The role and scope of the Clinical Nurse Consultant in Wentworth Area Health Service: a qualitative study

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1 The role and scope of the Clinical Nurse Consultant in Wentworth Area Health Service: a qualitative study Karolyn Vaughan, Wentworth Area Health Service Lesley M Wilkes, University of Western Sydney/Wentworth Area Health Service Jenny O Baugh, Wentworth Area Health Services Robert O Donohue, Wentworth Area Health Service New South Wales Health introduced the role of the Clinical Nurse Consultant in A review of the role was undertaken by an area health service in Western Sydney, NSW, Australia in 1992 and a number of issues were highlighted in the review process, including diverse roles and responsibilities. In 2000, New South Wales Health acknowledged the diversity of roles and developed a grading system based on five domains of practice. This paper reports the second phase of a two-part study that investigated the scope of practice and perceived level of organisational support provided for the Clinical Nurse Consultants in the area health service. Focus group interviews, one for managers and two for nurse consultants, were conducted in order to collect data. Ten Clinical Nurse Consultants, representative of each grade and seven managers, covering various clinical streams, took part in the study. Data were analysed using content analysis and coded using constant comparison and contrast of codes. Results of the study reveal a lack of clarity and understanding of the new grading system. There is an indication that the role is very individual and the incumbents are often overloaded by work and the maze of demands put on them by numerous competing forces. Many of the Clinical Nurse Consultants felt they were working at a grade higher than their position classification. There appears to be a significant need to clarify the roles of each of these members of the health care system and to provide a better reporting scheme. Key words: Clinical Nurse Consultant, role clarification, grading system, nurse managers Karolyn Vaughan RN CM C&FHN IBCLC BASc (Nursing), Grad Cert Research, MA Nursing (Honours), Clinical Nurse Consultant, Child & Family Health, Wentworth Area Health Service Lesley M Wilkes RN CM PhD MHPEd BSc(Hons)GradDipEd(Nurs), Professor of Nursing, University of Western Sydney/Wentworth Area Health Service l.wilkes@uws.edu.au Jenny O Baugh RN MN GradDipClinNsg OncNsgCert, Clinical Nurse Consultant (Cancer Care), Wentworth Area Health Service Robert O Donohue RN BHA(NSW), Wentworth Area Health Service Introduction The role of Clinical Nurse Consultant (CNC) was developed in response to an identified need to keep experienced nurses in clinical practice by providing a career structure commensurate with their advanced skills. In 1986, New South Wales (NSW), Australia, gazetted the position of Clinical Nurse Consultant (Elliott et al 1992). In 2000, the NSW Department of Health determined five domains of functioning to differentiate between three award grades (NSW Department of Health Circular 2000) and these were incorporated into the NSW Nurses Award in The five domains of functioning described by the Department of Health (NSW Department of Health Circular 2000) supported this work. They consist of a number of functions, increasing with complexity according to the grade of the CNC, as follows: 1. Clinical service and consultancy: provides expert clinical advice and develops, facilitates implementation, and evaluates care management plans for patients with complex health needs. 2. Clinical leadership: provides leadership that facilitates the ongoing development of clinical practice. 3. Research: initiates and utilizes findings of research. 4. Education: develops and delivers specialty related education programs. 5. Clinical services planning and management: participates in formal processes for the strategic and operational planning for the clinical service. The NSW Health Circular stated that the domains were not intended to describe the whole range of functions undertaken by CNCs but rather related directly to the award wage. This paper describes the perceptions of CNCs and managers in an area health service in NSW in relation to the issues of CNCs enacting their role according to these domains. Literature review The role of the CNC in NSW can be aligned to that of the Clinical Nurse Specialist (CNS) in the United States (US) (Appel et al 1996), the Advanced Practitioner in the United Kingdom (UK) (Coyne 1996, Mills 1996) and the Clinical Nurse Specialist (CNS) role in Queensland, Australia (Bull & Hart 1995). The 14 Collegian Vol 12 No

2 The role and scope of the Clinical Nurse Consultant in Wentworth Area Health Service: a qualitative study CNC was envisaged as an expert clinical practitioner who had extensive knowledge, experience and clinical skills in their chosen specialty. They were seen to operate with expanded autonomy directing their efforts toward improvements in patient care and nursing practice and to provide an institution wide consultancy service to nurses and other health professionals (Elliot et al 1992, Walters 1996). The general definition of a CNC at the time of development was: A registered nurse appointed as such to a position approved by the Department and who has at least five years post basic registration experience and who has in addition approved post basic nursing qualifications relevant to the field in which he/she is appointed. CNCs carry out an across hospital role primarily involved with consulting, researching, assessing and reviewing the delivery of clinical nursing services (Elliott et al 1992 p26). The definition was broad and consequently individual CNCs and their employing institutions have developed site specific roles with a general focus on the areas of clinical practice, consultation, education and research (Dawson et al 1998). For many of the early CNCs, the roles were poorly developed, giving both freedom in deciding the direction of the roles and responsibility for ensuring that the roles were consistent with the professional aspirations of the position and the organisational requirements. This formed the basis for future role developments (Appel et al 1996). Since the creation of the role in NSW, there have been a number of studies that have tried to delineate the domains of practice of the CNC in various practice settings including: area health services (Dawson & Benson 1997, Dawson et al 1998, Harvey 1998); acute hospitals (Elliott et al 1992, Walters 1996); community health (Jannings & Maynard 1998, Jannings & Armitage 2001); and neonatal intensive care (Dawson 2001). Most of these studies concluded that the role of CNC is complex and ill defined. Elliott et al (1992) defined a CNC activity model, which included: consultation; education; administration; professional development; and research. Dawson (2001) refined these domains in her study of neonates to include: consultation and clinical practice; education; research; clinical leadership; clinical services planning; and management. Harvey (1998) found that CNCs and the managers in an area health service in Sydney had differing views of the components of the role. The CNCs ranked the components as: consultation; education; clinical research; professional development; service planning; and development. Managers, however, did not rank the CNC activities but suggested they include: clinical; consultation; education; research; availability of CNC; accountability; and service planning. Key concepts within the literature support the classification of these domains of practice. A number of authors have attempted to clarify and define the central themes of providing a specialist, advanced nursing practice. The core issues included providing specialised knowledge and skill (Appel et al 1996); focussing on practice, research, education/teaching (Castledine 1998); influencing the workplace by modelling expert clinical practice, coaching, framing issues and valuing nursing s contribution (Disch et al 2001); remaining clinically focused, involved in education and training, providing a consultancy, research, administrative tasks and liaison (Gibson & Bamford 2001); being a clinical expert, researcher, consultant, teacher and change agent (Armstrong 1999). The variety of issues highlights the diversity of the role and the potential for role confusion. It is acknowledged that within the domains of practice, different problems can arise. Kajermo et al (2000) described the barriers and facilitators to research utilisation and found a need for positions in clinical practice for nurse researchers, in order to promote a research-based nursing practice. A number of authors have highlighted that support from managers is essential to enable CNCs to fully enact the position (Appel et al 1996, Dawson 2001, Disch et al 2001). The CNC, if appropriately prepared and supported, is ideally placed to fulfil this role. It was stated in the guidelines that all the domains/functions listed at higher grades are not necessarily required for an area health service to establish a higher-grade CNC position. The area health service, when establishing a new CNC position, is only required to clearly establish its requirements and have due regard to the level that contains the majority of functions listed in the domains (NSW Department Health Circular 2000 p2). The 2000 Circular also stipulated that CNCs may be required from time to time to perform functions identified as part of the role of a Clinical Nurse Consultant at a higher grade (p 2). This paper addresses the differences in perception between CNCs and managers as to the CNC role and its scope and their relationships. It is Phase 2 of a two-part study, which investigated the scope of the CNC positions within an area health service. Phase 1 was a mailed survey aimed at determining CNCs' perceptions of their scope of practice in a particular area health service in Western Sydney, NSW, Australia, and compare this to the functions/domains used to differentiate the three grades of CNCs in the current grading criteria set by the Health Department in that state (NSW Department of Health Circular 2000). Phase 2 reported here used focus groups to explore the perceptions of the CNCs and the managers in the area health service as to the issues related to CNCs enacting their role as set by the grading system. Method Research design This phase of the project used a qualitative descriptive approach and is part of a study that used a mixed design. Data collection, coding and sorting began simultaneously. Research instrument Focus group interviews were conducted to collect rich qualitative descriptions of the participants perceptions. With proper guidance from the focus group leader, this method allows the members of the group to describe the rich details of complex experiences and Collegian Vol 12 No

3 the reasoning behind their actions, beliefs, perceptions and attitudes (Martin 1999). This was particularly important in this phase of the project to explore the participants issues. The setting This project was undertaken in an area health service which comprises three local government areas in the West of Sydney, NSW, Australia. Facilities provided by the area health service include: maternity, gynaecology, neonatal intensive care, coronary care, rehabilitation and mental health services. Historically, there had been CNCs in the area since the inception of the role by the state health department in The role of the CNC has been reviewed a number of times in the ensuing years (Dawson et al 1998). In 2001 the area health service adopted the NSW Health grading system for CNCs. Participants All 42 CNCs and managers to whom they reported were invited by to participate in one of three focus groups; one for the managers and two for CNCs. Participants were all volunteers and an independent counsellor was available for anyone for whom the process was distressing. No participants required counselling. Data collection s were sent out with details of when and where the focus groups would be held. The focus groups lasted 60 to 90 minutes. The groups were audiotaped and a scribe was present to take notes. The facilitator gave a short explanation of the history of CNCs in the area health service. A set of questions and prompts were used to broadly channel the discussion and to assist in making comparisons between and within groups in the analysis of data (Kingry et al 1990, Morgan 1993). For the CNCs the concepts covered included: preparation and orientation to the role, their perceptions and reality of the role, support and barriers in developing role and ability to implement the 1992 recommendations. For the managers, concepts covered were their perception of the role, how the role fits within the service structure, and challenges in implementing 1992 recommendations. Data analysis The data from the focus group interviews were transcribed verbatim and subsequently analysed using content analysis and coded for themes relating to the major issues for the CNCs and managers. Each researcher coded individually and a consensus of the final list of themes was made. This process added to the rigor of the analysis. Using constant comparison analysis of codes (Glaser & Strauss 1967), a description of major issues for the CNCs and managers was written. Ethical considerations The Human Research Ethics Committee of the area health service reviewed and approved the project. No names or identifying characteristics have been used in any publications. Data are managed according to National Health and Medical Research Council (NHMRC) guidelines (NHMRC 1999). Findings Participants Ten CNCs, representative of each grade, attended the focus groups. They had occupied their current role in the current area health service for five months to 18 years. Two had recently had their position upgraded, two were employed into new positions from other CNC roles and three had moved into the role from non- Table 1: Major themes derived from focus group interviews Theme/sub themes CNC Managers Role description Individual Individual Expert role Expert role Clinical role Clinical leader Overloaded Super specialisation/narrow role Lack of clarity Lack of clarity (research not part of role) Grading system Lack of clarity Lack of clarity Level inequity within and between area health services Management of role Line management not clear Matrix of management Resource inadequate Communication inadequate Should have one manager Need resource framework Communication inadequate Support for role Lack of support Inadequate work plan Work plan Peer rather than management support needed Preparation for role Historical nature of role Need clarity when developing new CNC roles Succession planning Educational preparation of new CNCs Orientation 16 Collegian Vol 12 No

4 The role and scope of the Clinical Nurse Consultant in Wentworth Area Health Service: a qualitative study CNC positions. Seven managers, covering various clinical streams, took part in the study. Two had previously held CNC positions and all had CNCs reporting to them. Issues in enacting CNC role The findings from the three focus groups will be described together in order to provide comparison. Table 1 depicts the five major themes that emerged from the analysis of the text. Exemplars will be provided from the text to describe these themes in more detail with the tag cfg indicating CNC focus groups and mfg, the mangers focus group. Role description Both the managers and CNCs emphasised that delineating aspects of the role was very individual: CNC positions being very individual, the individual brings their own learning etc to it but part of that is that its part of their own personal progression too, to go on to be a CNC (cfg). At the end of the day somebody decides what s reasonable and what s not because everybody wants a different thing (mfg). In most cases both managers and CNCs thought that individuals were overloaded by the demand of the role: We want them to be all singing all dancing all things to all people (mfg), and: Expectation of my role is humongous (sic) in one that s a level 3 its hospital nursing home community health it s anybody that wants it the pressure never stops you feel like everybody s dogs body (cfg). While the managers emphasised clinical leadership, the CNCs emphasised being an expert clinician: When the concept of CNCs came in it was still to have a good clinical role and I do sometimes get concerned that we are losing a lot of that area management sometimes has tried to change the CNC role and actually take out more and more of that clinical component and that sometimes does concern me (cfg). One of the problems the managers perceived was narrowness of the expertise of CNCs to super specialities: We are getting CNCs being defined by pathology and disease processes versus the broader view of health as is reflected in what came out of the award they can become very focused on a specialty and a particular part of that specialty like research (mfg). The CNCs commented that they often tailored the role: To our strengths (cfg). Lack of role clarity permeated all focus groups. All participants emphasised that for CNCs to be utilised effectively both the incumbent and management needed a clear idea of the role: If management has a clear idea of the niche you re supposed to fill then that gives you clearer guidelines and freedom to develop the role, but you need broad brush strokes from management (cfg). This lack of clarity extended to the organisational system and this made it difficult for the incumbent CNC: It s incredibly difficult for our CNCs because they get caught up in multiple structures, and from a system organisational point of view we need to clarify the role for our CNCs otherwise it s reactive (mfg). Grading system Lack of role clarity was particularly obvious when discussing the grading system. As one manager stated: We have got to become much clearer when we start determining what we want at each level because otherwise we re all competing with each other, it gets to all mine are 3 all yours are 2 I am not sure if we are looking at the same framework people s perception is the majority of CNCs think they should be Level 3 (mfg). The CNCs confirmed manager misunderstanding of the grades: Management understanding I think is probably the biggest stumbling block about where you go and how people accept you (cfg). However, the CNCs themselves had differing views of the enactment of the different levels. They also suggested that CNCs should work their way up the levels. The inequity in the levels was often an expression of differences across area health systems and the way the executives in the areas had established the CNC position: While there are such inequities amongst the CNCs even within that one area let alone comparing one area with another area health service I don t know that management can support us I think this really needs to come back to the area health service executive working out what they want the CNCs to do give us some direction (cfg). Management of role The managers and CNCs saw management of the role differently. A number of managers felt there should be one line manager for day-to-day accountability. When it came to replacing stores and processing time sheets, this would best be a Nurse Unit Manager (NUM). In terms of professional issues they saw themselves as the person to whom the CNC would relate. However, in reality the CNCs were: Working across divisions across streams and across settings, so they often have many masters and I think that that s the difficulty that I believe we face (mfg). The CNCs felt that it was appropriate for the NUM to be responsible for administrative duties but they should not be there to control the CNC: It s OK if you have a NUM who does your time sheets and looks after your budget and pay but it s very difficult if you have a controlling person (cfg). The mangers confirmed that the CNCs often had an issue of being responsible to a NUM: I ve got CNCs on each floor operationally linked, operationally not professionally because they have a problem being professionally linked into the nursing unit manager because there is a level differentiation between the two (mfg). However, in many cases the CNCs had many masters and this provided much discussion among the manager group: One of the difficulties we have in [our area] is that they [CNCs] have many masters the staff get blurred as to what their priorities are (mfg) and: They all want multiple masters until something goes wrong and then everyone they thought was their master is gone for dust and someone ultimately decides what s reasonable and what s not because everyone wants a different thing (mfg). A major focus of the management of the CNC role was the need for resources: These positions are advertised as they are supposed to be one of the senior clinical positions but we don t even have basic resources (cfg). The managers agreed the CNCs needed resources: I don t have a problem with providing resources to anyone that enables them to do the job we re asking them to do or access them if it s reasonable (mfg). Collegian Vol 12 No

5 However, they emphasised a framework to make it work and questioned whether it had been investigated as a need: We ve got lots of guidelines of frameworks to roll out data systems, do we actually know what CNCs in this health system might require (mfg). Lack of communication was an issue in managing the CNC role: I don t know what my role is and don t really have an idea about what I m supposed to be doing on an area basis (cfg) and: I do have a problem that the CNC group meets, we have no idea when the meetings are we have no minutes from the meetings and these are our staff (mfg). Support for role Both the managers and CNC groups felt that the CNCs had inadequate support in enacting their roles: I think some structures don t necessarily support them to be quite honest.. I think its [structure] too fluid because of the hugeness of where we find ourselves clinically (mfg). To expect a person to do five different domains with any sort of justice or competence is ludicrous, nobody expects somebody to do five roles without some kind of support. I m not just talking about CNS support I think that s important not just for CNC level threes (cfg). The CNCs felt they did not have enough support, particularly when it came to conferences and external meetings: I presented at the national conference about a year and a half ago, I had to fight to get money and I was presenting thought you get the kudos from this, this is bull I don t know where this is coming from (cfg). The managers thought differently: From a managerial perspective do we have a different view of when a CNC or RN gives us an application for a conference I think the CNCs perception is they should be treated differently (mfg). As well, the managers questioned the value of the annual professional development day the CNCs held. The CNCs did feel they received some support, particularly from their peers: I found that the CNCs were very supportive if I had a problem I went to them you know (cfg). They did feel that a mentorship program was necessary and suggested that this could be provided from within or outside the area health service: You need a mentor within your specialty and if that s in- house then great but if not then out of house if coming in as a CNC to a new role that nobody really knew (cfg). In order to have effective support both managers and CNCs felt that there needed to be an annual work plan: If there s research it should be within the work plan so every one knows exactly what they re doing in a year It s a work plan you ve actually planned this allocation of time (mfg). However, the CNCs queried whether the plan was actioned effectively and co-operatively: It s just on paper and that s as good as it gets we don t actually and if we don t act on it then oh we ll put it in next years or we ll address that in next years budget and it just continues on (cfg). Preparation for the role Managers were more focussed on clarifying new CNC positions than preparing nurses to assume a CNC role: I think when you want to establish a CNC role there should be more discussion goes on in the broader context so that we don t have one in one part and one in another one we actually as a group look at what s really needed. I have problems where we end up with little pockets that don t really relate and aren t really performing at that role (mfg). The CNCs confirmed the need to plan for a new position but more important was planning for succession into the role: We need to foster that growth or we ll never have people wanting to be CNCs It s about a career structure, teaching people to come up behind you to nurture people CNCs are to pass their skills on I haven t learnt all of this information just to keep it to my self (cfg). However, many of the incumbents had moved into the role in the 1980s and it was succession by history and there was little education. Education was seen as important for people moving into the role and there was more available now: It might be different now in terms of doing clinical Masters degrees and things and you can now do a clinical doctorate so those things can much better prepare you for the role of CNC than what s been traditionally available in terms of education (cfg). However, often the CNCs had: Chosen directions for education and interest and followed those and then the position sort of appeared rather than working directly towards the position as such it s sort of been a natural progression (cfg). The CNCs emphasised the need for orientation once someone arrives to start in a role: Orientation is different for each and every one of us in terms of what we need to know and that we should be professional enough to be able to go and source what we need to know we ve all worked in hospitals (cfg). Often the problem with orientation was that the position was new: I shouldn t say no orientation there was no one doing that role in the area let alone facility I was working in therefore there wasn t any specific orientation but that doesn t necessarily stop you if you what to know what you re supposed to be doing you go out and ask (cfg). Discussion This study has shown that a lack of clarity and understanding of the new grading system exists. It demonstrates that the role is very individual and the incumbents are often overloaded by work and the maze of demands put on them by numerous competing forces. These findings support the conclusions of other studies in NSW (Appel et al 1996, Harvey 1998,) prior to the new grading system being introduced. CNCs and the managers in this study did not verbalise any benefits of the new system apart from the monetary ones. Many of the CNCs felt they were working at a grade higher than their position classification. This could be because they were motivated to do so or that they felt they deserved higher remuneration. The mangers felt there was a general lack of consistency in the way the CNCs enacted the various grades. The issue of the CNCs work overload in this study is no different from that found by Bull and Hart (1995) and Harvey (1998) and further reinforces the point that the grading system provides little benefits in terms of role clarity. This multiplicity of role expectations was highlighted in earlier studies of the CNC role within this area health service (Dawson & Benson 1997, Dawson et al 1998). An interesting outcome of the original study (Dawson & Benson 1997) was the initiation of a structured support system for the CNCs including regular meetings of a CNC group and an annual development day. The follow up survey in 18 Collegian Vol 12 No

6 The role and scope of the Clinical Nurse Consultant in Wentworth Area Health Service: a qualitative study 1998 (Dawson et al) demonstrated the importance of this support network to the CNCs including support from managers, the importance of which has been stressed by Dawson (2001). It is interesting to note that the managers questioned the value of the professional development day in the current study. There is clearly a need for better communication between the two groups, managers and CNCs, on this and other issues related to professional development. This was also evident in the need for ongoing planning and assessment, for example the development of annual work plans. An interesting issue that emerged from the data was the balance of assumed power between CNCs and NUMs within the organisation. There appears to be a significant need to clarify the roles of each of these members of the health care system and to provide a better reporting scheme. The role and scope of the NUM and CNC positions requires examination and a possible way forward would be the development of a collaborative working party including NUMs, CNCs and other nurse managers to determine how the provision of patient care could be improved by a clarification of roles and responsibilities between these two nursing classifications. The confusion about whether CNCs should be predominantly in clinical roles, in research roles or in super-specialities adds to the demands on the CNCs. This study has demonstrated the diversity of the role and illustrates that without structured education and support, CNCs will implement the role in a divergent manner (this may or may not be a bad thing) but clearly managers will continue to lack an understanding of the role if some clear guidance about the specific priorities of each specific position is not documented. The demands on the CNCs for hands-on clinical work could be a result of the growing organisational imperative of too many patients and not enough nurses. Conclusions This study has provided new insight into the role of the CNC in NSW since the establishment of a new framework of grading. It has shown that the new grading system has not made the role of CNCs any clearer or less challenging in the area health service involved. The situation appears little different than it was a decade before. It has shown that communication is essential and both clinicians and managers need to work together to support and manage the CNC role effectively and efficiently. A recommendation that flows from this study is that a manager and CNC need to work together to form effective working relationships especially at the unit level. Further evaluative research after such development will enable the development of better support and management structures to support enhanced patient care. 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