Richard Baldwin

The role and functions of Clinical Nurse Consultants, an Australian advanced practice role: A descriptive exploratory cohort study

BACKGROUND The NSW Health Policy Directive (NSW Department of Health, 2000) lists clinical service and consultancy; clinical leadership; research; education; clinical services planning and management as the five domains of practice for nurses appointed as Clinical Nurse Consultants (CNCs), an Australian advanced practice nurse (APN) role. However, there is no clear definition of what is meant by advanced practice in the Australian nursing context. Nowhere is this more evident than in differentiating between the roles of Clinical Nurse Consultants (CNCs) and Nurse Practitioners (NP) in NSW. To date, limited empirical research has been done to characterise or delineate CNC role activity and responsibility. OBJECTIVES To investigate (i) the nature of CNC roles, activities and responsibilities, (ii) differentiate between CNCs by their work patterns and activities, and (iii) empirically conceptualize and differentiate ways CNCs practice in terms of an APN typology. PARTICIPANTS The study sample was 56 CNCs at one tertiary level public hospital in Australia. METHODS A descriptive exploratory cohort study was conducted to explore CNC role characteristics and patterns of activity. Data were triangulated using an online survey, a follow-up survey, and semi-structured interviews. The data were analysed using descriptive statistics to examine differences between CNC work patterns and role activities. The survey data and the individual reports were thematically analysed to investigate for difference across the population of CNCs. RESULTS Interpretation of survey and interview data led to an analyst-developed CNC typology of four CNC categories based on the work patterns and activities of Sole Practitioner, Clinic Coordinator, Clinical Team Coordinator and Clinical Leader. The typology was based on the themes interprofessional, role focus, clinical focus and setting as these themes distinguished and differentiated CNC roles. CONCLUSIONS The study provides evidence of great diversity and prioritization within CNC roles. The CNC typology identified in this study is similar to the categorisation of the roles of APNs reported by other researchers. With further testing, the CNC typology could be useful to service managers and policy makers in making decision on the category of CNC required for a position and may also be able to be applied to other APN roles.

Development of a tool to describe the role of the clinical nurse consultant in Australia.

AIMS AND OBJECTIVES To develop a tool for defining and measuring the role characteristics and responsibilities of an advanced practice nursing role in Australia. BACKGROUND Internationally, there is considerable confusion about the precise role responsibilities of advanced practice nursing positions. In Australia, the clinical nurse consultant is an advanced practice role with five nominated domains of practice. However, there are no tools for measuring the performance of clinical nurse consultants against the listed domains. DESIGN AND METHODS Participants were 56 clinical nurse consultants at a tertiary public hospital. The existing literature, an online survey, and position descriptions were used to generate the a priori themes for the initial template. Semi-structured interviews were conducted (in 2010) to test the template characteristics. The template underwent multiple iterations in its development. RESULTS A 50-item tool was devised, which consisted of five domains with a ten-point hierarchical scale within each domain. In preliminary testing, the revised template was found to provide greater clarity regarding roles and grades than the original position descriptions. CONCLUSIONS Further testing and refinement of the modified rating scale is needed, but it offers the possibility of a new tool that can be used by health service managers to determine the grade of a clinical nurse consultant position and for evaluating role performance. RELEVANCE TO CLINICAL PRACTICE This preliminary study suggests that the tool provides a useful means of measuring advanced nursing practice and responsibilities across different domains and levels of appointment. The tool may be able to be adapted for use with other advanced practice nursing roles both within Australia and internationally.

Domains of practice and Advanced Practice Nursing in Australia

A key component of workforce reform is the international growth in Advanced Practice Nursing (APN) roles. This study evaluated one APN role in Australia, the Clinical Nurse Consultant (CNC). All 56 CNCs employed in a tertiary hospital in New South Wales took part in the study. Demographic and work activity data were collected by an online questionnaire. Face-to-face interviews included the administration of a 50-point tool to score the level of practice of each CNC against five domains. The domains of practice did not appear to have played a central role in the design of these CNC roles despite being defined in the industrial legislation and linked to a pay structure. There was widespread variability in the level of practice both within and between the CNC grades as well as significant differences in job content. Few CNCs managed to achieve a moderate level of practice across all five domains. The findings suggest that the distinctive features of the CNC roles as articulated in the domains of practice are often not realized in practice.

Expanding the Role of Practice Nurses in Australia

Like other countries, Australia is looking to reforms in the primary health care sector to meet the growing demand for care. Expansion of the role of practice nurses (PNs) is one way in which this demand may be met. To date the Federal Australian government has played a significant role in encouraging growth in the PN workforce. If PNs tend to be GP directed, with little autonomy, care must be taken to consider whether to expand existing scopes of practice. In contrast, if PNs rely on their own independent clinical judgment and skill, this would support potential expansions to the scope of the PN role. Understanding these issues is important to inform the development of future workforce policy. This paper examines the structural policy dimensions within which these changes are occurring, and makes recommendations for future research on PNs.

Nursing in general practice: organizational possibilities for decision latitude, created skill, social support and identity derived from role

AIM This article is a report of a study to describe the factors that support organizational opportunities for practice nurse decision-making and skill development for nurses employed in general practice in New South Wales, Australia. BACKGROUND Corresponding to the availability of subsidies from the Australian universal health insurer (Medicare), there has been an increase in the number of nurses employed in general practice. Currently, there is no Australian evidence as to the organizational possibilities for these practice nurses to make decisions, develop their own skills and abilities, derive identity from their role or how their role is influenced by social support. METHODS Over a 8-month period in 2008 practice, nurses employed in general practice in the State of New South Wales were invited to complete a 26-item self-administered online questionnaire utilizing constructs from Karaseks (1998) Job Content Questionnaire (valid n = 160). RESULTS Confirmatory Factor Analysis indicated that all scales demonstrated acceptable levels of internal consistency. Sequential regression models revealed that social support exerts a weak influence on decision latitude (R(2) = 0·07); the addition of self-identity through work significantly improved the predictive ability of the model (R(2) = 0·16). Social support and self-identity through work exerted a negative influence on created skill (R(2) = 0·347), whereas social support was effective in predicting self-identity through work (R(2) = 0·148). CONCLUSIONS   Collegial and supervisory support in the work environment predicts organizational possibilities for practice nurse decision-making.

Residential Aged Care Policy in Australia – Are We Learning from Evidence?

The residential aged care industry in Australia will expand rapidly over the next 10 years leading to substantial increases in government expenditure. Recent and future reforms are likely leading to changes in the structure of the industry with a potential impact on quality of care. The purpose of this paper is to stimulate broader public debate, based on the available evidence, about the preferred structure of this important industry. It examines the literature on the impact structure has on the quality of services and compares this with a fresh analysis of current trends. The paper argues that future policy should be evidence based and explicit about the structure of the industry that will emerge from current policy reforms.

Job enrichment: Creating meaningful career development opportunities for nurses

AIM This paper presents an evaluation of a career development policy in South Australia which increased the number of senior staff nurse positions and provided senior registered nurses with time away from clinical duties to undertake agreed projects. We use Kanters model of structural power and commitment theory to understand the dimensions of this policy. BACKGROUND Development strategies for experienced staff who wish to remain at the bedside are needed, especially in smaller health services with limited opportunities for horizontal or vertical mobility. METHODS Face-to-face semistructured interviews were conducted with 54 senior staff nurses who participated in the career structure arrangements. RESULTS The policy enhanced the structure of opportunity in three ways: by increasing the number of senior staff nurse positions, the ladder steps were improved; undertaking strategic projects developed new skills; and the job enrichment approach facilitated time out from the immediate pressures of ward work and challenged nurses in a different way. CONCLUSIONS Through job enrichment, South Australia has found a novel way of providing meaningful career development opportunities for experienced nurses. IMPLICATIONS FOR NURSING MANAGEMENT Methods of job enrichment need to be considered as part of career development policy, especially where movement between clinical facilities is limited and staff wish to remain at the bedside.Aim This paper presents an evaluation of a career development policy in South Australia which increased the number of senior staff nurse positions and provided senior registered nurses with time away from clinical duties to undertake agreed projects. We use Kanters model of structural power and commitment theory to understand the dimensions of this policy. Background Development strategies for experienced staff who wish to remain at the bedside are needed, especially in smaller health services with limited opportunities for horizontal or vertical mobility. Methods Face-to-face semistructured interviews were conducted with 54 senior staff nurses who participated in the career structure arrangements. Results The policy enhanced the structure of opportunity in three ways: by increasing the number of senior staff nurse positions, the ladder steps were improved; undertaking strategic projects developed new skills; and the job enrichment approach facilitated time out from the immediate pressures of ward work and challenged nurses in a different way. Conclusions Through job enrichment, South Australia has found a novel way of providing meaningful career development opportunities for experienced nurses. Implications for nursing management Methods of job enrichment need to be considered as part of career development policy, especially where movement between clinical facilities is limited and staff wish to remain at the bedside.

Quality failures in residential aged care in Australia: The relationship between structural factors and regulation imposed sanctions

To examine the relationship between structural factors and the imposition of sanctions on residential aged care services across Australia for regulatory compliance failure.

Building a resilient and sustainable workforce in aged care.

In the 1960s the Australian government established the aged care programme to provide subsidies to residential aged care providers. Within a couple of decades, Australia had one of the highest proportions in the world of its older citizens in residential care. In the mid-1980s, to remedy this overdependence on residential care, the Australian government introduced the home and community care (HACC) programme. The HACC programme provided care to the frail aged and disabled; and funded the establishment of many small, stand-alone, non-government service providers. Community care developed separately from residential aged care. The legacy of these policy decisions is two sectors that together constitute one large aged care sector providing complementary and sometimes overlapping services but with separate cultures and workforce traditions. Aged care workers are currently employed by a mix of public, private-for-profi t and not-for-profi t service providers and, compared with the acute care sector, are distributed across a large number of mostly small to medium sized services, operated by small to large organisations, with most having little individual capacity for workforce planning and development. Over recent years the sector has developed a reputation for staffi ng shortages and high staff turnover. This diversity of settings, variety of ownership types, range of sizes of services and organisations, and reported workforce issues are, arguably, the outcomes of past government policy. The Living Longer Living Better reforms to the aged care sector announced by the Australian government in 2012 introduce a period of reform in aged care and it is timely to examine the similarities and differences across these sectors and to identify the policies and management practices that are likely to enable the industry to develop the resilient and sustainable workforce needed to meet the predicted demand. EDITORIAL Building a resilient and sustainable workforce in aged care

Does size matter in aged care facilities? A literature review of the relationship between the number of facility beds and quality.

Background: Theory suggests that structural factors such as aged care facility size (bed numbers) will influence service quality. There have been no recent published studies in support of this theory, and consequently, the available literature has not been useful in assisting decision makers with investment decisions on facility size. Purpose: The study aimed to address that deficit by reviewing the international literature on the relationships between the size of residential aged care facilities, measured by number of beds, and service quality. Methods: A systematic review identified 30 studies that reported a relationship between facility size and quality and provided sufficient details to enable comparison. There are three groups of studies based on measurement of quality—those measuring only resident outcomes, those measuring care and resident outcomes using composite tools, and those focused on regulatory compliance. Findings: The overall findings support the posited theory to a large extent, that size is a factor in quality and smaller facilities yield the most favorable results. Studies using multiple indicators of service quality produced more consistent results in favor of smaller facilities, as did most studies of regulatory compliance. Discussion: The theory that aged care facility size (bed numbers) will influence service quality was supported by 26 of the 30 studies reviewed. Practice Implications: The review findings indicate that aged care facility size (number of beds) may be one important factor related to service quality. Smaller facilities are more likely to result in higher quality and better outcomes for residents than larger facilities. This has implications for those who make investment decisions concerning aged care facilities. The findings also raise implications for funders and policy makers to ensure that regulations and policies do not encourage the building of facilities inconsistent with these findings.