ISSU ES I N CLINICA L NUR SIN G
doi: 10.1111/j.1365-2702.2006.01576.x
Clinical nurse specialists as entrepreneurs: constrained or liberated Lynn Austin
PhD, MsC, RGN
(Formerly) Research Fellow, School of Nursing, Midwifery and Health Visiting, University of Manchester, Manchester, UK
Karen Luker
PhD, Fmed Sci, Bnurs
Queen’s Institute, Professor of Community Nursing, School of Nursing, Midwifery and Health Visiting, University of Manchester, Manchester, UK
Martin Ronald
DM
Director, National Primary Care Research and Development Centre, University of Manchester, Manchester, UK
Submitted for publication: 26 April 2005 Accepted for publication: 12 November 2005
Correspondence: Lynn Austin Telephone: 0161 275 5333 E-mail:
[email protected]
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A U S T I N L , L U K E R K & R O N A L D M ( 2 0 0 6 ) Journal of Clinical Nursing 15, 1540– 1549 Clinical nurse specialists as entrepreneurs: constrained or liberated Aims. This qualitative study explored the experiences of two groups of clinical nurse specialists – continence advisors and tissue viability nurses – working in primary care in the UK. In particular, the study focused on how clinical nurse specialists’ relationships with other health-care professionals had an impact on their role. Background. Clinical nurse specialists are recognized worldwide as having expertise in a given field, which they use to develop the practice of others. Additionally, clinical nurse specialists share many of the characteristics of entrepreneurs, which they use to develop services related to their speciality. However, little research has been conducted in relation to clinical nurse specialists’ experiences as they attempt to diversify nursing practice. Design/methods. An ethnographic approach was adopted comprising many elements of Glaserian grounded theory. Data were collected via participant observation and face-to-face interviews with 22 clinical nurse specialists. Findings. Services provided by clinical nurse specialists were not static, clinical nurse specialists being the main drivers for service developments. However, clinical nurse specialists encountered difficulties when introducing new ideas. Given their role as advisors, clinical nurse specialists lacked authority to bring about change and were dependent on a number of mechanisms to bring about change, including ‘cultivating relationships’ with more powerful others, most notably the speciality consultant. Conclusions. The UK government has pledged to ‘liberate the talents of nurses’ so that their skills can be used to progress patient services. This study highlights the fact that a lack of collaborative working practices between health-care professionals led to clinical nurse specialists being constrained. Relevance to clinical practice. Health-care organizations need to provide an environment in which the entrepreneurial skills of clinical nurse specialists may be capitalized on. In the absence of an outlet for their ideas regarding service developments, clinical nurse specialists may remain dependent on the mechanisms witnessed in this study for some time.
2006 Blackwell Publishing Ltd
Issues in clinical nursing
Clinical nurse specialists as entrepreneurs
Key words: clinical nurse specialists, collaboration, continence advisors, entrepreneurs, primary care, tissue viability nurses
Background Clinical nurse specialists (CNSs) are acknowledged, internationally, as advanced practitioners who have expertise in a given field. Their role comprises the advancement of nursing by influencing the practice of others, and developing services (Royal College of Nursing 1988, Hamric 1989, Appel & Malcolm 1998). Clinical nurse specialists, alongside other advanced nursing roles have proliferated over the last decade in the UK (McGee & Castledine 1999, Read et al. 1999). Developments are attributed by some to external factors, with nurses simply plugging gaps left because of a shortage of medical staff (Williams et al. 1997). Others relate changes to the diversification of nursing practice, the distinction between these two models being made by a number of authors (Cotton 1997, Castledine 1998, Scholes & Vaughan 2002). Banham and Connelly (2002) characterize the difference between these models as follows: Drawing on the core concept of professionalism, that defines its own tasks…nurses and others advocate a wider role for nursing, to be achieved by extending the types of services available to patients and not by taking up work unwanted or discarded by doctors, here diversification and not substitution is adopted as the logic and motivation for change. (p. 260)
As seen, the underlying sentiment is that substitution models are driven by the medical agenda, whereas diversification models are led by nursing issues. It is CNSs who follow the diversification model of specialist practice who form the focus of this paper. In diversifying nursing practice, CNSs display entrepreneurial characteristics. The term ‘entrepreneur’, in relation to nursing practice, has been adopted on a wide scale relatively recently in the UK (Department of Health, DoH 2004), but lacks formal definition. However, the entrepreneurial nature of CNSs has been recognized for some time in the USA (White & Begun 1998, Dayhoff & Moore 2002, 2003a,b). These authors draw parallels between general definitions of entrepreneurs and the activities CNSs engage in. Entrepreneurs are viewed, traditionally, as individuals who set up their own business to develop a product or service (White & Begun 1998, Dayhoff & Moore 2002). However, those with entrepreneurial traits can be found in health-care settings. In essence, entrepreneurs are creative and innovative, driven by a ‘belief in a service that is critically needed and not currently being provided at an acceptable level of
quality’ (White & Begun 1998, p. 40). The characteristics associated with entrepreneurs, who wish to introduce new ideas regarding patient care, are summarized in Table 1. In the absence of any formal definitions of nurse entrepreneurs in the UK, the US literature provides a useful framework for exploring this aspect of CNS practice. Whilst the term ‘nurse entrepreneur’ is a relatively new addition to the vocabulary in the UK, the role nurses could play in developing services has been the focus of government initiatives aimed at modernizing the National Health Service (NHS) (DoH 1999, 2000, 2002). At the heart of these reports is a recognition that nurses have been subject to a number of constraints which have resulted in their qualities being underutilized (DoH 1999). In recognition of this, the government has committed itself to ‘liberating the talents’ of nurses so that patients may receive the ‘right care, in the right place at the right time’ (DoH 2002). Much of the modernization agenda (DoH 1999, 2000, 2002) is aimed at health-care professionals (HCPs) who work in a community setting. In the future, it is envisaged that nurses in primary care will be the first point of contact and will play a key role in initial patient assessments. Nurses will also be responsible for the ongoing care of some patient groups. Services in general will be designed around a patient’s ‘journey’ through the system and it is proposed that nurses will have more freedom to make decisions and be creative in relation to services that they provide. The DoH places considerable emphasis on using the skills of all team members (DoH 2002). Consequently, organizations have been charged with the responsibility of developing
Table 1 Characteristics of entrepreneurs 1. 2. 3. 4. 5. 6. 7. 8. 9.
Visionary/creative/energetic Change agent/negotiator/team leader Self-motivated and autonomous Innovative as opposed to just reaching certain performance expectations Solve patient problems by the introduction of new services/products Look at how others have solved similar problems Savvy and knowledgeable in how to ‘work’ the system Self-confident, persistent, do not take ‘no’ for an answer Skilled at building a coalition of supporters to minimize the barriers of introducing an innovation into practice
Adapted primarily from Dayhoff and Moore (2003a) with additions from White and Begun (1998) and Dayhoff and Moore (2002).
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services in line with these ideals, including looking at flexible working across professional boundaries. Practical measures that might aid more flexible ways of working are also outlined in the form of 10 key roles (Table 2) which would involve nurses in a number of activities including ordering diagnostic investigations, making direct referrals to other HCPs and triaging patients.
Rationale for study Whilst the literature on CNS roles is extensive, only a handful of generic (as opposed to role specific) studies regarding CNSs have been conducted (Lloyd-Jones 2005). Studies carried out over the last decade in the UK are typically small and few focus on the experiences of CNSs working in primary care. Typically, research has focused on CNSs roles in developing nursing in traditional areas of practice (Bousfield 1997, Bamford & Gibson 1999). Little research has been conducted on the CNSs role in the diversification of nursing practice beyond traditional boundaries. Therefore, little is known about how CNSs experience their roles when engaged in activities aimed at diversifying nursing practice. Two groups of nurses were selected as exemplars of specialist practice, namely, tissue viability nurses (TVNs) and continence advisors (CAs). These CNSs were selected as their role comprises components traditionally associated with CNSs (expert practice, consultation, education, research) and they represent two of the largest groups of CNSs employed in primary care.
Methods
This study explored how TVNs and CAs, working in primary care, experienced their roles and factors which impacted on
1. Ordering diagnostic investigations 2. Making direct referrals to other health-care professionals including doctors 3. Admitting and discharging some groups of patients according to protocols 4. Managing caseloads for some groups of patients 5. Running certain clinics 6. Prescribing specified items 7. Carrying out resuscitation procedures 8. Performing minor surgery and out patient procedures 9. Triaging patients 10. Taking a lead role in the organization of local services
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Methodology An ethnographic approach (Hammersley & Atkinson 1995), comprising aspects of Glaserian grounded theory (GT) (Glaser & Strauss 1967, Glaser 1978, 1992) was employed for the study. When used in combination, these approaches facilitate the identification of patterns of behaviour within a cultural group and provide the potential for theory generation (Spradley 1980, Charmaz & Mitchell 2001).
Participants Clinical nurse specialists working in one health region were invited to take part in the study, following formal access arrangements with the head of nursing and the research and development department at each trust. Eight CNSs (four TVNs and four CAs) were purposefully selected for observation visits, the attributes of individual CNSs having been established in an earlier survey (Austin 2002, 2003). A further 14 CNSs were interviewed, participants being selected via theoretical sampling. Study participants had a range of experience, some having been in post a number of months, whilst others had been in their role for many years.
Data collection
Aims
Table 2 Ten key roles for nurses (DoH 2000)
this, in particular, their relationships with other HCPs. As part of the study the challenges CNSs experienced in developing services were elicited, alongside the measures they took to address these.
Data were obtained during participant observation visits and individual interviews with CNSs shaped by a topic guide. Conferences and networking meetings held for TVNs and CAs were also attended. These interactions provided opportunities to gain an understanding of these specialist services, including CNSs’ interactions with other HCPs and the difficulties CNSs encountered in their roles. Issues discussed included how specialist services had changed over time and measures used by the CNS to bring about these changes. Eight CNSs were visited for two days each between October 2001 and January 2002. These visits provided an insight into the day-to-day work of CNSs. A diary was used to jot down field notes, which were subsequently expanded. Individual interviews with 14 CNSs took place between June and August 2002. These interviews were tape recorded and full transcripts made. Data were collected until theoretical saturation was achieved.
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Issues in clinical nursing
Clinical nurse specialists as entrepreneurs
Data analysis
Ethical considerations
Data collection and analysis were conducted concurrently in keeping with the principles of GT. Most of the data analysed were in the form of text (e.g. field notes, interview transcripts, memos and conference proceedings). Marginal notes indicating recurrent themes were made on texts to facilitate the coding of data. Following this process a number of broad categories and subcategories were produced which reflected patterns emerging from the data. Ultimately a core category was generated to which each of the conceptual/descriptive categories could be linked. The categories are signified in the findings section by the use of apostrophes.
Ethical approval for the study was obtained in May 2001 from the Multi-centre Research Ethics Committee. Participants were sent an individual letter and an information sheet outlining the purpose of the study. Ongoing consent was obtained with individuals during the time spent with them. Signed consent was obtained in accordance with the requirements of the ethics committee. Field notes, tapes and related material were stored in a safe place and confidentiality maintained by attributing an individual code to the participant, known only to the key researcher (LA).
Findings Rigour Principles associated with qualitative research were followed to ensure the rigour of this study (Sandelowski 1986, Murphy et al. 1998, Popay et al. 1998). Details have, therefore, been included in all sections of this paper to indicate the credibility of the study and the transferability of the findings to other settings.
Core category ‘realising the vision’: Clinical nurse specialists have a vision of what constitutes best practice in relation to the how services are organised
Clinical nurse specialists attempt to ‘develop services’, e.g. by ‘streamlining’ the process of patient assessment and referral
The primary finding from the study was that services provided by CNSs were not static. Clinical nurse specialists had a ‘vision’ of how services should be organized and many of their actions related to achieving this ambition. ‘Realizing the vision’ emerged as the core category to which each of the conceptual/descriptive categories could be related (Fig. 1).
Clinical nurse specialists do not have ‘authority’ to make changes to services. Therefore they are dependent on the use of ‘mechanisms’ to bring about changes in line with their vision.
Mechanism: ‘working the system’ Clinical nurse specialists ‘work the system’ to ‘circumvent the authority’ of medical staff when referring patients on to other health care professionals e.g. by: • Advising patients to attend the accident and emergency department • Slotting patients into out patients’ clinics by liaising with nursing colleagues
Mechanism: ‘changing the system’ • Clinical nurse specialists attempt to ‘change the system’ by tapping into sources of ‘vicarious power’ e.g.: • ‘Working with others with shared objectives’ • Developing care pathways subsequently endorsed by the organisation. • ‘Cultivating relationships’ with more powerful others (e.g. the speciality consultant)
Figure 1 Mechanisms used by clinical nurse specialist to ‘realize their vision’. 2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 1540–1549
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Whilst the development of individual services was idiosyncratic, there were some commonalities amongst the CNSs. On the whole, CNSs constantly expanded their repertoire, increasing their personal skills and extending services. Typical examples included introducing new clinics for specific patient groups and expanding the range of treatment options available to them. The following quotations clearly illustrate this:
Dependence on medical staff manifested itself in many ways. For example, whilst a number of CNSs worked in clinics in which patients were assessed and managed, few CNSs had authority to request further investigations. Likewise, many CNSs were unable to refer patients to another HCP, such as the speciality consultant or a physiotherapist. Clinical nurse specialists were dependent on GPs for the onward referral of patients:
I: We’ve got to move forward…and one of the things that we [TVN
I: Well, I can’t refer directly…as just a mere specialist nurse you can’t,
and vascular surgeon] are pushing for…we’ve managed to acquire a
you have to go through the GP because they are in effect…the
dietician who supports the service. But what he sees, and what I see as
patient’s consultant… It’d be so much better for patients but I guess
the way forward is that once a month the dermatologist comes in and
what they’re doing is, they’re trying to protect the consultant’s time
does a clinic. Once month a rheumatologist comes in, a plastic
from inappropriate referrals…but it does seem a rather long-winded
surgeon comes in and it works like that…and the diabetes team, I
way of doing things. (TVN 4)
think because everybody is working in isolation at the moment, and nobody is working together. And I think once you get that sort of set up going…I think it will be really good. I’ll be retired by then but that’s what we should be. (TVN 11) I: I started off [ten years ago] with this…little empty room and the desk and telephone and now we’ve got an empire…I [could] fill a clinic this size and use all little different rooms to do different things, as I said to you before about having a physiotherapist, because a little laboratory wouldn’t go amiss here to do culture and sensitivities and blood samples, a GP that could probably come in or a doctor that could come in and do so many sessions for us, counselling sessions, there’s loads… But it’s been ten years of hard work to do it because nobody then tells you to do what you do…you just do what you do because the need is there. (CA 1)
I: The vascular surgeon has allowed me to organize duplex scans and all sorts of things, because he’s got that confidence in me. Dermatology it depends on which registrar’s doing the rotational post as to whether they will see a referral from me, which has been really frustrating. Because GPs have referred to me, I see the patient, and it’s clearly a dermatology…but protocol dictates that they have to go back to their GP and the GP then has to refer them on to dermatology, and that’s a big problem. And that needs to be
Clinical nurse specialists seemed to be the main drivers with regard to ‘developing the service’. The employing organization, on the whole, had minimal expectations of the CNS as long as they were achieving certain broad objectives. Clinical nurse specialists, therefore, developed services in line with their own personal interests and skills. Consequently, configurations varied between sites, and, indeed, over time at any one site. Having said this, an example common to most CNSs was that of ‘streamlining the service’ such that the patient was seen by the ‘right person, in the right place, at the right time’. Another feature, common to the experience of CNSs was the difficulty they faced when seeking to bring about changes in line with their vision of good practice. Whilst CNSs were visionary in nature, given their appointment as advisors, CNSs lacked authority to bring about changes. Consequently, any changes CNSs wished to make had to be mediated through their colleagues. In particular, CNSs were very dependent on the consultant associated within the given speciality.
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A number of CNSs could make direct referrals. However, this seemed to be dependent on the individual consultant. For example, some TVNs said they were able to refer patients directly on to vascular surgeons, but not to dermatologists. In these instances the referral arrangement related to the relationship CNSs had developed with particular consultants:
addressed. LA: I’ve heard that a time or two, that seems commonplace. (TVN 11)
Difficulties could arise where a CNS felt a patient required urgent review by a consultant and the CNS was unable to persuade the GP of the urgency of the situation. In these circumstances, the CNS would ‘work the system’ so as to ‘circumvent’ the perceived bureaucracy and get the patient seen by the appropriate HCP. Means of ‘circumventing the authority’ of GPs included recommending a patient attend the accident and emergency (A&E) department, or contacting a nursing colleague in the relevant out patients’ department and arranging for the patient to be slotted into the clinic: I: Occasionally we’ve had to send them through A&E… So it’s not been a satisfactory sort of routine really… It’s not fair on the patient, its not fair on the A&E staff, because you’ve done a clinical assessment, and they’re sitting in A&E having it all done again… Occasionally we’ve managed to get them into outpatients… Its farcical.
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L: But speaking to other people it’s the same, people do have to find
sort of laid back about it as though you’ve been doing it for ages
ways of getting people in if there isn’t a formal method in place.
[initially], we had to write to the GP saying ‘this is what we
I: …We actually referred somebody yesterday, to the rapid response
recommend please would you consider’ and use all those flowery
team, because the GP didn’t want to refer in…but the GP is the
words [laughs]…but we have a much better pathway now so you
gatekeeper…so sometimes the difficulties I have through referring on
shouldn’t get a patient going straight to a vascular surgeon they can
are down to an individual’s perceptions and that’s why the care
come through us first. (TVN 13)
pathways, if they’re adopted by the urologist and the trusts and the GP lead – [will help]. CA 9
Whilst ‘working the system’ was used as a mechanism for getting patients seen in the short term, CNSs recognized that this practice was far from ideal. Consequently, CNSs sought to ‘change the system’ to one which provided them with authority to refer patients on. To make changes, CNSs needed to identify sources of ‘vicarious power’, that is, power located elsewhere which the CNS could tap into to support her perspective. Mechanisms, therefore, included ‘working with others with shared objectives’, for example, physiotherapists who also wanted to receive referrals directly from CNSs or refer patients on to a consultant. In some cases, CNSs worked with others towards ‘streamlining the system’ of patient assessment and referral when developing care pathways. Typically, care pathways outlined which HCPs should see which patients, the types of investigations patients should have, and the point at which they should be referred on to another HCP. Care pathways were helpful, as once endorsed by the organization, they legitimized the direct referral of patients and had the additional benefit of clarifying roles and boundaries, thus formalizing the CNS’s contribution to patient care: I: There’s discussions at the moment and everyone’s saying – yes we would be happy to take direct referrals…it’s just ensuring that
Care pathways facilitated what could be viewed as the broad agenda of CNSs, that of ‘streamlining the service’ in line with their ‘vision’, so that patients were moved through the system and seen by an appropriate HCP. What was also apparent is that, whilst ‘streamlining the service’ could reduce the demands placed on consultants, CNSs were not the passive recipients of devolved work. Clinical nurse specialists were invariably the driving force behind these changes, often acting as the lynchpin at meetings with others HCPs set up to discuss the reconfiguration of services. Whilst ‘streamlining the service’ in conjunction with other HCPs lent some weight to ‘changing the system’, the support of the relevant consultant was clearly pivotal. Given the value of a positive working relationship with a powerful ally, many CNSs actively ‘cultivated relationships’ with the speciality consultant. Whilst CNSs gave many examples of positive and complementary ways of working, this hinged on the receptivity of the individual consultant. Some CNSs were fortunate in that they had supportive and collegial relationships with the speciality consultant and there were many examples of joint working in clinics and interprofessional referral, sometimes initiated by the consultant. This can be seen in the following extract from TVN 8:
the trusts are quite happy with it…so we do have a pathway and
I: I’ve got an ally in the vascular consultant though, it’s great…
it’s really just to streamline all the referral mechanisms and
L: So how did you find this ally?
discharge arrangements etcetera. And in that group there’s a
I: Because of the [leg ulcer] clinic…there’s a lot of collaborative work
urologist, uro-gynaecologist, geriatrician, myself and physiotherapy
in there anyway, plus he relies upon me then. If he’s got a problem
where we’re establishing pathways of treatment but also pathways
wound or what have you, he’ll ring me and say ‘[TVN 8] can you
for referral…[it would] work better because the uro-gynaecologist
come and have a look at this?’ And, so I think there’s a mutual
would get less referrals…ours should be the initial point of contact
support there for each other…
to be triaged…I’ve seen people and they come to us after they’ve
L: Right, so you’ve always had the option of just directly getting them
seen the surgeons. They didn’t even want surgery but they’ve
to vascular –
waited eight months to go and see a uro-gynaecologist, who then
I: Yeah, that’s just evolved with the clinic really since we became
offers them urodynamics. In the end you think well, lets just start
nurse led it’s just, evolved and, and as I’ve become a single person
at the basics really…And they’re more effective treatments as
role if you like [TVN from leg ulcer nurse] I’ve taken that – I don’t
well…and I think that is how it should be, like a triaging filtering
know how to phrase it really – privilege of being able to do that from
system…if you see the word ‘continence’ it should come to this
the clinic.’ (TVN 8)
office. (CA 7) I: I have to say in the early days I didn’t refer direct to a vascular surgeon, I have to be careful now because it’s easy to be sort of very
This extract from TVN 8 serves to illustrate that, in some cases, the relationship between the consultant and CNS was definitely two-way. Both were benefiting and the CNS was
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recognized as having areas of expertise that differed from that of the consultant. One of the advantages of having such a collegial relationship is that TVN 8 had always been able to refer patients directly to the consultant. What is interesting is that, despite the apparently collegial working relationship between this TVN and the consultant, she viewed the ‘privilege’ of being able to refer as good fortune rather than something taken as read. In common with other CNSs, TVN 8 needed to work hard to be seen as having credibility in the eyes of the consultant; she was not afforded professional equality automatically. ‘Cultivating relationships’ seemed to be fuelled by the need to identify a source of power so that the CNS could tap into it and use this power vicariously. Without access to this power, CNSs could find it difficult to take things forward, this is illustrated clearly in this extended extract: I: One of the consultants was also a clinical director so he had some managerial clout as well. So I sort of liaise with him quite a bit really… L: So how did it come about? I: I think we started to do joint clinics together and they started to use me and refer to me…I also made sure that every single time we did an annual report and talked about the outcomes of our service that they got a copy of that…we gained credibility in their eyes by sort of communicating, making it clear where we were going with the service and how much we’d achieved ‘cos its never stood still the leg ulcer service… L: Because certainly from what I’ve been doing the relationship with the medical staff, it can be pivotal – pivotal in how well you’re able to move forward and develop the role. I: Absolutely, if you’ve got, like this chap the vascular surgeon, who’s a clinical director fortunately…he’s very pro nursing…he sits, or did sit, on the trust management team. Now if you can get in with people like that and work closely it can move services forward at such a rapid rate. (TVN 13)
Discussion Historically, developments in nursing have been dependent on the ‘vision, creativity and charisma of visionary leaders’, who have been successful in changing this vision into reality (McCormack et al. 1999). This study reinforces these findings highlighting the difficulties CNSs encountered and the mechanisms they used to achieve their vision. The CNSs shared the attributes of entrepreneurs (Table 1), however, they did not have authority to introduce changes in line with their vision. This had a constraining effect on their ambitions, making it necessary for them to locate sources of power, which they could then either circumvent, or acquire
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and use vicariously. The main source of power in this instance being the speciality consultant. The experiences of these CNSs are not unique; inequitable power relationships have existed since the inception of the NHS (Ham 1999, Wilmot 2003). Stein (1967), in a seminal text, describes ‘the doctor–nurse game’, which necessitates nurses finding ways of presenting their ideas in a manner that is palatable to more powerful doctors. Despite some developments in this area, as nurses strive towards greater equality (Stein et al. 1990), power imbalances continue. Consequently, as reflected in this study, nurses have employed a range of strategies to ‘contain and circumvent medical power’ (Wilmot 2003, p. 19). This study provides a picture of the negative impact inequities have on patient services, because of the duplication of investigative procedures and delays in the onward referral and treatment of patients. The constraints faced by CNSs are of interest, not least because in seeking to overcome barriers, the creative energy of CNSs is diverted to other sources (Dayhoff & Moore 2003a). The difficulties encountered also seem strange, given that CNSs’ ambitions are in tune with current policy objectives, which seek to streamline patient services (DoH 2002). The government’s desire to ‘liberate the talents of nurses’ (DoH 2002) could provide opportunities for entrepreneurial nurses. Many CNSs considered it appropriate for them to be the first point of contact for patients and a number of the 10 key roles, such as patient triage and referral, would facilitate the process of streamlining services. However, whilst the potential for liberation is evident, the CNSs in this study, were quite clearly constrained and, whilst DoH reports are high on rhetoric, they are limited in terms of how liberation might be achieved. For example, Liberating the Talents (DoH 2002, p. 2) provides a ‘framework’ for the provision of nursing services in a primary care setting…It does not tell PCTs what to do’ or, for that matter, how to do it. Therefore, whilst full of praiseworthy comments about the skills of nurses, which organizations need to ‘harness’ if nurses are to play a key role in the government’s modernization agenda, less emphasis is given to how these ideals can be achieved. The need for a cultural shift, if the espoused values are to be realized, is addressed to some extent in Shifting the Balance of Power (DoH 2001). However, whilst recognizing the need for empowerment of all staff, it does not address the power differentials between groups of HCPs, which appear to be at the root of problems faced by CNSs in this study. Collaboration has been ‘heralded as the solution to many of the problems arising from the more traditional, hierarchical
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Issues in clinical nursing Table 3 Characteristics commonly associated with collaborative teamwork 1. Common goal which places patients’ needs at the centre of decision making 2. Collegial/non-hierarchical relationships 3. Shared power/decision making/responsibility for patient outcomes 4. Complementary skills – boundaries are flexible and skills may overlap 5. Mutual respect and trust, including respect for each other’s knowledge and a willingness to learn from each other 6. Personal characteristics: willing participation of individuals, with excellent communication skills, who understand each others’ roles 7. Management structure which supports creativity in a non-hierarchical setting
work practices’ (Henneman 1995), and is now at the fore of the political agenda (Barr 2000, Bellman 2003). This is evident in the increasing amount of attention collaboration has received in government literature (DoH 1999, 2000, 2002). Nonetheless, collaborative working is not readily achieved. Whilst the term has become common parlance in government reports, it is used fairly loosely alongside other terms which denote joint working. However, collaboration has a specific meaning within the academic literature where factors associated with successful collaboration have been identified (Henneman 1995, Hanson et al. 2000, LockhartWood 2000, McCallin 2001). These are summarized in Table 3. On the surface, collaborative working would have much to offer CNSs. The focus on shared goals, which place the patient at the centre of decision making, and egalitarian relationships would reduce CNSs’ dependence on the mechanisms they adopted to develop services in line with their personal vision. However, texts make it clear that nonhierarchical power relationships are a prerequisite to collaborative working, not a product. That is, equality is required if collaboration is to be a success. Collaboration is not simply achieved by bringing together individuals from a range of backgrounds as the prevailing hierarchy will have an impact on how these individuals interact. Whilst striving towards the conditions required to make collaboration a success is an admirable goal, changing culture is a slow process which cannot be achieved by mandate. For example, not all potential participants may be equally willing to collaborate (McCallin 1999, Hanson et al. 2000, Rushmore 2005). Nor can cultural changes occur rapidly, as new ways of working together have to be learnt (Bellman 2003). However, the scenario in which power is viewed as a commodity that can be ‘acquired, owned or distributed’ is
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limiting, as this implies that power is finite and for someone to be empowered, those who already hold power must relinquish some part of this (Tew 2002). For this reason, it is argued, powerful others should be engaged in the process of change and shown how they may benefit, leading to the idea of ‘co-operative power’ (Tew 2002) or collective entrepreneurship (McCallin 2001). A concept highlighted by Stein et al. (1990) more than a decade ago, as seen in the following extract: Physicians and nurses can both benefit if their relationship becomes more mutually interdependent…when a subordinate becomes liberated, there is potential for the dominant one to become liberated too. (p. 549)
What is encouraging is that the issue of interprofessional working has received increased attention over recent years and professionals working in a range of disciplines are exploring matters relating to successful teamwork (Barr & Gilbert 2004). Initiatives such as interdisciplinary education, shared meetings and jointly produced care pathways, seek to cut through culturally embedded practice by increasing the number of interactions between different HCPs (Hanson et al. 2000, McCallin 2001, Barr & Gilbert 2004). These initiatives, in conjunction with the current policy context, may provide a number of opportunities for CNSs.
Conclusion The CNSs seen in this study had a passion for their speciality, however, their relatively powerless position meant that successes gained were highly dependent on their entrepreneurial skills. Organizations did not always capitalize on the expertise of CNSs, despite the fact that many of their ambitions were in tune with government imperatives which organizations needed to respond to. Despite the pressure being placed on HCPs to work in a collaborative way, this study illustrates that changes are required if joint working between different HCPs is to be based on egalitarian relationships. Otherwise, it seems possible that less powerful individuals, such as CNSs, will remain dependent on the mechanisms witnessed in this study for some time. This study has some limitations, given its focus on the perspective of CNSs working in a UK context. However, the reliance of nurses on mechanisms to effect their role is of relevance to others, as is the need for organizations to find ways of capitalizing on the expertise of those they employ. In a wider context, government imperatives aimed at liberating the talents of nurses appear to have much to offer CNSs. The means by which this liberation might be achieved
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was being detailed at the time this study was conducted. Only time will tell whether the rhetoric contained within these policy documents translates into reality.
Contributions Study design: LA, KL, MR; data analysis: LA, KL, MR and manuscript preparation: LA, KL, MR.
References Appel AL & Malcolm PA (1998) Specialist education and practice in nursing: an Australian perspective. Nurse Education Today 18, 144–152. Austin L (2002) A survey of tissue viability nurses’ role and background in one region. Journal of Wound Care 11, 347– 350. Austin L (2003) A survey of continence advisors in working in one health region. Journal of Community Nursing 17, 22–28. Bamford O & Gibson F (1999) The clinical nurse specialist role: key role components identified. Managing Clinical Nursing 2, 105– 109. Banham L & Connelly J (2002) Skill mix, doctors and nurses: substitution or diversification? Journal of Management in Medicine 16, 259–270. Barr H (2000) New NHS, new collaboration, new agenda for education. Journal of Interprofessional Care 15, 5–6. Barr H & Gilbert J (2004) Editorial: all together better health. Journal of Interprofessional Care 18, 221–223. Bellman L (2003) Nurse-led Change and Development in Clinical Practice. Whurr, London. Bousfield, C (1997) A phenomenological investigation into the role of the clinical nurse specialist. Journal of Advanced Nursing 25, 245– 256. Castledine G (1998) Clinical specialists in nursing in the UK: the early years. In Advanced and Specialist Nursing Practice (Castledine G & McGee P eds). Blackwell, Oxford. Charmaz K & Mitchell RG (2001) Grounded theory in ethnography. In Handbook of Ethnography (Atkinson P, Coffey A, Delamont S, Lofland J, Lofland L eds). Sage, Thousand Oaks. pp. 160–174. Cotton A (1997) Power, knowledge, and the discourse of specialization in nursing. Clinical Nurse Specialist 11, 25–29. Dayhoff N & Moore PS (2002) Entrepreneurial clinical nurse specialists: innovators of patient care. Clinical Nurse Specialist 16, 274–276. Dayhoff N & Moore PS (2003a) You don’t have to leave your hospital to be an entrepreneur. Clinical Nurse Specialist 17, 22–24. Dayhoff N & Moore PS (2003b) Entrepreneurship: start-up questions. Clinical Nurse Specialist 17, 86–88. Department of Health (1999) Making a Difference: Strengthening the Nursing, Midwifery and Health Visiting Contribution to Health and Health Care. DoH, London. Department of Health (2000) The NHS Plan: A Plan for Investment, A Plan for Reform. The Stationery Office, London. Department of Health (2001) Shifting the Balance of Power. DoH, London.
1548
Department of Health (2002) Liberating the Talents: Helping Primary Care Trusts and Nurses to Deliver the NHS Plan. DoH, London. Department of Health (2004) Nurse Encouraged to Become Entrepreneurs. CNO bulletin 26. DoH, London. Glaser BG (1978) Theoretical Sensitivity: Advances in the Methodology of Grounded Theory. Sociology Press, Mill Valley. Glaser BG (1992) Emergence Versus Forcing: Basics of Grounded Theory Analysis. Sociology Press, Mill Valley. Glaser BG & Strauss AL (1967) The Discovery of Grounded Theory. Aldine de Gruyter, New York. Ham C (1999) Power in health services. In Health Policy in Britain: The Politics and Organisation of the National Health Service, 4th edn (Fudge C & Hambleton R eds). Macmillan, Basingstoke. Hammersley M & Atkinson P (1995) Ethnography: Principles in Practice, 2nd edn. Routledge, London. Hamric AB (1989) History and overview of the CNS role. In The Clinical Nurse Specialist in Theory and in Practice, 2nd edn (Hamric AB & Spross JA eds). WB Saunders, Philadelphia, pp. 3–18. Hanson CM, Spross JA & Carr DB (2000) Collaboration. In Advanced Nursing Practice: An Integrative Approach, 2nd edn (Hamric AB, Spross JA & Hanson CM eds). WB Saunders, Philadelphia, pp. 315–347. Henneman E (1995) Collaboration: a concept analysis. Journal of Advanced Nursing 21, 103–109. Lloyd-Jones M (2005) Role development and effective practice in specialist and advanced practice roles in acute hospital settings: a systematic review. Journal of Advanced Nursing 49, 191–209. Lockhart-Wood K (2000) Collaboration between nurses and doctors in clinical practice. British Journal of Nursing 9, 276–280. McCallin A (1999) Pluralistic dialogue: a grounded theory of interdisciplinary practice. Australian Journal of Rehabilitation Counselling 5, 78–85. McCallin A (2001) Interdisciplinary practice – a matter of teamwork: an integrated literature review. Journal of Clinical Nursing 10, 419–428. McCormack B, Manley K, Kitson A, Titchen A & Harvey G (1999) Towards practice development – a vision without reality or a reality without vision? Journal of Nursing Management 7, 255–264. McGee P & Castledine G (1999) A survey of specialist and advanced nursing practice in the UK. British Journal of Nursing 8, 1074– 1078. Murphy E, Dingwall R, Greatbatch D, Parker S & Watson P (1998) Qualitative research methods in health technology assessment: a review of the literature. Health Technology Assessment 2, 163–197. Popay J, Rogers A & Williams G (1998) Rationale and standards for the systematic review of qualitative literature in health services research. Qualitative Health Research 8, 341–351. Read S & the ENRiP team (2001) Exploring New Roles in Practice (ENRiP). Final Report, School of Health and Related Research, Sheffield. Royal College of Nursing (1988) Specialities in Nursing: A Report of the Working Party Investigating the Development of Specialities within the Nursing Profession. RCN, London. Rushmore R (2005) Blurred boundaries damage inter-professional working. Nurse Researcher 12, 74–85.
2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 1540–1549
Issues in clinical nursing Sandelowski M (1986) The problem of rigor in qualitative research. Advances in Nursing Science 8, 27–37. Scholes J & Vaughan B (2002) Cross boundary working: implications for the multiprofessional team. Journal of Clinical Nursing 11, 75– 82. Spradley JP (1980) Participant Observation. Harcourt College, Fort Worth. Stein LI (1967) The doctor–nurse game. Archives of General Psychiatry 16, 699–703. Stein LI, Watts DT & Howell T (1990) The doctor–nurse game revisited. The New England Journal of Medicine 322, 546–549.
Clinical nurse specialists as entrepreneurs Tew J (2002) Social Theory Power and Practice. Houndmills, Basingstoke. White KR & Begun JW (1998) Nursing entrepreneurship in an era of chaos and complexity. Nursing Administration Quarterly 22, 40– 48. Williams A, Robins T & Sibbald B (1997) Cultural Differences between Medicine and Nursing: Implications for Primary Care. National Primary Care Research and Development Centre, University of Manchester, Manchester. Wilmot S (2003) Ethics Power and Policy: The Future of Nursing in the NHS. Palgrave, MacMillan, Basingstoke.
2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 1540–1549
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