Dissertationen zum Thema „Nursing practice“

Background: Nursing shortage is a worldwide phenomenon; in rural areas, this shortage is exacerbated by geographical imbalances. Reducing the inequality of health outcomes between rural and urban areas requires improvement in the rural nursing workforce. Thus far, little research has been conducted on the recruitment of nursing students to rural nursing in China. Aim: This study aimed to explore nursing students’ perspectives of rural nursing practice and their intentions to work rurally after graduation, and to identify factors contributing to those intentions. Methods: Exploratory interviews were conducted with eleven nursing students to obtain their perspectives of rural nursing practice. This was followed by a hand distributed and collected self-completion questionnaire survey that involved 445 final year nursing students in six nursing schools in one province in China. The questionnaire measured students’ rural career intentions and their perceptions of rural nursing practice. The survey data were collected between December 2011 and March 2012. The response rate for the questionnaire survey was 89%. Results: The results indicated that the majority of final year nursing students did not intend to work rurally. The most frequently cited barriers deterring them from considering a rural job were the perceived fewer opportunities for skills development and learning, potentially lower financial rewards, and family members’ disapproval of rural working. Regression analysis showed that the length of time living rurally and educational level were the most important predictors of nursing students’ intentions to take a rural job immediately following graduation. The logistic regression illustrated that rural identification, degree, and rural placement experiences were significant predictors for nursing students’ intentions to work rurally in their future nursing career. Conclusion: Nursing students with high intentions to work rurally were rare in China. Rural background had a positive impact on students’ intentions to work rurally. Students with a degree were less likely to work rurally.

This qualitative study sought to examine perioperative nursing from the perspective of its practitioners. It was undertaken in two operating theatre sites within NHS Trusts in England. The study used the ethnographic approaches of non-participant observation and semi-structured interviews, with ten observation sessions totalling 85 hours undertaken and eight interviews conducted. Thematic data analysis was undertaken supported by the NVivo qualitative data analysis software program. Two main themes emerged as being core components of perioperative nursing work. The first, ‘Managing Momentum’, related to the work that the nurses undertook to ensure that the operating lists went smoothly and progressed throughout the day. The second, ‘Accounting for Safety’, focussed on the need to ensure that patients were kept safe from harm at all points of their perioperative journey. Three different perioperative nursing roles were identified (anaesthetic, scrub and recovery nurses) and these different types of perioperative nurse undertook managing momentum and accounting for safety work, but each enacted them differently. There was tension between the two components of the work that these nurses had to resolve. The study concludes that perioperative nursing is not a homogenous entity. Nonetheless, perioperative nursing centres on balancing momentum and risk. This insight provides a new understanding of this ‘hidden’ or backstage type of nursing practice. This work will inform perioperative nurses’ understandings of their work, and can also feed into formal definitions of perioperative nursing, recruitment and professional development.

Evidence demonstrates the health benefits of early breastfeeding for mothers as well as infants. The World Health Organization states, "Breast milk should be given within the first hour of life." This purpose of this project was to develop a breastfeeding educational toolkit to promote breastfeeding in the hospital environment. The question that guided this project was, "Will the development of a breastfeeding education toolkit, designed to serve as a learning tool to support the breastfeeding mothers, be found to be useful and valid by professional staff and lay end-users?" The goals of the project were to provide an educational toolkit aimed at supporting new mothers, and to validate the toolkit with stakeholders from the Mother/Baby unit. The benefits of breastfeeding and breastfeeding research were established through an evidence-based search of peer-reviewed journals. The developed toolkit was reviewed by10 stakeholders from the Mother/Baby unit: 1 physician, 3- lactation consultants, 5 nursing professionals, and 1 layperson of childbearing age. To assess the quality of the guidelines, the Logic Model and the 4 domains of the AGREE II Instrument were used. The descriptive data analysis from the AGREE II instrument led to the recommendations for the toolkit. All reviewers acknowledged the need for the toolkit as a support for the mothers and their babies. The stakeholders provided their support for the developed toolkit. The breastfeeding education toolkit has the potential to support positive social change by improving the health of the mothers and babies through improved breast-feeding knowledge.

The view is offered within this thesis that nursing is essentially a practice-based discipline and therefore any theory of nursing must reflect what happens in practice. By analysing research material from a study of practice employed and attached nurses, the nurses' pattern of work was described within the context of the primary health care. Both delegated and more autonomous roles were examined, and the implications of these and their relationship with holistic care and experiential learning were described in view of the continued expansion of the role. The objectives were: a) to examine the process of care and identify any changes in workload or differences in working patterns of practice employed and attached nurses as a result of the introduction of the New GP Contract in April 1999; b) to measure patient satisfaction with nurse consultations and ascertain their views on the changing role of community nurses; and c) to determine the opinions and attitudes of community nurses and general practitioners to future developments and educational opportunities for primary care nursing. Thirty four nurses participated in 1990 with a total of 6675 consultations; 33 nurses in 1991 with a total of 6050 consultations. The largest proportion of patients seen by both groups of nurses during both periods of recording was by general practitioner referral. Practice employed nurses initiated more of their own appointments in the second year and saw fewer general practitioner referrals. This tend was reversed for attached nurses. By the second recording period both attached and practice employed nurses had experienced a reduction in the time spent on routine treatment room work and an increase in clinic activity. Practice employed nurses reported a higher level of therapeutic listening than the attached nurses both years. It was found that 39% of all nurse consultations in 1990 and 27% in 1991 had an interruption either before or during surgery sessions.

The art of nursing is discussed throughout nursing literature but research on the topic is lacking. The purpose of this research was to reveal experiences of the art of nursing. Nurses were asked to describe experiences about the art of nursing from their own nursing practice. This study was qualitative in nature and used a phenomenological approach to answer the research question, “What is the experience of the art of nursing in nursing practice?” The study was guided by the philosophical stance of Merleau-Ponty and the research strategies of Thomas and Pollio. Participants included nurses who had experience using the art of nursing to provide patient care and a willingness to articulate these experiences. With IRB approval, eleven nurses participated in the interview process. Participants had between twenty-one and over thirty years of nursing experience and a range of clinical experiences that included hospice, acute care, nurse management, pediatrics, labor and delivery, medical/surgical, mother/baby, intensive care, progressive care, outpatient day surgery, free standing clinic, cardiac surgical step down, outpatient hemodialysis, nursing instructor, neonatal intensive care, prison nurse, telemetry, school nursing, emergency room, hospital nursing education, orthopedics, post-op, chemotherapy, behavioral health, long term care, code team, and one had been a family nurse practitioner in a rural setting. Results demonstrate the art of nursing in nursing practice includes showing up, staying, and helping patients, connecting to patients, intuitive caring, and making a difference in the lives of both patients and nurses. Findings from this study confirm the art of nursing as an essence of nursing with implications for nursing practice, nursing education, and future research.

Nursing specialization involves focusing on nursing practice in an identified specific area within the entire field of professional nursing. A defined specialty scope of practice statement and standards of professional practice, with accompanying competencies, are unique to each nursing specialty. These documents help assure continued understanding and recognition of nursing’s diverse professional contributions. The purpose of this article is to demystify the process for specialty nurses who are creating or revising their specialty nursing scope and standards of practice. We provide best practices for the developmental process based on our recently published scope and standards of specialty nursing practice. The conclusion provides strategies to disseminate scope and standards documents to appropriate stakeholders.

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Bachelors
Health and Public Affairs
Nursing

This PhD by publication brings together several pieces of research undertaken in order to explore issues in advanced practice in a number of different settings. The focus of the programme of work has been to gain a better understanding and widen available knowledge of the drivers and essential elements of advanced practice nursing roles. The whole body of the work is based on my continuing academic and professional role embracing clinical practice and education as well as research. It is my strongly held belief that these three components are intrinsically linked and that one without the others, for professionals in practice, is incomplete and inherently flawed as an underpinning to the work of health care professionals. The work on this thesis began because of concerns and issues around personal practice and has grown to involve national and international perspectives on a number of clinical areas. This programme of work with each new study considering different aspects of advanced practise while building on the results and conclusions of the preceding works, leads to a consideration of some of the implications for future practice, education and research in this important area of nursing. The opportunities for research were, in the main, on a small scale and unfunded. Qualitative techniques were chosen in order to explore the ideas and experience of the participants, rather than those preconceived ideas held by the researcher(s). The demographic and quantitative data collected in the surveys was represented by descriptive statistics only as no inferences (in a statistical sense) could possibly have been drawn from such data. The publications associated with the planned areas of enquiry add to the evidence base for advanced nursing practice and seek to promote discussion and debate and promote change around an essential element of healthcare provision. The studies consider aspects of advanced practice including: " Decision making and safety: Decision making reflects expertise and has been shown, in the work here as well as in many other areas, to be safe and effective. 9 Acceptability of roles: There is a huge volume of research available that shows overwhelmingly that patients like these advanced practice roles. Research undertaken here showed the acceptability of the role to the multidisciplinary team and the importance of the whole team to role functioning. " The organisation of advanced practice: Some issues identified in the study relating to aspects of role development such as prescribing, have subsequently been successfully addressed. Others, such as the rigidity of job descriptions and the lack of support for risk taking, still prove problematic, " The process of role development is, as has been highlighted in other literature, often ad hoc, local, ill thought through and without the infrastructure to support it. Nevertheless, roles are evidently successful. " Regulation of advanced practice: What has become clear throughout the process and the time span of the programme of research is that whether regulation is in place or not, nursing responds to the needs of the service and while regulation of one part of nursing ensures that the particular advanced practice role is protected, others evolve outside the framework as easier (and cheaper) options. " Policy as a driver of roles: It is clear that policy, whether local or national drives the areas in which advanced practice flourishes. Where there are gaps in service, nurses and now other health professionals undertaking such roles, move in to address the service imperatives. The nature of healthcare is about to change quite fundamentally in the UK, and if we are to be able to know what is going on and the effect it is having, research on advanced practice roles must continue. My intentions are to build on this work in the future and include replication studies as well as studies employing sequential explanatory designs to widen the scope of the research presented here. Other areas of potential research include outcomes for patients in acute care settings as well as issues such as value for money which, at present are very difficult to quantify. As nurses move into even more complex roles, it will also be important to keep an eye on the educational underpinnings of such roles. The private sector is playing an increasing part in the UK's health provision and, with a diverse range of organisations involved, little is known about advanced practice roles in these organisations. This gap in the original research, coupled with the much wider role of such providers in the future, also opens up future research possibilities.

Doctor of Philosophy
Aim and significance: The aim of this research was to investigate how evidence-based practice (EBP) in nursing homes is understood in the context of Taiwan, a non-Western country. There is a growing movement towards using research evidence to inform practice in the nursing profession with variable success. To date, factors that promote or inhibit implementation of EBP in health care have been investigated through research conducted in hospital settings in Western countries. Remarkably little is known about nurses’ experience and perceptions of EBP in residential aged care facilities (RACFs), especially in non-Western countries. Method: The study adopted a mixed method approach. Subjects were recruited from six nursing homes in the Hsinchu district of Taiwan. In Stage 1, 89 registered nurses completed a comprehensive questionnaire specifically developed for this project. It was designed to elicit information about (1) their experience of and attitudes towards research and EBP; (2) the barriers they perceive to its implementation; and (3) what strategies they believe would enhance its implementation in the nursing home setting. In Stage 2, six nursing managers participated in semi-structured in-depth interviews that explored the same topic areas as those in the questionnaire but used an open-ended format which allowed for new themes to emerge. Findings: The majority of nurses and nursing managers expressed positive attitudes towards research and EBP but reported relatively little experience in its implementation. Nurses relied most heavily on knowledge derived from past experience and on interactions with nursing colleagues, medical staff and patients to inform their clinical practice. They identified the main barriers to EBP as: insufficient authority to change practice, their own lack of research knowledge and insufficient time to implement new ideas in the workplace. They believed EBP would be facilitated by: improved access to computers and internet facilities in the workplace; more effective research training; collaboration with academics; and dedicated time to search for and read research articles. As anticipated, nurses viewed the issues from a practical stance in relation to their own time, resources and lack of authority to effect change. Nursing managers expressed similar views to the nurses in relation to attitudes towards EBP implementation. However, they identified barriers which related to aspects of the organizational framework. In particular, they expressed concerns about issues such as budgetary constraints, staff quality (notably the reliance on minimally trained assistants in nursing (AINs) for direct resident care), as well as factors that reflected the wider political and economic context of health care in Taiwan. Conclusion: The findings of this study have implications for research, policy and practice in both Western and non-Western countries. Further research on EBP would be beneficial if conducted in settings other than hospitals, such as RACFs. There remains also the need to examine the potential for EBP in different social-cultural contexts, such as those in non-Western countries. Nursing managers have generally been excluded in previous research but, because of their particular role, there is a need to examine their perspectives of EBP and then compare these with those of the nurses. In Taiwan specifically, policy change is needed at both government and institutional levels to encourage and support the development of protocols and procedures for the implementation of EBP. If EBP was a government requirement for accreditation and a standard for protocols in hospitals and RACFs, it would lead to improved standards of care and cost effectiveness. This study supports the findings of a number of investigations conducted in Western countries which indicate that further education and training in research for nurses may lead to higher standards of patient care, greater job satisfaction and higher staff retention rates.

The typical picture that is conjured up when one thinks of a nurse is that of a matronly figure, in a uniform and cap, sitting at the patient’s bedside administering care. Associated with this is the traditional view held by the public, in which nurses are beholden to doctors and dependent on them for instruction, and perform a generally subservient role. However, those who have had the misfortune to require treatment more recently will testify to a far different situation, in which nurses perform a more professional and clinically autonomous role, as well as having a caring and compassionate function. In fact, the picture that exists in most clinical environments is one in which nurses are recognised as knowledgeable and capable clinicians, and independent practitioners in their own right, rather than obedient medical handmaidens. The delivery of modern healthcare has also changed beyond recognition, with interventions that were once considered to be the domain of hospital practitioners now provided in a more liberated community-based system. Within this structure, the role of healthcare professionals has similarly been transformed, such that the ‘power’ has shifted away from doctors and towards non-medical clinicians. This has, in turn, resulted in non-medical practitioners, most notably nurses, having more authority, autonomy and responsibility for clinical decision-making, rendering them more equal in the clinical hierarchy and more evenly aligned as professionals. This thesis explores the range of traditional medical activities that are now performed by nurses who have expanded their practice in order to accommodate the additional responsibilities that this 'power' affords. In particular, it looks at those nurses who have advanced their practice such it constitutes a new clinical role and, in some cases, act as medical substitutes. With the further devolution of clinical tasks inevitable, and the creation of more clinical roles likely, this thesis looks at the regulatory framework that underpins advanced nursing practice. In particular, it questions whether the existing framework provides the regulatory safeguards that are required to ensure patient and public protection and asks whether an alternative approach, such as that which is provided by another professional regulator, may be more appropriate. In concluding, this thesis will assert that a compelling case for the statutory regulation of advanced nursing practice can be made, and will suggest a number of options regarding how this regulatory solution can be achieved.

This thesis presents a body of publications in the area of critical care nursing, for the consideration of the award Doctor of Philosophy by publication. The publications and their dissemination herein contribute to a new and original body of knowledge within critical care nursing practice. This thesis aims to demonstrate how an original contribution to the advancement of critical care practice has developed through an on-going integration of academic and practice work and has led to the development of a model for advancing practice. Based on the know-that and know-how framework of advanced knowledge, consideration is given how this approach could be better developed to incorporate other dimensions attributed to experiential learning, namely pattern recognition and an exemplar of the knowing-how knowing-that framework is offered. However, it emerged that there are problems with advancing practice because it is considered the work of the advanced practitioner, yet it is contended that there needs to be a process which allows individuals to advance their own practice. Therefore, it was necessary to develop a working definition of advancing practice not only to map professional advancement of critical care nursing practice and how published works illustrate this, but to offer model of knowledge integration based around theoretical, practical, reflective and reflexive practice and supervisory support to enable individual practitioners the framework to advance practice. This thesis is presented in three chapters: Introduction, Body of Work and The Way Forward. In the first chapter, an overview of the origins and trends of advanced nursing practice and the emergence of advancing nursing practice in critical care. The purpose of this first section, however, is not to engage in the politico-professional debate on the meaning of advanced practice, because this is well developed within the literature, but is to set the scene in the context of published work. By using a narrative approach as a journey of personal discovery, a description of how published works illustrate progress in this respect and show the advancing of critical care practice.The second chapter not only comprises publications with regard to critical care nursing practice but also presents a detailed critique of these publications and their contribution to advancing critical care nursing practice and knowledge. Moreover this discussion identifies three themes which are further developed into the classification of knowledge attributable to advancing practice. In the concluding chapter, recommendations for the way forward are discussed with the development of a critical care nursing knowledge integration model. An exemplar of the model demonstrates that advancing practice in critical care is a continual process of development, analysis and practice that advances the knowledge and skill of critical care nursing. More importantly, it is the integration of all these facets that allows for the growth of the individual to become an advanced practitioner. In summary, this thesis represents a portfolio of work that makes an original contribution to critical care nursing knowledge. The product of this thesis is the development of a knowledge integration model as the basis for advancing practice:"

Aim and significance: The aim of this research was to investigate how evidence-based practice (EBP) in nursing homes is understood in the context of Taiwan, a non-Western country. There is a growing movement towards using research evidence to inform practice in the nursing profession with variable success. To date, factors that promote or inhibit implementation of EBP in health care have been investigated through research conducted in hospital settings in Western countries. Remarkably little is known about nurses’ experience and perceptions of EBP in residential aged care facilities (RACFs), especially in non-Western countries. Method: The study adopted a mixed method approach. Subjects were recruited from six nursing homes in the Hsinchu district of Taiwan. In Stage 1, 89 registered nurses completed a comprehensive questionnaire specifically developed for this project. It was designed to elicit information about (1) their experience of and attitudes towards research and EBP; (2) the barriers they perceive to its implementation; and (3) what strategies they believe would enhance its implementation in the nursing home setting. In Stage 2, six nursing managers participated in semi-structured in-depth interviews that explored the same topic areas as those in the questionnaire but used an open-ended format which allowed for new themes to emerge. Findings: The majority of nurses and nursing managers expressed positive attitudes towards research and EBP but reported relatively little experience in its implementation. Nurses relied most heavily on knowledge derived from past experience and on interactions with nursing colleagues, medical staff and patients to inform their clinical practice. They identified the main barriers to EBP as: insufficient authority to change practice, their own lack of research knowledge and insufficient time to implement new ideas in the workplace. They believed EBP would be facilitated by: improved access to computers and internet facilities in the workplace; more effective research training; collaboration with academics; and dedicated time to search for and read research articles. As anticipated, nurses viewed the issues from a practical stance in relation to their own time, resources and lack of authority to effect change. Nursing managers expressed similar views to the nurses in relation to attitudes towards EBP implementation. However, they identified barriers which related to aspects of the organizational framework. In particular, they expressed concerns about issues such as budgetary constraints, staff quality (notably the reliance on minimally trained assistants in nursing (AINs) for direct resident care), as well as factors that reflected the wider political and economic context of health care in Taiwan. Conclusion: The findings of this study have implications for research, policy and practice in both Western and non-Western countries. Further research on EBP would be beneficial if conducted in settings other than hospitals, such as RACFs. There remains also the need to examine the potential for EBP in different social-cultural contexts, such as those in non-Western countries. Nursing managers have generally been excluded in previous research but, because of their particular role, there is a need to examine their perspectives of EBP and then compare these with those of the nurses. In Taiwan specifically, policy change is needed at both government and institutional levels to encourage and support the development of protocols and procedures for the implementation of EBP. If EBP was a government requirement for accreditation and a standard for protocols in hospitals and RACFs, it would lead to improved standards of care and cost effectiveness. This study supports the findings of a number of investigations conducted in Western countries which indicate that further education and training in research for nurses may lead to higher standards of patient care, greater job satisfaction and higher staff retention rates.

Control over nursing practice (CONP) is a participatory process through which nurses have input and engage in decision making about the context of practice and unit operations related to nursing practice. CONP has been associated with a number of positive outcomes related to nurse satisfaction, nurse status, effectiveness of patient care, and quality of patient outcomes. However, no comprehensive model has been created nor comprehensive analysis been conducted related to approaches for increasing CONP. This study tested a hypothesized model of antecedents to CONP developed from a review of the literature in nursing, psychology, and organizational management using a complexity theory perspective.The study used a nonexperimental, comparative design. The sample for data analysis consisted of 28 nurse managers and 583 staff nurses from 32 units in 10 hospitals. Existing instruments were used in a paper and pencil format to collect demographic and perceptual data on CONP and the hypothesized antecedent variables. Data were aggregated to provide an analysis of organizational and unit level contextual and variable effects related to CONP.Contextual regression indicated a greater influence of unit-level variables than organizational-level variables on nurses' perceptions of CONP. Regression analyses and revised model testing demonstrated that nurse manager supportiveness, implementation of a formal structure for CONP, and information flow consisting of open and accurate communication were positively related to CONP. Hierarchy of authority was negatively related to CONP. The relationship between CONP and job codification and autonomy varied based upon the measurement of the dependent variable. Manager's perception that participative decision making enhances organizational effectiveness; manager's perception that participative decision making does not reduce their power; nurses' experience, expertise, and educational preparation; and nurses' desire for control did not significantly relate to CONP as hypothesized.This study contributes to nursing research and clarifies strategies for improving the work environment for nurses by delineating antecedents to CONP in the acute care hospital setting. These data will be useful to nurses, nurse managers, and hospital administrators who want to improve patient safety, reduce patient mortality, increase nurse satisfaction, and increase nurse retention.

This descriptive survey study investigated the value of faculty practice among Commission of Collegiate Nurse Education (CCNE) Accredited Nursing Schools. The sample included all CCNE accredited schools that offered a Masters degree. Subjects from the 66 schools in the sample the dean and three Nurse Practitioner faculty who are teaching a clinical course. Response rate was 51% for the deans and 35% for the faculty. The opinions of deans were compared to the opinions of faculty on the views of faculty practice as research and the incorporation of faculty practice in the tenure and merit review system. The results showed faculty and deans differed on the value of faculty practice as research. However, only 6.5 % of statistically significance difference was contributable to whether the response was from a dean of a faculty. There was no significant difference to the inclusion of faculty practice in the tenure and merit review system. Boyer's expanded definition of research was used as a theoretical background. Deans viewed faculty practice more important as compared to the traditional faculty expectation of research than faculty did. The operational definition of faculty practice was that it required scholarly outcomes from the practice. Deans were more willing than faculty to acknowledge there were scholarly measurable outcomes to evaluate faculty practice than faculty were. The greatest difference in opinion of outcomes was the deans were more willing to accept clinically focused articles as an outcome than faculty were. Faculty were asked how the money from faculty practice was distributed. Faculty overwhelmingly reported that money generated from faculty practice most often goes to the individual faculty member. Suggested areas for future research involve investigation of the role of tenure committees in tenure decisions relating to research and faculty practice.

Book Summary: Perspectives on Nursing Theory is a comprehensive anthology of important articles addressing diverse theoretical and philosophical perspectives on the nature of theory and knowledge development in nursing. This informative and contemporary resource features some of the most widely read and cited articles that facilitates thought and discussion among nurses, researchers, students, and teachers.Features 52 of the most widely read and frequently cited articles reflecting seminal, modern, and futuristic perspectives on nursing theory. Includes new articles reflecting current, cutting-edge views of nursing theory and trends. Includes biographical information about each author that provides insight into the author's perspective.

The authors propose connecting the dots among theory, practice, and research by adopting an expanded conceptual-theoretical-empirical structure of nursing knowledge and matrix process to guide the placement of nursing knowledge in a contextual whole. An overview of the theoretical journey of nursing knowledge development is contrasted with the journey from practice resulting in a theory-practice disconnect. Both approaches are united to present an integrated view of the dimensions of the knowledge development of nursing as a professional discipline.

Over 15,000 master’s and doctoral degree students in the United States were denied admission to nursing schools in 2014 because of insufficient nursing faculty. In 2016, over 64,000 undergraduate and graduate students were unable to gain admission to nursing school due to the effects of faculty shortages. This project explored the role of the Doctor of Nursing Practice (DNP)-prepared nurse in academic settings using a systematic review of the literature to determine the role of DNP-prepared nurses in academia. Souza’s systematic review model and Melnyk’s levels of evidence were used to guide the search, review, and the selection of scholarly articles published between 2005 to 2019. A chart of preferred reporting items for systematic reviews and meta-analyses chart was used to organize and select 14 articles meeting the review criteria and included in the analysis. Four themes emerged from the analysis of literature: role in academia from the dean’s and director’s perspective, DNP role as a teacher, preparation for faculty role, and leaving the faculty role. Confusion over the role of the DNP in academia was also identified as a factor affecting DNPs in academic practice settings; however, DNPprepared nurses have the clinical experience, knowledge, and skills to provide evidence-based teaching and fill the gap in practice needed in academic settings. This project may promote positive social change by raising awareness of the role of the DNP in academia to reduce the faculty shortage.

Nurses working in haemato-oncology require specialised knowledge and yet, formal education programmes and textbooks devoted to the speciality are limited. In advancing knowledge for haemato-oncology nursing practice this project endeavours to develop, synthesise, organise and disseminate available evidence making it more accessible to practising nurses. The project consists of two inter-related parts: reflection on, and critique of, the development and editing of the second edition of a nursing textbook and a Delphi study of research priorities in haemato-oncology nursing included as a chapter of the textbook. In aiming to expand and advance the knowledge base for nurses working in haematooncology the concept of knowledge, ways of acquiring knowledge and types of nursing knowledge are explored and critically analysed. A textbook is mainly a source of empirical knowledge but ways of encouraging the development of other forms of relevant knowledge are discussed in relation to the format of the textbook. Critical reflection on the development of the textbook is also undertaken to detennine usefulness and value. Development of the first edition of the textbook and analysis of existing literature in haemato-oncology nursing highlighted the paucity of research informing the speciality. This provided the incentive to undertake the Delphi study. Round 1 generated a wide range of research topics, subsequently used to develop the questionnaire for round 2. Round 2 results demonstrated close clustering and little discrimination between research topics. Round 3 was therefore undertaken to increase the reliability and credibility of results and further discriminate between research priorities. Results from rounds 2 and 3 were remarkably consistent with several strong research themes emerging. These themes provide the foundations for the development of a research strategy with the potential to further advance knowledge for haemato-oncology nursing practice.

One of the requirements for high quality individualised nursing care is that nurses must recognise and attempt to solve patients' health problems. It is generally agreed that this needs a problem-solving approach. It was decided to investigate the perceptions and understanding of problem solving in nursing using a model derived from the general literature. This model, from an analysis of 55 studies, consists of 5 phases which happen to be similar to the 4 or 5 stages in discussions of the nursing process. Insight into nurses' perceptions of problem solving was obtained by presenting 120 nurses, in individual interviews, with 7 specially constructed and validated vignettes of clinical problem solving. Deliberately, only one of the vignettes was complete, containing all 5 elements of the derived model. The remaining vignettes had one or more of the elements missing. The nurses were encouraged to comment on each vignette and the protocols were analysed in detail. Analysis revealed that the phase model was generally understood by all types of informants, but a number failed to detect the missing phases in some vignettes, in particular, problem identification, planning and evaluation. On the other hand, problem assessment and implementation almost always attracted comment. There did not appear to be a relationship between informants' nursing experience and the recognition or non-recognition of phases. Another finding was that informants were not always systematic in their analysis of the vignettes; that is, some did not begin their analysis with problem identification and conclude with evaluation. Overall, the findings lend support to a stages model as a theoretical basis for problem solving in nursing. The theoretical basis of problem solving in nursing is also discussed in relation to problem solving in allied professional disciplines. Finally, the implications of the study for nursing education and practice are explained and recommendations made for further study.

This study addresses the challenge of preparing undergraduate student nurses to be able to engage profitably in Evidence -based Practice. It focuses on the tension between learning about Evidence-based Practice within the Academy and the competencies and skills required to utilise it in clinical settings. Evidence-based Practice is a dynamic process which has core components and defined steps. Nurse education programmes are required by regulatory bodies to prepare nurses to utilise the best evidence to underpin their practice. However, they provide no specific guidance on how this should be organised and delivered or how it can be measured within nurse education programmes. This study evaluated a teaching module in nurse education which was re-designed to embed Evidence-based Practice into its teaching, learning and assessment strategies. The new module aimed to foster capability for Evidence-based Practice at undergraduate level through specifically modified teaching, learning and assessment strategies; and to evaluate the impact of the intervention on the attitudes, beliefs, knowledge and utilisation of Evidence-based Practice. The study was a pre-test/post-test quasi-experimental design employing two questionnaires administered to the same cohort on two separate occasions. The pre-test was administered immediately before the module commenced; the post-test was administered after the module, following a year-long placement in clinical nursing practice. Participants were also asked two free text response qualitative questions regarding their views on aspects relating to Evidence-based Practice in practice. Results indicated static levels of knowledge, attitudes and beliefs about Evidence-based Practice between pre-test and post-test phases. Declined levels of utilisation were demonstrated on post-test measurement. The findings suggest that programme-wide curricular reform coupled with a focused, structured collaboration with clinical partners is required if Evidence-based Practice is to become embedded in nurse education and practice. A number of theoretical perspectives offer real promise of greater insight and understanding of how nurses learn, know and practice and the factors that can and do affect these characteristics. Such insight could facilitate more sensitive, appropriate and targeted integration of Evidence-based Practice knowledge into practice ensuring its success and sustainability

A perceived discrepancy exists in understanding between nursing educators' and hospital nurse leaders' views on job performance expectations and the reality of current job performance that may contribute to the difficulty experienced by novice nurses during their transition period. Lack of clarity in expectations may lead novice nurses to change jobs or leave the nursing profession within the first year of practice. The purpose of this descriptive study, guided by Benner's novice to expert theory, was to determine whether a difference exists between hospital nurse leaders' beliefs and nursing educators' beliefs about the frequency and competency levels, including leadership for novice nurses transitioning into practice, critical care nursing performance, teaching and collaboration, ability to plan and evaluate, interpersonal relations and communications, and professional development. Survey data were collected from 52 nursing educators and 52 hospital nurse leaders using the Schwirian's 6-dimension scale of nursing performance and analyzed using MANOVA and independent t tests. No differences were identified between hospital nurse leaders' and nurse educators' beliefs on the frequency and competency level in all areas examined for novice nurses transitioning into practice. Hospital nurse leaders' and nurse educators' expectations for novice nurses aligned. Further research should focus on ways to strengthen novice nurses' knowledge, critical thinking, and skills so they are better prepared to enter the transition period. Outcomes from this study may be used to improve education and transition to practice for novice nurses, which can result in positive social change.

Nurse practitioners (NPs) have been undergoing a rapid transition in their entry-level degree, from Master of Science in Nursing (MSN) to Doctor of Nursing Practice (DNP). At this time, it is important to establish research evidence on the effects of doctoral education on NP practice. Therefore, a qualitative study of practicing NPs that have returned for the DNP degree was conducted. The purpose was to describe NPs' perceptions of their DNP education, and particularly its influence on their professionalism and patient care. A literature review and evidence synthesis process showed that the available body of research provides little insight into the question of how DNP education affects NP practice; therefore, qualitative description methodology was used to describe this phenomenon. The research questions that guided the study were: 1) What changes do practicing NPs describe about their clinical practice after the experience of completing a DNP?; and, 2) What are the NPs' perceptions of and concerns about the influences of their DNP educational experience on their clinical practice? Two published models and the DNP Essentials (AACN, 2006) informed and guided the data collection and analysis process. Purposive sampling and analyses continued concurrently until data saturation was achieved. Ten DNP prepared NPs were interviewed, and there was wide variation in the sample. The overarching theme Growth into DNP Practice summarizes the participants' perceptions of the changes that have occurred as a result of their DNP educational experience. Four major themes that support the overarching theme are: (a) Broader Thinking and Work Focus; (b) New Knowledge and Interests; (c) New Opportunities; and, (d) "Doctor" Title an Asset. Conceptual categories under each major theme are described. Participants were overwhelmingly positive about the influences of their DNP education on their practice, but the role of the DNP graduate in knowledge translation has yet to be fully operationalized.

Learning to care and first encounter to care patients for male nursing students introduce a unique set of dilemmas to the predominantly female nursing educational process. The purpose of this study was to describe the experience male nursing students learning to care and first encounter care patients in their first nursing practice. A purposive sampling of seven male nursing students were interviewed by internet interview and analyzed by Qualitative content analysis. The results show that the Thai male nursing student stairway to confidence in nursing they start with feelings of stressfulness, developing sensitiveness, developing co—operation and developing strategies to care and encounter with patient. The results also seem to include gender specific questions on how to handle dilemmas in the predominantly female nursing education. These may reflect facilitators and barriers of developing a caring mind among male nursing students. Implication for nursing education and practice are presented and discussed.  In the clinical practice, the method of teaching was important to encourage, but also to gain additional knowledge and support peer groups as a suitable learning environment.

Nurse practitioners (NPs) have been undergoing a rapid transition in their entry-level degree, from Master of Science in Nursing (MSN) to Doctor of Nursing Practice (DNP). At this time, it is important to establish research evidence on the effects of doctoral education on NP practice. Therefore, a qualitative study of practicing NPs that have returned for the DNP degree was conducted. The purpose was to describe NPs' perceptions of their DNP education, and particularly its influence on their professionalism and patient care. A literature review and evidence synthesis process showed that the available body of research provides little insight into the question of how DNP education affects NP practice; therefore, qualitative description methodology was used to describe this phenomenon. The research questions that guided the study were: 1) What changes do practicing NPs describe about their clinical practice after the experience of completing a DNP?; and, 2) What are the NPs' perceptions of and concerns about the influences of their DNP educational experience on their clinical practice? Two published models and the DNP Essentials (AACN, 2006) informed and guided the data collection and analysis process. Purposive sampling and analyses continued concurrently until data saturation was achieved. Ten DNP prepared NPs were interviewed, and there was wide variation in the sample. The overarching theme Growth into DNP Practice summarizes the participants' perceptions of the changes that have occurred as a result of their DNP educational experience. Four major themes that support the overarching theme are: (a) Broader Thinking and Work Focus; (b) New Knowledge and Interests; (c) New Opportunities; and, (d) "Doctor" Title an Asset. Conceptual categories under each major theme are described. Participants were overwhelmingly positive about the influences of their DNP education on their practice, but the role of the DNP graduate in knowledge translation has yet to be fully operationalized.

This qualitative research project is an exploration of how nursing faculty make meaning of their experiences in the disjuncture between what is taught about best practice and what is found in many clinical practice sites. Nursing faculty members teach best practices, but when they take students into practice arenas, the students do not necessarily see those best practices. Instead, they may see caregivers substituting “supposed efficiencies” for best practice. As guests in a hospital, faculty members have no clear-cut entry point to make changes. As both nurses and educators, they face quandaries in places where practice is inadequate; they may want to remove their students but because they are nurses, feel ethically obligated to stay and to attempt to change practice. As educators, they must role model competent nursing care yet may be in a setting where structural conditions create a situation in which nurses are unable to provide best practice. The nursing faculty’s role creates a unique liminal place at the practice-education interface that is challenging and uncomfortable. Constructivism/interpretivism and critical theory inform this study. The main theorist is Dorothy Smith (1992, 2005, 2006). Smith’s critical theory perspective brings into view power relations that organize, but are often invisible to, the everyday activities of nurse faculty in clinical settings. Twenty-four clinical nurse faculty members from post-secondary institutions were interviewed. The main themes arising from these interviews were conflicts, dual consciousness, being a guest and maintaining placements. Analysis of these themes found that faculty members engage in a complex set of negotiations to address disjunctures as they seek to meet the needs of students, patients and staff. The complexity of the navigation is reflective of how faculty and staff nurses are embedded in a nest of social relations with other caregivers, administrators, patients and their families under conditions of neoliberalism. A neoliberal corporate ideology that has infused the health care system has made it difficult for nurses to provide care as they are taught. These uncomfortable moments can become teachable moments not only about “good practice” but also about advocacy for change in structural conditions that constrain “good practice.”

INTRODUCTION: The expansion of professional roles has been proved to be an innovative solution across some countries in order to help address healthcare integration, coordination, continuity, access and health care sustainability. The development and implementation of different roles in advanced practice nursing has been considered one of those innovations in pioneering healthcare reforms. The need for nurses to adapt their practice in all settings has been a necessary step to meet the demands of our changing health care system and to contribute to address objectives and sustainable development goals set by different human resources strategies. However, entwine with the development and implementation process of new nursing roles are its environment and context. In Catalonia, some nurses have evolved and adapted to international standards without the legal acknowledgment of advanced practice that other countries have. The evolution of these high-standard nurses shares the confusion with the international nursing profession about the terminology, specific function and scope of practice of other advanced practice nursing roles. Understanding changes made in nursing practice and how context affects implementation of these changes can be crucial to manage difficulties that arise during this process. Similarly, grasping how implementation of advance nursing roles affects practice, organization and national contexts can be essential to better predict and measure the impact of these innovations in healthcare. OBJECTIVES: In order to gain an enhanced evaluation of the implementation of advanced practice nursing in Catalonia this study presents a workforce role delineation in Catalonia and a comprehensive insight into the dynamics of context in Catalonia, Spain and Quebec, Canada. METHODOLOGY: The research had two stages. In Stage 1, the study intended to collect data on the practice of those working in advanced practice roles. A translation, cross- cultural adaptation and psychometric analysis of the Spanish version of the Modified Advanced Practice Role Delineation (APRD) tool was performed followed by a role delineation study of advanced practice nursing. A cross-sectional survey of practice domains and trends in role functions was implemented through a cross-sectional, descriptive, exploratory study. The study population were Spanish specialist nurses and expert nurses that have been previously identified by the authors as nurses with a more advanced competency profile than a general nurse in Spain. The study had a convenience sample of 151 nurses employed by a dual tertiary and community hospital in Barcelona, Spain. The data was collected over six months in 2015 -2016. The tool comprised 41 items across five domains of advanced practice nursing (direct comprehensive care, support of systems, research, education and publication and professional leadership). Variables used in this stage of the study were length of nursing experience, educational qualifications, context of practice, level in professional career ladder and role implication on other disciplines, services and patients. In the second stage of the study, to better understand the context of advanced practice implementation a visual network analysis of relations connecting contextual factors in advanced Practice Nursing development in Catalonia. The study design was qualitative, descriptive and explanatory. Participants from the diverse perspectives of practice, organization and environment levels were engaged to participate in semi-structured focus groups in March 2016. They were asked to inform on different dimensions of the context of role development: understanding of the role, felt needs, perceived outcomes, barriers and facilitators. Further data was gathered through interviews in Quebec, Canada to inform about of the context dimensions at external, organization and team level. The study was approved by the Clinical Research Ethics Committee (CEIC) at Hospital Clínic, Barcelona (Reg. HCB/2014/0811 and HCB/2016/0055). Participants provided written informed consent prior to participation in the study. Participants were guaranteed anonymity in the findings report and research analysis. RESULTS: The results provided support for the instrument´s validity and reliability in advanced practice nursing in a tertiary and community hospital. The tool showed internal consistency, with a Cronbach’s alpha coefficient of 0.86 and stability over time. The cross-sectional study was designed to explore the extent and patterns of advanced nursing practice activity within the domains of expert care planning, integrated care, inter-professional collaboration, education, research, evidence- based practice and professional leadership. Advanced practice domains were more strongly influenced by the predictors of nursing position and professional career ladder while age and experience were found to be weak predictors of advanced practice domains. The conceptualization of the advanced nursing practice profile provides data which allow description of activities and domains in the context of practice along with description of healthcare adaptation and change management. On the context analysis, 30 interviews were conducted in Quebec while 44 participants were interviewed in Catalonia. Integration of findings reflected a vast predominance of convergent themes despite differences in context and population characteristics. The study identified common and diverge context factors of advanced practice development and implementation across both countries. Barriers and facilitators were prominent almost evenly across all groups, however, it remained difficult to understand the interrelated dynamics between implementation and context. CONCLUSIONS: This study represents the first attempt to examine the reliability and the validity of a Spanish tool capable to delineate advanced practice nursing domains and activities. It is the first attempt to describe the profile of advanced nursing practice in Spain by exploring the extent and patterns of advanced practice activity in newly developing roles. The study achieved conceptual, semantic and content equivalence of the Spanish instrument which allows to define the extent of advanced practice activities and domains using a validated, adapted instrument. The second stage of the study provided a visual network of relations connecting contextual factors in Advanced Practice Nursing development in Catalonia. Also, it identified common and diverge context factors of advanced practice development and implementation across two countries. Barriers and facilitators were prominent almost evenly across all groups, however the organisation and environment level themes were the most coded and discussed during the interviews. IMPLICATIONS FOR PRACTICE: Innovative advanced practice nursing roles are of greater relevance in terms of transforming the model of care such as orientation towards long-term conditions, greater resolution, accessibility, quality in high specialization and interdisciplinary public health. Greater clarity around these roles may assist in optimizing workforce utilization, meeting new service delivery requirements and enabling greater internal organizational cohesion, consistency and professional clarity.
INTRODUCCIÓN: La expansión de los roles profesionales ha demostrado ser una solución innovadora en algunos países para ayudar a abordar la integración, la coordinación, la continuidad, el acceso y la sostenibilidad del sistema sanitario. El desarrollo y la implementación de diferentes roles en la práctica avanzada de enfermería se ha considerado una de esas innovaciones en reformas de sistemas sanitarios pioneros. La necesidad de que las enfermeras adapten su práctica en todos los entornos ha sido un paso necesario para satisfacer las demandas de nuestro dinámico sistema sanitario y para contribuir a abordar los objetivos de desarrollo sostenible establecidos por diferentes estrategias internacionales de recursos humanos. Sin embargo, entrelazado con el proceso de desarrollo e implementación de los nuevos roles de enfermería está su entorno y contexto. En Cataluña, algunas enfermeras han evolucionado y se han adaptado a las normas internacionales sin el reconocimiento legal que la práctica avanzada tiene otros países. La evolución de estas enfermeras comparte la confusión con la profesión de enfermería internacional sobre la terminología, la función específica y el alcance de la práctica de éstos roles de enfermería en la práctica avanzada. Comprender los cambios realizados en la práctica de enfermería y cómo el contexto afecta la implementación de estos cambios puede ser crucial para gestionar las dificultades que surgen durante este proceso. Del mismo modo, entender cómo la implementación de los roles avanzados de enfermería afecta la práctica, la organización y los contextos nacionales puede ser esencial para predecir y medir el impacto de estas innovaciones en el cuidado de la salud. OBJETIVOS: Con el fin de obtener una mejor evaluación de la implementación de la práctica avanzada de enfermería en Cataluña, este estudio presenta una definición del rol en Cataluña y una visión dinámica e integral del contexto en Cataluña, España y Quebec, Canadá. METODOLOGÍA: La investigación se realizó en dos etapas. En la primera etapa, el estudio pretende recoger datos sobre aquellos que trabajan en roles de práctica avanzada. Se realizó una traducción, adaptación intercultural y un análisis psicométrico de la versión en español de la herramienta “Modified Advanced Practice Role Delineation (APRD)” seguido de un estudio de delineación de funciones de la enfermería de práctica avanzada. Mediante un estudio exploratorio, descriptivo y transversal se implementó una encuesta de tendencias en funciones y dominios de práctica. La población del estudio fueron enfermeras especialistas españolas y enfermeras expertas que los autores identificaron anteriormente como enfermeras con un perfil de competencia más avanzado que una enfermera general en España. El estudio contó con una muestra de conveniencia de 151 enfermeras empleadas por un hospital dual terciario y comunitario en Barcelona, España. Los datos se recopilaron durante seis meses en 2015-2016. La herramienta consta de 41 ítems en cinco dominios de enfermería de práctica avanzada (atención integral directa, apoyo de sistemas, investigación, educación y publicación y liderazgo profesional). Las variables utilizadas en esta etapa del estudio fueron la experiencia en enfermería, la educación, la posición laboral, el nivel de carrera profesional y la implicación del rol en otras disciplinas, servicios y pacientes. En la segunda etapa del estudio, para comprender mejor el contexto de la implementación de la práctica avanzada, se realizó un análisis de redes entre las relaciones que conectan la práctica avanzada y los factores contextuales que influyen en el desarrollo de la enfermería en Cataluña. El diseño del estudio fue cualitativo, descriptivo y explicativo. Los participantes pertenecían a diversas perspectivas a nivel de práctica, organización y entorno externo y se comprometieron a participar en grupos focales semiestructurados en marzo de 2016. Se les pidió que informaran sobre diferentes dimensiones de la implementación y desarrollo de la práctica avanzada y de su entorno: comprensión del rol, necesidades percibidas, percepción de resultados, barreras y facilitadores. Además, se recogieron más datos a través de entrevistas en Quebec, Canadá, para informar sobre las mismas dimensiones de contexto a nivel externo, organizacional y de equipo. El estudio fue aprobado por el Comité de Ética en Investigación Clínica (CEIC) del Hospital Clínico de Barcelona (Reg. HCB / 2014/0811 y HCB / 2016/0055). Los participantes proporcionaron un consentimiento informado por escrito antes de participar en el estudio. A los participantes se les garantizó el anonimato en el informe de hallazgos y análisis de investigación. RESULTADOS: Los resultados respaldaron la validez y fiabilidad del instrumento de delineación de la práctica avanzada de enfermería en un hospital terciario y comunitario. La herramienta mostró consistencia interna, con un coeficiente alfa de Cronbach de 0,86 y estabilidad a lo largo del tiempo. El estudio transversal fue diseñado para explorar el alcance y los patrones de la actividad de la práctica avanzada de enfermería dentro de los dominios de planificación del cuidado experto, atención integrada, colaboración interprofesional, educación, investigación, práctica basada en la evidencia y liderazgo profesional. Los dominios de práctica avanzada estuvieron fuertemente influenciados por los predictores del puesto de trabajo y nivel de carrera profesional, mientras que la edad y la experiencia fueron predictores débiles de los dominios de práctica avanzada. La conceptualización del perfil de la práctica avanzada de enfermería proporciona información que permite la descripción de actividades y dominios en el contexto de práctica, junto con la descripción de adaptación al sistema sanitario y la gestión del cambio. En el análisis de contexto, 30 entrevistas se realizaron en Quebec, mientras que 44 participantes fueron entrevistados en Cataluña. La integración de los hallazgos refleja un gran predominio de temas convergentes a pesar de las diferencias en el contexto y las características de la población. El estudio identificó factores de contexto comunes y divergentes sobre el desarrollo e implementación de prácticas avanzadas en ambos países. Las barreras y los facilitadores fueron prominentes casi de manera uniforme en todos los grupos, sin embargo, siguió siendo difícil comprender la dinámica interrelacionada entre la implementación y el contexto. CONCLUSIONES: Este estudio representa el primer intento de examinar la fiabilidad y la validez de una herramienta española capaz de delinear dominios y actividades de enfermería de práctica avanzada. El estudio logró la equivalencia conceptual, semántica y de contenido del instrumento español, lo que permite definir el alcance de las actividades de práctica avanzada y los dominios utilizando un instrumento validado y fiable. Se describe el perfil de práctica de avanzada de enfermería en España mediante la exploración del alcance y los patrones de actividad de la práctica avanzada en los roles recientemente desarrollados. La segunda etapa del estudio proporcionó una red visual de relaciones que conecta factores contextuales en el desarrollo de la práctica avanzada de enfermería en Cataluña. Además, identificó factores de contexto comunes y divergentes del desarrollo y la implementación de prácticas avanzadas en dos países. Las barreras y facilitadores fueron prominentes casi uniformemente en todos los grupos, sin embargo, los temas de organización y entorno externo fueron los más codificados y discutidos durante las entrevistas. IMPLICACIONES PARA LA PRACTICA: Los roles innovadores de enfermería de práctica avanzada son de mayor relevancia en términos de transformación del modelo de atención, como la orientación hacia condiciones a largo plazo, mayor resolución, accesibilidad, calidad en alta especialización y salud pública interdisciplinaria. Una mayor claridad en torno a estos roles puede ayudar a optimizar la utilización de la fuerza de trabajo, cumplir los nuevos requisitos de prestación de servicios y permitir una mayor cohesión organizacional interna, consistencia y claridad profesional.
INTRODUCCIÓ: L'expansió dels rols professionals ha demostrat ser una solució innovadora en alguns països per ajudar a abordar la integració, la coordinació, la continuïtat, l'accés i la sostenibilitat del sistema sanitari. El desenvolupament i la implementació de diferents rols en la pràctica avançada d'infermeria s'ha considerat una d'aquestes innovacions en reformes de sistemes sanitaris pioners. La necessitat que les infermeres adaptin la seva pràctica en tots els entorns ha estat un pas necessari per a satisfer les demandes del nostre dinàmic sistema sanitari i per contribuir a abordar els objectius de desenvolupament sostenible establerts per diferents estratègies internacionals de recursos humans. No obstant això, entrellaçat amb el procés de desenvolupament i implementació dels nous rols d'infermeria és el seu entorn i context. A Catalunya, algunes infermeres han evolucionat i s'han adaptat a les normes internacionals sense el reconeixement legal de la pràctica avançada que tenen altres països. L'evolució d'aquestes infermeres amb alt nivell comparteix la confusió amb la professió d'infermeria internacional sobre la terminologia, la funció específica i l'abast de la pràctica d'altres rols d'infermeria de pràctica avançada. Comprendre els canvis realitzats en la pràctica d'infermeria i com el context afecta la implementació d'aquests canvis pot ser crucial per a gestionar les dificultats que sorgeixen durant aquest procés. De la mateixa manera, entendre com la implementació dels rols avançats d'infermeria afecta la pràctica, l'organització i els contextos nacionals pot ser essencial per predir i mesurar l'impacte d'aquestes innovacions en la cura de la salut. Objectius: Per tal d'obtenir una millor avaluació de la implementació de la pràctica avançada d'infermeria a Catalunya, aquest estudi presenta una definició del rol a Catalunya i una visió integral de la dinàmica de l'entorn a Catalunya, Espanya i el Quebec, Canadà. Metodologia: La investigació es va realitzar en dues etapes. A la primera etapa, l'estudi pretenia recollir dades sobre aquells que treballen en rols de pràctica avançada. Es va realitzar una traducció, adaptació intercultural i una anàlisi psicomètric de la versió en espanyol de l'eina "Modified Advanced Practice Role Delineation (APRD)" seguit d'un estudi de delineació de funcions de la infermeria de pràctica avançada. Mitjançant un estudi exploratori, descriptiu i transversal es va implementar una enquesta de tendències en funcions i dominis de pràctica. La població de l'estudi van ser infermeres especialistes espanyoles i infermeres expertes que els autors van identificar anteriorment com infermeres amb un perfil de competència més avançada que una infermera general a Espanya. L'estudi va comptar amb una mostra de conveniència de 151 infermeres emprades per un hospital dual terciari i comunitari a Barcelona, Espanya. Les dades es van recopilar durant sis mesos en 2015-2016. L'eina consta de 41 ítems en cinc dominis d'infermeria de pràctica avançada (atenció integral directa, suport de sistemes, investigació, educació i publicació i lideratge professional). Les variables utilitzades en aquesta etapa de l'estudi van ser l'experiència en infermeria, l'educació, la posició laboral, el nivell de carrera professional i la implicació del paper en altres disciplines, serveis i pacients. En la segona etapa de l'estudi, per comprendre millor el context de la implementació de la pràctica avançada, es va realitzar una anàlisi de xarxes entre les relacions que connecten la pràctica avançada i els factors contextuals que influeixen en el desenvolupament de la infermeria a Catalunya. El disseny de l'estudi va ser qualitatiu, descriptiu i explicatiu. Els participants pertanyien a diverses perspectives a nivell de pràctica, organització i entorn extern i es van comprometre a participar en grups focals semiestructurats al març de 2016. Se'ls va demanar que informessin sobre diferents dimensions de la implementació i desenvolupament de la pràctica avançada i del seu entorn : comprensió del paper, necessitats percebudes, percepció de resultats, barreres i facilitadors. A més, es van recollir més dades a través d'entrevistes a Quebec, Canadà, per informar sobre les dimensions del context a nivell extern, organitzacional i d'equip. L'estudi va ser aprovat pel Comitè d'Ètica en Investigació Clínica (CEIC) de l'Hospital Clínic de Barcelona (Reg. HCB / 2014/0811 i HCB / 2016/0055). Els participants van proporcionar un consentiment informat per escrit abans de participar en l'estudi. Als participants se'ls va garantir l'anonimat en l'informe de troballes i anàlisis de recerca. RESULTATS: Els resultats van donar suport la validesa i fiabilitat de l'instrument de delineació de la pràctica avançada d'infermeria en un hospital terciari i comunitari. L'eina va mostrar consistència interna, amb un coeficient alfa de Cronbach de 0,86 i estabilitat al llarg del temps. L'estudi transversal va ser dissenyat per explorar l'abast i els patrons de l'activitat de la pràctica avançada d'infermeria dins dels dominis de planificació de la cura expert, atenció integrada, col·laboració interprofessional, educació, investigació, pràctica basada en l'evidència i lideratge professional. Els dominis de pràctica avançada van estar fortament influenciats pels predictors del lloc de treball i nivell de carrera professional, mentre que l'edat i l'experiència van ser predictors febles dels dominis de pràctica avançada. La conceptualització del perfil de la pràctica avançada d'infermeria proporciona informació que permet la descripció d'activitats i dominis en el context de pràctica, juntament amb la descripció d'adaptació al sistema sanitari i la gestió del canvi. En l'anàlisi de context, 30 entrevistes es van realitzar al Quebec, mentre que 44 participants van ser entrevistats a Catalunya. La integració de les troballes reflecteix un vast predomini de temes convergents tot i les diferències en el context i les característiques de la població. L'estudi va identificar factors de context comuns i divergents del desenvolupament i implementació de pràctiques avançades en tots dos països. Les barreres i els facilitadors van ser prominents gairebé de manera uniforme en tots els grups, però, va seguir sent difícil comprendre la dinàmica interrelacionada entre la implementació i el context. CONCLUSIONS: Aquest estudi representa el primer intent d'examinar la fiabilitat i la validesa d'una eina espanyola capaç de delinear dominis i activitats d'infermeria de pràctica avançada. És el primer intent de descriure el perfil de pràctica d'avançada d'infermeria a Espanya mitjançant l'exploració de l'abast i els patrons d'activitat de pràctica avançada en els rols recentment desenvolupats. L'estudi va aconseguir l'equivalència conceptual, semàntica i de contingut de l'instrument espanyol, el que permet definir l'abast de les activitats de pràctica avançada i els dominis utilitzant un instrument validat i fiable. La segona etapa de l'estudi va proporcionar una xarxa visual de relacions que connecta factors contextuals en el desenvolupament de la pràctica avançada d'infermeria a Catalunya. A més, va identificar factors de context comuns i divergents del desenvolupament i la implementació de pràctiques avançades en dos països. Les barreres i facilitadors van ser prominents gairebé uniformement en tots els grups, però, els temes d'organització i entorn extern van ser els més codificats i discutits durant les entrevistes. IMPLICACIONS PER A LA PRACTICA: Els rols innovadors d'infermeria de pràctica avançada són de major rellevància en termes de transformació del model d'atenció, com l'orientació cap a condicions a llarg termini, més resolució, accessibilitat, qualitat en alta especialització i salut pública interdisciplinària. Una major claredat al voltant d'aquests rols pot ajudar a optimitzar la utilització de la força de treball, complir els nous requisits de prestació de serveis i permetre una major cohesió organitzacional interna, consistència i claredat professional.

This study examines complex areas of nursing practice in secure mental health care, offering historical and contextual analyses of these highly politicised services. A survey design is used to consider educational preparation of nurses working in these settings; and to define competencies required by those working at varying levels of security. Data from focus groups (N=19) and interviews (N'24) with key service and educational personnel were content-analysed to yield a theory of nursing in secure environments comprising of an overarching definition incorporating eleven key themes supported by forty-five-statements of competency. The theory was translated into a questionnaire and distributed to national samples of nursing staff working in high, medium and low security environments (N852) for testing. Respondents (N=276) stated whether individual competencies were part of their current practice or supervisory involvement; and the degree of importance they accorded to each competency. Findings suggest that the theory proposed is strongly supported by nurses working within all levels of secure mental health services in the UK. This study also suggests that the preparation of nurses to work in secure mental health care is deficient at pre-registration, induction and postregistration levels. Students attending pre-registration placements were poorly prepared by educational staff who generally knew little of the specialty. In many instances, these placements also failed to make explicit the intended learning outcomes. Induction and post-registration training tended to be ad hoc; was frequently deficient in basic safety standards; and seldom skills-based. The competence framework received widespread support from nurses at all levels of security in relation to their level of importance. Perceptions of specific competencies in relation to role perfonnance varied with level of security regarding nurses' involvement with the patient's family; patient's preparation for transfer and support following discharge; and involvement with patient's local community. Results identified issues in relation to security and how procedures in parts of the system - notably in high security - militate against therapeutic care. Noticeable differences emerged between respondents working in high and medium secure environments. Issues of concern common to all levels of security included teamwork; balancing security and therapy; boundaries of professional practice; and clinical supervision. Conclusions suggest that the proposed competence framework provides an appropriate infrastructure for development of nursing in secure mental health care. It has clear implications for educational preparation of nurses, providing a suggested curriculum at pre-registration, induction and post-registration levels. It also encourages service planners to utilise competencybased job descriptions and focus staff development within their services more precisely.

This article introduces the feature article on policy implications of integrative nursing. It describes unitary ontology in nursing, highlighting the Rogerian view of holism. The importance of linking philosophy to practice policy is emphasized.