thorne, C h a i r of my T h e s i s Committee, i s a v a i l a b l e to answer any questions as w e l l , and she can be contacted at UBC, telephone # xxx-xxxx. Thank you f o r your c o n s i d e r a t i o n and I look forward t o h e a r i n g from you. Sincerely,  Katherine  Cox.  APPENDIX B ELIGIBILITY CRITERIA AND DEMOGRAPHICS 1.  Are you c u r r e n t l y employed as a CNS?  2.  Have you been employed as a CNS f o r a minimum of one year?  3.  Do you have a Master's degree?  4.  What f a c u l t y i s your degree in?  5.  Demographics: Age  Gender F  Years employed as CNS Specialty  M  yes  no  yes  no  yes  no  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 d e f i n e advanced n u r s i n g p r a c t i c e and how do they d e s c r i b e t h e i r p r a c t i c e i n r e l a t i o n t o c l i e n t h e a l t h outcomes?" PROMPTS 1.  Demographics, p r e v i o u s p r o f e s s i o n a l h i s t o r y , l e n g t h 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 f a c u l t y master's degree i s i n .  2.  Please t e l l me something about your p r a c t i c e .  3.  So i t sounds l i k e t h i s c o u l d be c a l l e d p r a c t i c e i n nursing.  4.  I t sounds l i k e you are d i f f e r e n t i a t i n g between p r a c t i c e and advanced n u r s i n g p r a c t i c e .  5.  What you j u s t noted there i s a c l i e n t h e a l t h outcome, to speak. I am i n t e r e s t e d i n t h a t . . .  6.  How do.you d e f i n e c l i e n t h e a l t h outcomes? So you seem to be making a l i n k t o the immediate e f f e c t of your care on the c l i e n t ? Is t h e r e any b e n e f i t t o examining or e x p l o r i n g long term e f f e c t s ?  7.  You seem t o be making a l i n k between advanced n u r s i n g p r a c t i c e and c l i e n t h e a l t h outcomes. Can you e l a b o r a t e on t h a t . . . ?  8.  How do you see your p r a c t i c e as i n f l u e n c i n g c l i e n t h e a l t h outcomes?  9.  I t sounds l i k e you t h i n k t h a t t h i n g s you do a f f e c t the client...(pause).  Adapted from P a t t e r s o n and Haddad,  1992.  "advanced" expert so  198 APPENDIX D CONSENT FOR INTERVIEW In s i g n i n g t h i s document, I am g i v i n g my consent t o be i n t e r v i e w e d by Katherine Cox, a Master of Science i n N u r s i n g student from the U n i v e r s i t y of B r i t i s h Columbia. I understand t h a t 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 f o r research i n a nursing t h e s i s . The r e s e a r c h area of i n t e r e s t i s advanced n u r s i n g p r a c t i c e and c l i e n t h e a l t h outcomes and w i l l i n v o l v e one t o three audio-taped i n t e r v i e w s of approximately one hour i n l e n g t h . There w i l l not be any f i n a n c i a l renumeration f o r any of the p a r t i c i p a n t s . I am aware t h a t the tapes used d u r i n g the i n t e r v i e w w i l l be t r a n s c r i b e d f o r the purposes of a n a l y s i s by K a t h e r i n e . The tape may be t r a n s c r i b e d 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 listen to them w i l l be t h r e e of Katherine's p r o f e s s o r s . I am assured of my c o n f i d e n t i a l i t y , i n t h a t the tape and t r a n s c r i p t i o n s w i l l not i d e n t i f y me p e r s o n a l l y . I understand t h a t I was s e l e c t e d to p a r t i c i p a t e i n t h i s study because of my i n t e r e s t i n advanced n u r s i n g p r a c t i c e and the f a c t t h a t 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 p a r t i c i p a n t e l i g i b i l i t y c r i t e r i a as they have been e x p l a i n e d to me by K a t h e r i n e . I have been informed t h a t the i n t e r v i e w i s e n t i r e l y v o l u n t a r y , and t h a t at any p o i n t d u r i n g the i n t e r v i e w I can r e f u s e to d i s c u s s any s p e c i f i c t o p i c s , and i n f a c t , can terminate the i n t e r v i e w without j eopardy. T h i s study has the p o t e n t i a l to c o n t r i b u t e to a d e f i n i t i o n of advanced n u r s i n g p r a c t i c e and the e v a l u a t i o n of how t h i s p r a c t i c e a f f e c t s c l i e n t h e a l t h outcomes, which to date i s l a c k i n g . I am aware t h a t I am f r e e to c o n t a c t Katherine f o r any questions r e l a t e d 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 t h a t Dr. S a l l y Thorne (Thesis Committee C h a i r : xxx-xxxx) or Dr. A n i t a Molzahn (xxx-xxxx), are the n u r s i n g f a c u l t y to c o n t a c t i f I have any questions about t h i s process or study. I a l s o understand t h a t Katherine may c o n t a c t me f o r more i n f o r m a t i o n i n the f u t u r e . In a d d i t i o n , Katherine w i l l share the f i n d i n g s of t h i s study with me i f I am interested. Date Acknowledgement t h a t the p a r t i c i p a n t has been given a copy of the consent form ( w i l l be / once signed by both the p a r t i c i p a n t and r e s e a r c h e r and a copy given to the p a r t i c i p a n t ) .  Respondent's s i g n a t u r e Interviewer's  Interviewer's number  signature  telephone  

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