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Understanding Nurse Consultant role engagement in metropolitan and rural contexts
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Collegian (2016) xxx, xxx—xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/coll
Understanding Nurse Consultant role engagement in metropolitan and rural contexts Michelle Giles, RN, CM, BBus MIS, PhD a,∗, Vicki Parker, RN, PhD b, Rebecca Mitchell, PhD c a
Clinical Nurse Consultant Research, Hunter New England Local Health District, University of New England, James Fletcher Campus, 72 Watt Street , Newcastle, NSW 2300, Australia b School of Health, University of New England, Hunter New England Local Health District, Australia c School of Business and Law, University of Newcastle Australia Received 3 August 2015; received in revised form 19 March 2016; accepted 1 April 2016
KEYWORDS Advanced nursing practice; Nurse Consultant; Role ambiguity
Summary Background: Role ambiguity is known to impact negatively on role effectiveness. Nurse Consultants (NCs) are clinical leaders in Australia and similar roles exist internationally. Factors that lead to role ambiguity for NCs include dynamic and complex health care contexts and roles. To reduce ambiguity there is an urgent need to demonstrate NCs’ contribution to health care outcomes. Aim: This paper reports findings of a study exploring the role, scope and level of engagement of the NC across metropolitan and rural context in New South Wales, Australia. Design: This study used a cross sectional sequential mixed method design examining the complex and multifaceted nature of the NC’s work. Method: NCs were recruited across rural and metropolitan services in a large local health district in New South Wales, Australia. Phase one used a validated questionnaire to gather work engagement and activity data, phase two involved interviews with NCs and others stakeholders. Phase one findings are presented in this paper. Results: Work engagement patterns were influenced by role grade (1, 2 or 3), higher grades engaging at higher levels across domains and health sectors. NCs in rural locations had greater emphasis on education, clinical leadership and clinical consultancy and significantly more direct patient contact in their roles.
∗
Corresponding author. Tel.: +62 2 49246702. E-mail addresses: [email protected] (M. Giles), [email protected] (V. Parker), [email protected] (R. Mitchell). http://dx.doi.org/10.1016/j.colegn.2016.04.002 1322-7696/© 2016 Australian College of Nursing Ltd. Published by Elsevier Ltd.
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M. Giles et al. Conclusion: NCs engage consistently across domains of practice, contributing across multiple health sectors with flexibility to fulfilling health service needs. Findings highlight the relevance of the role in meeting dynamic workplace needs for high level nursing expertise and inform role application, implementation and workforce planning initiatives. © 2016 Australian College of Nursing Ltd. Published by Elsevier Ltd.
1. Introduction
1.1. Background
As senior expert clinicians, Nurse Consultants (NCs) significantly impact on clinical, service outcomes. However, the extent and value of this role is not well reported. This is largely due to the inability to ‘‘delineate distinct areas of work that everyone is able to recognize as NC’s work’’ (Dean, 2011, p. 1). Health organizations have become so complex that understanding how they do their business is an increasing challenge (Pslek & Wilson, 2001; Weberg, 2012). This increasing complexity calls for more complex roles with multiple layers that are required to change, evolve according to the needs of the organization (Kerr, 1978). The NC role, due to its dynamic, multifaceted, highly flexible, boundary spanning nature has absorbed some of that complexity (Cashin et al., 2014; Giles, Mitchell, & Parker, 2015; Lamont, Brunero, Lyons, Foster, & Perry, 2014). For individuals, the increasing complexity associated with the role can lead to unclear or ambiguous role definitions and unclear accountabilities (Birkinshaw & Heywood, 2010). Role ambiguity, defined as a ‘‘disconnect between information available to an individual, the information that is required for effective role performance’’ (Kahn, Wolfe, Quinn, Snoek, & Rosenthal, 1964, p. 73) is identified as a major issue in much of the literature related to NC type roles (Chang, Gardner, Duffield, & Ramus, 2010; Chiarella, Harford, & Lau, 2007; Drennan & Goodman, 2011; Duffield et al., 2011; Gardner, Chang, & Duffield, 2007; Lloyd Jones, 2005). This has led to a decline in these advanced practice nurse (APN) roles internationally (Dean, 2011; Ellis & Morrison, 2010) and in Australia (Baldwin et al., 2013; Bloomer & Cross, 2010; Duffield, Gardner, Chang, & Catling-Paull, 2009). It is imperative that the NC role and its impact are clearly identified and recognized as a valuable resource and service asset integral to future health service delivery models (Bloomer & Cross, 2010; Franks, 2014). This will only occur through close examination of the scope and characteristics of the role so that impact and value are more visible and can be differentiated from other roles. Identifying practice patterns is important when considering the introduction and development of APN roles (De Geest et al., 2008) and examining scope of role engagement will assist in identifying where the role can and will have impact (Gerrish et al., 2011; King & King, 1990). There is little research that examines in depth the work NCs do or the contribution they make to service delivery. This paper reports finding from a study examining how the NC role is enacted and integrated into health organizations and service delivery models in NSW, Australia
Health care environments are experiencing substantial reform in the midst of scarce health funding (AIHW, 2012; HWA, 2013; IMF, 2012). This has led to initiatives that have seen senior nursing roles in transition, with the creation of different roles with an emphasis on service replacement, gap filling and expanded scope of practice (Lowe, Plummer, O’Brien, & Boyd, 2012). However, the NC role is decreasing internationally (Dean, 2011; Ellis & Morrison, 2010) and in Australia (Baldwin et al., 2013; Duffield et al., 2009) despite the recognized value of these roles (Franks & Howarth, 2012; Gerrish, McDonnell, & Kennedy, 2013; McSherry, Mudd, & Campbell, 2007; Newhouse et al., 2011; Woodward, Webb, & Prowse, 2005). The NC role is recognized particularly in supporting and advancing the practice of other healthcare professionals, connecting and integrating care across services and strategic leadership of change and innovation in practice (Berwick, 2011; Dowling, Beauchesne, Farrelly, & Murphy, 2013; Franks & Howarth, 2012; Hutchinson, East, Stasa, & Jackson, 2014; Jokiniemi, Pietila, Kylma, & Haatainen, 2012). The NC role aligns across OECD countries, in that it comprises several key attributes: clinical expertise, leadership, autonomy and role development (Dowling et al., 2013; Guest et al., 2001, 2004; Jokiniemi et al., 2012). The role is described and appropriated through domains of practice similarly in the UK, Australia and Canada. In Australia these domains are; Clinical Service and Consultancy, Clinical Leadership, Research, Education and Clinical Services Planning and Management (NSW Department of Health, 2005). The Australian NC position is typically graded (grade 1, 2 or 3) to reflect complexity in levels of engagement within each domain of practice, a grade three requirement is for State and National participation and activities, requiring high level expertise in all five practice domains (NSW Department of Health, 2005). Role ambiguity has been repeatedly identified as one of the most prominent factors hindering the NC’s effectiveness in practice and the progression of APN roles internationally (Chang et al., 2010; Chiarella et al., 2007; Dowling et al., 2013; Drennan & Goodman, 2011; Duffield et al., 2011; Gardner et al., 2007; Lloyd Jones, 2005). This has contributed to inconsistent implementation of the NC role (Duffield et al., 2009; Hutchinson et al., 2014; Jokiniemi et al., 2012; Pulcini, Jelic, Gul, & Loke, 2010) because of lack of clarity regarding core role characteristics and differentiation from other senior nursing roles (Baldwin et al., 2013; Duffield et al., 2009; Gardner et al., 2007; Lowe et al.,
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Nurse Consultant role engagement 2012; Pulcini et al., 2010; Thoun, 2011). Role ambiguity is known to increase in the face of organizational change related to growth requiring reorganization, technological and personnel change (Lyons, 1971). Recent Health reforms and organizational restructuring have seen the emergence of new and unclear demands on the nursing profession. These demands have predominantly changed the APN role, blurring profession boundaries and scope of practice (Duffield et al., 2009; Lloyd Jones, 2005; Lowe et al., 2012). Increasing complexity of health care organizations has contributed further to this ambiguity (Dowling et al., 2013; Pslek & Wilson, 2001; Weberg, 2012). In complex organizations such as in Health, individuals are constantly required to meet a variety of expectations both from themselves and others to get the job done (Keller, 1975). When there is no pre-defined or agreed upon consensus of what the role should look like in complex roles that change over time (Kerr, 1978), expectations can become unclear (Birkinshaw & Heywood, 2010). The NC role is described as highly collaborative, working across traditional boundaries (Cashin et al., 2014; Giles et al., 2015; Lamont et al., 2014), complex and multidimensional, leading and supporting practice, with, in many cases, no direct relationship to patients (Coster et al., 2006; Duffield et al., 2009; Higgins, 2003; Kennedy et al., 2012; Por, 2008). These unique role characteristics heighten the degree of role ambiguity and make it difficult to attribute specific patient outcomes (Drennan & Goodman, 2011; Fairley & Closs, 2006; Gerrish et al., 2011, 2013; Singh, 1993). It is well established that a clear understanding of role responsibilities and expectations will enable better role performance (Rheiner, 1982). This can only be achieved with close examination of existing NC roles and strategic alignment with service and professional goals. Identifying practice patterns is important when considering the introduction and development of NC roles (De Geest et al., 2008). Examining scope of role engagement will assist in identifying where the NC can and will have impact (Gerrish et al., 2011; King & King, 1990). New and emerging integrated and interdisciplinary models of health care delivery imply changing practice patterns within interdisciplinary teams (De Geest et al., 2008). However, little is known about the full extent of the NC role across systems and services (Gerrish et al., 2011). It is vital that other health professions have a clear understanding of the role NCs can play in their teams to ensure optimal effectiveness and outcomes (Jackson & Randall, 1985). Managers can play a lead role in eliminating role ambiguity (Singh, 1993), but only with full understanding of the scope and nature of NCs actual and potential role engagement across and within services. This inturn informs understanding of where and how NCs contribute and their impact. It also enables managers to better sponsor, support and deploy their NCs for maximum impact. Without clarity the role is at risk of becoming displaced or redundant in evolving efficiency focussed models of care (Baldwin et al., 2013; Dean, 2011; Ellis & Morrison, 2010). There are very few studies that effectively examine the NC role specifications against award guidelines and domains of practice, or how the NC workforce is positioned across health service sectors. There has also
3 been no attempt to differentiation between the nature of the role in metropolitan and rural context, despite rural clinical practice differing markedly from that of metropolitan practice (AIHW, 2004, 2012; Newhouse et al., 2011; Wakerman, 2008). Rural contexts have many more challenges related to workforce shortages, retention (Paliadelis, Parmenter, Parker, Giles, & Higgins, 2012) and shortage of specialist services (Wakerman, 2008). Researchers have called for studies that clarify the scope of all APN roles. It is critical that complex health care institutions are clear about the NC scope and functions and that the boundaries with other nursing roles and health professionals are clearly articulated so that NCs can be effective members of the health care team (Chang et al., 2010; Duffield et al., 2011; Gardner et al., 2007; Lloyd Jones, 2005; Lowe et al., 2012). This specification needs to be understood across professions to minimize the risks associated with role ambiguity. This study informs this agenda and will enable health organizations and managers to maximize NC impact in current and future health service delivery models.
2. The study 2.1. AIM This study aim is to examine the nature and impact of the NC role in New South Wales (NSW), Australia (Giles, Parker, & Mitchell, 2014). This paper reports the findings related to NC activity, scope of practice and patterns of role engagement across health service delivery contexts in both metropolitan and rural areas.
2.2. Design A sequential mixed method cross sectional design to examine the diverse nature of the NC role (Giles et al., 2014). Mixed method approaches provide a mechanism for understanding and explaining complex organizational and social phenomena through the integration of qualitative and quantitative approaches (Cao, Maruping, & Takeuchi, 2006). Phase one used a validated questionnaire and phase 2 involved interviews with NCs and others stakeholders. Findings from phase one are presented in this paper.
2.3. Context A local health district (LHD) comprising metropolitan, rural and very remote regions across an extensive geographic area in NSW, Australia. A NSW LHD ‘‘operates public hospitals and institutions and provides health services to communities within designated geographical areas’’ (NSW Health, 2015).
2.4. Participants There were 194 NCs employed within the health district, 64% (n 124) located in a metropolitan area. All NCs identified from the workforce database were invited to participate in an online survey via their employee email account. Required sample size was 130 respondents to provide a representative sample with a 95% confidence level and 5% margin of error.
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2.5. Data collection A survey developed by Guest et al. (2001) was modified, with the permission of the authors, to meet the Australian context. A 43-question survey with Likert scale, and multiple-choice responses was developed. Questions were clustered into sections according to constructs of interest. The findings reported here relate to the NC role scope, activities and engagement patterns. There were 27 activity items included in the domain related factors and these are detailed in Table 1. Prior to release the survey was piloted with ten nursing staff (educators and consultants) who provided feedback and comment on content validity, clarity, online functionality, questions of bias and user friendliness. It was then modified and made available online using the computer survey software Survey Monkey (SurveyMonkey Inc., 1999). The URL address of the survey was then circulated via individual work emails to all NCs with an invitation to voluntarily participate in the research. Face to face information sessions were held prior to survey distribution. The survey was made available to participants in February 2010 and remained open for 6 weeks until 31 March 2010 and email reminders were circulated every fortnight.
2.6. Ethical considerations The study was approved by the Hunter New England Human Research Ethics Committee (approval no. 12/07/18/5.07). Participation in the study was entirely voluntary and all potential participants were provided with an opportunity to attend information sessions and provided with detailed information sheets to ensure informed consent. The online survey did not require the participants to disclose any identifying information and assurance was given that privacy would be protected during reporting processes, particularly for those working in rural locations in unique circumstances.
2.7. Data analysis Quantitative data were analyzed using IBM SPSS software version 18 (SPSS Inc., 2009). Analysis of survey data included descriptive statistics to produce demographic and geographic descriptions of the consultant workforce and their roles. Categorical analysis and analysis of variance using Kruskal—Wallis identified variables predicting differences using a significance level of 0.05 for position grades and metropolitan and rural location.
2.8. Validity and reliability The use of a previously validated survey (Guest et al., 2001) which incorporates a range of the constructs identified in the literature related to exploring the nature and function of the role strengthen data reliability. Cronbach alpha scores for each of the domain factors reported in this paper were between 0.7 and 0.9. Cronbach alpha is a measure of internal consistency and scale reliability used
Table 1
Survey activity items included in each factor.
Research Factor/Domain (alpha .91) (26) Participation as part of a research team (27) Undertaking research at a local level (28) Leading research teams (31) Developing research protocols (32) Applying for research funding Education Factor (alpha .84) (16) Identifying and responding to individual and team education needs (18) Mentoring staff (19) Supervising staff (20) Engaging in professional development of staff in my service/unit (21) Engaging in professional development of staff across this LHD (22) Teaching staff & students in partnership with universities/colleges Clinical Service Planning and Management Factor (alpha .82) (4) Developing professional protocols, documentation systems & guidelines (5) Monitoring the effectiveness of current therapeutic programs (24) Setting, auditing and monitoring standards (25) Evaluating local services against best practice (14) Generating and implementing new solutions that will best meet the needs of patients/clients Clinical Leadership Factor (alpha .87) (7) Advising and supporting colleagues where standard protocols do not apply (8) Advising and supporting colleagues (9) Advising and supporting colleagues in rural settings (10) Advising and supporting colleagues across this LHD (11) Advising and supporting colleagues across the State and/or nationally (15) Offering expert advice to your own and other professions on care practices, delivery and service development (17) Consulting with staff across this LHD Clinical Service/Consultancy Factor (alpha .70) (1) Making referrals to other professionals (2) Prescribing aids or equipment (3) Managing complete programs of care (33) Undertaking interventions normally undertaken by medical or other professional staff
when multiple-item measures of a concept or construct are employed (Tavakol & Dennick, 2011).
3. Results The most significant findings were how extensively many individual NC’s engaged across many service delivery sectors (Fig. 2) and how that engagement played out and differed, in the form of activities and work patterning, between NCs working within metropolitan and rural work environments.
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Nurse Consultant role engagement Table 2
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Respondent demographics.
All nurses and midwives in LHD Total CNC’s Grade 1 Grade 2 Grade 3 Female Mean age (years) Years employed in LHD (years) Years employed in current role (years)
3.1. Demographics At the time of data collection there were 7279 nurses and midwives employed within the LHD and 3% were APNs. NC numbers had increased from 163 in 2007 to 194 in 2010. The survey response rate was higher than expected at 95% (n = 184) however some respondents did not complete the survey from start to finish. Only 140 respondents completed the survey in full, a final response rate of 72%. The following results are based on these 140 respondents. Table 2 outlines demographic information of respondent. Mean age of NC’s was greater in rural locations (49 years) when compared with their metropolitan colleagues (47 years). Over 60% of respondents had been in their current consultant role for 6 years or more. The majority of respondents (80%) were working in fulltime positions and on permanent contracts (89%). Some positions were fulltime and job shared. However 11% were in fixed term project specific positions. Thirty percent (n = 54) of all respondents and 60% (n = 20) of grade 3 respondents had a Master’s degree as their highest qualification. Eight percent (n = 15) of respondents’ identified a certificate as their highest qualification; however none of these respondents were grade 3. There were no differences noted across the metropolitan and rurally based groups. Respondents were asked how many people reported directly to their position; 70% (n = 94) had no direct line management responsibilities. However, 30% did have line management responsibilities with the number of individuals reporting to them ranging from 1 to as high as 44. Only 36% of respondents had a nurse or midwife as their direct line manager, the remaining 64% reported to non-nursing/midwifery positions such as Service Managers, Service and Medical Directors, Clinical Network Directors, Operations Managers and General Managers. NCs with rural responsibilities were more likely to have a nurse or midwife position as their line manager (54%) than those with responsibilities in either both or metropolitan only jurisdictions (31%).
3.2. Nurse Consultant workforce engagement Our investigation of engagement focused on three related issues:
All LHD workforce
Survey respondents
7279 194 84 71 39 85%
— 140 (72%) 49 (59%) 56 (79%) 34 (87%) 88% 48 (range 30—64) 18 (1—40) 8 (1 month—28 years)
1. Scope of the role across the LHD. 2. The health service delivery sectors in which the position engages. 3. Level of this engagement in a variety of activities described within the domains of the State Award policy directive (NSW Department of Health, 2005).
3.2.1. Scope of role engagement across the district Respondents were asked if their role responsibilities encompassed rural or metropolitan responsibilities or both and whether the focus of their role was across the entire LHD. Fig. 1 details the results by role grade. Seventy one percent of grade 3 NCs and 35% of grade 1 and 2 NCs saw themselves as having district wide responsibilities. Despite 64% of all NC positions within this LHD being located in metropolitan areas, only 23% (n = 26) said they had metropolitan only responsibilities.
3.2.2. Engagement across health service delivery sectors To gain clarity related to what sectors of service delivery the NC workforce spend their time in, respondents were asked to estimate the percentage of their time spent in each of the following six sectors of health service delivery; Prevention/Promotion/Protection, Primary Health, Ambulatory Care, Emergency Care, Acute Care, Rehabilitation and Extended care (including Palliative Care). The majority of respondents (83% of all respondents and 91% of Grade 3) spent time across more than one of the above categories (Fig. 2), 37% (n = 52) of all respondents and 36% (n = 13) of grade 3 respondents spent time across four or more categories. The most common category identified was Prevention/Promotion/Protection where 64% (n = 89) spent some time and 14% spent over 50% of their time. The next most common categories were Acute Care (58%, n = 82) and Primary Health (56%, n = 78). In the grade 3 group 30% spent some time across five or six of the sectors in the course of their employment activities. In rural positions 41% of respondents spent time across four or more health service delivery sectors, double that of the metropolitan based group at 20%, but comparable to 38% in the group who have role responsibilities in both jurisdictions.
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Figure 1
Scope of the role across the LHD as a percentage of total numbers by grade.
3.2.3. Domain related work activity and patterns To gain a clearer understanding of how NCs engage with their expected domains of practice, respondents were asked to what extent they were involved/contributed to a variety of activities using the following ranking scale; 1 — not involved at all, 2 — minor involvement, 3 — moderate involvement, 4 — major involvement and 5 — I take the lead in this activity. Activities were grouped into one of five factors to reflect the five domains under which the NC role is expected to practice within the NSW Award (NSW Department of Health, 2005).
Figure 2
The level of involvement overall was highest in activities related to Clinical Leadership and Clinical Service Planning and Management. Grade 3 respondents’ overall mean score (3.53) reflected higher involvement across all domains (Fig. 3) with their lowest mean score in research related activities (2.91). Grade 3 respondents had significantly less involvement in Clinical Service Consultancy activities (p < 0.01, Kruskal—Wallis) and greater involvement in research (p < 0.01) and clinical leadership activities (p < 0.05, Kruskal—Wallis) than lower grades.
Nurse Consultant workforce engagement across health service delivery sectors.
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Figure 3
Mean score in domain related activity factors.
Rural respondents had less activities related to the research domain, but more education, service planning and service consultancy activities (Fig. 4). They also identified significantly more clinical leadership activities within their roles (p < 0.01, Kruskal—Wallis). Further exploration of domain factor activity included patterns of involvement in each domain and is detailed in Fig. 5. Degree of involvement was measured at 3 levels • Low involvement: score of less than 2. • Moderate involvement: score of between 2 and 3.9. • High involvement: score 4—5.
Figure 4
Clinical Service Planning/Management (n 53, 67%) and Clinical Leadership (n 48, 69%) had the most number of respondents with a high involvement score. This was followed by education, where 26% (n 35) of respondents scored their involvement within the high range. Low involvement levels were more common in Research (50%) and Clinical Service Consultancy (27%). A moderate level of involvement was the most common pattern across all the domains except Research. Again the results demonstrated that grade 3 respondents had less involvement in Clinical Service Consultancy activities and more involvement in Research and Clinical Leadership activities.
Mean score in domain related activity by scope of practice.
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Figure 5
Level of involvement in domain activity as percentage of Nurse Consultants.
Overall metropolitan and rural comparisons were similar with a moderate level of involvement as the most common work pattern. Research featured more strongly in roles with metropolitan and both rural and metro responsibilities. Clinical leadership presented mostly in moderate and high involvement patterns and was more prominent at these higher levels of involvement in rural respondent’s activities. Level of education also influenced degree of involvement in Clinical Leadership activities and respondents with a masters level qualification and above had significantly higher levels of involvement in Clinical Leadership activities (p < 0.01, Kruskal—Wallis).
4. Discussion The results reported in this paper provide unique insight into the NC role integration within health service delivery models by identifying role responsibilities, sphere of role influence across health sectors as well as types of role activities, engagement and patterning of the NC role. This is critical information at a time when workforce costs are being closely
scrutinized from within and outside the profession (Baldwin et al., 2013) and the NC role is at risk in future health service delivery models (Baldwin et al., 2013; Dean, 2011; Duffield et al., 2009; Ellis & Morrison, 2010). Study findings demonstrating the scope of role engagement and how that engagement occurs in terms of the practice domains provides many benefits. The NC role, described as a highly engaged, collaborative and connected role working across boundaries, is well supported by our findings (Cashin et al., 2014; Giles et al., 2015; Lamont et al., 2014). Role engagement patterns demonstrate that NCs largely work across several health service delivery sectors, with higher grades working across more sectors, some across five or more. Twice as many rural NCs work across four or more sectors of health service delivery than their metropolitan counterparts. This supports evidence that rural practitioners function with a more flexible and generalist expanded scope of practice, adjusting to the needs of the service (Paliadelis et al., 2012). This in-depth insight gives managers and other health care professionals better understanding of the NC’s contribution and potential in a variety of contexts. It also ensures
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Nurse Consultant role engagement NC visibility to other professions, lessening ambiguity and misunderstanding (Coster et al., 2006). Clear understanding of role responsibilities and expectations enables better role performance within health care teams (Rheiner, 1982). Impact of the role is then recognizable at an organizational level, reducing the likelihood of the NC role being undervalued and potentially disappearing (Bloomer & Cross, 2010; Dean, 2011; Drennan & Goodman, 2011; Franks & Howarth, 2012). Only a third of NCs are line managed by a nursing position and some have more than one line manager. Non-nursing line management positions may contribute to role ambiguity if there is limited knowledge of nursing role functions. Having more than one line manager can lead to managers having competing expectations. This situation can also increased role ambuguity, role conflict, role stress and job dissatisfaction leading to less effective role performance and influencing an individuals’ intention to stay (Rheiner, 1982). The findings from this study will assist managers in delineating the NCs function as distinct from that of other health care team members, informing role alignment to health service need. In line with current research (Baldwin et al., 2013; Duffield et al., 2009; Hutchinson et al., 2014; Jokiniemi et al., 2012; Pulcini et al., 2010) this study highlights inconsistencies in the way positions are appointed. Some positions, despite being employed under the classification of NC, can be project specific roles or come under a different title, further adding to the confusion (Chang et al., 2010; Chiarella et al., 2007; Duffield et al., 2009, 2011; Gardner et al., 2007; Lowe et al., 2012). The level of seniority built into the Australian NC award through grading (NSW Department of Health, 2005) is well substantiated in the study findings where the nature and complexity of roles is determined substantially by their grading. There is a general consensus that higher grade NCs have District wide jurisdiction in their role and that the lesser grades tend to be more unit or department based. However, findings from this study indicate that, although a large number of higher grade positions (71%) function with a wide geographic purvue, a third have more limited scope. A third of both grade one and two NCs see themselves as having district-wide responsibilities. This reflects perhaps how roles have evolved over time, as well as inequities in how postions are classified and implemented. How daily activities are configured into the patterns or domains of practice provide validation of the complexity of the NC role across context. Low involvement across all domains does not necessarily reflect low impact. Perhaps it more accurately reflects the diversity in many of the roles, their high level of engagement and scope of influence across a considerable range of activities and sectors. Higher-grade respondents generally had more domain activity related to research, education, management and collaboration and significantly less time spent in Clinical Service Consultancy. Respondents rated activities related to Clinical Leadership and Clinical Service Consultancy as having the highest level of priority in their roles. Bloomer and Cross (2010) reported an underutilization of the clinical leadership capacity of the NC because of inconsistent role application. However our respondents reported moderate to high levels of clinical leadership activity and these activities were significantly
9 higher in rural based roles. Again this may be a reflection of the flexibility in practice described by Paliadelis et al. (2012) when adjusting to meet health service needs in rural based practice. In some instances rural clinicians working with minimal support structures (Paliadelis et al., 2012) provide high level leadership in advising and supporting others. NCs, described in the literature as having key attributes of autonomy, role development, leadership and clinical expertise (Dowling et al., 2013; Guest et al., 2001, 2004; Jokiniemi et al., 2012) are perfectly positioned to be flexible in function and scope to fulfill the needs within evolving health service models. As health care delivery has become more and more complex the NC role has cushioned the potential chaos by changing and evolving to help meet the needs of this changing environment. This is particularly evident in rural context where access to specialist resources can be limited. A key strategy highlighted by Wakerman (2008) to address the current rural—metropolitan health inequities is to enhance primary prevention and health promotion. Study findings demonstrate that 60% of rural based NCs spend some time in this sector. Findings related to work patterns support the notion that there is great diversity and variation in work activities in NC roles (Baldwin et al., 2013; Coster et al., 2006; Duffield et al., 2009; Por, 2008). In particular there is a tendency for individual roles to have certain practice domain activities emphasized and others deemphasised. This is evidenced in activities related to management, where only 30% of respondents identified having line management responsibilities, but some managed over 40 staff. In terms of other types of role engagement the higher the grade the lower the percentage of time working in direct patient contact. Otherwise the time spent on activities is fairly uniform across all grades. Surprisingly, the amount of time spent on research activity was similar across all grades and rural respondents tended to spend less time on research, and more time on education, management and collaboration. Rural respondents identified a higher level of involvement in direct patient contact, double that of their metropolitan counterparts. The findings of this research provide managers with valuable information on how NCs can best be engaged and successfully integrated into health care services in the future. In order to accommodate best fit for NC roles it is imperative that role function and impact is clear and can be differentiated from other roles. The ever increasing complexity of individual NC roles means that role ambiguity is likely for NCs without a clear and agreed understanding of their function and remit. Such ambiguity can lead to overload and stress-related absence and turnover. In addition, a lack of clarity regarding the NC role has significant negative implications for its perceived utility and effectiveness. Increased clarity is likely to strengthen perceptions of the NC role contribution and value, which lessens the likelihood of stress in NCs and the diminution of the role by other professions and healthcare management. Not all role complexity is bad, but what creates the complexity needs to be well understood and managed more effectively by managers (Birkinshaw & Heywood, 2010). Ambiguity is a role characteristic that can be most influenced by managerial intervention (Kahn et al., 1964). Awareness of role engagement and activities will assist managers in making decisions related to realignment of
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10 current roles, and placing and support of new roles for maximum contribution. This multi-dimensional role needs supporting through shared expectations, capacity building and integration into current and future models of care and service delivery. The information gained from this research provides insight for future succession planning and planning capacity building strategies to strengthen the role and its contribution to health care teams and patient outcomes. Of particular importance are the findings related to emphasis and de-emphasis of practice domains of individual roles across context. This information provides guidance to workforce planners, service managers and healthcare teams identifying and filling skill mix gaps to ensure the NC can function as clinical leaders to maximize their impact. Many NCs provide clinical leadership within current health care delivery models. They have been described as change agents (Berwick, 2011) and supporting the practice of others across disciplines and boundaries (Giles et al., 2015). Contemporary understandings of complex organizations highlight the need for leadership that operates from within systems, is organic and has the capacity to be refocused to accommodate dynamic imperatives. This study indicates that NCs are working, some more than others, to achieve this. The challenge for managers, who have NCs within their team, is how to deal with the conflicting need for both regulation and flexibility in organizations that are inherently dynamic and controlled by regulation and standardization.
4.1. Limitations Finding from this study are based on results from one large LHD in NSW Australia, however there is representation from metropolitan, rural and remote health care context across multiple service delivery models from highly specialist service to district wide networks.
5. Conclusion This study makes a significant contribution to understanding of the NC role and its contribution to practice. It had demonstrated that although most NC work within the Domains of practice designated within job descriptions, many are able to adjust their work patterns and levels of engagement in accordance with changing circumstances and local need. This is particularly evident in rural areas subject to lack of access and fluctuating access to services. Complex organizations and systems of care require clinical leadership that is characterized by responsiveness, flexibility and agility. The NC is possibly the only role that is able to provide such leadership through enactment of supporting, connecting and consulting functions in relation to enhancing nursing practice and participation in inter-professional teams. Further research is needed to explore how the role can be developed and deployed to contribute optimally in particular contexts. Such research, together with the findings reported here will inform workforce planning, professional development and advanced practice tertiary education programs.
M. Giles et al.
Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
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Collegian (2016) xxx, xxx—xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/coll
Understanding Nurse Consultant role engagement in metropolitan and rural contexts Michelle Giles, RN, CM, BBus MIS, PhD a,∗, Vicki Parker, RN, PhD b, Rebecca Mitchell, PhD c a
Clinical Nurse Consultant Research, Hunter New England Local Health District, University of New England, James Fletcher Campus, 72 Watt Street , Newcastle, NSW 2300, Australia b School of Health, University of New England, Hunter New England Local Health District, Australia c School of Business and Law, University of Newcastle Australia Received 3 August 2015; received in revised form 19 March 2016; accepted 1 April 2016
KEYWORDS Advanced nursing practice; Nurse Consultant; Role ambiguity
Summary Background: Role ambiguity is known to impact negatively on role effectiveness. Nurse Consultants (NCs) are clinical leaders in Australia and similar roles exist internationally. Factors that lead to role ambiguity for NCs include dynamic and complex health care contexts and roles. To reduce ambiguity there is an urgent need to demonstrate NCs’ contribution to health care outcomes. Aim: This paper reports findings of a study exploring the role, scope and level of engagement of the NC across metropolitan and rural context in New South Wales, Australia. Design: This study used a cross sectional sequential mixed method design examining the complex and multifaceted nature of the NC’s work. Method: NCs were recruited across rural and metropolitan services in a large local health district in New South Wales, Australia. Phase one used a validated questionnaire to gather work engagement and activity data, phase two involved interviews with NCs and others stakeholders. Phase one findings are presented in this paper. Results: Work engagement patterns were influenced by role grade (1, 2 or 3), higher grades engaging at higher levels across domains and health sectors. NCs in rural locations had greater emphasis on education, clinical leadership and clinical consultancy and significantly more direct patient contact in their roles.
∗
Corresponding author. Tel.: +62 2 49246702. E-mail addresses: [email protected] (M. Giles), [email protected] (V. Parker), [email protected] (R. Mitchell). http://dx.doi.org/10.1016/j.colegn.2016.04.002 1322-7696/© 2016 Australian College of Nursing Ltd. Published by Elsevier Ltd.
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M. Giles et al. Conclusion: NCs engage consistently across domains of practice, contributing across multiple health sectors with flexibility to fulfilling health service needs. Findings highlight the relevance of the role in meeting dynamic workplace needs for high level nursing expertise and inform role application, implementation and workforce planning initiatives. © 2016 Australian College of Nursing Ltd. Published by Elsevier Ltd.
1. Introduction
1.1. Background
As senior expert clinicians, Nurse Consultants (NCs) significantly impact on clinical, service outcomes. However, the extent and value of this role is not well reported. This is largely due to the inability to ‘‘delineate distinct areas of work that everyone is able to recognize as NC’s work’’ (Dean, 2011, p. 1). Health organizations have become so complex that understanding how they do their business is an increasing challenge (Pslek & Wilson, 2001; Weberg, 2012). This increasing complexity calls for more complex roles with multiple layers that are required to change, evolve according to the needs of the organization (Kerr, 1978). The NC role, due to its dynamic, multifaceted, highly flexible, boundary spanning nature has absorbed some of that complexity (Cashin et al., 2014; Giles, Mitchell, & Parker, 2015; Lamont, Brunero, Lyons, Foster, & Perry, 2014). For individuals, the increasing complexity associated with the role can lead to unclear or ambiguous role definitions and unclear accountabilities (Birkinshaw & Heywood, 2010). Role ambiguity, defined as a ‘‘disconnect between information available to an individual, the information that is required for effective role performance’’ (Kahn, Wolfe, Quinn, Snoek, & Rosenthal, 1964, p. 73) is identified as a major issue in much of the literature related to NC type roles (Chang, Gardner, Duffield, & Ramus, 2010; Chiarella, Harford, & Lau, 2007; Drennan & Goodman, 2011; Duffield et al., 2011; Gardner, Chang, & Duffield, 2007; Lloyd Jones, 2005). This has led to a decline in these advanced practice nurse (APN) roles internationally (Dean, 2011; Ellis & Morrison, 2010) and in Australia (Baldwin et al., 2013; Bloomer & Cross, 2010; Duffield, Gardner, Chang, & Catling-Paull, 2009). It is imperative that the NC role and its impact are clearly identified and recognized as a valuable resource and service asset integral to future health service delivery models (Bloomer & Cross, 2010; Franks, 2014). This will only occur through close examination of the scope and characteristics of the role so that impact and value are more visible and can be differentiated from other roles. Identifying practice patterns is important when considering the introduction and development of APN roles (De Geest et al., 2008) and examining scope of role engagement will assist in identifying where the role can and will have impact (Gerrish et al., 2011; King & King, 1990). There is little research that examines in depth the work NCs do or the contribution they make to service delivery. This paper reports finding from a study examining how the NC role is enacted and integrated into health organizations and service delivery models in NSW, Australia
Health care environments are experiencing substantial reform in the midst of scarce health funding (AIHW, 2012; HWA, 2013; IMF, 2012). This has led to initiatives that have seen senior nursing roles in transition, with the creation of different roles with an emphasis on service replacement, gap filling and expanded scope of practice (Lowe, Plummer, O’Brien, & Boyd, 2012). However, the NC role is decreasing internationally (Dean, 2011; Ellis & Morrison, 2010) and in Australia (Baldwin et al., 2013; Duffield et al., 2009) despite the recognized value of these roles (Franks & Howarth, 2012; Gerrish, McDonnell, & Kennedy, 2013; McSherry, Mudd, & Campbell, 2007; Newhouse et al., 2011; Woodward, Webb, & Prowse, 2005). The NC role is recognized particularly in supporting and advancing the practice of other healthcare professionals, connecting and integrating care across services and strategic leadership of change and innovation in practice (Berwick, 2011; Dowling, Beauchesne, Farrelly, & Murphy, 2013; Franks & Howarth, 2012; Hutchinson, East, Stasa, & Jackson, 2014; Jokiniemi, Pietila, Kylma, & Haatainen, 2012). The NC role aligns across OECD countries, in that it comprises several key attributes: clinical expertise, leadership, autonomy and role development (Dowling et al., 2013; Guest et al., 2001, 2004; Jokiniemi et al., 2012). The role is described and appropriated through domains of practice similarly in the UK, Australia and Canada. In Australia these domains are; Clinical Service and Consultancy, Clinical Leadership, Research, Education and Clinical Services Planning and Management (NSW Department of Health, 2005). The Australian NC position is typically graded (grade 1, 2 or 3) to reflect complexity in levels of engagement within each domain of practice, a grade three requirement is for State and National participation and activities, requiring high level expertise in all five practice domains (NSW Department of Health, 2005). Role ambiguity has been repeatedly identified as one of the most prominent factors hindering the NC’s effectiveness in practice and the progression of APN roles internationally (Chang et al., 2010; Chiarella et al., 2007; Dowling et al., 2013; Drennan & Goodman, 2011; Duffield et al., 2011; Gardner et al., 2007; Lloyd Jones, 2005). This has contributed to inconsistent implementation of the NC role (Duffield et al., 2009; Hutchinson et al., 2014; Jokiniemi et al., 2012; Pulcini, Jelic, Gul, & Loke, 2010) because of lack of clarity regarding core role characteristics and differentiation from other senior nursing roles (Baldwin et al., 2013; Duffield et al., 2009; Gardner et al., 2007; Lowe et al.,
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Nurse Consultant role engagement 2012; Pulcini et al., 2010; Thoun, 2011). Role ambiguity is known to increase in the face of organizational change related to growth requiring reorganization, technological and personnel change (Lyons, 1971). Recent Health reforms and organizational restructuring have seen the emergence of new and unclear demands on the nursing profession. These demands have predominantly changed the APN role, blurring profession boundaries and scope of practice (Duffield et al., 2009; Lloyd Jones, 2005; Lowe et al., 2012). Increasing complexity of health care organizations has contributed further to this ambiguity (Dowling et al., 2013; Pslek & Wilson, 2001; Weberg, 2012). In complex organizations such as in Health, individuals are constantly required to meet a variety of expectations both from themselves and others to get the job done (Keller, 1975). When there is no pre-defined or agreed upon consensus of what the role should look like in complex roles that change over time (Kerr, 1978), expectations can become unclear (Birkinshaw & Heywood, 2010). The NC role is described as highly collaborative, working across traditional boundaries (Cashin et al., 2014; Giles et al., 2015; Lamont et al., 2014), complex and multidimensional, leading and supporting practice, with, in many cases, no direct relationship to patients (Coster et al., 2006; Duffield et al., 2009; Higgins, 2003; Kennedy et al., 2012; Por, 2008). These unique role characteristics heighten the degree of role ambiguity and make it difficult to attribute specific patient outcomes (Drennan & Goodman, 2011; Fairley & Closs, 2006; Gerrish et al., 2011, 2013; Singh, 1993). It is well established that a clear understanding of role responsibilities and expectations will enable better role performance (Rheiner, 1982). This can only be achieved with close examination of existing NC roles and strategic alignment with service and professional goals. Identifying practice patterns is important when considering the introduction and development of NC roles (De Geest et al., 2008). Examining scope of role engagement will assist in identifying where the NC can and will have impact (Gerrish et al., 2011; King & King, 1990). New and emerging integrated and interdisciplinary models of health care delivery imply changing practice patterns within interdisciplinary teams (De Geest et al., 2008). However, little is known about the full extent of the NC role across systems and services (Gerrish et al., 2011). It is vital that other health professions have a clear understanding of the role NCs can play in their teams to ensure optimal effectiveness and outcomes (Jackson & Randall, 1985). Managers can play a lead role in eliminating role ambiguity (Singh, 1993), but only with full understanding of the scope and nature of NCs actual and potential role engagement across and within services. This inturn informs understanding of where and how NCs contribute and their impact. It also enables managers to better sponsor, support and deploy their NCs for maximum impact. Without clarity the role is at risk of becoming displaced or redundant in evolving efficiency focussed models of care (Baldwin et al., 2013; Dean, 2011; Ellis & Morrison, 2010). There are very few studies that effectively examine the NC role specifications against award guidelines and domains of practice, or how the NC workforce is positioned across health service sectors. There has also
3 been no attempt to differentiation between the nature of the role in metropolitan and rural context, despite rural clinical practice differing markedly from that of metropolitan practice (AIHW, 2004, 2012; Newhouse et al., 2011; Wakerman, 2008). Rural contexts have many more challenges related to workforce shortages, retention (Paliadelis, Parmenter, Parker, Giles, & Higgins, 2012) and shortage of specialist services (Wakerman, 2008). Researchers have called for studies that clarify the scope of all APN roles. It is critical that complex health care institutions are clear about the NC scope and functions and that the boundaries with other nursing roles and health professionals are clearly articulated so that NCs can be effective members of the health care team (Chang et al., 2010; Duffield et al., 2011; Gardner et al., 2007; Lloyd Jones, 2005; Lowe et al., 2012). This specification needs to be understood across professions to minimize the risks associated with role ambiguity. This study informs this agenda and will enable health organizations and managers to maximize NC impact in current and future health service delivery models.
2. The study 2.1. AIM This study aim is to examine the nature and impact of the NC role in New South Wales (NSW), Australia (Giles, Parker, & Mitchell, 2014). This paper reports the findings related to NC activity, scope of practice and patterns of role engagement across health service delivery contexts in both metropolitan and rural areas.
2.2. Design A sequential mixed method cross sectional design to examine the diverse nature of the NC role (Giles et al., 2014). Mixed method approaches provide a mechanism for understanding and explaining complex organizational and social phenomena through the integration of qualitative and quantitative approaches (Cao, Maruping, & Takeuchi, 2006). Phase one used a validated questionnaire and phase 2 involved interviews with NCs and others stakeholders. Findings from phase one are presented in this paper.
2.3. Context A local health district (LHD) comprising metropolitan, rural and very remote regions across an extensive geographic area in NSW, Australia. A NSW LHD ‘‘operates public hospitals and institutions and provides health services to communities within designated geographical areas’’ (NSW Health, 2015).
2.4. Participants There were 194 NCs employed within the health district, 64% (n 124) located in a metropolitan area. All NCs identified from the workforce database were invited to participate in an online survey via their employee email account. Required sample size was 130 respondents to provide a representative sample with a 95% confidence level and 5% margin of error.
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2.5. Data collection A survey developed by Guest et al. (2001) was modified, with the permission of the authors, to meet the Australian context. A 43-question survey with Likert scale, and multiple-choice responses was developed. Questions were clustered into sections according to constructs of interest. The findings reported here relate to the NC role scope, activities and engagement patterns. There were 27 activity items included in the domain related factors and these are detailed in Table 1. Prior to release the survey was piloted with ten nursing staff (educators and consultants) who provided feedback and comment on content validity, clarity, online functionality, questions of bias and user friendliness. It was then modified and made available online using the computer survey software Survey Monkey (SurveyMonkey Inc., 1999). The URL address of the survey was then circulated via individual work emails to all NCs with an invitation to voluntarily participate in the research. Face to face information sessions were held prior to survey distribution. The survey was made available to participants in February 2010 and remained open for 6 weeks until 31 March 2010 and email reminders were circulated every fortnight.
2.6. Ethical considerations The study was approved by the Hunter New England Human Research Ethics Committee (approval no. 12/07/18/5.07). Participation in the study was entirely voluntary and all potential participants were provided with an opportunity to attend information sessions and provided with detailed information sheets to ensure informed consent. The online survey did not require the participants to disclose any identifying information and assurance was given that privacy would be protected during reporting processes, particularly for those working in rural locations in unique circumstances.
2.7. Data analysis Quantitative data were analyzed using IBM SPSS software version 18 (SPSS Inc., 2009). Analysis of survey data included descriptive statistics to produce demographic and geographic descriptions of the consultant workforce and their roles. Categorical analysis and analysis of variance using Kruskal—Wallis identified variables predicting differences using a significance level of 0.05 for position grades and metropolitan and rural location.
2.8. Validity and reliability The use of a previously validated survey (Guest et al., 2001) which incorporates a range of the constructs identified in the literature related to exploring the nature and function of the role strengthen data reliability. Cronbach alpha scores for each of the domain factors reported in this paper were between 0.7 and 0.9. Cronbach alpha is a measure of internal consistency and scale reliability used
Table 1
Survey activity items included in each factor.
Research Factor/Domain (alpha .91) (26) Participation as part of a research team (27) Undertaking research at a local level (28) Leading research teams (31) Developing research protocols (32) Applying for research funding Education Factor (alpha .84) (16) Identifying and responding to individual and team education needs (18) Mentoring staff (19) Supervising staff (20) Engaging in professional development of staff in my service/unit (21) Engaging in professional development of staff across this LHD (22) Teaching staff & students in partnership with universities/colleges Clinical Service Planning and Management Factor (alpha .82) (4) Developing professional protocols, documentation systems & guidelines (5) Monitoring the effectiveness of current therapeutic programs (24) Setting, auditing and monitoring standards (25) Evaluating local services against best practice (14) Generating and implementing new solutions that will best meet the needs of patients/clients Clinical Leadership Factor (alpha .87) (7) Advising and supporting colleagues where standard protocols do not apply (8) Advising and supporting colleagues (9) Advising and supporting colleagues in rural settings (10) Advising and supporting colleagues across this LHD (11) Advising and supporting colleagues across the State and/or nationally (15) Offering expert advice to your own and other professions on care practices, delivery and service development (17) Consulting with staff across this LHD Clinical Service/Consultancy Factor (alpha .70) (1) Making referrals to other professionals (2) Prescribing aids or equipment (3) Managing complete programs of care (33) Undertaking interventions normally undertaken by medical or other professional staff
when multiple-item measures of a concept or construct are employed (Tavakol & Dennick, 2011).
3. Results The most significant findings were how extensively many individual NC’s engaged across many service delivery sectors (Fig. 2) and how that engagement played out and differed, in the form of activities and work patterning, between NCs working within metropolitan and rural work environments.
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Nurse Consultant role engagement Table 2
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Respondent demographics.
All nurses and midwives in LHD Total CNC’s Grade 1 Grade 2 Grade 3 Female Mean age (years) Years employed in LHD (years) Years employed in current role (years)
3.1. Demographics At the time of data collection there were 7279 nurses and midwives employed within the LHD and 3% were APNs. NC numbers had increased from 163 in 2007 to 194 in 2010. The survey response rate was higher than expected at 95% (n = 184) however some respondents did not complete the survey from start to finish. Only 140 respondents completed the survey in full, a final response rate of 72%. The following results are based on these 140 respondents. Table 2 outlines demographic information of respondent. Mean age of NC’s was greater in rural locations (49 years) when compared with their metropolitan colleagues (47 years). Over 60% of respondents had been in their current consultant role for 6 years or more. The majority of respondents (80%) were working in fulltime positions and on permanent contracts (89%). Some positions were fulltime and job shared. However 11% were in fixed term project specific positions. Thirty percent (n = 54) of all respondents and 60% (n = 20) of grade 3 respondents had a Master’s degree as their highest qualification. Eight percent (n = 15) of respondents’ identified a certificate as their highest qualification; however none of these respondents were grade 3. There were no differences noted across the metropolitan and rurally based groups. Respondents were asked how many people reported directly to their position; 70% (n = 94) had no direct line management responsibilities. However, 30% did have line management responsibilities with the number of individuals reporting to them ranging from 1 to as high as 44. Only 36% of respondents had a nurse or midwife as their direct line manager, the remaining 64% reported to non-nursing/midwifery positions such as Service Managers, Service and Medical Directors, Clinical Network Directors, Operations Managers and General Managers. NCs with rural responsibilities were more likely to have a nurse or midwife position as their line manager (54%) than those with responsibilities in either both or metropolitan only jurisdictions (31%).
3.2. Nurse Consultant workforce engagement Our investigation of engagement focused on three related issues:
All LHD workforce
Survey respondents
7279 194 84 71 39 85%
— 140 (72%) 49 (59%) 56 (79%) 34 (87%) 88% 48 (range 30—64) 18 (1—40) 8 (1 month—28 years)
1. Scope of the role across the LHD. 2. The health service delivery sectors in which the position engages. 3. Level of this engagement in a variety of activities described within the domains of the State Award policy directive (NSW Department of Health, 2005).
3.2.1. Scope of role engagement across the district Respondents were asked if their role responsibilities encompassed rural or metropolitan responsibilities or both and whether the focus of their role was across the entire LHD. Fig. 1 details the results by role grade. Seventy one percent of grade 3 NCs and 35% of grade 1 and 2 NCs saw themselves as having district wide responsibilities. Despite 64% of all NC positions within this LHD being located in metropolitan areas, only 23% (n = 26) said they had metropolitan only responsibilities.
3.2.2. Engagement across health service delivery sectors To gain clarity related to what sectors of service delivery the NC workforce spend their time in, respondents were asked to estimate the percentage of their time spent in each of the following six sectors of health service delivery; Prevention/Promotion/Protection, Primary Health, Ambulatory Care, Emergency Care, Acute Care, Rehabilitation and Extended care (including Palliative Care). The majority of respondents (83% of all respondents and 91% of Grade 3) spent time across more than one of the above categories (Fig. 2), 37% (n = 52) of all respondents and 36% (n = 13) of grade 3 respondents spent time across four or more categories. The most common category identified was Prevention/Promotion/Protection where 64% (n = 89) spent some time and 14% spent over 50% of their time. The next most common categories were Acute Care (58%, n = 82) and Primary Health (56%, n = 78). In the grade 3 group 30% spent some time across five or six of the sectors in the course of their employment activities. In rural positions 41% of respondents spent time across four or more health service delivery sectors, double that of the metropolitan based group at 20%, but comparable to 38% in the group who have role responsibilities in both jurisdictions.
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Figure 1
Scope of the role across the LHD as a percentage of total numbers by grade.
3.2.3. Domain related work activity and patterns To gain a clearer understanding of how NCs engage with their expected domains of practice, respondents were asked to what extent they were involved/contributed to a variety of activities using the following ranking scale; 1 — not involved at all, 2 — minor involvement, 3 — moderate involvement, 4 — major involvement and 5 — I take the lead in this activity. Activities were grouped into one of five factors to reflect the five domains under which the NC role is expected to practice within the NSW Award (NSW Department of Health, 2005).
Figure 2
The level of involvement overall was highest in activities related to Clinical Leadership and Clinical Service Planning and Management. Grade 3 respondents’ overall mean score (3.53) reflected higher involvement across all domains (Fig. 3) with their lowest mean score in research related activities (2.91). Grade 3 respondents had significantly less involvement in Clinical Service Consultancy activities (p < 0.01, Kruskal—Wallis) and greater involvement in research (p < 0.01) and clinical leadership activities (p < 0.05, Kruskal—Wallis) than lower grades.
Nurse Consultant workforce engagement across health service delivery sectors.
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Figure 3
Mean score in domain related activity factors.
Rural respondents had less activities related to the research domain, but more education, service planning and service consultancy activities (Fig. 4). They also identified significantly more clinical leadership activities within their roles (p < 0.01, Kruskal—Wallis). Further exploration of domain factor activity included patterns of involvement in each domain and is detailed in Fig. 5. Degree of involvement was measured at 3 levels • Low involvement: score of less than 2. • Moderate involvement: score of between 2 and 3.9. • High involvement: score 4—5.
Figure 4
Clinical Service Planning/Management (n 53, 67%) and Clinical Leadership (n 48, 69%) had the most number of respondents with a high involvement score. This was followed by education, where 26% (n 35) of respondents scored their involvement within the high range. Low involvement levels were more common in Research (50%) and Clinical Service Consultancy (27%). A moderate level of involvement was the most common pattern across all the domains except Research. Again the results demonstrated that grade 3 respondents had less involvement in Clinical Service Consultancy activities and more involvement in Research and Clinical Leadership activities.
Mean score in domain related activity by scope of practice.
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Figure 5
Level of involvement in domain activity as percentage of Nurse Consultants.
Overall metropolitan and rural comparisons were similar with a moderate level of involvement as the most common work pattern. Research featured more strongly in roles with metropolitan and both rural and metro responsibilities. Clinical leadership presented mostly in moderate and high involvement patterns and was more prominent at these higher levels of involvement in rural respondent’s activities. Level of education also influenced degree of involvement in Clinical Leadership activities and respondents with a masters level qualification and above had significantly higher levels of involvement in Clinical Leadership activities (p < 0.01, Kruskal—Wallis).
4. Discussion The results reported in this paper provide unique insight into the NC role integration within health service delivery models by identifying role responsibilities, sphere of role influence across health sectors as well as types of role activities, engagement and patterning of the NC role. This is critical information at a time when workforce costs are being closely
scrutinized from within and outside the profession (Baldwin et al., 2013) and the NC role is at risk in future health service delivery models (Baldwin et al., 2013; Dean, 2011; Duffield et al., 2009; Ellis & Morrison, 2010). Study findings demonstrating the scope of role engagement and how that engagement occurs in terms of the practice domains provides many benefits. The NC role, described as a highly engaged, collaborative and connected role working across boundaries, is well supported by our findings (Cashin et al., 2014; Giles et al., 2015; Lamont et al., 2014). Role engagement patterns demonstrate that NCs largely work across several health service delivery sectors, with higher grades working across more sectors, some across five or more. Twice as many rural NCs work across four or more sectors of health service delivery than their metropolitan counterparts. This supports evidence that rural practitioners function with a more flexible and generalist expanded scope of practice, adjusting to the needs of the service (Paliadelis et al., 2012). This in-depth insight gives managers and other health care professionals better understanding of the NC’s contribution and potential in a variety of contexts. It also ensures
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Nurse Consultant role engagement NC visibility to other professions, lessening ambiguity and misunderstanding (Coster et al., 2006). Clear understanding of role responsibilities and expectations enables better role performance within health care teams (Rheiner, 1982). Impact of the role is then recognizable at an organizational level, reducing the likelihood of the NC role being undervalued and potentially disappearing (Bloomer & Cross, 2010; Dean, 2011; Drennan & Goodman, 2011; Franks & Howarth, 2012). Only a third of NCs are line managed by a nursing position and some have more than one line manager. Non-nursing line management positions may contribute to role ambiguity if there is limited knowledge of nursing role functions. Having more than one line manager can lead to managers having competing expectations. This situation can also increased role ambuguity, role conflict, role stress and job dissatisfaction leading to less effective role performance and influencing an individuals’ intention to stay (Rheiner, 1982). The findings from this study will assist managers in delineating the NCs function as distinct from that of other health care team members, informing role alignment to health service need. In line with current research (Baldwin et al., 2013; Duffield et al., 2009; Hutchinson et al., 2014; Jokiniemi et al., 2012; Pulcini et al., 2010) this study highlights inconsistencies in the way positions are appointed. Some positions, despite being employed under the classification of NC, can be project specific roles or come under a different title, further adding to the confusion (Chang et al., 2010; Chiarella et al., 2007; Duffield et al., 2009, 2011; Gardner et al., 2007; Lowe et al., 2012). The level of seniority built into the Australian NC award through grading (NSW Department of Health, 2005) is well substantiated in the study findings where the nature and complexity of roles is determined substantially by their grading. There is a general consensus that higher grade NCs have District wide jurisdiction in their role and that the lesser grades tend to be more unit or department based. However, findings from this study indicate that, although a large number of higher grade positions (71%) function with a wide geographic purvue, a third have more limited scope. A third of both grade one and two NCs see themselves as having district-wide responsibilities. This reflects perhaps how roles have evolved over time, as well as inequities in how postions are classified and implemented. How daily activities are configured into the patterns or domains of practice provide validation of the complexity of the NC role across context. Low involvement across all domains does not necessarily reflect low impact. Perhaps it more accurately reflects the diversity in many of the roles, their high level of engagement and scope of influence across a considerable range of activities and sectors. Higher-grade respondents generally had more domain activity related to research, education, management and collaboration and significantly less time spent in Clinical Service Consultancy. Respondents rated activities related to Clinical Leadership and Clinical Service Consultancy as having the highest level of priority in their roles. Bloomer and Cross (2010) reported an underutilization of the clinical leadership capacity of the NC because of inconsistent role application. However our respondents reported moderate to high levels of clinical leadership activity and these activities were significantly
9 higher in rural based roles. Again this may be a reflection of the flexibility in practice described by Paliadelis et al. (2012) when adjusting to meet health service needs in rural based practice. In some instances rural clinicians working with minimal support structures (Paliadelis et al., 2012) provide high level leadership in advising and supporting others. NCs, described in the literature as having key attributes of autonomy, role development, leadership and clinical expertise (Dowling et al., 2013; Guest et al., 2001, 2004; Jokiniemi et al., 2012) are perfectly positioned to be flexible in function and scope to fulfill the needs within evolving health service models. As health care delivery has become more and more complex the NC role has cushioned the potential chaos by changing and evolving to help meet the needs of this changing environment. This is particularly evident in rural context where access to specialist resources can be limited. A key strategy highlighted by Wakerman (2008) to address the current rural—metropolitan health inequities is to enhance primary prevention and health promotion. Study findings demonstrate that 60% of rural based NCs spend some time in this sector. Findings related to work patterns support the notion that there is great diversity and variation in work activities in NC roles (Baldwin et al., 2013; Coster et al., 2006; Duffield et al., 2009; Por, 2008). In particular there is a tendency for individual roles to have certain practice domain activities emphasized and others deemphasised. This is evidenced in activities related to management, where only 30% of respondents identified having line management responsibilities, but some managed over 40 staff. In terms of other types of role engagement the higher the grade the lower the percentage of time working in direct patient contact. Otherwise the time spent on activities is fairly uniform across all grades. Surprisingly, the amount of time spent on research activity was similar across all grades and rural respondents tended to spend less time on research, and more time on education, management and collaboration. Rural respondents identified a higher level of involvement in direct patient contact, double that of their metropolitan counterparts. The findings of this research provide managers with valuable information on how NCs can best be engaged and successfully integrated into health care services in the future. In order to accommodate best fit for NC roles it is imperative that role function and impact is clear and can be differentiated from other roles. The ever increasing complexity of individual NC roles means that role ambiguity is likely for NCs without a clear and agreed understanding of their function and remit. Such ambiguity can lead to overload and stress-related absence and turnover. In addition, a lack of clarity regarding the NC role has significant negative implications for its perceived utility and effectiveness. Increased clarity is likely to strengthen perceptions of the NC role contribution and value, which lessens the likelihood of stress in NCs and the diminution of the role by other professions and healthcare management. Not all role complexity is bad, but what creates the complexity needs to be well understood and managed more effectively by managers (Birkinshaw & Heywood, 2010). Ambiguity is a role characteristic that can be most influenced by managerial intervention (Kahn et al., 1964). Awareness of role engagement and activities will assist managers in making decisions related to realignment of
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10 current roles, and placing and support of new roles for maximum contribution. This multi-dimensional role needs supporting through shared expectations, capacity building and integration into current and future models of care and service delivery. The information gained from this research provides insight for future succession planning and planning capacity building strategies to strengthen the role and its contribution to health care teams and patient outcomes. Of particular importance are the findings related to emphasis and de-emphasis of practice domains of individual roles across context. This information provides guidance to workforce planners, service managers and healthcare teams identifying and filling skill mix gaps to ensure the NC can function as clinical leaders to maximize their impact. Many NCs provide clinical leadership within current health care delivery models. They have been described as change agents (Berwick, 2011) and supporting the practice of others across disciplines and boundaries (Giles et al., 2015). Contemporary understandings of complex organizations highlight the need for leadership that operates from within systems, is organic and has the capacity to be refocused to accommodate dynamic imperatives. This study indicates that NCs are working, some more than others, to achieve this. The challenge for managers, who have NCs within their team, is how to deal with the conflicting need for both regulation and flexibility in organizations that are inherently dynamic and controlled by regulation and standardization.
4.1. Limitations Finding from this study are based on results from one large LHD in NSW Australia, however there is representation from metropolitan, rural and remote health care context across multiple service delivery models from highly specialist service to district wide networks.
5. Conclusion This study makes a significant contribution to understanding of the NC role and its contribution to practice. It had demonstrated that although most NC work within the Domains of practice designated within job descriptions, many are able to adjust their work patterns and levels of engagement in accordance with changing circumstances and local need. This is particularly evident in rural areas subject to lack of access and fluctuating access to services. Complex organizations and systems of care require clinical leadership that is characterized by responsiveness, flexibility and agility. The NC is possibly the only role that is able to provide such leadership through enactment of supporting, connecting and consulting functions in relation to enhancing nursing practice and participation in inter-professional teams. Further research is needed to explore how the role can be developed and deployed to contribute optimally in particular contexts. Such research, together with the findings reported here will inform workforce planning, professional development and advanced practice tertiary education programs.
M. Giles et al.
Conflict of interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
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Please cite this article in press as: Giles, M., et al. Understanding Nurse Consultant role engagement in metropolitan and rural contexts. Collegian (2016), http://dx.doi.org/10.1016/j.colegn.2016.04.002