Core components of the Rural Nurse Specialist role in New Zealand

A thesis presented in partial fulfillment of the requirements for the degree of

Master of Nursing

at the Eastern Institute of Technology

Taradale, New Zealand

Jennie Bell 2015

Copyright is owned by the Author of the thesis. Permission is given for a copy to be downloaded by an individual for the purpose of research and private study only. The thesis may not be reproduced elsewhere without the permission of the Author.

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The author asserts her moral right to be identified as the author of this work.

Originality DeclarationI declare that the work presented in this Thesis is, to the best of my knowledge and belief, originial and my own work, except as acknowledge in the text.

Signed Date

Jennie Bell

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AbstractNew Zealand has a rural population with unique health needs which were traditionally provided by General Practitioners (GPs) practicing within a rural area (Goodyear & Janes, 2008). The Rural Nurse Specialist (RNS) role developed in response to a decline in GPs in rural areas. The RNS is a registered nurse (RN) with advanced nursing skills, enabling independent and autonomous practice. The RNS role has developed according to local needs leading to limited consistent information regarding the RNS. This thesis was undertaken to provide a description of the RNS role within New Zealand.

MethodA descriptive exploratory approach was taken for this study. Phase One involved a document analysis of five position descriptions of Rural Nurse Specialist or similar from district health boards. In Phase Two four RNSs from rural areas participated in semi-structured interviews. Data were analysed using categories from the Modified Strong Model of Advanced Practice (Gardner, Chang, & Duffield, 2007).

ResultsThe RNS role is an advanced practice role which focusses on direct patient care, creating a specialist generalist role. RNSs have an advanced knowledge base to assess, treat and diagnose patients within nurse-led clinics, and to provide after-hours emergency services. Engaging in postgraduate education is a priority for the RNS. Lack of recognition of the RNS role affects effective collaboration with other health professionals.

ConclusionsRNSs provide independent patient care including assessment, diagnosis and treatment. In order to provide independent patient care it is important that RNSs have postgraduate education. RNSs perceive the NP role to be better recognised than the RNS role, and all were considering furthering their advanced practice by becoming a Nurse Practitioner.

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AcknowledgementsI would like to thank those who have supported me throughout this journey.

To my patient supervisors Dr. Ruth Crawford and Dr. Kathy Holloway, thank you for answering my questions and providing feedback on all my revised work.

To the Rural Nurse Specialists who participated in the interviews, I was inspired and humbled to be able to share your stories. To my amazing husband, thank you for all the dinners, extra house cleaning, dog walking and especially the enforced relaxation time to clear my head. I would never have got here without you. Thank you to Jason Blair for the technical support and Brittany Jenkins for all the visits to her office and supportive chats. Thanks also needs to go to Janelle Matheson for being my test subject.

Lastly thank you to all my colleagues who have listened to me, asked me questions and were understanding when I pulled out articles to read in the quiet moments!

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Contents1. Introduction 1

1.1 Background of the researcher 11.2 Aim and purpose of the study 11.3 Background to the topic 21.4 Definition of rural 21.5 Advanced nursing practice 31.6 Nurse specialist 41.7 Rural Nurse Specialist 41.8 Organisation of thesis 51.9 Abbreviations used in this thesis 51.10 Chapter summary 5

2. Literature Review 62.1 Introduction 62.2 Search strategy 6

2.2.1 Critique process 62.3 Themes 72.4 Advanced nursing practice role 7

2.4.1 History of the advanced nursing practice role 72.4.2 Scope of practice 7

2.5 Rural healthcare 92.5.1 Rural population 92.5.2 Rural health consumers 92.5.3 Rural health 102.5.4 Relationship between the RNS and the rural community 102.5.5 The RNS and the provision of emergency rural healthcare 10

2.6 Educational requirements of the RNS role 102.6.1 Barriers to RNS education 13

2.7 Isolation 132.7.1 Geographical isolation 142.7.2 Professional isolation 152.7.3 Community Isolation 16

2.8 Generalist role 162.9 Retention of RNS staff 172.10 Chapter summary 17

3. Method 193.1 Introduction 193.2 Research design 19

3.2.1 Qualitative research 193.2.2 Descriptive exploratory approach 19

3.3 Data collection 203.3.1 Phase One data collection 203.3.2 Phase Two data collection 21

3.4 Analysis 233.4.1 Phase One document content analysis 233.4.2 Phase Two thematic analysis 24

3.5 Ethical considerations 243.5.1 Ethical approval 24

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3.5.2 Informed consent 253.5.3 Confidentiality 253.5.4 Cultural considerations 25

3.6 Trustworthiness 263.6.1 Credibility 263.6.2 Auditability 263.6.3 Transferability 263.6.4 Confirmability 27

3.7 Chapter Summary 27

4. Results 284.1 Introduction 284.2 Overview of position descriptions. 284.3 Participant background 294.4 Modified strong model of advanced practice domains 304.5 Domain One: direct comprehensive care 30

4.5.1 Phase One results 304.5.2 Phase Two results 31

4.6 Domain Two: support of systems 344.6.1 Phase One results 344.6.2 Phase Two results 35

4.7 Domain Three: Education 364.7.1 Phase One results 364.7.2 Phase Two results 37

4.8 Domain Four: Research 404.8.1 Phase One 404.8.2 Phase Two results 41

4.9 Domain Five: Publication and professional leadership 414.9.1 Phase One results 424.9.2 Phase Two results 42

4.10 Additional themes 424.10.1 Stress management 424.10.2 Lack of advanced practice role recognition 44

4.11 Chapter summary 46

5. Discussion 485.1 Introduction 485.2 Direct comprehensive care 48

5.2.1 Defining ‘rural’ 485.2.2 Generalist practice 485.2.3 Specialist practice 495.2.4 Specialist generalist role 505.2.5 Advanced practice 505.2.6 Treatment provision 51

5.3 Support of systems 515.3.1 Role clarity 515.3.2 Collaborative practice 535.3.3 Autonomous role development 545.3.4 Relationship-centred practice 555.3.5 Relationships with medical team 565.3.6 Relationships with wider healthcare team 57

5.4 Education 585.4.1 Postgraduate education 595.4.2 Impact of isolation on education 60

5.5 Nurse Practitioner 615.6 Professional leadership 62

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5.6.1 Chapter summary 62

6. Conclusion 646.1 Introduction 646.2 Summary of findings 64

6.2.1 Direct patient care provision 646.2.2 Postgraduate education engagement 646.2.3 RNS to NP role 646.2.4 Conceptual model of findings 65

6.3 Use of method 666.4 Limitations 666.5 Recommendations for nursing practice 66

6.5.1 Interprofessional education 666.5.2 Expanded role 676.5.3 Professional leadership 67

6.6 Recommendations for nursing education 676.6.1 Barriers to education 676.6.2 Career pathway 67

6.7 Recommendations for nursing research 676.7.1 RNS vs NP role 676.7.2 Prescribing rights 686.7.3 Rural health outcomes 686.7.4 Community perception 68

6.8 Chapter summary 68

7. References 69

Appendix 1. Email request to human resources 77

Appendix 2. Email from a DHB describing equivalent role to Rural Nurse Specialist 78

Appendix 3. Informational flyer 79

Appendix 4. Newsletter request 80

Appendix 5. Consent Form 81

Appendix 6. Information for participants 82

Appendix 7. Interview schedule 84

Appendix 8. Transcriber confidentiality 85

Appendix 9. Research approval 86

Appendix 10. Health and Disability Ethics Committees flowchart 87

Appendix 11. Ethics approval 88

Appendix 12. Summary of findings 89

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List of Figures and TablesTable 1: RN and NP scope of practice 8

Table 2: Education requirements for Registered Nurse and Rural Nurse Specialist 11

Table 3: Research process 20

Table 4: Position descriptions 29

Figure 1: Characteristics of participants in Phase Two 30

Figure 2: The core components of the Rural Nurse Specialist role in New Zealand 65

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1. IntroductionRural populations have specific health needs based on their isolation, socioeconomic demographics and patient population (Howie, 2008). Traditionally rural health services were led by General Practitioners (GPs), however in the last decade, there has been a decrease in the numbers of GPs practicing in rural New Zealand, limiting patient access to rural health services (Goodyear-Smith & Janes, 2008; New Zealand Institute of Rural Health, 2008). This service gap has been partially filled by Rural Nurse Specialists (RNSs) who provide many general health services that may have previously been provided by the GP (Fitzgerald, 2008: Goodyear-Smith & Janes, 2008). The RNS is a registered nurse (RN) with advanced nursing skills, enabling independent and autonomous practice. The RNS role has developed according to local needs (Janes, 2006) leading to limited consistent information regarding the RNS. The research described in this thesis explores the core descriptors of the Rural Nurse Specialist role in New Zealand. There is little information about the RNS role nationally and internationally.

In this chapter, background information into the evolution and current RNS role in New Zealand is presented. A description of advanced nursing practice in the context of the RNS role is provided. The lack of a consistent definition for the term ‘rural’ and the ongoing effects of this inconsistency on the RNS title is addressed. The purpose of the research and potential significance are discussed. A brief explanation of the layout of this thesis will be outlined.

1.1 Background of the researcher

I am a registered nurse currently practicing in an Emergency Department (ED) in a rural base hospital in New Zealand. My initial nursing education and first two years of RN practice were in urban settings in tertiary hospitals. Five years ago I moved employment to a rural base hospital and found that rural nurses, especially RNSs were functioning at a more advanced level than I had expected. The base hospital provides the only secondary health service for a population of 34,000, spread over approximately 500km of mostly native bush. Health service provision in this isolated area is provided by RNSs who are well established in their role. In my practice as a Registered Nurse (RN) in ED, I frequently work with locum doctors who are expected to provide phone support for RNS practice and will frequently have no understanding of the RNS role or environment in which the RNS is practicing. It became evident that medical staff had little understand of the RNS role, which led to my interest in this topic.

1.2 Aim and purpose of the study

The aim of this study is to provide a description of the RNS role within New Zealand. The research question is:

“What are the core descriptors of the Rural Nurse Specialist (RNS) role in New Zealand?”

Addressing this question will provide RNSs, employers and professional bodies information about the requirements of the RNS role. A clear description of the role will enable professional bodies such as the College of Nurses Aotearoa and the New Zealand Nursing Organisation to become aware of

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the professional networks that may be required by the RNS to practice effectively. Future RNSs may use results of this study to inform their undergraduate and postgraduate education choices and career decisions. Employers may use this findings of this study to inform future workforce decisions. Overall, this study will provide insight into future of the RNS role in health service provision to the rural population.

1.3 Background to the topic

The typical role of the RNS is very hard to describe as each RNS practices in a role which is unique to the community within which they work (Howie, 2008; Kulig, Kilpatrick, Moffitt, & Zimmer, 2013; MacLeod et al., 2004). The rural community and their needs differ according to the population (Fitzwater, 2008; Howie, 2008; Kulig et al., 2013; MacLeod et al., 2004; Prior, Farmer, Godden, & Taylor, 2010). Within New Zealand rural healthcare was traditionally provided by a GP who was on-call1 24 hours a day/seven days a week (Goodyear-Smith & Janes, 2008). However, with a decreasing GP workforce and a higher number of female GPs searching for a work/life balance with their families, this is no longer a practical option for many GPs (Janes, 2006). Small populations within a rural area also makes healthcare provided by one GP financially unfeasible (Goodyear-Smith & Janes, 2008). As a result, RNSs are providing health services to rural populations previously undertaken by doctors (Fitzgerald, 2008; Goodyear-Smith & Janes, 2006; Janes, 2006).

Within New Zealand the number of RNSs currently practicing is unknown. The Nursing Council of New Zealand release workforce statistics regarding the number of Nurse Practitioners, Registered Nurses and Enrolled Nurses within New Zealand (Nursing Council of New Zealand, 2013). While 1.5% of registered nurses identified working within the rural setting there is no clear explanation of what working within a rural setting entails or level of nursing expertise required for these positions (Nursing Council of New Zealand, 2013).

1.4 Definition of rural

In order to understand the context in which a RNS practices, it is important to appreciate the area in which they work. A lack of a consistent definition for the term ‘rural’ is acknowledged in the literature (Bushy, 2002; Howie, 2008; MacLeod, Browne, & Leipert, 1998; MacLeod et al., 2004; Mills, Birks, & Hegney, 2010; Roberts, Hibberd, Lewis, & Turley, 2014). Goodyear-Smith and Janes (2008) define rural in relation to healthcare provided by GP services, based on the distance from the rural GP practice to secondary health services, however this definition is specifically for rural GPs in New Zealand. While there is no one clear definition for ‘rural’, the traits of a small population and a distance between health providers and geographical isolation exist internationally (Bushy, 2002). The only agreement in the literature is that rural populations are isolated (Coleman & Lynch, 2006; Dillon, 2008; Howie, 2008; Sedgwick, Grigg, & Dersch, 2014).

Rurality is often defined based on geography, as the geographic nature of land creates difficult access for supplies and support (Brown, Hart, & Burman, 2009; Coleman & Lynch, 2006; Haydon-Clarke, 1 On-call: when the health professional is not physically at work but can be called by patients and other professionals for emergencies

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McKinlay, & Moriarty, 2011; Hounsgaard Jensen, Wilche, & Domer, 2013; Howie, 2008). There is often a sparse population of patients across the lifespan, spread out within an isolated area (Prior et al., 2010) with few health professionals available, thus creating a need for advanced nursing practice (Howie, 2008; Ross, 1999). Within New Zealand rural areas are classified according to the distance to commute to work in an urban area (Statistics New Zealand, 2012). A rural area with a high urban influence is a community in which a large percentage of the rural residents commute to work in a large urban centre on a daily basis (Statistics New Zealand, 2012). This means people in this community have easy access to the services available in the urban centre (Statistics New Zealand, 2012). A rural area with a moderate urban influence is a community in which a moderate to large percentage of the population commute to a minor urban centre (Statistics New Zealand, 2012). A minor urban centre is a town with a smaller population which also has close proximity to a main urban centre (Statistics New Zealand, 2012). A rural area with low urban influence may be a small town that which acts as a centre for a rural area; and highly rural/remote areas are those in which the population is unable to commute to a major urban area for employment (Statistics New Zealand, 2012). Therefore those areas with a low urban influence or classified as highly rural are unable to easily access other services, including health services, in a main urban centre (Statistics New Zealand, 2012). Despite the lack of definition for the term ‘rural’ it is acknowledged that advanced nursing practice is essential for nurses working rurally (Brown et al., 2009; Howie, 2008; MacLeod et al., 2004; Ross, 1999).

1.5 Advanced nursing practice

Advanced practice is an umbrella term for a number of roles within the nursing profession (Hamric, Spross, & Hanson, 2009). Advanced nursing practice refers to the ability of the nurse to demonstrate complex decision-making while providing direct patient care (Hamric et al., 2009). The characteristics demonstrated by a nurse in an advanced practice role include autonomous practice, management of complex patient problems and diagnosis and treatment of problems (Hamric et al., 2009; Gardner, Chang, Duffield, & Doubrovsky, 2013; Lowe, Plummer, O’Brien, & Boyd, 2012). Advanced nursing practice is undertaken in consultation with the patient and their families, using evidence-based practice and in collaboration with other health professionals (Gardner et al., 2013; Hamric et al., 2009). Professional leadership is also a characteristic of advanced nursing practice (Gardner et al., 2013; Hamric et al., 2009). Advanced practice is within the registered nurse scope of practice (Nursing Council of New Zealand, 2010) however the advanced practice nurse builds on initial registration to develop their nursing practice. Advanced practice nurses will develop new skills in response to the need of their specialty, such as complex activities previously completed by other health professionals for example intubation or incision and drainage of abscesses (Hamric et al., 2009; Lowe et al., 2012). Expanded practice is demonstrated when the nurse has an increased amount of responsibility and has gained skills through education which include diagnosis and prescription of medication (Holloway, 2009). RNs in New Zealand can utilize the expanded scope of practice, which enables specific healthcare activities that may have previously been carried out by other health professionals to be done by an RN (Nursing Council of New Zealand, 2011). Expanded practice is applied for in conjunction with the employer, and is noted on the RNs annual practicing certificate (Nursing Council of New Zealand, 2011). In order to maintain an expanded

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scope of practice the RN must demonstrate certain competencies which include demonstrating ongoing knowledge and skills in the specialty area via postgraduate education, competency assessments and clinical training. (Nursing Council of New Zealand, 2011). Further competencies include participating in audits and utilizing knowledge around the specialty from other healthcare teams (Nursing Council of New Zealand, 2011). These competencies are demonstrated within the Professional Development and Recognition Programme offered by the employer or via audits from the New Zealand Nursing Council (Nursing Council of New Zealand, 2011). Advanced nursing practice roles includes the RNS and Clinical Nurse Specialist (CNS) (Donald et al., 2010; Duffield, Gardner, Chang, & Catling-Paull, 2009).

1.6 Nurse specialist

The RNS is considered a nurse specialist within the rural setting (Crooks, 2004; Howie, 2008). Internationally and nationally, the nurse specialist role is inconsistently defined (Holloway, 2012; Roberts, Floyd, & Thompson, 2011). Despite the lack of a consistent definition, the nurse specialist title is recognized in New Zealand within the Multi-Employer Collective Agreement as many nurses are employed as nurse specialists in New Zealand District Health Boards (Roberts, 2009). Internationally, definitions of nurse specialist vary according to the health system within which the nurse specialist is employed (Donald et al., 2010). The International Council of Nurses have defined the nurse specialist role as “a nurse prepared beyond the level of a generalist nurse and authorized to practice as a specialist with advanced expertise in a branch of the nursing field. Specialist practice includes clinical, teaching, administration, research and consultant roles” (International Council of Nurses, 2009, p. 6). In New Zealand, the National Nursing Organisation endorsed a national glossary that defines specialist as an advanced level of practice and specialty as an area of practice (Holloway, 2009). A RNS is considered a nurse specialist within the rural setting by some authors, due to the advanced level of practice within the rural specialty demonstrated (Crooks, 2004; Howie, 2008; MacLeod et al., 2010; Mills et al., 2010a).

1.7 Rural Nurse Specialist

Despite the important role played by the RNS in the provision of rural healthcare there is a lack of definition for the title of RNS (Bushy, 2002; Kulig et al., 2013; Mills et al., 2010a). The lack of definition for the title rural nurse relates to the lack of a consistent definition for the term ‘rural’, because being unable to define rural leads to inability to define a nurse who operates as a rural nurse (Kulig et al., 2013; MacLeod et al., 1998). There is a noticeable lack of definition for rural nursing internationally (Litchfield & Ross, 2000; Macleod et al., 1998; Mills et al., 2010a), creating difficulty when trying to define a Rural Nurse Specialist (Kulig et al., 2013). This means that the Rural Nurse Specialist is specializing in an undefined area: that of a rural nurse. This research into the core descriptors of the RNS role will add to knowledge about the role, thus providing clarity for the RNS role.

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1.8 Organisation of thesis

Chapter One is an introduction to the Rural Nurse Specialist role. The context of rural and advanced nursing practice in which the research question is based is described.

Chapter Two presents literature currently available on this topic. This literature was used to inform the researcher of the current knowledge around this research, as well as providing an understanding of the context of practice for the participants.

Chapter Three describes the research design and the rationale of a descriptive exploratory approach to this research. The two phases of data collection are outlined. The data collection and analysis methods used are described and ethical considerations and steps taken to ensure rigour are presented.

Chapter Four presents the results from this study. Phase One and Phase Two results are presented using the Modified Strong Model of Advanced Practice (Gardner et al., 2007) as a framework. Qualitative data is illustrated with verbatim data.

Chapter Five provides an in-depth discussion of the major themes from the results. The relevance of the results to current literature are presented.

Chapter Six summarizes the thesis. The main findings are outlined and recommendations arising from this study for nursing practice, nursing education and nursing research are proposed. A conceptual model of the findings are presented. Study limitations are outlined.

1.9 Abbreviations used in this thesis

Clinical Nurse Specialist (CNS) General Practitioner (GP) Nurse Practitioner (NP) Registered Nurse (RN) Rural Nurse Specialist (RNS)

1.10 Chapter summary

This chapter provides an introduction to the research question “What are the core components of the Rural Nurse Specialist Role in New Zealand?” The current role of the RNS has evolved due to a declining number of GPs and as such has been developed in response to rural community needs (Janes, 2006). A lack of definition for the term ‘rural’ has also contributed to difficulty in defining the rural nurse role and the role of the RNS (Kulig et al., 2013; MacLeod et al., 1998). Advanced nursing practice is an umbrella term incorporating both the CNS and the RNS role (Donald et al., 2010). The concept of advanced nursing practice provides a better understanding of how the RNS practices. The lack of clarity surrounding the CNS role in New Zealand (Roberts et al., 2011) contributes further to the poor understanding of the RNS role. This research will work towards clarification of the RNS role by providing a description of the RNS role in New Zealand. The following chapter, Chapter 2, will provide a review of the current literature available on the topic.

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2. Literature Review

2.1 Introduction

In this chapter, current knowledge regarding the core components of the Rural Nurse Specialist role in New Zealand is presented. The purpose of a literature review is to inform the researcher about the current understanding of the topic they are investigating (Flick, 2009). Reviewing the literature also gives insight into the context of the topic, which will inform understanding of potential findings during analysis (Flick, 2009). Within a thesis a literature review also establishes an overview of the current understanding of a topic and identifies gaps to justify the research topic (Holloway, 2008). This review includes New Zealand and international literature.

2.2 Search strategy

The literature was reviewed following database searches using the Cumulative Index of Nursing and Allied Health Literature (CINAHL), Google Scholar and ScienceDirect. Search terms included; rural nurse specialist and New Zealand; rural nurse specialist; rural and nurse; rural nurse and role. Limitations to the search included full text articles, English language and peer reviewed articles. The date of publication was not included as a limitation as all literature on the development of the RNS role were valuable, however no literature was found published prior to 1998. Government reports, primary research and literature reviews were included in the search. The literature found was then reviewed for relevance and critiqued.

2.2.1 Critique process

The initial search yielded 10,000 plus results. Despite this number of articles, many of the articles retrieved were not included in this review as they were related to specialty areas in the rural setting, for example palliative care and rural nurses. The first step of exclusion included reviewing titles and abstracts to see if they were based in a hospital setting, a specialty or primary care. The second step involved reading 31 articles to see if the content was relevant to this study. Articles related to nursing in a rural hospital were only included if they had information related to an RNS in the community. Some articles were read in full and excluded as they were related to rural hospital nursing or a specialty area. The Ministry of Health website in New Zealand was used to find reports to gain insight into the current understanding of rural health and RNS in New Zealand.

Twenty-five research articles were identified which met the search criteria; one editorial, 19 qualitative research studies, three quantitative research and two mixed method approach. A text titled Rural Nursing Aspects of Practice (Ross, 2008) was utilized as it provided an overview based on academic research of 17 New Zealand rural nurses. The John Hopkins Nursing Evidence Based Practice tool was used as a guide for critiquing research articles (American Nursing Association, 2015). After critiquing the literature three major themes were identified.

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2.3 Themes

The three major themes which emerged from the literature reviewed were educational requirements, the challenges of isolation and poor retention of rural nursing staff. The educational requirements of the RNS role are discussed as well as the effect of geographical, professional and community isolation on this aspect of the RNS role. The ‘generalist’ concept is deliberated as well as potential issues regarding recruitment and retention of the RNS. This review begins with a discussion of the history of advanced nursing practice and scope of practice. The concept of rural is expanded, specifically in regards to rural healthcare in order to provide an understanding of the context of the RNS role.

2.4 Advanced nursing practice role

Advanced nursing practice roles are seen as a cost-effective mechanism to reach populations, such as rural, who may have difficulty retaining other healthcare staff (Bonsall & Cheater, 2008; Goodyear-Smith & Janes, 2008). A key benefit of advanced nursing practice is providing accessible healthcare for patients (National Nursing Centers Consortium, 2014). Increased availability of advanced practice nurses can help improve health outcomes as the advanced practice nurse can be responsible for providing complex continuing care and managing chronic conditions, especially in underserviced populations such as rural (Bonsall & Cheater, 2008).

2.4.1 History of the advanced nursing practice role

Advanced nursing practice has developed as nurses have expanded and extended their practice in order to fulfil shortages from other health professionals (Duffield et al., 2009; Hamric et al., 2009). The CNS role began in the USA in the 1960s (Hamric et al., 2009). Further development accelerated in Canada and the USA during the 1970s and 1980s as the number of academic programs available increased alongside a greater need for the CNS role by patients (Lowe et al., 2012). The United Kingdom (UK) began development of the advanced practice role in the 1980s with Australia following in the 1990s (Duffield et al., 2009). In New Zealand the advanced practice role has been documented since the 1980s with development of the Nurse Practitioner competencies in 2008 (Duffield et al., 2009; Nursing Council of New Zealand, 2008).

2.4.2 Scope of practice

According to the country the nurse is working in, there are a number of titles that may be considered advanced nursing practice (Gardner et al., 2013). In New Zealand there is a clear delineation between nurse practitioner (NP) and registered nurse (RN), with both having their own separate regulated title and scope of practice (Nursing Council of New Zealand, 2008). Two noticeable differences between the NP and RN role in New Zealand is the expectation of an expert level of knowledge for the NP, and the ability to diagnose and treat patients within a specific area of practice (Nursing Council of New Zealand, 2008). The RN is expected to utilize assessment skills and complex decision-making skills across a general area of practice (Nursing Council of New Zealand, 2010). While the NP scope of practice is limited to the NP role (Nursing Council of New Zealand, 2008), the RN scope of practice covers an array of nursing roles according to the educational preparation and practice experience of the RN (Nursing

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Council of New Zealand, 2010). The scope of practice of the RN and the NP are shown in the following Table

Table 1: RN and NP scope of practice

Registered Nurse Scope of Practice Nurse Practitioner Scope of Practice

Registered nurses utilize nursing knowledge and complex nursing judgment to assess health needs and provide care, and to advise and support people to manage their health. They practice independently and in collaboration with other health professionals, perform general nursing functions and delegate to and direct enrolled nurses, healthcare assistants and others. They provide comprehensive assessments to develop, implement, and evaluate an integrated plan of health care, and provide interventions that require substantial scientific and professional knowledge, skills and clinical decision making. This occurs in a range of settings in partnership with individuals, families, whanau and communities. Registered nurses may practice in a variety of clinical contexts depending on their educational preparation and practice experience. Registered nurses may also use this expertise to manage, teach, evaluate and research nursing practice. Registered nurses are accountable for ensuring all health services they provide are consistent with their education and assessed competence, meet legislative requirements and are supported by appropriate standards. There will be conditions placed in the scope of practice of some registered nurses according to their qualifications or experience limiting them to a specific area of practice. (Nursing Council of New Zealand, 2010 p.3)

Nurse practitioners are expert nurses who work within a specific area of practice incorporating advanced knowledge and skills. They practice both independently and in collaboration with other health care professionals to promote health, prevent disease and to diagnose, assess and manage people’s health needs. They provide a wide range of assessment and treatment interventions including differential diagnoses, ordering, conducting and interpreting diagnostic and laboratory tests and administering therapies for the management of potential or actual health needs. They work in partnership with individuals, families, whanau and communities across a range of settings. Nurse Practitioners may choose to prescribe medicines within their specific area of practice. Nurse Practitioners also demonstrate leadership as consultants, educators, managers and researchers and actively participate in professional activities and local and national Policy development. (Nursing Council of New Zealand, 2008 p.2).

Additionally, in 2011 a formal expanded role was introduced within the registered nurse scope of practice, for nurses who have new skills outside of the registered nurse scope, as a response to patient need (Nursing Council of New Zealand, 2011). The Nursing Council of New Zealand (2011) have

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specific guidelines for the RN wishing to expand their role which is undertaken in conjunction with the employer, provided the RN has the appropriate level of education and has followed a framework set up by the professional body for their specialty area of practice (Nursing Council of New Zealand, 2011).

2.5 Rural healthcare

The provision of healthcare in a rural setting is unique as the each community is different and health services are tailored to the community needs (MacLeod et al., 2004; Mills et al., 2010a). These needs are influenced by the population characteristics of each community (Howie, 2008; Prior et al., 2010). In this section of the review, the provision of rural healthcare to the rural population is discussed.

2.5.1 Rural population

In New Zealand, the rural population varies from place to place but will often have a high percentage of Māori2 and other minority groups as well as a lower average income than urban areas (Howie, 2008). Rural populations are often transient due to seasonal influx of workers such as fruit pickers (Howie, 2008). Tourists are emerging health consumers within rural areas in New Zealand (Fitzwater, 2008). The rural population may struggle to access healthcare due to the isolation of geographical barriers such as mountains, oceans, poor road conditions and weather (Dillon, 2008; Howie, 2008; Wong & Regan, 2009). Access to healthcare for the rural population is also made difficult as more geographically isolated areas have less population and therefore less health professionals available (Howie, 2008; MacLeod et al., 2004; Mills et al., 2010b). Less available health professionals means that the rural health consumers may not be able to access appropriate healthcare easily (Brown et al., 2009; MacLeod et al., 2004; Mills et al., 2010a). As healthcare can be difficult to access, self-reliance is a recognized trait of rural health consumers (Howie, 2008).

2.5.2 Rural health consumers

Rural health consumers are recognized as being self-reliant (Bushy, 2002; Howie, 2008; Lee & Winters, 2004), as they will attempt to treat their presenting condition themselves prior to accessing healthcare. When rural consumers do access healthcare, they consider where the most appropriate service is available (Lee & Winters, 2004). For example if rural health consumers considers he or she has a broken bone, they may choose to access a facility further away from their home, where they can get an x-ray rather than seeing the local services and be referred onwards (Lee & Winters, 2004; Mills et al., 2010a; Wong & Regan, 2009). However, as the rural health population and societal expectations of health services change, some areas are experiencing an increase in unnecessary after-hours call outs due to lack of patient understanding of available health services (Janes, 2006). Patients may not realize that the health professional is the only person on-call for the area and may be needed elsewhere (Janes, 2006). In many places education of patients regarding accessing healthcare for conditions such as a cold within business hours has helped reduce the load of after-hours care (Janes, 2006). These on-call services have traditionally been provided by GPs in rural areas, however this is now changing and RNS are doing on-call work (Fitzgerald, 2008; Goodyear-Smith & Janes, 2008).

2 IndigenouspeopleofNewZealand(Moorfield,2015)

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2.5.3 Rural health

Geographical isolation creates an environment which requires the health professional to work autonomously and with minimal support in order to provide services to areas that can be difficult to access (Bushy, 2002; MacLeod, Browne, & Leipert, 1998). In New Zealand rural GPs have traditionally provided a 24 hour health service to rural populations (New Zealand Institute of Rural Health, 2008). However, the RNS with advanced nursing practice providing rural healthcare can make healthcare more accessible for the rural population (Fitzgerald, 2008; National Nursing Centres Consortium, 2014). The RNS can provide after-hours on-call care, which reduces the workload on the GP whilst meeting the needs of the community (Janes, 2006).

2.5.4 Relationship between the RNS and the rural community

The importance of understanding the rural community in order to provide safe healthcare is reflected in the literature (Brown, Hart, & Burman, 2009; Hauenstein et al., 2014; Howie, 2008). Isolation will shape the needs of the community, therefore influencing the nature of the practice of the RNS (Bushy, 2002). The RNS needs to understand the community in order provide safe and appropriate healthcare (Brown et al., 2002; Howie, 2009). Understanding the community will help counteract potential barriers to provision of care, such as the nurse being an outsider in the community (Brown et al., 2002; Howie, 2008). In order for members of the community to access healthcare, people need to trust the RNS and understand the services provided by the RNS (Brown, Eckhoff, Lindley, & Jones, 2002). An understanding of the available services will influence patient decision-making when healthcare is required (Lee & Winters, 2004).

2.5.5 The RNS and the provision of emergency rural healthcare

Self-reliant rural health consumers, or an inability to travel may lead to late presentations of illness, as treatments at home have not helped (Lee & Winters, 2004). Therefore the patient can often be quite unwell at presentation, and the health professional may be in an environment with less access to resources (Brown et al., 2002; Bushy, 2002). Isolation which prevents the patient from accessing primary health care, may also prevent emergency services from reaching the patient easily (Brown et al., 2002; Howie, 2008). Isolation potentially means that the RNS may be the only person available to provide care with very limited diagnostic and treatment options until transport can be arranged (Brown et al., 2002). In this situation the RNS is required to use advanced nursing skills to provide care as able (Armstrong, 2008; Brown et al., 2002).

2.6 Educational requirements of the RNS role

The RNS is an advanced nursing practice role, according to both the international and national literature (Brown et al., 2009; Crooks, 2004; Haydon-Clark, McKinlay & Moriarity, 2011; National Health Committee, 2010), requiring the RNS to have a unique skill set and an advanced knowledge base (Armstrong, 2008; Barber, 2007; Brown et al., 2009; Fitzgerald, 2008; Howie, 2008; MacLeod et al., 2004; Mills et al., 2010a; Nexøe, Skifte, Niclasen & Munck, 2012; Ross, 1999). The RNS is required to be educated to the required level for registration within their country of practice in order

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to practice as a RNS (Brown et al., 2009; MacLeod et al., 2004; Mills et al., 2010b; Nexöe et al., 2012). However, despite a demonstrated need for advanced skills there is no consistent requirement for advanced education nationally or internationally as demonstrated in Table 2.

Table 2: Education requirements for Registered Nurse and Rural Nurse Specialist

Country Current education requirement for Registered Nurse scope

Current education requirement for Rural Nurse Specialist

New Zealand Baccalaureate (Nursing Council of New Zealand, 2010).

No consistent requirements for extra education, employer dependent (Donald et al., 2010).

Australia Baccalaureate (Nursing and Midwifery Board of Australia, 2015)

The RN is able to gain an endorsement for medication prescription in the rural setting (Australian Health Practitioner Regulation Agency, 2010). There is also an advanced nursing education program available in Queensland (Mills et al., 2010).

United States of America

All nurses required to gain licensure by completing the NCLEX exam (National Council of State Boards of Nursing, 2015). The level of education to qualify to sit for NCLEX is decided by the Board of Nursing according to each State. Licensure is according to each State’s requirements (National Council of State Boards of Nursing, 2015).

Dependent on the State the nurse is registered in, may be any number of recognised advanced practice roles (Brown et al., 2009)

Canada Baccalaureate (Canadian Nurses Association, 2015)

Education up to Master’s level available, however it is not required for role (MacLeod et al., 2004).

Greenland Baccalaureate Degree

(Nexøe et al., 2012)

Education to baccalaureate level required for registration, nothing specific mentioned for RNS (Nexøe et al., 2012).

As noted in Table 2, in New Zealand there is no legislative requirement for further education for advanced practice roles within the registered nurse scope of practice (Nursing Council of New Zealand, 2010). In many countries individual RNSs choose to have higher education due to the demands of the RNS role, such as autonomous assessment and treatment of patient conditions (Brown et al., 2009;

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Hauenstein et al., 2014; Howie, 2008; Macleod et al., 2010; Mills et al., 2010b). Brown et al. (2009) expressed concern that if RNSs did not have the postgraduate education to foster advanced practice then a barrier to providing adequate rural healthcare is created. Hauenstein et al. (2014) showed that while there is a requirement for advanced practice for the RNS role, education needs to be suitable for those in a rural environment, including an education program focusing on understanding the unique needs and challenges of practicing within a rural environment (Hauenstein et al., 2014; Jukkala, Henly, & Lindeke, 2008).

The need for education stems from the broad range of knowledge required by the RNS, as well as the unique healthcare requirements of rural practice (Hauenstein et al., 2014). Although as noted in Table 2 there are no specific educational requirements for the RNS role nationally or internationally. The nature of the role demands complex assessment and decision-making skills which can be informed and enhanced by further education (Sheer & Wong, 2004).

Within New Zealand Ross (1999) demonstrated the need for continuing education for the RNS in response to the requirement for a broad range of skills and advanced practice utilised in everyday practice. Ross conducted a survey as part of the Rural Practice Nurse Skills Project (Ross, 1999). The survey was sent to rural nurses, general practitioners and managers from Crown Health Enterprises identified as employing a rural nurse (Ross, 1999). The survey response rate was high with 54 respondents from 68 questionnaires received (Ross, 1999). The survey had six categories; practice/personal details (optional), variety of rural nurse skills required, on-call emergency services and education/support provided, education requirements including appropriateness of postgraduate education, telephone consultations and isolation from education, peers and support (Ross, 1999). Themes identified as important included isolation, expanding roles and professional education (Ross, 1999). Isolation, expanding roles and professional education continue to be relevant in the current literature and provide research opportunities to improve accessibility to healthcare for the rural population (Mills et al., 2010a). Isolation, expanding roles and professional education are also identified as key areas for the recruitment and retention of staff (Mbemba, Gagnon, Pare, & Cote, 2013).

Also in New Zealand, Lancaster (2011) conducted a survey of nurses who had completed a postgraduate rural primary health diploma, to discover if the nurses considered the diploma useful. The findings indicated that completion of this qualification provided the nurse with increased confidence and advanced assessment skills (Lancaster, 2011). A further benefit of completing a postgraduate qualification was reduced professional isolation as the RNS perceived communication skills within their own health team were improved as well as developing a support network with peers from the education program (Lancaster, 2011). Further, there was a perception by RNSs that RNSs who completed a postgraduate diploma gained increased respect from other health professionals (Lancaster, 2011).The relationships formed within the learning environment continued into a professional network which decreased the feelings of isolation experienced by the RNS (Lancaster, 2011).

Continuing education in New Zealand is also available through short courses such as Primary Response in Medical Emergencies (PRIME), Acute Cardiac Life Support (ACLS) and Trauma Nurse Core Competencies (TNCC) and Triage (Brown et al., 2002). PRIME training provides the rural nurse with

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resources to support the volunteer ambulance team when called out to an emergency (Ministry of Health, 2014) and is usually contracted to an employer who then decides who will attend the training (Brown et al., 2002). TNCC is provided by the Australian College of Emergency Nurses at venues within New Zealand (Australian College of Emergency Nursing, 2015) and Triage is provided at venues nationally by the New Zealand College of Emergency Nurses (College of Emergency Nurses New Zealand, 2014).

Short courses such as ACLS, TNCC, Triage, Paediatric Emergency Core Course, Advanced Paediatric Life Support certifications such as vaccination were considered relevant by Brown et al., (2002). However it is noted that it is the employer who makes the final decision regarding attendance at courses, based on the requirements of the RNS role in that specific community (Brown et al., 2002). The RNS may choose to undertake any of these study options in order to extend their own learning (Haydon-Clark et al., 2011) or the employer may request a certain level of education (Brown et al., 2002). However, there are barriers to accessing both these short courses and postgraduate education (Jukkala et al., 2008).

2.6.1 Barriers to RNS education

While the literature reflects a need for further RNS education, (Brown et al., 2009; MacLeod et al., 2004; Ross, 1999), there are barriers to further education especially for the advanced nurse in a rural area (Jukkala et al., 2008).Geographical isolation can lead to difficulty accessing education (Howie, 2008; MacLeod et al., 2004; Ross, 1999). A further barrier to education is lack of adequate time to complete study (MacLeod et al., 2004) which creates a conundrum where education is required but not easily accessible (Jukkala et al., 2008). As education is often provided in urban centres, education is frequently aimed at those with urban resources available to them (Hauenstein et al., 2014; Jukkala et al., 2008). Some tertiary institutions in New Zealand offer rural-specific study pathways at postgraduate level, however travel and having a replacement to cover time off may hamper access (Brown et al., 2002; Hauenstein et al., 2014; Howie, 2008; Ross, 1999). Lack of access to education funding is also a concern for many nurses (Adair, Coster, & Adair, 2013; Lancaster, 2011). In New Zealand access to funding for rural nurses is currently controlled by District Health Boards rather than the New Zealand Institute of Rural Health which previously enabled access to rural specific education (Lancaster, 2011). There is a concern rural nurses currently may not have as much access to funding and education as previously (Lancaster, 2011).

In summary, there are no clear educational requirements for the RNS in New Zealand, despite a documented need for an advanced practice knowledge base within this role (Barber, 2007; Bushy, 2002; Ross, 1999). Having a core description of the RNS role will support the provision of clear educational requirements, and further opportunities for research into educational requirements of the RNS role. One of the major barriers to accessing education is isolation experienced by the RNS (Bushy, 2002; Howie, 2008; Jukkala et al., 2008; Mills et al., 2010a).

2.7 Isolation

Isolation is a global phenomenon related to the RNS role (Brown et al., 2009; Ross, 1999). Isolation is the separation from other services, usually caused by geography and the environment within which

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the RNS practices (Howie, 2008). The theme of isolation will be further explored in sub-themes of professional isolation, community isolation and geographical isolation.

Geographical isolation occurs when support services are more difficult to access because of the natural barriers created by the land, for example mountain passes or the separation from the mainland by the ocean (Dillon, 2008; Howie, 2008). Geographical isolation creates a challenge in physically accessing support, equipment and education (Haydon-Clark et al., 2011; Ross, 1999). Professional isolation refers to isolation from the health team, support and education (Howie, 2008; Jukkala et al, 2008; MacLeod et al., 2004; Mbemba et al., 2013; Mills et al., 2010b). Professional isolation occurs as the nurse practises alone separated from other members of the health team by distance and geography (Mills et al., 2010b). A large contributor to professional isolation is communication difficulties (Mills et al., 2010b), arising from a lack of understanding of the rural environment from other health professionals and lack of face-to-face communication (Armstrong, 2008; Higgens, 2008; Mills et al., 2010b; Ross, 2001). Community isolation includes sub-themes of social isolation within the community and difficulty treating patients due to the concept of the nurse as an outsider (Barber, 2007; Haydon-Clark et al., 2011; Macleod et al., 2004; Mills et al., 2010b). Community isolation refers to the prominent community role of the RNS which can isolate the RNS from social interactions within the community (Barber, 2007) and provide potential barriers to the provision of care (Haydon-Clark et al., 2011). Geography is the element creating both community and professional isolation for the RNS, due to environmental barriers (Howie, 2008; MacLeod et al., 2004).

2.7.1 Geographical isolation

Geographical isolation is not easily defined, and changes for each rural community (Howie, 2008). Geographical isolation is a term which acknowledges that there are conditions such as weather and road conditions which make it difficult for the population to easily access health services (Howie, 2008). The physical geography may be an island, road conditions or a mountain pass (Dillon, 2008; Howie, 2008). The RNS may be in a rural area away from any major towns or cities or may be on an isolated island (Dillon, 2008). Geographical isolation can make travel difficult and time-consuming and can make obtaining resources such as wheelchairs and medications for patients challenging (Haydon-Clark et al., 2011). Geographical isolation also means that the RNS may find it problematic to travel to study (Hauenstein et al., 2014; Howie, 2008; Jukkala et al., 2008; Ross, 1999). Isolation also dictates the need for an advanced role as patients may travel a long distance to see the RNS (Brown et al., 2009), which in turn creates a need for comprehensive treatment provision by the RNS as further travel for treatment may not be feasible (Brown et al.; 2009; Hauenstein et al., 2014).

Wong and Regan (2009) conducted a qualitative descriptive study into the effect of geographical isolation on healthcare provision from the patient perspective. Seven focus groups were conducted across six rural (non-metropolitan) communities across British Columbia in Canada. Findings from this study were that geography created a need for ‘trade-offs’, affected continuity of care and was compounded by inefficiency within the health system (Wong & Regan, 2009). ‘Trade-offs’ refer to the concept that patients are required to pay to access health services, for example specialists and diagnostic services, due to travel cost. Health services that are not in the patient’s community require money for transport,

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or finding transport and sometimes services may not be accessed for personal safety (Wong & Regan, 2009), for example a patient may choose not to access a specialist or attend an appointment such as an x-ray due to road conditions, for example flooding, snow or high winds (Wong & Regan, 2009). Continuity of care is disrupted as geographical isolation creates difficulties retaining doctors. Chronic condition management was often sub-optimal as there was a lack of relationship with a doctor (Wong & Regan, 2009). Continuity of care was also affected as there may be a lack of communication between the specialist and the local doctor, especially when there was a high turnover of doctors due to poor retention (Wong & Regan, 2009). Health system efficiency was challenged as patients were required to travel for specialist prescriptions or diagnostics for a specialist which patients believed could have been undertaken locally and sent through to the specialist (Wong & Regan, 2009). In this study patients felt that some of these issues could be resolved using other health professionals such as a NP with whom patients could have a trusting relationship and who would manage their care, especially the management of chronic conditions (Wong & Regan, 2009). However, the health professional managing this care would be practising in professional isolation (MacLeod et al., 2004).

2.7.2 Professional isolation

Professional isolation is a multi-faceted phenomenon which includes isolation from the health team, from collegial support and from further education (Bushy, 2002; Howie, 2008; Jukkala et al., 2008; Kenny & Allenby, 2013; MacLeod et al, 1998; Mbemba et al., 2013; Ross, 2001). Professional isolation is exacerbated by geographical isolation as the RNS is part of the healthcare team, but may never have face-to-face contact with colleagues in a professional situation such as during a patient transfer (Barber, 2007; Mills et al., 2010b; Ross, 2001). As the RNS practises independently they often feel isolated by lack of communication with other members of the healthcare team (Mills et al., 2010b; Mbemba et al., 2013). Communication with health professionals in the acute health sector who have limited comprehension of the RNS skill set, practice environment and resources available can be challenging and create situations where poor advice that is unsuitable for the environment may be given by medical staff (Armstrong, 2008; Fitzgerald, 2008; Higgins, 2008; Mills et al., 2010b). Communication difficulties can be eased if the RNS is communicating with a health professional already familiar with the RNS skill set and there is a pre-existing basis of trust (Armstrong, 2008; Haydon-Clark et al., 2011; Higgins, 2008).

Communication styles are adjusted depending on whom the RNS is communicating with, for example Mills et al. (2010) found that the RNS has a different communication style when discussing patients with medical staff than they may have had prior to commencing the RNS role. RNSs have noted that they begin to use more diagnostic terminology and medical language when discussing the potential diagnoses in order to be able to clearly communicate their concerns and have medical staff take heed (Armstrong, 2008; Fitzgerald, 2008; Mills et al., 2010b). Lancaster (2011) noted that nurses who have completed a postgraduate diploma feel more comfortable discussing patients with medical colleagues as they are able to utilise appropriate language and have an increased confidence in their own critical thinking, assessment and diagnostic skills. As interprofessional communication is key to the patient receiving appropriate healthcare, communicative isolation needs to be reduced as much as possible (Mills et al., 2010b; Ross, 2001). Professional isolation could potentially be decreased as communication is enhanced

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with the more frequent use of technology such as videoconferencing (Bonney et al., 2015; Litchfield & Ross, 2000; Moffatt & Eley, 2010; National Health Committee, 2010). Communication technology such as videoconferencing has also been noted to reduce perceived isolation as the RNS is able to communicate with the health team as well as attend education sessions (Hauenstein et al., 2014; Howie, 2008; Moffatt & Eley, 2010). While professional isolation is a concern (Mbemba et al., 2013), isolation within the community is a challenge faced by many RNSs (Barber, 2007; Bushy, 2002).

2.7.3 Community Isolation

Barber (2007) and Haydon-Clark et al. (2011) both acknowledge that the prominent nature of the RNS role in a small community leads to the RNS perceiving there is no true “time off ”, that is the RNSs always feel “on call” and at work. Howie (2008) describes rural nursing as a lifestyle due to the intertwining of the RNS’s personal and professional life. A further effect of the blurring of boundaries between the personal and professional roles are patient apprehensions that they may not feel able to express their health concerns to the local RNS due to feeling they are talking to another community member rather than a health professional (Haydon-Clark et al., 2011). In an attempt to remain professional, the RNS may remain socially separated from the community in order to protect patients (Bushy, 2002). This leads to the RNS perceiving they cannot relax as they are constantly observed and the behaviour of themselves or their family in leisure time may reflect badly in a professional situation in the future (Bushy, 2002; Haydon-Clark et al., 2011). Patient perception of their nurse’s competence is affected by their observation of the nurse during activities outside of work (Bushy, 2002).

Community isolation also occurs as the nurse may be considered as an outsider by the rural community (Brown et al., 2002; Macleod et al., 2004) which may reduce the process of building rapport with the patient, especially if the nurse is not originally from that community (Barber, 2007). Community isolation can lead to reticence in community members seeking healthcare from the RNS (Brown et al., 2002). This potential lack of rapport between the RNS and community members may create an environment where it can be difficult to build up social relationships, especially if the nurse is from another locale (Barber, 2007).

The challenge of living and working within a small community is a unique part of the RNS role (Brown et al., 2002; MacLeod et al., 2004). In some areas, RNSs collaborate to give each other adequate time off to leave the area for a short break to help alleviate this issue (Haydon-Clark et al., 2011). The ability to work within these constraints of community isolation is an important part of the RNS role (Barber, 2007; Brown et al., 2002; Bushy, 2002; Fitzgerald, 2008; Haydon-Clark et al., 2011). Within these constraints the RNS is operating as a “generalist” (Howie, 2008).

2.8 Generalist role

A further theme arising from the literature is the concept of a generalist role. Generalist refers to a nurse who undertakes a broad range of activities within their daily practice (Brown et al., 2009; Hauenstein et al., 2014). In an editorial Crooks (2004) argues that the RNS is a specialist within their role as they are experts at providing generalist care. Within a rural environment, there can be limited access to other health service providers such as occupational therapists so the RNS is required to fulfil this need as part

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of their nursing role (Haydon-Clark et al., 2011; Kenny & Allenby, 2013; MacLeod et al., 1998). The RNS also undertakes administrative duties in a nurse-led clinic where they see presenting patients and provide advanced nursing care (Brown et al., 2009; Haydon-Clark et al., 2011; MacLeod et al, 2004). After-hours weekdays and during the weekend the RNS is also required to attend emergencies in the ambulance and provide first response care (Brown et al., 2004; Ross, 1999). Other requirements of the role include assessing patients with mental health concerns in order to make appropriate referrals (Brown et al., 2009; Haydon-Clark et al., 2011) and conducting routine baby health checks as well as providing sexual health clinics and cervical smear services (Haydon-Clark et al., 2011). The diversity of the RNS role requires liaison with many different areas of the health sector to ensure holistic, appropriate patient care (Mills et al., 2010b).

The RNS generalist role arises from the isolation of the area the nurse practises in and creates a need for ongoing education (Brown et al., 2009; MacLeod et al., 2004; Ross, 1999). Investigating the role of the RNS will enable greater understanding of the RNS role. Findings from this study may also provide insight into the RNS role in meeting the diverse needs of the rural population. There is also a potential for workforce developers to consider how to best utilise the RNS role as the number of available GPs declines.

2.9 Retention of RNS staff

Educational requirements, isolation and the generalist role prove a challenge when attracting and retaining new RNSs (Brown et al., 2002). The prominent role led by the RNS in the community can lead to RNS attrition as they struggle with lack of privacy (Barber, 2007). While RNSs require ongoing post-registration education, this in itself may cause a loss of staff as the RNS migrates for further education opportunities (MacLeod et al., 2004). Furthermore there is no clear career path in rural health which may also discourage retention of staff (Kenny & Allenby, 2013). Other factors which can influence the RNS decision to remain in rural practice include professional support, which may be improved by using communication technology such as videoconferencing (Kenny & Allenby, 2013). A clear description of the RNS role will assist in providing an indication to future RNSs of what will be expected and allowing them to be adequately prepared for these challenges may also assist with retention.

2.10 Chapter summary

The literature reviewed demonstrated that the RNS is an advanced role which requires ongoing education following nursing registration (Brown et al., 2009; Bushy, 2002; Hauenstein et al., 2014; Macleod et al., 2004; Nexöe et al., 2012; Ross, 1999). However ongoing education is not considered essential by employers despite the need for advanced nursing practice (Brown et al., 2009; Bushy, 2002; Hauensteinet al., 2014; Macleod et al., 1998; Mills et al., 2010a; Ross, 1999). Education facilitates the RNS role by providing an extensive knowledge base and decreasing professional isolation as well as providing communication skills (Jukkala et al., 2008; Lancaster, 2011; Ross, 1999).

Isolation shapes the practice of the RNS; geographical isolation physically separates the RNS from support services creating professional isolation and communication difficulties with the healthcare team

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(Dillon, 2008; Howie, 2008; Mills et al., 2010b; Ross, 2001). Geographical isolation also provides a barrier to the RNS accessing appropriate education (Hauenstein et al., 2014; Howie, 2008; Jukkala et al., 2008; Ross, 1999). This isolation is part of the challenge in recruiting and retaining staff (Mbemba et al., 2013). While geography creates professional isolation and divides the RNS from support services, it also creates a need for a generalist role (Brown et al., 2009; Howie, 2008; Ross, 1999). The RNS role is considered generalist as there is a broad range of knowledge required to fulfil the needs of the role (Howie, 2008; Macleod et al., 1998, 2004).The generalist role generates a need for education for the RNS (Jukkala et al., 2008; Macleod et al., 2004) which is hindered by geographical isolation preventing access to education and support (Hauenstein et al., 2014; Jukkala et al., 2008; Mbemba et al., 2013). This generalist role is created by the needs of the community (Howie, 2008), especially as there has been a reduction in the number of GPs available in the rural areas (Fitzgerald, 2008; Goodyear-Smith & Janes, 2008).

This study focuses on exploring and describing the core components of the RNS role in New Zealand. The results of this study will add to our current knowledge, particularly with regard to appropriate education requirements for the RNS. Identifying core components of the RNS role will further inform other health professionals about the RNS role, leading to improved interprofessional collegiality and reduction of communication difficulties. The results will also provide insight into the usefulness of the role for future workforce planning as GPs in rural areas decline. The following chapter, Chapter 3, presents the research approach and methods used in this study.

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3. Method

3.1 Introduction

In this chapter the method used to undertake this research is described. First the research design and the rationale for the use of the descriptive explorative approach are discussed, followed by a description of the data collection and subsequent analysis. Ethical considerations, including informed consent and respect for participants are outlined. Finally, the rigour of the study, focusing on trustworthiness are discussed.

Data collection for this study was divided into two phases, Phase One and Phase Two. Phase One of data collection involved collecting RNS position descriptions from New Zealand District Health Boards (DHBs) and thematically analysing them based on the Modified Strong Model of Advanced Practice (Gardner, Chang, & Duffield, 2007) to categorize the data. This analysis was then used to generate semi-structured questions for Phase Two of the study which consisted of interviewing four RNSs and using thematic analysis to analyse the gathered data.

3.2 Research design

3.2.1 Qualitative research

Qualitative research is an approach to research which focuses on the subjective human perspective of a topic (Polit & Beck, 2004; Speziale & Carpenter, 2003; Tolich & Davidson, 2011). When analysing qualitative research the focus is on words, or groups of words and their meaning (Polit & Beck, 2004; Speziale & Carpenter, 2003). An inductive approach is used to analyse data, with the researcher examining sets of data in detail and then using the results to create a general set of findings (Polit & Beck, 2004). A qualitative approach is different to quantitative research which takes an objective approach and utilizes a deductive approach to gain insight into the findings (Polit & Beck, 2004). A qualitative approach was chosen as it would give the opportunity to analyse rich data that would describe the experience of the RNS within NZ from the perspective of DHBs and RNSs.

3.2.2 Descriptive exploratory approach

In qualitative research the descriptive approach looks to simply describe what a phenomenon is, while the exploratory approach looks more in depth at the phenomena (Polit & Beck, 2004). The descriptive exploratory approach is a qualitative method which encompasses a wide range of methods of inquiry across the qualitative spectrum (Sandelowski, 2010). Having access to a wide range of methods allows the researcher more freedom when analysing data and is considered especially appropriate when seeking to describe a phenomena from the participants’ perception (Whitehead, 2013). One of the characteristics of descriptive exploratory research is the ability to use analysis techniques from many different forms of qualitative research, especially free form analysis (Sandelowski, 2010; Whitehead 2013). Free form analysis is when the researcher does not follow a set framework for analysis (Harding & Whitehead, 2013). Alternatively the researcher may choose to use a known framework in order to make the research more robust (Vaismoradi, Turunen & Bondas, 2013). An example of the use of descriptive exploratory

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approach in nursing research is an investigation into the information needs of patients undergoing procedural sedation in the Emergency Department conducted by Revell (2013). This study utilized a descriptive exploratory approach to describe the experience of procedural sedation in the Emergency Department from the perspective of staff and patients (Revell, 2013).

A descriptive exploratory approach was used in this research as the aim was to describe the core components of the RNS in New Zealand. By using a descriptive exploratory approach the topic was able to be investigated from the perspectives of both the DHBs and the RNS. The descriptive exploratory approach meant content analysis was available as a technique to describe the position descriptions from employers. The descriptive exploratory approach was broad enough to incorporate semi-structured interviews and thematic analysis to explore the RNS perception of the core components for comparison.

3.3 Data collection

Data collection in this study was carried out in two phases. Phase One was the document content analysis of five position descriptions of a RNS role or similar. This phase allowed the researcher to gain insight into the current perception of the RNS role from the viewpoint of the DHBs. Phase Two consisted of semi-structured interviews with four New Zealand RNSs. The structure of the interviews and questions asked were informed by the results of the document content analysis. The purpose of Phase Two was to gain understanding of the RNS role from those in current practice. By investigating the viewpoint of both the DHBs and the RNSs, an overall picture of the core components of the RNS role in New Zealand at present was gained. Table 3 below provides a summary of the steps taken to complete each phase of the data collection and analysis.

Table 3: Research process

Phase One – Document Content Analysis of RNS position description or similar

Phase Two – Semi-structured interviews with RNSs

Contact DHBs and request a copy of RNS position description

Use results from content analysis of position descriptions to develop semi-structured interview questions

Utilise modified Strong model of Advanced Practice as a basis for content analysis

Utilise word of mouth to recruit potential participants

Use results of content analysis as a basis to inform semi-structured interviews

Interview up to six participants

Use thematic analysis to analyse results

Present written results

3.3.1 Phase One data collection

3.3.1.1 Sample

When completing document content analysis, the sample needs to be relevant to the research question (Flick, 2009). In this study the sample area for the position descriptions was based on the Rural Health Institute Comparison of Five District Health Boards (DHB) report (New Zealand Institute of Rural

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Health, 2011). The Comparison of Five District Health Boards (New Zealand Institute of Rural Health, 2011) report presented a varied geographical sample of services which provided healthcare to a diverse population with many different communities and needs, thus providing a wide overview of the entire New Zealand rural population (New Zealand Institute of Rural Health, 2011). Five appropriate DHBs were approached to participate in this research and three DHBs agreed to participate. One DHB replied, but did not send through the position description.

In order to recruit DHBs to participate in this study, contact was initially made by email or phone with the human resources department of each selected DHB (Appendix 1). Two DHBs were contacted by phone and the details of the appropriate human resources staff member were given to the researcher by the reception staff of the respective DHB. In the third contact, a generic email address from the DHB website was contacted and the enquiry was forwarded to the appropriate person (Appendix 1). To contact the fourth DHB, phone calls were made over a three week period, endeavouring to locate an appropriate contact, which was made via a corporate receptionist. The fifth DHB was contacted via the intranet at a DHB which shares nursing recruitment with the human resources of another DHB. The fifth DHB was contacted by email initially with a follow up phone call and email reply. Finding an appropriate person to contact at each DHB was problematic as phoning and speaking with clerical staff led to uncertainty about who would be the appropriate person to contact for nursing related queries. Eventually a contact person in three DHBs was located and the request to participate in this study forwarded to either the general manager of nursing or associate director of nursing. Organisation E answered the initial email (Appendix 2) with a suggestion of the equivalent role in their DHB, but did not send the position description. A Google search using Rural Nurse Specialist New Zealand and position description produced a copy of the position description. Organisation D did not reply to the request, however the position description for Organisation D was found on Google using the keywords Rural Nurse Specialist position description New Zealand. Organisation C had a specific nursing recruitment officer within human resources who emailed the position description within an hour of the initial inquiry. Organisatons A and B emailed the position description as a reply to the initial enquiry. This process resulted in five position descriptions from five DHBs, with varying titles and content being collected.

3.3.2 Phase Two data collection

Within descriptive exploratory research it is common to use a number of approaches to collect data including analysis of written documents and individual interviews or focus groups (Whitehead, 2013). The snowball technique is a method used within qualitative research, such as the descriptive exploratory approach (Lopez & Whitehead, 2013). Recruiting research participants via contacts with others is known as the snowball technique and is useful when trying to contact participants in a small population who may not be visible (Holloway, 2008). When conducting this study it was found the RNS is not visible due to a variance in employers and role titles around New Zealand.

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3.3.2.1 Recruitment

In the original research proposal for this study, it was planned that the recruitment for participants for Phase Two would be completed via the DHBs, using the same sample pool as Phase One. However as the study progressed this was not feasible as many DHBs did not employ Rural Nurse Specialists or similar. One DHB was excluded due to a conflict of interest, as the researcher worked with RNSs in the same geographical area.

Instead of the above recruitment strategies, the New Zealand College of Primary Nurses and the New Zealand Institute of Rural Health were contacted with informational fliers about the study (Appendix 3) and were asked to distribute these via email to people who they personally knew to be practicing as a RNS. A request was also placed in the New Zealand College of Primary Nurses newsletter (Appendix 4). Both the informational flyer (Appendix 3) and the newsletter request (Appendix 4) contained the contact details of the researcher and asked that interested individuals who met the inclusion criteria contact the researcher via email. Registered nurses employed as Rural Nurse Specialists with a broad range of patients in a rural area met the inclusion criteria. Using this criteria, one potential participant was excluded as his/her main focus was on respiratory illnesses in a rural area. Five potential participants contacted the researcher by email. The researcher then sent each potential participant a copy of the Consent Form (Appendix 5) and Information sheet for participants (Appendix 6) by email. The Consent Form (Appendix 5) and the Information sheet for participants (Appendix 6) was also sent out in hard copy to potential participants identified address with a pre-paid envelope. It was initially anticipated that six RNSs would participate in the study, however only four participants who met the inclusion criteria agreed to participate. Following the receipt of the signed hard copy Consent Form (Appendix 5), the researcher then contacted each participant again by email and a convenient date and time was arranged to conduct the interview.

3.3.2.2 Interviews

Semi-structured interviews are used in qualitative research with a basis of open-ended questions allowing both the interviewer and the interviewee the opportunity to expand on any information (Pope & Mays, 2006). The interview questions (Appendix 7) were based on data gained in the document content analysis in Phase One of this study. The interview questions were open-ended to encourage the participant to give information that they thought was important.

Interviews with the four participants were completed over a landline or cell phone and recorded on a digital recorder. The interviews were conducted in a quiet, confidential environment in the researcher’s own home or a private room where others could not hear the conversation. Interview times ranged from 32 minutes to 49 minutes, averaging 45 minutes, which was consistent with the proposed time of 45 minutes. Digital recordings were stored in a locked digital folder in a password protected computer to maintain confidentiality.

Each interview began confirming verbal consent with the participants. The interviews then followed the semi- structured interview schedule (Appendix 7). If any further topics were uncovered during the

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interview, the researcher followed this with an open inquiry about that topic. Field notes were also taken throughout the interview.

The interview recordings were transcribed verbatim by a transcriber. Prior to undertaking the transcriptions, the transcriber signed a confidentiality agreement (Appendix 8) and completed all transcriptions on a password protected computer. The transcriptions were then emailed to the researcher, who checked them for accuracy, listening to the recordings again, allowing the researcher complete immersion in the data prior to analysis.

3.4 Analysis

Data analysis is conducted in order to gain an understanding of what the phenomena described means for the participants (Flick, 2009; Polit & Beck, 2004). In this study, data analysis was conducted in two phases. Phase One was the document content analysis of five position descriptions. Phase Two was thematic analysis of transcriptions from the four interviews. The analysis was conducted by the researcher for both phases and all raw data and analysis results were reviewed by EIT thesis supervisors.

3.4.1 Phase One document content analysis

Document content analysis enables data to be compressed into categories allowing the researcher to recognize replicable inferences from the data (Krippendorf, 1989; Stemler, 2001), in order to provide a broad description of the data (Elo & Kyngäs, 2007). Document content analysis can be approached from an inductive or deductive approach depending on the aim of the research (Elo & Kyngäs, 2007). A deductive approach is most appropriate when proving a theory (Elo & Kyngäs, 2007). As this research aimed to describe the position description for the RNS role, an inductive approach was appropriate enabling the researcher to analyse the document and present a general, descriptive statement (Elo & Kyngäs, 2007).

The Modified Strong Model of Advanced Practice (Gardner et al., 2007) provided a guiding framework for the document content analysis. This model provided a basis for exploring advanced nursing practice and was designed to differentiate between advanced nursing practice and that of a registered nurse (Gardner et al., 2007). Using the Modified Strong Model of Advanced Practice (Gardner et al., 2007) an a priori coding process was created where the data were coded and placed into categories (Stemler, 2001). Initially a simple read through was conducted allowing the researcher to become immersed in the data (Elo & Kyngäs, 2007). The document was then re-read and information categorised according to the Modified Strong Advanced Model of Practice (Gardner et al., 2007), following which any remaining information was separated into distinct categories, provided by the Modified Strong Model of Advanced Practice (Gardner et al., 2007). The categories were direct comprehensive care, support of systems, education, research and professional leadership. Any data that did not fit into the modified Strong Model of Advanced Practice (Gardner et al., 2007) were then coded using inductive analysis, where the data were grouped according to categories that emerged from the data itself (Stemler, 2001).

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3.4.2 Phase Two thematic analysis

Thematic analysis is a simple form of analysis that is suitable for use in descriptive exploratory research (Pope & Mays, 2006; Vaismoradi et al., 2013). Thematic analysis requires the researcher to get to know the data well before scrutinizing certain data sets more closely, in order to identify themes (Flick, 2009; Roberts & Taylor, 2002; Vaismoradi et al., 2013). When completing thematic analysis the researcher needs to start by reading and re-reading the data to become familiar with the data (Elo & Kyngäs, 2007; Roberts & Taylor, 2002). It is helpful to read through the transcripts and delete any conversations or comments that are not helpful to the research (Roberts & Taylor, 2002). The transcript is then read again, with descriptive headings created in a separate document for sections of text (Flick, 2009; Roberts & Taylor, 2002). After creating groups of text under descriptive headings and sub-headings the researcher then creates a list of themes and can place the text, headings and sub-headings under each theme (Flick, 2009). During this process some data may be merged, some may be deleted and some may be placed under different headings (Roberts & Taylor, 2002).

To complete thematic analysis of the interview data in this study, following checking of the transcriptions, a master copy and a checked copy were saved in separate documents as a digital file on a password protected computer. Each interview was analysed separately, however all data were placed in one document. Thus, the researcher gained descriptive headings from the data in the first interview. These headings were created in a separate document and the relevant text was copied and pasted into this document. When analysing the following three interviews, any text that was relevant to the headings which had already been created from the first interview was placed under those headings. Any new descriptive headings were added to the document. This process was repeated from all four interviews, creating one document with descriptive headings containing information from all interviews. A separate document was then created for themes and the descriptive headings and text was then placed under the relevant themes. Data were placed under themes according to the descriptive headings, each piece of text under the descriptive heading was re-read and placed into relevant themes. This process was repeated and a third document was created which placed the information from the themes into the Modified Strong Advanced Model of Practice (Gardner et al., 2007). Any information which did not fit into the Modified Strong Advanced Model of Practice (Gardner et al., 2007), was then re-read and these themes were considered the emergent themes. For this third document, information was also re-read and placed into relevant categories with some data changing categories several times.

3.5 Ethical considerations

3.5.1 Ethical approval

A research proposal was written prior to beginning this research. This was submitted to the Faculty Academic Committee at EIT to obtain approval to proceed with the study and apply for ethical approval (Appendix 9).The Health and Disability Ethics Committee (HDEC) tool (Appendix 10) was used to identify this research as low- risk. (Health and Disability Ethics Committee, 2013).The nature of the questions were not considered a risk of causing harm to participants or the researcher and no tissue/blood samples were required (Health and Disability Ethics Committee, 2013). Identifying information

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including location about the participants were not published. Ethical approval was gained from the Eastern Institute of Technology Research Ethics and Approval Committee on 11/09/2014, Reference 39/14 (Appendix 11).

3.5.2 Informed consent

Informed consent is part of the principle of respect for human dignity (Roberts & Taylor, 2002). Providing informed consent means that the participant is aware of the researcher’s identity, the aim of the study, the benefits and risks of participation and steps taken to ensure confidentiality (Roberts & Taylor, 2002). Informed consent includes the ability of the participant to withdraw from the research with no ramifications (Roberts & Taylor, 2002). It is not acceptable to gain consent using coercion even unintentionally (Roberts & Taylor, 2002).

The participants in Phase Two were asked to contact the researcher if they were interested in participating in the study. The researcher works in a base hospital for a rural area and the RNSs in this area were excluded as they may know the researcher and feel obligated to participate. The Information for Research Participants (Appendix 6) and Consent Form (Appendix 5) was provided for participants via email and in hard copy. The Information for Research Participants (Appendix 6) introduced the researcher and the aim of the study and stated the benefits and risks of participation. The steps taken to protect confidentiality and the right to withdraw were also explained in the Information for Research Participants (Appendix 6). The Consent form (Appendix 5) reinforced the right to withdraw and asked the participant to sign acknowledging they understood their rights. All participants returned the hard copy signed via mail and there were no questions from participants. Verbal consent was also at the start of the interview (Appendix 7) and an opportunity for further questions given to the participant.

3.5.3 Confidentiality

It is important that the participants are protected while participating in research. Part of protection is maintaining anonymity so that participants are not able to be identified by those reading the research (Roberts & Taylor, 2002). This study is underpinned by the principles of the Treaty of Waitangi, partnership, participation and protection (Ministry of Health, 2012a). The second part is taking steps to maintain anonymity and confidentiality such as using pseudonyms and separating names from data (Roberts & Taylor, 2002). The transcripts of the interviews were stored under pseudonyms and the signed Consent forms were stored separately in a locked drawer. In order to maintain confidentiality the documentation from the research process has all been stored on a password protected laptop as well as in a locked drawer.

3.5.4 Cultural considerations

While this study is not centred on Māori, there may have been Māori RNSs in the population interviewed. In order to ensure the principles of the Treaty of Waitangi (Ministry of Health, 2012a) were fulfilled, a local Māori health provider was contacted by phone regarding the research, its objectives and the proposed interview questions. Potential effects on Māori participants were ascertained prior to commencing interviews which meant the location of the participants within New Zealand was not

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known. During this conversation, verbal support for data collection was given by the local Māori health provider.

3.6 Trustworthiness

Trustworthiness is the concept used to identify that data produced during qualitative research is useful and of good quality (Harding & Whitehead, 2013). Trustworthiness is supported by the concepts of credibility, auditability, confirmability and fittingness (Elo et al., 2014). These four concepts formed the basis of the trustworthiness of this study.

3.6.1 Credibility

Credibility refers to the truthfulness of the findings as seen by participants, co-workers and co-researchers (Graneheim & Lundman, 2004; Speziale & Carpenter, 2003). The sample in Phase One was a purposeful sample, ensuring relevant and useful information was gathered (Elo et al., 2014). The snowball technique used to gather the sample in Phase Two enabled a specific population which is not normally visible to be found (Holloway, 2008). Although the snowball technique was used, the sample remained purposeful as the information emailed to the New Zealand College of Primary Nurses (Appendix 4) and the New Zealand Institute of Rural Health (Appendix 3) was directed to a RNS or similar.

Following the completion of analysis, a summary of findings (Appendix 12) was sent to the four participants following data analysis and they were invited to comment on the researcher’s interpretation (Appendix 12). One participant responded stating that they agreed with all of the findings. One participant responded to say they would not be able to reply within the timeframe. There was no reply from the other two participants. Data collected in this study, especially around the importance of role recognition and postgraduate education were reflected in the literature. This confirms the credibility of the data that was collected.

3.6.2 Auditability

Auditability refers to the potential for data change and researcher decision-making during the analysis process (Graneheim & Lundman, 2004). In order to gain approval for this study from the Eastern Institute of Technology (Appendix 11), a research proposal was submitted and approved. This proposal was used as a guide during the research process. This thesis clearly states the research process undertaken in this study, thus providing an audit trail for the study.

3.6.3 Transferability

Transferability is also described as fittingness and refers to the usefulness of these findings within other settings (Elo et al., 2014; Graneheim & Lundman, 2004; Harding & Whitehead, 2013). By using the Comparison of Five DHB’s (New Zealand Institute of Rural Health, 2011), a wide range of DHBs across New Zealand with a varied population base were accessed. The RNSs who participated in Phase Two of the study were from a wide geographical area across New Zealand, with two in the North Island and one in the South Island. The fourth participant had resigned from a position in the North Island within the previous three months and had worked in the South Island in the last five years. The broad coverage of

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both the North and South Island provided by the sample enabled transferability of the study resonating with a wide range of rural areas within New Zealand. During Phase One of this study the position descriptions were found to contain a lot of variability within both title and content. While this may reflect the general lack of definition and confusion around the role, it may also limit the transferability of the study findings.

3.6.4 Confirmability

Confirmability refers to the reflection of the application of credibility, auditability and fittingness within the findings (Harding & Whitehead, 2013). The confirmability of this study can be seen within the results and discussion chapters as all findings are linked to quotations from the participants and compared with local and international literature.

Additional steps taken to maintain trustworthiness include the use of supervisors provided by EIT to maintain an open process, and a notebook used to record the steps taken during the research.

3.7 Chapter Summary

In order to answer the question “What are the core descriptors of the Rural Nurse Specialist Role in New Zealand?” this research was undertaken using a descriptive exploratory design. The study was conducted in two phases. Phase One required the acquisition of the position description of five RNS. Contacting the five DHBs and retrieving position descriptions for Phase One proved a lengthy process. The sample from Phase One was going to be used as a basis for the sample for Phase Two, however this was not feasible as the position descriptions provided did not meet inclusion criteria.

Phase One involved document content analysis and the Modified Strong Model of Advanced Practice (Gardner et al., 2007) was used as a framework for the data collected. This information was then used to assist in the creation of the questions for the semi-structured interviews with RNSs in Phase Two of the study.

Ethical issues affecting this study have been discussed alongside the research steps taken to ensure trustworthiness. The following chapter will discuss the results gained using this method to complete the study.

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4. Results

4.1 Introduction

In this chapter the results of the study will be presented. First an overview of the position descriptions provided for the document content analysis in Phase One and background information of the participants in Phase One is provided. The Modified Strong Model of Advanced Practice (Gardner et al., 2007) is used as a framework for presenting the results. Phase One and Two will be presented alternately within the five domains provided by the Modified Strong Model of Advanced Practice (Gardner et al., 2007). The additional themes from the research are then presented. Themes emerging from this study include legal/educational requirements from Phase One and advanced role recognition, collaboration and generalist-specialist arising from Phase Two. The theme of stress management emerged from both Phase One and Phase Two. Words in italics are either direct quotes from documentation received in Phase One or verbatim comments from participants.

4.2 Overview of position descriptions.

In Phase One, position descriptions were received from five District Health Boards (DHBs) within New Zealand. The original request to the DHBs was for a Rural Nurse Specialist position description or similar. The position descriptions received had a range of titles and role descriptions as described in Table 4 on page 29. The position title is presented with an organisational pseudonym in order to protect the anonymity of the DHB along with the corresponding role description.

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Table 4: Position descriptions

Organisation: Title Role description

Organisation A: Clinical Nurse Specialist

The role is a generic clinical nurse specialist position description. The position description provided would be used by the clinical nurse specialist with a rural portfolio, although the definition of a rural portfolio for this organisation was not provided.

Organisation B: Clinical Nurse Specialist-District Nursing

The aim of the Clinical Nurse Specialist, District Nursing is to provide clinical leadership and support to the district nursing team to achieve optimum patient management and care. This is a nursing leadership and education role, leading two teams of district nurses which operate in separate rural areas, from an urban base.

Organisation C: Clinical Rural Nurse Specialist

The Clinical Rural Nurse Specialist role includes an on-call component for medical emergencies and accidents. The nurse specialist provides health promotion, chronic disease management and a ‘drop-in’ clinic for general healthcare at a time and place acceptable to the community.

Organisation D: Rural Nurse Specialist

The Rural Nurse Specialist (RNS) is predominantly involved in direct nursing care with patients. This includes on-call for medical emergencies and accidents as a ‘first responder’ with the ambulance service. The role involves fulfilling primary care contracts on behalf of the employer such as well-child checks. There is also a requirement that a clinic service be provided for visiting medical specialists.

Organisation E: Clinical Nurse Specialist, Chronic Disease Management

The Clinical Nurse Specialist, Chronic Disease Management is responsible for providing specialist, outreach case management, assessment, education and advice for clients with chronic and complex long term health conditions. The focus of the role is on maintaining optimal health and wellbeing, in liaison with primary and secondary medical services. This role is based in an urban area with travel to rural areas to provide chronic disease management including health education, monitoring the condition and medication management.

4.3 Participant background

In Phase Two, all four participants were female registered nurses (RNs). All participants started their professional practice in an acute hospital setting with varied roles in the emergency department, medical,

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surgical, oncology, paediatrics and obstetrics and gynaecology. All participants were currently employed by a primary health care provider and were working in a medical centre alongside a GP. None of the participants had undertaken postgraduate study prior to beginning their current role. The following chart (Figure 1) shows the characteristics of the participants in relation to previous experiences influencing their journey to their current role, their current place of work and their years of experience. It is important to note that one participant was currently practising in Australia, however during her interview, she was asked to focus on her New Zealand experiences which were less than six months prior to the interview

Figure 1: Characteristics of participants in Phase Two

4.4 Modified strong model of advanced practice domains

The results from Phase One and Two will be presented within each domain (Gardner et al., 2007). There are five domains comprising of direct comprehensive care, support of systems, education, research and publication and professional leadership (Gardner et al., 2007).

4.5 Domain One: direct comprehensive care

Direct comprehensive care relates to direct patient care including assessments and dissemination of patient results. It includes all elements required to coordinate patient care (Gardner et al., 2007).

4.5.1 Phase One results

Each position description had varying amounts of information relating to this domain. Organisation A included the requirements,

Demonstrates effective clinical management of rapidly changing/crisis situation [Organisation A].

Organisation C provided a general overview of activities required of the nurse including,

50+25+25+t 75+25+0+t 25+25+50+t 75+25+0+tPrevious

experience

Living Rurally Rural Nurse Specialist<10New Zealand

Nurse specialist role No Role Title10-20AustraliaRural undergraduate student experience

20+

Years of experience

Role title of Rural Nurse Specialist

Current place of work

Characteristics of Participants

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To provide holistic, culturally safe nursing care, including acute clinical and emergency care-both acute, [i.e. emergency call outs and acute care] and ongoing [i.e. health maintenance and health promotion] [Organisation C].

The concept of effective clinical management of patient needs was echoed by Organisation C and Organisation D. Organisation E had a similar requirement to the above, but direct care was related to a specific patient group living with chronic conditions. Organisation B did not include requirements for direct patient care by the nurse. Aside from Organisation B, all positions required advanced patient management skills. Organisation A described the,

provision of advanced clinical care incorporating nursing and medical care of the highest standard which is safe and appropriate, in a range of settings that can include nurse led clinics [Organisation A].

Organisation D had a high element of on-call work including PRIME (Primary Response in Medical Emergencies) providing support to ambulance staff as a first responder (Ministry of Health, 2014; St John, 2015). Organisation C had a further requirement that the nurse provide drop-in clinics in a location considered accessible for the community.

4.5.2 Phase Two results

All participants described undertaking direct patient care which involved using advanced assessment skills to facilitate independent clinics providing patients both chronic condition and acute care management. The sub-themes in this domain include: independent clinics with acute presentations, patient management, chronic disease management, on-call/acute services and advanced assessment skills.

4.5.2.1 Independent clinics with acute presentations

Each participant spent a large component of each working day consulting patients in their own nurse-led clinics. Patients could access nursing services using a booking system as well as presenting as acute patients to be seen that day,

I work autonomously assessing, diagnosing and treating, under a set of standing orders, the patients with minor accident and medical related complaints as well as working alongside GPs in relating to, responding to, emergencies during our clinic hours [Nurse D].

During clinics participants would use advanced assessment skills to assess, diagnose and treat the patient. Patients with a wide range of conditions are seen during the course of the day as this participant explains,

I see children with infections, sick children, I diagnose and treat UTI’s, I do a bit of upper respiratory tract infections, throat infections, skin infections and mastitis. I see essentially anything that walks through the door realistically [Nurse D].

After assessing and diagnosing the patient, the participants described frequently treating patients using standing orders, enabling more independent practice. Standing orders are issued by a doctor and used by

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health professionals who do not have prescribing rights to administer or supply medications to patients under specific conditions (Ministry of Health, 2012b). The specific conditions are written into the standing order and include the situation in which it is appropriate to use the standing order, the condition it can be used for and the drug, dose and method of administration (Ministry of Health, 2012b),

We’ve got standing orders; that covers a huge amount of stuff that we see in general practice and usually if there is a standing order then we deal with it in the nurse-led clinic [Nurse A].

Standing orders are detailed protocols maintained by the participants working with other members of the healthcare team in the workplace,

there’s quite a lot of work or developing standing orders keeping up with them, auditing them [Nurse A].

Nurse B practised in an area where the standing orders were based on an established protocol from another part of New Zealand, rather than established by their own practice.

4.5.2.2 Patient management

Patient follow-up is considered an important part of overall patient management by participants. Participants described reviewing patients for repeat prescriptions and were then required to follow-up on any investigations ordered,

if we requested them [blood tests], we need to be responsible [Nurse B].

There was a variance between participants as to how much time was spent on paperwork, as documentary requirements depended on the needs of the community and the role of the participant within their practice. All participants also mentioned spending a reasonable portion of their time completing forms to enable patients to receive funding for chronic conditions,

being a high needs population quite frankly we keep pretty busy with those [patients with a high user health card] but if they’re high priority because patients need some things for access so I try and get through them [Nurse A].

Management of patients with chronic diseases is also a major part of the nurses’ role,

so the rural nurse specialist I see as working in more of an advanced role and is not only the nurse that will see a patient for a blood pressure check but will help manage long term conditions and identify problems basically and seek to find remedies for those problems [Nurse C].

This management is in collaboration with other health professionals, for example Nurse A utilised communication technology to facilitate a nurse-led diabetic clinic in collaboration with a nurse practitioner based in a major urban centre.

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4.5.2.3 On-call acute services

The provision of a service to meet the needs of the community meant that there were differences in the after-hours services provided. Nurse A did not provide on-call services. Nurse B worked in one position where on-call services were provided and one position where after-hours provision was contracted to the GP. Nurse D was planning to complete further certification to undertake after-hours work and Nurse C had a large component of on-call work. In all clinics the on-call role involved a PRIME contract, accompanying ambulance staff when answering emergency calls. This participant also reviewed patients on behalf of the medical centre,

when I’m on call for weekends, I do 64 hours over a weekend and that’s continuous from a Friday night to a Monday morning. So that’s yeah it’s a dual role, so I see the sick patients for the medical centre as well as carrying the pager for the ambulance and attending ambulance calls [Nurse C].

The provision of on-call services was considered a stressor and was avoided by some participants when applying for a position,

I’ve been very careful about where I place myself as a Rural Nurse Specialist because there’s certainly, even though you’re not called out to PRIME all the time there’s that wait of you are on call and you’re expected to go if required [Nurse A].

Providing an on-call service also required travelling alone, into isolated conditions, which could be potentially unsafe,

you’re on your own so it can be quite scary whereas the ambulance often have pairs, so we’re often quite exposed to dangers [Nurse B].

4.5.2.4 Advanced assessment skills

A recurring theme throughout the data were the participant’s use of advanced assessment skills. This was interwoven amongst all of the participant’s everyday practice from facilitating a clinic to independent patient management, to the on-call aspect of the role. Advanced assessment skills were described by Nurse C as,

the ability to assess and treat patients through taking a really accurate comprehensive history and working through a systematic framework [Nurse C].

The use of a systematic assessment framework was then connected to the next step of treating the patient, as described by Nurse C,

a systematic assessment so the collection of data both subjective and objective, looking at family history, looking at social history, looking at current histories including what patients are presenting with, medications that they are on, family history, risk factors like smoking, alcohol intake, obesity and then looking at the whole picture to come to developing differential diagnosis and then being able to order appropriate tests or suggest appropriate tests for that patient to have in order to develop a complete diagnosis and then plan treatment [Nurse C].

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The outcome of this process was connected to the value of a therapeutic relationship with an example of a patient who was eventually referred to secondary care,

because that gentleman, I mean I managed to build a relationship with him and he felt comfortable coming back to me and saying “look I’m really still not right” and we admitted him [Nurse C].

These advanced assessment skills enabled autonomous, independent practice, as summarized by Nurse D,

I think that I guess as a rural nurse we do work a lot more autonomously [Nurse D].

4.6 Domain Two: support of systems

Domain Two, support of systems focuses on ensuring the nursing service provided is promoting innovative care and supporting the patient’s progress through the health system, with a focus on role advocacy (Gardner et al., 2007). Support of systems relates to indirect activities undertaken by the nurse which facilitate patient progress through the health system (Gardner et al., 2007). Phase Two discusses the indirect tasks currently carried out by the participants, as well as the sub-theme of collaboration. Collaboration refers to the ability of the health professionals to work together, utilising each other’s strengths, in order to promote the best outcome for the patient (Ross, 2001).

4.6.1 Phase One results

All position descriptions had a requirement that the nurse was able to show effective communication skills in order to maintain good working relationships with other health professionals within the immediate and wider team. This is demonstrated by Organisation C, with the requirement that the nurse,

liaise with colleagues at hospital and other community services for the ultimate care of the patient [Organisation C].

Another example is demonstrated by Organisation E with the expectation that the nurse will,

work collaboratively with Primary care organisations, other agencies and multidisciplinary teams [Organisation E].

A second aspect of this domain is the application of the principles of the Treaty of Waitangi; partnership, participation and protection. This was especially noted by Organisation B,

in practice partnership, working together with iwi3, hapu4, whānau5 and Māori6 communities to develop strategies for improving the health status of Māori. Participation; involving Māori at all levels of the sector in planning, development and delivery of health and disability services that are put in place to improve the health status of Māori. Protection; ensuring Māori wellbeing is protected and improved as well as safeguarding Māori cultural concepts values and practices [Organisation B].

3 tribe4 Clan; section of the tribe5 family6 IndigenouspeopleofNewZealand(Moorfield,2015).

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Included in this domain are quality assurance activities. All five position descriptions had a focus on health and safety which ranged from being responsible for the health and safety of all clients, visitors and staff on the property (Organisation B), to the maintenance of a hazard register (Organisation D). Quality was also maintained with regular reports of clinic statistics such as numbers of patients and use of consumables, to the nurse’s manager (Organisation A; Organisation C).

4.6.2 Phase Two results

The participants described different perspectives regarding this domain with each employer having diverse requirements for this aspect of the role. Nurse D was involved in the Practice management out of necessity whereas Nurse A was involved in innovative health technology projects with patients. Although the tasks performed by Nurse A and Nurse D are very different they both demonstrate practice which facilitates patient movement through the health system. However, Nurse C was only involved in activities related to recalling patients for scheduled follow-ups. The main activity discussed by three participants was the use of audits for accreditation and as a safety net,

I think there’s something to be said about what standing orders can do in terms of improving the knowledge and skill of nurses and if they’re audited individually then the doctors looking at everything you prescribe [Nurse A].

Audits were also used as agents of change in relation to patient policy and treatment,

it was quite a comprehensive sort of survey, just to sort of see how our documentation was and I think you know some things kind of shows up for the practice then sort of we used to have regular meetings and obviously then we would say this is now policy that we all have to do this [Nurse B].

Nurse D was in a unique situation where her role involved aspects of practice management,

I deal with our practice management which is the other thing that’s evolved because no one else has done it…I do a lot of order fixed store ordering and email the manager of the PHO in terms of statistics and things like that, lodging, a lot of lodging ACC claims and clinical primary options which is a care pathway for drugs that are given out of hospital; those kind of finicky paperwork related things [Nurse D].

This background work ensures the patients continue to receive medications and support required and ensures the clinic is well supplied with patient resources. Nurse B also had responsibility for supplies; however this was for the after-hours clinics and stocking the dispensary,

we did have our own PRIME bag, drug checks that we were responsible for, we were responsible for the dispensary where we had to check all our drugs [Nurse B].

4.6.2.1 Collaboration

Collaboration is the ability of the health professional to work with others on the health team (Ross, 2001). Collaboration is influenced by the ability of the health team to recognise the role of the RNS (Ross, 2001), which will be discussed as an additional theme. The participants observed that collaboration

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includes more than medical colleagues, it includes nurses and those in the wider health service team such as pre-hospital care and secondary care,

it’s important to work in collaboration as well with the doctors and the rest of the health care team [Nurse C].

The ability of the nurse to collaborate with other health care professionals was influenced by their interprofessional relationships with members of the health care team. Part of collaborating with the immediate health team has evolved into taking on more work that would traditionally be undertaken by a GP,

I think that I take a lot of the minor or more or less complex stuff away from the GP to free up time for them to deal with more complex things [Nurse D].

Relieving GP workload included acting as an acute clinic in order to see patients,

so like we sort of acted as if we were just another available appointment for someone to see so we would always be doing the day clinic [Nurse B].

4.7 Domain Three: Education

This domain is related to the nurse educating both nurse colleagues and patients, using their advanced scientific knowledge (Gardner et al., 2007). This domain is split into sub-themes of staff education, patient education and the formal educational expectations of the RNS role for Phase One. For Phase Two, the sub-themes include health promotion, specialist generalist, upskilling the RNS and formal educational expectations from the perspective of the participants.

4.7.1 Phase One results

4.7.1.1 Staff Education

Overall, there was a high requirement for nurses to act as a resource for other staff within their role. Organisation E clearly demonstrates this with the requirement to,

acts as a nursing resource providing timely current research based information and clinical advice to nursing staff and other health care professionals including medical students within the scope of specialty practice [Organisation E].

This means the employee will provide education, within the organisation, to the wider health team. Organisation B also has a requirement that the nurse promote education amongst other staff including,

provide supervision and teaching for staff [Organisation B].

4.7.1.2 Patient education

This domain includes education that will promote wellness and self-care amongst patients (Gardner et al., 2007). Organisation A requires that the,

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DHB will focus on increasing wellness through prevention, promotion and awareness activities promoting an overall culture of education provision to the community [Organisation A].

Organisation D also had a patient focused approach,

The RNS will provide a quality nursing service that includes education of patients to encourage self- management of chronic conditions [Organisation D].

On the other hand Organisation E required a patient-focused approach based on an expert knowledge base,

provide expert counselling to clients and carers through all stages of the disease progression in conjunction with other healthcare professional [Organisation E].

4.7.1.3 Educational expectations

Organisation A and B both required that the nurse,

hold or be working towards postgraduate certification in their area [Organisation A].

Organisation C, D and E all required that the nurse be working towards a Master’s degree related to their area of work. Organisations C and D specified a rural focus for the RNS Master’s study, however Organisation E had a very specific focus,

holds or is working towards a Clinical Master’s in Nursing incorporating health assessment and diagnostic reasoning and applied science for nurses [Organisation E].

Additional educational expectations were the maintenance of legal certification such as an annual practicing certificate as well as ongoing professional development within the organisation. Organisations C and D required that the nurse had an understanding of their own legal obligations. Organisation C also noted professional development requirements necessary from within their own organisation such as defibrillation, cardiopulmonary resuscitation and intravenous cannulation. Both Organisation C and D required the nurse to have or be willing to work towards nationally recognized certification for specific activities such as cervical smears, vaccinations, PRIME and ACLS (advanced cardiac life support) and also to have a New Zealand driver’s licence. All organisations required the nurses to be registered in New Zealand and maintain a current annual practicing certificate, which is a requirement of all nurses in New Zealand by the regulatory authority, the Nursing Council of New Zealand.

4.7.2 Phase Two results

4.7.2.1 Health promotion

Health promotion and education of patients was considered one of the most important aspects of the role by all participants. Nurse B described patient education as a skill which differentiates the role of the nurse from the medical staff mainly because of the amount of time health education takes,

we like to sort of spend more time doing all the health education, the whole promotion because we’re trained as nurses [Nurse B].

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In order to provide effective health promotion, there needs to be an effective therapeutic relationship with the patient,

its relationships and respect — whakawhanaungatanga7 …it’s something that’s sat with me ever since I heard it used by some of the Iwi8 writers, is if you haven’t got that then you can’t help them and if we keep everything in general practice then you’ve got that through them being part of a whānau9 that sees.. they got the income under general practice to see the nurses… whereas if you are an outreach nurse from the diabetes clinic at the hospital in [Town C] or [Town D] you haven’t got that and you’re not going to get a very far with them [Nurse A].

Part of building relationships is providing care that is responsive to the needs of each rural community,

the connection with the local community is another really important aspect [Nurse D].

For Nurse A this meant providing chronic disease management in a patient’s home, enabling Nurse A to see three generations of patients with the same condition in one visit and ensuring all family received the same information. This opportunity provided effective reinforcement of health messages.

Effective communication in order to promote health was considered an essential part of the participants’ skill set; not only clarity in communication but also the ability to communicate and care for patients in a wide range of settings across the life span. Nursing patients across the lifespan was considered one of the most challenging aspects of this role,

You have got to know how to have the conversation with the kids but then you can also have a conversation that shows respect to someone that’s dealing with an elder passing [Nurse A].

I deal with people of all ages so it’s a whole life span [Nurse D].

4.7.2.2 Specialist generalist

The term specialist generalist was used by all participants to describe the nature of their advanced role. A specialist generalist is a term used to describe rural nurses who see a wide range of patients, and provide advanced assessment and treatment (Bushy, 2002; Crooks, 2004) Being a specialist generalist was thought by the participants to be a unique characteristic of rural nursing, and the RNS role and one of the most challenging aspects of the role,

that’s what I found it is quite a challenging job because of the broadness [Nurse B].

Participants described a specialist generalist as someone with a broad range of knowledge, who knew a little bit about everything,

you are very generalist and you do know a lot about a lot of things but you also collaborate because you don’t know everything [Nurse C].

7 Māoriwordmeaningtheprocessofbuildingrelationships(Moorfield,2015)8 tribe9 family(Moorfield,2015)

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This concept of a specialist generalist role was a motivator for keeping the participants upskilled and up-to-date with best practice.

4.7.2.3 Upskilling the Rural Nurse Specialist

Upskilling the RNS relates to the need for the RNS to maintain advanced practice responses to clinical presentations. One of the challenges perceived by all participants is to keep upskilled and current with practice when faced with a wide array of patient presentations,

Nurse Specialists in rural medicine, we’re not, you know, going deep in any one particular field so it makes it really confusing if you’re, you know if you kind of have your drugs that you’re familiar with using and you just update with best practice [Nurse B].

The constant requirement for knowledge on a wide range of presentations was considered one of the more challenging aspects of the rural role,

I also had to learn lots about everything else and be really generalist and I was a bit fearful of how much I know, as to how much I’ve you know the capacity that I had to upskill [Nurse A].

One of the methods of learning that the participants felt was most beneficial when upskilling was to learn from those around them. If participants were able to build up a good working relationship with a health professional more advanced than themselves, such as the GP, the participants then were able to safely advance their learning. Conversely in the case of Nurse D, the GP took the opportunity to learn about healthcare given from the participant’s perspective.

we’re happy to dispute decisions with each other as well which is really helpful so I think that promotes really safe practice and I think that’s really important when you are working individually and it’s so much nicer relationship realistically so I think yeah it creates really safe practice and it also creates a really robust practice [Nurse D]

If participants felt well supported, a positive learning environment was created and the participants felt more confident to deal with challenging situations. Nurse D worked with a particularly supportive GP who would learn about health care from a nursing perspective as well as teaching from a medical perspective,

You need to have a good supporting GP so you advance in it [advanced practice] at that level. If you just get thrown into it and you work there and don’t get any more support from there on it then I kind of think you can actually start to learn bad things because you’re not actually really getting the medical supervision [Nurse B].

4.7.2.4 Educational expectations of participants

The requirement to have a wide generalist knowledge base has led all participants into further postgraduate study. All participants had completed a Master of Nursing in Rural or Primary Health. One nurse had completed all the pre-requisites to complete the Nurse Practitioner practicum, however her employer did not support her to finish the prescribing practicum after completing her Master’s degree. The other

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three participants are all completing their Nurse Practitioner practicum or planning to do so within the next two years. However, participants have experienced barriers to completing the Nurse Practitioner training,

the business model and the government funded don’t share the cost of upskilling to an NP [Nurse Practitioner] and the work that goes into mentoring an NP. Like, I’ve got two supervisors; I’ve got a Nurse Practitioner supervisor and a Doctor supervisor and my whole team that I work with in rural everyday supporting me in becoming an NP and the amount of work that they have that comes with that it’s quite onerous and there’s no income until I’m an NP so for three years they’ve got no extra funding. I’ve taken reduced wages to compensate for the fact that they are helping me so we’ve all lost out in terms of what are we investing in rural practice [Nurse A].

Completing the Nurse Practitioner training was considered useful in order to gain prescribing rights,

Because I see the difference between the Rural Nurse Specialist and Nurse Practitioner is the continuation of your Masters and then your prescribing practicum paper [Nurse C].

All four participants felt that the study they had completed so far in terms of finishing a Masters qualification was relevant to their practice and enhanced their patient care by developing advanced assessment skills. The postgraduate education also allowed them to keep up–to-date with the most relevant practice,

I guess the difference between myself, that I thought between myself and a practice nurse was having that postgraduate study and using more of an advanced brain work to when I see patients [Nurse C].

4.8 Domain Four: Research

This domain refers to the ability to generate knowledge and integrate research into practice and to pass this on in order to sustain a culture of change (Gardner et al., 2007), therefore this domain applies to the development of a workplace culture as well as participation in research. Phase One results will be discussed, then results in Phase Two of this section will include sub-themes of policy development and innovative health care.

4.8.1 Phase One

Research participation was required in the position descriptions in a number of ways. For example in this role in Organisation A,

researching, evaluating, developing and implementing standards of nursing practice in the specific area of practice [Organisation A].

While research use and participation is a requirement of the role in Organisation A, there are no further details on what is expected in the position description provided to the researcher. Organisation B requires the nurse to review protocols. Organisation C requires a,

commitment towards ongoing education and professional development [Organisation C].

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However, they do not specify evidence that the nurse is undertaking ongoing education and professional development. Organisation D requires the nurse to update the orientation manual for their individual area which is reviewed with the Clinical Nurse Leader, although there is no specific timeframe for how regularly the manual is to be updated. Organisation D also specifically requires the nurse to,

maintain a formulary that is appropriate for supplying urgent and emergency medication [Organisation D].

Organisation E has a specific requirement that the nurse is able to,

develop and implement innovative approaches to improve the patients pathways [Organisation E].

All organisations required the nurses to maintain documents that indirectly influence patient care and the day-to-day function of the service.

4.8.2 Phase Two results

In Phase Two the participants spoke about the necessity of maintaining knowledge of recent research in order to keep developing policies for their area and keep an up-to-date, broad knowledge base.

4.8.2.1 Policy development

Policy development was a motivator for the participants to keep up with research relevant to their practice. These policies are used within their own workplace. Improving health services refers to research undertaken by the participants within their own workplace in order to provide a better health service that is responsive to the needs of their community. Three participants considered policy development to be an integral part of their role. Nurse C was practising at a relatively new practice, and was developing new policies and procedures. All participants had regular meetings with colleagues in their workplace to discuss the development of new policies,

we used to have regular meetings and obviously then we would say this is now policy that we all have to do this and we all have to do this, so and we did constantly check up on things like that [Nurse B].

Much of the policy development occurred as the participants saw a clinical need and then an evaluation of current best practice was completed in order to develop a policy,

“this is the evidence that we have on gout, can we have a standing order please?” and this is what developed and we have monthly meetings that give us the opportunity to talk about there’s a need for a new standing order [Nurse A].

4.9 Domain Five: Publication and professional leadership

This domain relates to the dissemination of knowledge beyond the area of work (Gardner et al., 2007) and participation of the RNS in supporting organisations outside the institution that the nurse is employed (Gardner et al., 2007). Professional leadership relates to the RNS sharing their expert knowledge outside of their current work role (Gardner et al., 2007).

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4.9.1 Phase One results

In the position descriptions provided there was no specific requirement that the RNS be involved in anything outside of the workplace, aside from postgraduate study. However, leadership within the team was a requirement for both Organisation A and B,

Clinical leadership is evident through the empowerment and motivation of others [Organisation A].

Works to build team spirit facilitates resolution of conflict within the team. Promotes and protects team reputation, shows commitment to contributing to the teams success [Organisation B].

4.9.2 Phase Two results

Professional leadership outside the workplace was mentioned by two participants and one was in relation to stress management. Nurse A commented that the requirement to be involved in activities relating to professional leadership needed time and commitment which could be exhausting,

not join up to too many committees ‘cos I think that’s a lot of it, its not just the patient demand, its because you’re in a senior role in a, I think, uh, quite a high political arena that in particularly rural primary care is that you do want to jump on these committees and implement some policy making and stuff but that comes, a lot of work comes with that [Nurse A].

Nurse D was the chairperson of a group of rural nurses within that district who met regularly for peer support and education.

4.10 Additional themes

This section covers themes emerging from both phases that did not fit into any of the five domains of the Modified Strong Model of Advanced Practice (Gardner et al., 2007). From Phases One and Two stress management emerged as a theme. A further unanimous theme was lack of recognition of the advanced practice role. Lack of recognition of the advanced practice role includes the recognition that participants currently receive. Participants felt that a position description will affect the recognition a role receives, therefore it is considered a priority to have a position description which adequately describes the role.

4.10.1 Stress management

In Phase One stress management initially referred to the requirements by employers that the nurse manage stressful situations. However, participants discussed several different aspects of stress management including recognising stress triggers, personal and professional boundaries and the importance of a support network.

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4.10.1.1 Phase One results

Phase One analysis revealed some organisations identified stress management formally such as Organisation C which requires the nurse to undergo regular clinical supervision. Organisation A also formally recognise self-care,

demonstrates responsibility and accountability of own practice in accordance with specialty, professional and organisational policies and standards [Organisation A].

Organisation D required that the nurse have the,

ability to understand stress management and be able to use available resources in dealing with stress, critical incidents and consequence [Organisation D].

However, there is no mention of what resources are available in order for the nurse to manage stress. Organisation B had a behavioural approach rather than a safety approach taken by other organisations and requested that the nurse,

adjusts behaviour to the demands of the work environment in order to remain productive through periods of transition, ambiguity, uncertainty and stress [Organisation B].

Organisation E did not have any requirements for self-care.

4.10.1.2 Phase Two results

Participants described stress management in a number of areas. Each participant had strategies to manage stress unique to their own situation. It was considered important to recognize stress triggers and be able to deal with any arising situation,

I know when I’m stressed I have real triggers, I know when I’m stressed and I’ve got good coping mechanisms, so I think its important to know what your triggers are [Nurse C].

On-call work was considered a stressor for many reasons, including long working hours and being a sole practitioner. This was a concern when travelling to an isolated area, with environmental conditions such as weather or roads that prevented easy communication with others. There was also the challenge of safely accessing the accident scene,

you got to think about you being safe first, you got to drive the speed you can drive, you’ve got to make sure you’re wearing the right warm gear because you could be standing out there for hours and if you have wet feet you got frozen toes [Nurse B].

Part of the emergency aspect of the RNS role that was challenging and considered a stressor was the trauma of attending an accident,

I think when you work rurally especially in my role, I mean the emergency role in particular, you know you need good safe people that you can talk to because you often come across quite gory things and you need to have that outlet. I mean I’m lucky I have really supportive husband and my kids understand a bit about what I do in my role [Nurse C].

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The rural environment provided another stressor as the small community made it difficult to disengage from work. Clear boundaries needed to be set in order for the participant to feel they were able to relax away from work,

I am quite good at setting boundaries particularly with friends. I’ve got some quite close friends who are patients in the clinic because of the nature of the area, you know, they can’t be somewhere else and I’m really clear that if someone does bring something up with me outside of work, I say “come and speak to me about this at work” [Nurse D].

Nurse A purposefully took time away from work to spend with her family. All participants utilised family members as a part of their support network. One nurse went to regular counselling to cope with stress and one nurse utilised formal clinical supervision and peer reviews as a self-care mechanism.

4.10.2 Lack of advanced practice role recognition

Lack of advanced practice role recognition data emerged in Phase Two only, however participants emphasized the importance of this theme thus it is included as an additional theme. Participants felt strongly that one of the main issues they faced as an advanced practice nurse was lack of recognition for the role from other health professionals.

I don’t think we’re recognised for our, for what we actually do to be honest [Nurse D].

Perceived lack of recognition was seen as a potential adverse influence on patient care, as if the role was not recognized by other health professionals then the RNS felt that they were being undermined and their assessments were not taken at face value. This could be demoralising and potentially created unsafe practice,

if you don’t know the GP and they don’t you, there’s a lot of area where they question you unnecessarily a lot of time wastage, say kind of want to always verify what you are doing [Nurse B].

For participants new to the role, with no established position description or role recognition, interprofessional relationships within the health team became a challenge. Nurse B had been employed in one role with a clear position description and had taken a copy of this position description to her new role as a RNS in a different area, which did not have a current position description,

I gave them my position description from Town B and they looked at it and said “oh yeah no that’s good you’ll just work like that”, because it was new, they hadn’t had them, but of course that puts me at a barrier anyways, because some of the practice nurses were unaware of it and half the GP’s were unaware of it [Nurse B].

Participants were asked about the relevance of their current position description in relation to their current role. The participants responded to this question with varied responses, reflecting a general lack of recognition of the role as each employer provided different expectations, required that the participant set their own as there was currently no position description. One participant developed her own position description and another had neither title nor position description,

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I guess my job description doesn’t say Rural Nurse Specialist but I would consider myself and my colleagues to be Rural Nurse Specialist [Nurse D].

There were various reasons participants felt recognition of their advanced role was important, ranging from interprofessional relationships through to financial reasons,

probably you know you don’t get remunerated at any, I don’t get remunerated at a higher rate than any of my practice nurse colleagues who have been working as a practice nurse for a number of years, so you know that’s something that is an ongoing challenge [Nurse C].

A major component of the need for recognition was that participants felt they had worked hard to gain an advanced knowledge base and this was not recognised,

I think just acknowledgement that you have actually gone further in your career than being a registered nurse, you know there is no matter where you’re heading whether or not you’re heading in terms of being, and I think rural does make you different. You know, working in a rural area certainly does make you different than working in an urban area because the challenges that you had [Nurse C].

Nurse D described her colleagues in her location also found lack of recognition an ongoing issue,

all really proud to stand up and say “I’m a rural nurse I work in rural areas” look what you really special and its really different and I think it’s probably not particularly well recognised [Nurse D].

Poor role recognition was seen to create a lack of understanding and recognition from others within the immediate health team, especially other nurses,

we were not accepted as a practice nurse, because we’re not practice nurses [Nurse B],

which creates a difficult environment for the participants to work in, as explained by Nurse C,

helping your colleagues to understand why you actually go on and develop your postgraduate education ‘cos that is often I mean, you know I had nurses saying to me “well what is it that you do that is different?” They don’t understand that your knowledge is different and it actually makes their practice differently. That’s been a real challenge, yeah like I mean I’ve had comments from staff of “what makes you think you can call yourself a Rural Nurse Specialist, we don’t have those here” [Nurse C].

Lack of recognition was seen by the participants as a barrier to ongoing professional development,

you’re beyond practice nursing and a lot of the PHO’s do clinical training for practice nurses but nowhere near as advanced enough as what you need in your role as a Clinical Nurse Specialist. So you really need to be going to GP things and a lot of the GP things you’re excluded from [Nurse B].

Peer support was considered important for safe practice, although sometimes difficult to access,

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but I think peer review and having discussions with colleagues and regular meetings is really important and to remember that horizontal violence is alive and well out there so we really need to look after each other, because we don’t have an easy job so why add something else on top of it to make our job even harder, I just think it’s really important that there’s colleagues we really take care of each other [Nurse C].

4.11 Chapter summary

In this chapter, the results of the study have been described. Direct patient care has been found to be a priority for participants and in the DHB position descriptions. Participants provide advanced rural nursing care in both nurse-led clinics and on-call emergency settings. Much of this care is provided independently utilising advanced assessment skills to assess, diagnose and treat patients, often using standing orders when appropriate. There was a high expectation of interprofessional collaboration in the position descriptions, which was mirrored in practice with the participants reporting that collaboration was an important part of their role.

Activities related to quality control also emerged from both phases of this study. However, in position descriptions this was related to health and safety while participants believed it was more important to utilise quality audits to improve patient care. Education was considered in three different ways: supporting other staff, educating patients and education of themselves. The position descriptions describe the importance of supporting other staff, however this was not a concern of the participants. Education of patients was seen as a priority in both phases. Participants emphasized the development of the therapeutic relationship in order to facilitate health promotion and patient education. The specialist generalist role requires a broad knowledge base which led participants to continually upskill themselves in order to be up-to-date with current practices. Postgraduate education was a requirement in position descriptions which was echoed by participants who had all completed a master’s qualification.

Frustration with limitations of RNS practice, including the inability to prescribe, led all participants to express a desire to be a nurse practitioner, thus enabling prescribing which they perceived would be a benefitto the rural community. However there are barriers to pursuing this scope of practice, mainly financial.Participation in research was highlighted in position descriptions and by the participants who understood that research was important in maintaining policy development.

Professional publication and leadership received minimal acknowledgement in both Phases, however there was a requirement for nursing leadership within the role in position descriptions. Additional themes emerging from this study include the importance of stress management strategies for a nurse operating in this advanced practice role. In Phase One there were minimal requirements for formal recognition of stress management techniques, however in Phase Two participants took a preventative approach to managing stress. Methods of self-care to manage stress included managing personal boundaries, workload management by working only in certain areas, family support, clinical supervision and counselling.

An important theme emerging from Phase Two is the impact of lack of recognition of the advanced practice role of the rural nurse. Lack of recognition creates difficulties for RNSs when interacting with

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other members of the health team and is in part related to the variety of different position descriptions and titles. This is reflected in Phase One as when DHB’s were requested for the Rural Nurse Specialist (or similar) position description, a number of different position descriptions were provided. This variation creates confusion within the health team, leading to difficulties facilitating patient care and interrupting the nurse’s ability to utilise the health team as a professional development opportunity.

In the next chapter, Discussion, these results are discussed in the context of current literature.

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5. Discussion

5.1 Introduction

In this chapter the main themes emerging from the study results will be discussed with reference to current literature. Themes include a description of a specialist generalist role. Advanced practice of the RNS will be defined as well as the development of an autonomous role. Lack of role clarity and poor role recognition hampering collaborative practice is discussed. The need for postgraduate education and professional development and some of the barriers to accessing education are presented. The importance of professional leadership for the RNS is acknowledged. This chapter is framed using the Modified Strong Advanced Model of Practice (Gardner et al., 2007).

5.2 Direct comprehensive care

Direct comprehensive care is the first domain identified in the Modified Strong Advanced Model of Practice (Gardner et al., 2007). Direct comprehensive care is any activity undertaken by the RNS which is directly related to the patient, including assessment and treatment (Gardner et al., 2007). A discussion on the definition of rural is provided in order to provide an understanding of the context in which the RNS carries out these activities.

5.2.1 Defining ‘rural’

Position descriptions analysed in Phase One of this study, omitted any reference or definitionof the term ‘rural’. Within Phase Two, participants came from a wide range of different practices, all of which were deemed rural by the participants, without however a consistent definitionfor the term ‘rural’. This lack of a consistent definitionfor the term ‘rural’ is acknowledged in the literature (Bushy, 2002; Howie, 2008; MacLeod et al., 1998; MacLeod et al., 2004; Mills et al., 2010a; Roberts et al., 2014). The only agreement in the literature is that rural populations are isolated (Coleman & Lynch, 2006; Dillon, 2008; Howie, 2008; Sedgwick et al., 2014). While there is no consistent definitionfor rural, the traits of a small population, a distance between health providers and geographical isolation exist internationally (Bushy, 2002).

5.2.2 Generalist practice

All participants in this study described providing a wide range of care in response to the community needs in a rural setting. The participants described the RNS role as generalist because the range of presentations they were required to assess and treat were broad across specialties and lifespan. Participants emphasized that the generalist practice requirement is created by the needs of the rural community, which is also commonly observed in the literature (Howie, 2008; MacLeod et al., 2004; Roberts et al., 2014; Ross, 1999).

Generalist refers to the wide range of presentations across the lifespan that the RNS will see, often infrequently and at different stages of severity of illness (Brown et al., 2009; Bushy, 2002; Coleman & Lynch, 2006; Hegney, McCarthy & Pearson, 1999; Hounsgaard et al., 2013; MacLeod et al., 1998;

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Nexøe et al., 2012; Sedgwick et al., 2014). The term generalist can be confusing as in some international literature a generalist nurse is the equivalent to a registered nurse in New Zealand (Holloway, 2009). For example, the generalist nurse is described by the International Council of Nurses as “a nurse who is prepared to a level where they are able to competently practice within a wide range of settings in primary, secondary and tertiary level care” (International Council of Nurses, 2009, p.6).

Participants in this study typically met patients in a clinic setting during the day, treating both patients who were booked previously and those who arrived with an acute presentation. They saw a wide range of presentations in these clinics, demonstrating the generalist nature of the RNS role. The generalist nature of RNS practice, as discussed in international literature, is a consequence of the the small number of health professionals in the rural area leaving a gap which means the RNS needs to have skills to treat a wide range of presentations (Brown et al., 2009; Hegney et al., 1999; MacLeod et al., 1998; Nexøe et al., 2012; Roberts et al., 2014).

Participants in this study described the need to extend their skills to undertake some of the health care interventions traditionally carried out by GPs. GPs were no longer undertaking this patient care due to staff shortages and GP retention issues. Participants also described taking on administrative roles such as practice management, or receptionist work on the weekends as well as organising medication dispensing during the weekend. Generalist practice within the rural specialty is unique as the small number of health professionals means the RNS may also undertake activity not traditionally seen as nursing (Barber, 2007; Bushy, 2002; Fitzgerald, 2008; Howie, 2008; Kenny & Allenby, 2013; MacLeod et al., 2004; Ross, 1999). The RNS could complete a large share of administrative duties and take on some activities that may be customarily considered allied health tasks, such as organising mobility equipment and assisting with social problems (Brown et al., 2009; Bushy, 2002; Haydon-Clarke et al., 2011; Hounsgaard et al., 2013; Howie, 2008; MacLeod et al., 2004). A unique characteristic of the RNS is their ability to incorporate aspects of other health professionals’ core skills into their own RNS practice, such as social work or medical practice (Hounsgaard et al., 2013; Howie, 2008). Despite a varied generalist practice the RNS is still considered a specialist by many (Castledine, 2004; Crooks, 2004).

5.2.3 Specialist practice

Participants in this study believed that the term specialist could be applied to their role as their advanced assessment, diagnosis and treatment practice distinguished them from a practice nurse (a registered nurse working within a medical practice). Participants also observed that their postgraduate study had equipped them with an ability to develop enhanced clinical judgement enabling advanced assessment diagnosis and treatment in comparison to practice nurse role. Participants further related several experiences of providing patient care within different environments ranging from clinics and patient homes, to inside vehicles on the roadside. The RNS utilizes advanced assessment skills and reasoning to provide treatment for patients (Coleman & Lynch, 2006; Howie, 2008; Roberts et al., 2014; Sedgwick et al., 2014). The RNS needs to be able to use advanced assessment skills in a variety of environments from the clinic, to the roadside, to the farm or bush (Fitzwater, 2008). The RNS’s ability to utilise advanced skills in unexpected situations is expected of a capable specialist nurse rather than a competent

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registered nurse (Holloway, 2012). A specialist nurse is therefore working at an advanced practice level, serving a specific population (the specialty) and using a specific skill set to do so (Castledine, 2004).

While there is no consistent definition for rural population (Howie, 2008), there is growing belief that the rural population is the specific patient group that a RNS treats (Castledine, 2004; Fitzwater, 2008). The generalist nature of the population served combined with the specialist skills utilised creates a specialist generalist role.

5.2.4 Specialist generalist role

Participants in this study described being specialist generalists in their practice, referring to the wide range of patient presentations seen by the RNS and the advanced skills they needed (Coleman & Lynch, 2006; Howie, 2008; Roberts et al., 2014; Sedgwick et al., 2014). The term specialist refers to the level of practice the RNS is operating at (Holloway, 2009), which is an advanced level within their scope of registered nurse (Castledine, 2004; National Nursing Organisation, 2014). In summary, the term specialist generalist indicates that the RNS is operating at an advanced nursing practice level (specialist), seeing a wide range of presentations within the rural population (generalist).

5.2.5 Advanced practice

Advanced practice was consistently reported within a number of settings by participants in this study. All participants considered providing direct patient care as the main component of their role, demonstrating consistency with advanced nursing practice as defined by Hamric et al., (2009). During Phase One it was noted that one position description did not include any direct patient care; this role was considered a nurse specialist by the DHB due to the strong emphasis on nursing leadership. Hamric et al., (2009) state that one of the main characteristics of advanced practice nurses versus advanced nurses such as educators, is direct patient care. Within this study, participants felt that their advanced nursing practice was demonstrated within their advanced assessment skills and clinical decision making with patients

Three of the position descriptions analysed in Phase One intimated that advanced practice skills including assessment skills would be utilised by RNSs. Participants in Phase Two reported utilising advanced practice skills within their everyday practice. The use of advanced practice skills is a response to geographical isolation, the small number of rural health professionals in the rural area and specific community needs (Brown et al., 2009; Bushy, 2002; Hegney et al., 1999; MacLeod et al., 2004; Roberts et al., 2014; Ross, 1999). In this study participants described using advanced assessment skills within nurse-led clinics and when doing after-hours call, with GP support. This is echoed in the practice of rural nurses in both Greenland and (USA) (Brown et al., 2009; Hounsgaard et al., 2013) as well as New Zealand (Ross, 1999). In the USA there has been formal recognition of advanced practice with specific titles and prescribing rights in rural practice (Brown et al., 2009). Greenland does not have a formal title for the RNS role and advanced practice is not formally recognised although clearly demonstrated (Hounsgaard et al., 2013; Nexøe et al., 2012).

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5.2.6 Treatment provision

While the participants in this study all used standing orders for treatment of rural patients, this is not always the case internationally as some advanced practice nurses have prescribing rights (Australian Health Practitioner Regulation Agency, 2010; Brown et al., 2009). Brown et al. (2009) found that a higher percentage of rural nurses in the USA prescribed medication as opposed to their urban counterparts, in response to the needs of the community, influenced by patient isolation, and a lack of access to other types of treatment. While standing orders are effective in many cases, all participants in this study noted that becoming an authorized prescriber as a NP would improve their abilities to manage patient care. Implementing standing orders can create some uncertainty for the RNS as if the patient presents with a condition outside the parameters of the standing order, the RNS is required to get a verbal order for medication from a prescriber (Armstrong, 2008; Fitzgerald 2008). Standing orders are designed to be created by a GP or dentist who is working with the nurse providing the standing order, however a lack of GPs within the workforce creates an environment where the RNS may not always work with the same GP (Wilkinson, 2015). Keeping standing orders up-to-date with evidence-based practice and working with the GP when using them are also factors which create confidence when using standing orders (Wilkinson, 2015). Internationally the need for prescribing rights is difficult to compare as different health systems have different prescribing rights for nurses. However there is an international trend for rural nurses to be required to prescribe due to isolation and lack of other health professionals in the rural area (Brown et al., 2009; Hounsgaard et al., 2013).

5.3 Support of systems

Support of systems is the second domain in Modified Strong Model of Advanced Practice (Gardner et al., 2007). Support of systems refers to activities the RNS undertakes in order to facilitate the movement of the patient through the health system (Gardner et al., 2007). The RNS requires role clarity and role recognition in order to effectively facilitate patient movement through the health system. The development of an autonomous role to continue to provide services has been included in this discussion of support of systems as this development supports continued provision of healthcare in the rural area. For the RNS to effectively facilitate patient movement there needs to be effective role clarity (Ross, 2001).

5.3.1 Role clarity

Role clarity occurs when there is a clear understanding of the expected behaviours within that setting (Ross, 2001). Role clarity will aid effective collaborative care which can then provide more accessible care to patients (Ross, 2001; World Health Organisation, 2010). Lack of role clarity leads to lack of recognition of a role (Ross, 2001). In this study all participants stated that lack of role recognition was motivation for participating in this study. All participants had experiences of poor communication with other health professionals and general lack of understanding of their role and boundaries, leading to difficult relationships within the healthcare team. One participant felt autonomy was lost when GPs did not trust their judgment due to a poor understanding of the RNS role, this nurse eventually left that practice setting to work elsewhere as she felt her skills were not recognized.

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Rural nursing has not been recognized as a specialty for a number of reasons including geographical isolation and a traditional ‘get on with it’ attitude as discussed by Crooks (2004). In this study, participants overwhelmingly believed that their advanced nursing practice role was not recognised by medical and other nursing staff. The reported negative effects of this lack of recognition include lack of financial remuneration, lack of recognition of advanced skills, lack of professional development, exclusion from the healthcare team and lack of professional support required for this unique role (Armstrong, 2008; Crooks, 2004; Ross, 2001).

The five different position descriptions collected for Phase One of this study demonstrated a lack of role clarity given the overall variety seen in title and requirements. Title variety seen in Phase One include Clinical Nurse Specialist, Rural Nurse Specialist, Rural Clinical Nurse Specialist, Clinical Nurse Specialist-Chronic Disease Management and Clinical Nurse Specialist-District Nursing. Requirements for the position ranged from being patient focused including assessment, health promotion and collaboration with other health professionals to exhibiting nursing leadership skills with no patient focus. Lack of role clarity leads to problems for the RNS as they are unsure of what tasks or responsibilities may be expected of them, as well as confusion for other members of the health team as the skill set expected of the advanced nurse is not clear (Stasa, Cashin, Buckley, & Donoghue, 2014). There are concerns within the literature that patients may have difficulty understanding what it is appropriate to consult the RNS about, as the skill set and abilities of the nurse are unclear (Stasa et al., 2014).

5.3.1.1 Role clarity and the patient accessibility

The participants in this study believed that following RNS management of rural community patients, the patients gained confidence in the RNS’s care. Participants reported that patients were comfortable waiting longer to see the RNS as they trusted the RNS, and knew the RNS would consult with medical colleagues if required. The participants also believed that cost was an influencing factor in patient decision to see the RNS in preference to a doctor, as the lower cost of seeing the RNS meant the RNSs were more accessible to the community.

In rural areas where there is little patient choice, patients are satisfied with the care provided by a RNS (Fitzgerald, 2008; Wong & Regan, 2009). Overall patient satisfaction with nurse specialist care in primary health is high, with many patients stating that the relationship is more equal with a nurse than with a doctor and care provided is more holistic (Bonsall & Cheater, 2008). Patients are not so much concerned with who will give the care but rather that there is good continuity of care provided and that the healthcare is accessible (Bonsall & Cheater, 2008). Accessible healthcare is becoming a global concern, with the use of advanced practice nurses advocated as a strategy to address this concern (National Nursing Centres Consortium, 2014). However, the continuing confusion over the definition of advanced practice nurse and different titles and frameworks within separate countries remain barriers to utilising advanced nurses to their full capabilities (National Nursing Centres Consortium, 2014). Part of the advanced nursing role is the ability to work collaboratively with other health professionals to promote patient care (Hamric, et al., 2009).

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5.3.1.2 Role clarity and the healthcare team

Role clarity is considered essential by Gardner et al., (2007) to allow an understanding of the boundaries of a role from the wider healthcare team, the nurses and patients. The concept of an interprofessional health team working in close collaboration to provide patient care is promoted by Sommerfeldt (2013) and the World Health Organisation (2010) as the way forward in providing accessible healthcare. Health professional collaboration requires role clarity for all health professionals, enabling each member to fulfil their own function (Lowe et al., 2012; Sommerfeldt, 2013) as well as understanding the role of others to promote clear communication (Donald, et al., 2010). Role clarity creates more accessible services as patients understand the abilities of the health professional they are seeing (Lee & Winters, 2004).

5.3.2 Collaborative practice

In this study, participants indicated that collaborative practice was a large part of their patient care. Collaborative practice enables the provision of care that is faster and more accessible to the rural population of New Zealand (Higgens, 2008; Ross, 2001). Collaborative practice relates to the interprofessional relationship between the RNS and the medical team (doctors), as well as the wider health team to provide health services (Higgens, 2008; Ross, 2001). Collaborative practice occurs when members of the healthcare team are educated about the role of each health professional and how these roles can best be utilized to meet the needs of the local population (World Health Organisation, 2010). This education is termed interprofessional education (World Health Organisation, 2010). Collaborative practice is recognised by the World Health Organisation (2010) as a means of strengthening the dwindling healthcare workforce to provide better healthcare by employing the full capacity of each team member thus improving health outcomes. Clarity and recognition regarding the role of the RNS by the healthcare team will influence the ability of the RNS to effectively collaborate with the whole healthcare team (Ross, 2001).

The level of collaborative practice within the healthcare team will influence the patient care provided (Ross, 2001; World Health Organisation, 2010). Distance to care is a unique factor influencing patient care in a rural setting as demonstrated by one participant who gave a scenario where she collaborated with a team in a rural medical centre and gave treatment based on that communication in order to avoid travel for the patient. Within the literature, distance to care is a recognised barrier which creates a need for the RNS to collaborate with members of the health team based elsewhere (Armstrong, 2008; Higgens, 2008; Mills et al., 2010b). This collaboration would be enhanced by role understanding (Ross, 2001). However collaboration is hampered by distance as there may be no face-to-contact and poor understanding of the context of the role which could be mitigated by an on-site visit (Ross, 2001).

Participants in this study found it difficult when members of their own team did not understand their role, leading to an unwillingness to work together. Collaborative practice requires role understanding from all parties, so it is also helpful if the RNS understands the role of the medical staff (Ross, 2001) and factors which may influence the medical staff’s decision-making such as lack of experience (Armstrong, 2008). Understanding the medico-legal standpoint of the medical staff when seeking advice will also help the RNS form a good working relationship and enable them to use medical staff as legal backup

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(Armstrong, 2008). One participant in this study reported supportive collaborative practice giving confidence to become more autonomous.

5.3.3 Autonomous role development

In this study two participants undertook on-call work as part of their advanced nursing practice role to ease stress on the GP and help retain medical staff in the rural location. One participant was looking forward to completing PRIME training in order to be a more effective member of the healthcare team, with a special mention that the acute presentations seen while on-call were considered by the RNS a good challenge for the advanced assessment skills gained through formal study and informal collegial learning. Providing on-call services is a role that has been taken on by more RNSs in an effort to respond to a lack of GP services or to support GPs to stay rural by reducing the GP workload (Goodyear-Smith & Janes, 2008). The opportunity to work alongside a GP in a rural health clinic was utilised by participants in order to gain further knowledge to use when completing on-call work. Fitzgerald (2008) found that this was one way the RNS ensured they had up-to-date skills for times when they were unsupported by medical colleagues. During clinics they would ask for advice and reflect on presentations in order to learn more (Fitzgerald, 2008).

As there has been a decrease in rural GPs in New Zealand (National Nursing Organisation, 2014), the RNS has been required to work more autonomously, by fulfilling the after-hours clinic and the on-call role that the GP would have traditionally undertaken (Fitzgerald, 2008; Goodyear-Smith & Janes, 2008). The opportunity to provide on-call services arose as GPs became less willing to be the sole practitioner on-call within the community (Fitzgerald, 2008; Goodyear-Smith & Janes, 2008). On-call work is considered by participants in this study to be one of the most stressful aspects of the RNS role, as they practised independently with long hours and in challenging situations with minimal collegial support. One participant in this study viewed on-call work as a stressor and avoided doing on-call work after-hours as a way to manage stress. However, other participants felt that on-call work was an enjoyable challenge.

When practising after-hours (outside the business hours of the clinic), participants described facilitating a weekend clinic at a specifictimes as well as being available for any call from the medical centre in which they practised. Three participants were also PRIME trained, entailing accompanying ambulance staff to emergency calls after receiving extra training from the ambulance services (Ministry of Health, 2014). On-call work as a PRIME operator requires the RNS to practice in an advanced role as the RNS is the sole practitioner, operating under standing orders (ACC, 2008; Brown et al., 2002). At these calls the RNS would often be the senior person in the team and would be required to use their advanced assessment skills to assess and diagnose presentations (Brown et al., 2002; Fitzgerald, 2008), thus enabling an advanced role for the RNS (Armstrong, 2008). The need for on-call work is dictated by the employer and the community needs, thus is different for each locality (Armstrong, 2008; Brown et al., 2002).

Within this study participants described the challenge of coordinating care for patient transport in an isolated area especially when providing after-hours care. The co-ordination of the care of an acutely unwell patient in an emergency situation is a specific skill used by the RNS (Bourke, Humphreys,

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Wakerman, & Taylor, 2012; Brown et al., 2002; Brown et al., 2009; MacLeod et al., 1998). Transport is a challenge due to the geographical isolation of rural communities preventing easy transport by land and weather often isolating islands and preventing air transfer (Brown et al., 2009; Haydon-Clarke et al., 2011; Hounsgaard et al., 2013; Howie, 2008; MacLeod et al., 1998). The PRIME contract requires the health provider to ensure there are no delays in getting the patient to a secondary level hospital, therefore emergency treatment is provided and transfer arranged as quickly as possible (ACC, 2008; Brown et al., 2002). On-call services and PRIME services are provided according to the needs of each community (Brown et al., 2002), therefore building up a strong relationship with the community is central to the practice of the RNS (Bourke et al., 2012).

5.3.4 Relationship-centred practice

The need to develop effective working relationships within the rural community was important to participants in this study. Unanimously participants believed that providing health services considered necessary by the community was the purpose for their role and pivotal to the services they provided. Participants identified the specialist generalist role and the need for on-call services as being created by the community.

The RNS role is community centred (Howie, 2008) and participants in this study believed that building a strong relationship within the community was important to facilitate health promotion and education (Bourke et al., 2012). Health services are provided differently in each area as services are essentially tailored to each community (Bourke et al., 2012; Brown et al., 2009; Haydon-Clarke et al., 2011; MacLeod et al., 1998; MacLeod et al., 2004; New Zealand Institute of Rural Health, 2008). Acute patient presentations are heavily influenced by the social demographics of the community, whether there is a high transient population, such as tourists, or casual employees, high accident rates in the primary industry in the area, such as forestry or a high indigenous population with different health needs from others in the community (Brown et al., 2002; Howie, 2008; MacLeod et al., 2004).

Participants in this study identified that a large portion of their time was spent undertaking health promotion/ education with community members. Innovative approaches were taken to ensure effective communication with patients, such as going to homes and workplaces or talking to several generations of a family at once. Within Phase One only one position description required the RNS to participate in community health promotion. A rural community is unique in the way it relies upon the social network of ‘who knows who’ in order to build up trust with a RNS, which then creates an environment which allows the RNS to identify health needs (Haydon-Clarke et al., 2011). Bourke et al., (2012) found that rural culture relies on social networks and relationships within the community. Within a rural culture there is a need for the RNS to build strong working relationships with community leaders, firstly to help identify health needs and then to identify the best way to meet those needs (Hauenstein et al., 2014; Howie, 2008; Mills et al., 2010a; Prior et al., 2010).

Participants in this study described their role becoming easier as they began to build relationships within the community and community members got to know them. Three participants mentioned that it was helpful to understand the patients’ social networks within the community as knowing who was friends with who and how they were related/knew each other helped the patients trust the RNS. Understanding

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patients’ social networks also gave participants insight into how the community functioned and what was considered socially acceptable.

Rural populations can be slow to trust a newcomer which can prove a challenge for a RNS new to a community (Brown et al., 2002; Haydon-Clark et al., 2011; MacLeod et al., 2004). Howie (2008) recommends that the RNS take time to learn about the social profile of the community to identify potential health problems, as well as the unspoken rules regarding social norms within the community. Health education is not just provided within work hours, the small population will often give the RNS opportunities to reinforce the health message both socially and professionally (Mills et al., 2010a). One participant described the provision of health education in a non-clinical setting as inevitable and helpful for some patients however another participant felt that in order to ensure there were appropriate professional boundaries, providing health education in a social setting was inappropriate.

Participants emphasized the need for professional and personal boundaries, as they felt that a lack of boundaries would mean they could never stop thinking about work. A lack of professional and personal boundaries may lead to burnout for the RNS, as they feel that they are never off duty (Barber, 2007; Brown et al., 2002; Howie, 2008). Boundary blurring can also create a conundrum for patients who may feel that they are unable to disclose information to the RNS due to the social stigma of their health concern, such as sexual or mental health issues (Haydon-Clark et al., 2011). The RNS needs to be aware that social behaviour will impact on the community’s impression of their professional ability and vice versa (Haydon-Clark et al., 2002; Howie, 2008).

Close communities are acknowledged to have a negative side, with a blurring of professional and personal boundaries (Barber, 2007; Brown et al., 2002; Bushy, 2002; Hauenstein et al., 2014; Haydon-Clarke et al., 2011; MacLeod et al., 2004). This blurring is common throughout rural communities and it is up to the individual nurse to provide clear boundaries of what is appropriate for social situations and what is appropriate at work (Barber, 2007; Brown et al., 2002). The Nursing Council of New Zealand (2012) acknowledge that close communities do present opportunities for blurred professional and personal boundaries and recommend the nurse is very open about what they can talk about at work and what is appropriate in a social setting. Close communities can also provide opportunities for a lack of patient privacy, and the RNS needs to take steps to ensure the patient’s privacy is always maintained (Nursing Council of New Zealand, 2012). While a strong relationship with the community is important, relationships with the medical team are equally important.

5.3.5 Relationships with medical team

Phase Two of this study demonstrated the importance of the RNS’s relationship with the medical team. Three participants had supportive medical staff working with them which gave them confidence within their practice and allowed them to develop new skills and reflect on their own clinical decision-making. However, a poor relationship with the medical team was reported by one participant who felt that this relationship had undermined ability to practice and could potentially create poor practice as there was a lack of opportunity to reflect on clinical decision-making. There is a long history of the nursing profession being subordinate to the medical profession (Hamric et al., 2009) and some argue that this history affects the ability of both doctors and nurses to build an interprofessional relationship which will

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provide the opportunity for effective collaborative practice (Fitzgerald, 2008; Ross, 2001). However, despite the history collaborative practice is a concept which is essential to the RNS due to the isolated environment they practice in (Fitzgerald, 2008; Higgens, 2008; Mills et al., 2010a).

Within this study one RNS had a very supportive relationship with the medical staff allowing for interprofessional education and creating a safe environment for professional development. Literature shows that benefits of a positive interprofessional relationship with the medical team include collaborative professional development and a lessening of the sense of professional isolation for the RNS (Armstrong, 2008; Ross, 2001). For the patient the benefit of a healthy interprofessional relationship is faster access to secondary care and less duplication of information (Armstrong, 2008). There is also a medico-legal aspect as the RNS needs support when a situation falls outside of the prescriptive guidelines for standing orders (Armstrong, 2008).

Participants in this study discussed incidents in rural practice where poor understanding of the RNS role led to difficulty making referrals to medical staff. Participants understood this difficulty was partly due to medical staff having limited understanding of the abilities of the RNS and expecting the RNS to provide treatment beyond the RNS’s ability, thus lack of role recognition. Conversely poor understanding of the RNS role by other health professionals within their practice also created an unsupportive environment where the judgment of the RNS was questioned unnecessarily, which may have had a negative effect on patient care. An ineffective relationship with the medical team can lead to a difficult interprofessional relationships with negative outcomes for the RNS and the patient (Armstrong, 2008). Negative outcomes for the RNS include increased professional isolation and decreased professional development (Armstrong, 2008; Ross, 2001). For patients there can be a delay in receiving essential care as the medical staff may not understand the distance to care or they may not use the skills of the RNS (Armstrong, 2008). These difficulties can arise when medical staff are unfamiliar with the RNS or the environment, leading to poor advice (Armstrong, 2008; Mills et al., 2010b). The medical staff may question the assessment of the RNS, especially if they are unfamiliar with the advanced nursing practice role (Armstrong, 2008; Haydon-Clarke et al., 2011) or if they themselves are inexperienced they may prevent care being given such as increasing analgesia using a verbal order (Armstrong, 2008).

Poor interprofessional relationships and a lack of trust in the RNS assessment skills has created ethical dilemmas for nurses such as the under-prescribing of analgesia and inappropriate withholding of intravenous antibiotics, when there is a difference in judgement between the RNS and the medical team (Armstrong, 2008). As well as the medical team the RNS needs to have effective interprofessional relationships with the wider healthcare team (Mills et al., 2010b).

5.3.6 Relationships with wider healthcare team

One position description in Phase One placed importance on communication and relationships within the healthcare team. While much of the data collected in Phase Two revolved around working with medical staff, participants did discuss working with other nurses and one participant discussed a working relationship with allied health services. In a rural area the healthcare team may include community members, allied health staff, mental health professionals, ambulance staff or fire and police services

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rather than medical or nursing staff (Mills et al., 2010a; Ross, 2001). The wider health team may include medical or surgical consultants or the emergency team within a regional hospital (Armstrong, 2008).

The wide variety of staff in a rural healthcare team requires the RNS to have effective communication skills, so they are able to adapt communication styles appropriately (Mills et al., 2010b). For the RNS, other health team members may be located on-site or be based some distance away and only accessible by phone (Armstrong, 2008; Fitzgerald, 2008; MacLeod et al., 1998; MacLeod et al., 2004; Mills et al., 2010b; Ross, 1999; Ross, 2001).

The lack of face-to-face relationship building created by this isolation creates difficulties when providing interprofessional education between all members of the healthcare team (Ross, 2001). Interprofessional education creates an effective collaborative practice which will enhance patient access to care (World Health Organisation, 2010). Having face-to-face contact and working alongside team members on a regular basis has been shown to enhance the interprofessional relationship and collaboration (Ross, 2001).

Higgens (2008) notes that collaboration is a voluntary part of the RNS role, unless stated in the position description. The position description from Organisation E prescribed working collaboratively with primary care organisations, other agencies and multidisciplinary teams. However the position description Organisation E provided was for a position based in an urban centre with an outreach to rural areas. Therefore, the RNS in Organisation E potentially works more closely with the members of the multidisciplinary team than RNS from other organisations. Organisation D provided a position description for a nurse based in a rural clinic and practising independently, with a requirement that the nurse collaborate with medical staff. In order to collaborate with medical staff, both the RNS and the medical staff must have an understanding of the RNS role (Ross, 2001). Within the position description from Organisation D is no discussion of steps taken to ensure that there is a good understanding of health colleagues within the organisation. Organisation C and D required that the RNS work with other organisations within the community to promote community safety. RNSs working within the community will then need to build up strong relationships with the community in order to provide care (Bourke et al., 2012). Organisation C focused on the use of communication and building interprofessional relationships rather than collaboration, however, collaboration remained a part of the position description. The RNS in Organisation C needs to demonstrate good communication skills, although there is no documentation as to how this will be achieved. Collaboration can be encouraged with both interprofessional education and postgraduate education (Ross, 2001).

5.4 Education

Gardner et al. (2007) described education with the Modified Strong Model of Advanced Practice as not only the education received by the RNS but as education given by the RNS. Providing education to other nurses was not discussed by participants in this study. Education and upskilling are considered important by health professionals working in a rural area (Hauenstein et al., 2014; Hunsberger, Baumann, Blythe, & Crea, 2009). Recieving education adds to job satisfaction and decreases feelings of professional isolation (Hauenstein et al., 2014; Hunsberger et al., 2009; Jukkala et al., 2008; Mbemba et al., 2013).

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5.4.1 Postgraduate education

In this study there was agreement by participants and in the position descriptions that postgraduate education was an essential requirement of the RNS role. Inconsistencies regarding the level of educational requirements between employers were evident within the position for example, one organisation only required postgraduate education, with no detail as to level of education or content, whilst another organisation required that the nurse hold a rural Master’s qualification. The variation in requirements by employers reflects the lack of consistency related to postgraduate education for the nurse specialist role within New Zealand (Roberts et al., 2011).

Within this study two participants believed that postgraduate qualifications gave them more confidence when completing assessment and diagnosis of patients. One participant gave evidence using a specific case, where postgraduate education led to consultation with a physician’s assistant in a hospital and cardiac medication was titrated by the RNS based on the physician’s assistants recommendations This participant felt that postgraduate education had given them confidence in their assessment findings which then enabled clear communication with the physician’s assistant. The participant then used skills gained from postgraduate education to reassess the patient as the condition changed and independently made a referral to a regional emergency department for further care. Fitzgerald (2008) demonstrated that postgraduate education encourages collaborative practice as health team members are able to communicate more clearly using language other health professionals may relate to more easily. Lancaster (2011) stated that postgraduate education made nurses feel more respected and listened to by team members.

Participants stated that the challenges of their specialist generalist role created a need for constant upskilling and postgraduate education. Postgraduate education was considered most beneficial by participants because education improved and added to the RNS skill set, especially when assessing and diagnosing patients. Having a postgraduate qualification, especially with a focus on patient assessment gave participants the confidence to practice autonomously at an advanced level as well as provide treatment via standing orders.

The skill of diagnosis is often thought to sit outside the registered nurse scope of practice (Wilkinson, 2015), however this skill is starting to fall into the domain of the RNS as the sole practitioner in rural areas (Fitzgerald, 2008; Goodyear-Smith & Janes, 2008; Litchfield & Ross, 2000; Long, Scharff, & Weinert, 1997). Wilkinson (2015) demonstrates that standing orders are used with more confidence when the nurse has undertaken postgraduate study. The generalist practice role of the RNS creates a unique postgraduate education requirement (Long et al., 1997; MacLeod et al., 2004; Mills et al,, 2010; Ross, 1999). The breadth of the generalist role requiring advanced knowledge is partly due to lack of other health professionals creating a need for role expansion, or role substitution (Brown et al., 2009; Bushy, 2002; Fitzgerald, 2008; Haydon-Clarke et al., 2011; Hegney et al., 1999; Long et al., 1997; Mills et al., 2010a). One of the key factors driving the need for a generalist role is isolation (Howie, 2008; MacLeod et al., 2004).

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5.4.2 Impact of isolation on education

Participants felt it was important to upskill and maintain education as a response to the wide range of services they are required to provide. RNSs work within a number of environments, some more isolated than others (Bushy, 2002; Kulig et al., 2013). For those RNSs working in more geographically isolated areas there are less health professionals available so the RNS needs to provide expanded nursing services (Bushy, 2002; MacLeod et al., 2004; Mills et al., 2010a). The need to provide a wider range of expanded nursing services creates a need for further education (Coleman & Lynch, 2006; Kulig et al., 2013; Mills et al., 2010a).

Participants identified time travelling away for education as a barrier to completing postgraduate education. Isolation is a barrier to education as it often necessitates travel away from the area requiring arranging cover for work as well as travel time away from family and the community (Jukkala et al., 2008; MacLeod et al., 2004; Ross, 1999). Travel can also be difficult to access if weather conditions close roads, or the RNS is based a long distance from the education provider (Jamieson, 2008; Jukkala et al., 2008; Robertson, 2008; Ross, 1999).

Another recognised struggle with education for the RNS is that until recently much postgraduate education has been aimed towards health professionals situated in urban centers and thus may not be relevant for RNS (Jukkala et al., 2008; Long et al, 1997; Ross, 1999). Participants in this study all planned their study to be clinically focused and relevant to rural health, whilst only two of the position descriptions collected in Phase One requested postgraduate education relevant to rural health. The two position descriptions with a rural health focus were that of Rural Nurse Specialist and Clinical Nurse Specialist Rural. The three that did not have a rural focus for postgraduate study, did not have rural nurse specialist in the title, although the position descriptions were provided in response to a request for RNS or equivalent. The Rural Nurse Specialist and Clinical Nurse Specialist Rural were both describing an autonomous role which included providing on-call and primary health care, in a rural community. One of the three other position descriptions was for a generic clinical nurse specialist. As this position description was generic for that organisation, there was no specific rural focus. The remaining two other position descriptions were based in an urban setting where supports were available, and one was focused on Chronic Disease Management, therefore a rural focus may not be helpful.

Postgraduate education received by the RNS was viewed as a barrier to receiving in-house professional development by some participants. As the RNS had received further postgraduate education, the practice nurse professional development was not appropriate for the RNS level of knowledge. However, the other professional development provided was aimed at the GPs practice. Difficulty accessing professional development was dependent on the employer as one participant was able to participate in GP professional development and another was able to travel to a group for RNSs. Due to isolation it is difficult for the RNS to travel or access other professional development opportunities at times (Bushy, 2002; Hauenstein et al., 2014; Jukkala et al., 2008; Mills et al., 2010a; Ross, 1999).

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5.5 Nurse Practitioner

All participants were educated to a Master’s level and believed that having a NP scope of practice would further enhance patient access to healthcare. However one participant cited barriers to furthering their education to gain NP registration such as lack of funding or no jobs available if they do get the extra qualifications. One participant felt that achieving NP registration was a challenge due to the time commitment. One participant noted that barriers included funding and the time burden on other members of her health team who were providing support and supervision or covering study leave.

All participants in this study wanted to complete further study to become a Nurse Practitioner (NP).One reason given by a participant to become a Nurse Practitioner was to achieve greater role clarity as the NP role is already clearly delineated and recognized in New Zealand as opposed to the Nurse Specialist role which is not. This finding is echoed by Roberts et al., (2011) who found that while the NP role is clearly defined in New Zealand, the CNS role is not. Donald et al. (2010) noted a similar concern in Canada, where the Nurse Practitioner role is clearly protected, whereas the nurse specialist role is not. Within a rural setting the NP role would foster more independence, especially with regards to prescribing treatment (Fitzwater, 2009).

Retaining a nurse specialist role can aid in retention of the workforce as autonomy and advanced practice are seen as valued by nurse specialists (Bonsall & Cheater, 2008). However, one of the major barriers to achieving autonomous practice is a lack of role clarity which can lead to obstructive behaviour, such as refusing to acknowledge the role of the RNS as being different to that of a practice nurse, or medical staff refusing to accept patients based on the RNS assessment (Bonsall & Cheater, 2008). In this study having prescribing rights and role recognition were seen as the main motivator for becoming a NP, otherwise the RNSs were satisfied with their role. As the NP role is currently recognised by the Nursing Council of New Zealand as a scope of practice (Nursing Council of New Zealand, 2008), some of the RNSs struggles to gain role recognition and financial remuneration may be mitigated by gaining NP qualifications and title (Donald et al., 2010). However, role recognition continues to be an issue for those NPs working in countries where there is a consistent definition for the NP role (Donald et al., 2010; Maw, 2008). Therefore becoming a NP may not provide further role recognition.

Barriers to gaining NP status expressed by participants in this study included lack of position availability for a NP position and lack of funding to achieve the NP role. Maw (2008) noted that the NP position within rural health care would be particularly helpful in providing accessible care which is becoming harder given the declining numbers of GPs. Maw (2008) describes authorised nurse prescribing as a motivator to achieve NP status, reflecting participants in this study who describe practising at an advanced level and administering medication in the community using standing orders. Given the longstanding nature of many RNS roles, which include using standing orders to provide medication, the community may well notice no change except the title of the nurse position (Maw, 2008). The barriers of funding, access to education and lack of job availability experienced by participants in this study are similar to barriers anticipated when the NP role was established (Maw, 2008). The barriers to NP training include gaining further education especially in light of the isolation in which the RNS is practicing (Mills et al., 2010a).

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Barriers to NP education and the current successful use of RNSs within the community indicates that the RNS role continues to have a place in the New Zealand health system.

5.6 Professional leadership

Professional leadership is described by Gardner et al., (2007) as a leadership role within professional support organisations related to the specialty. Professional leadership is discussed here as leadership was notably omitted from all five position descriptions collected in this study, and participants had limited discussions regarding professional leadership. One participant felt that leadership was an important aspect of the RNS role, however another participant felt that the pressure to take part in multiple professional leadership roles was a potential stressor to be minimized. Another participant was enthusiastic about leadership and had started a peer support group within their area of work. Within the interview questions there were no specific questions regarding professional leadership, so participants may not have discussed this if they did not think it was important.

Crooks (2004) notes that if RNSs make themselves more visible as a group they could potentially drive policy-making. However, with minimal involvement in professional leadership promoted by employers or undertaken by RNSs, they are less known and therefore less visible. The identified lack of role definition prevents the development of a leadership role for the RNS role as discussed by Crooks (2004). Professional leadership can be used to promote a role, as involvement with professional organisations keeps the role visible for other health professionals (Hamric et al., 2009). Involvement in a professional organisation would also give the health professional valuable learning in regards to clinical leadership (Hamric et al., 2009). While there is not a specific organisation providing professional leadership and support for RNS in New Zealand, the New Zealand Rural General Practice Network and New Zealand College of Primary Health Care Nurses, both have or have had RNSs in leadership roles (New Zealand Rural General Practice Network, n.d; New Zealand Nurses Organisation, 2014).

5.6.1 Chapter summary

The lack of consistent definition of the term ‘rural’ combined with the confusion surrounding the nurse specialist role makes it difficult to describe the core descriptors of the RNS. The findings of this study demonstrates that the majority of the care provided by the RNS is direct patient care, at an advanced level of practice with a wide range of presentations, creating a unique specialist generalist aspect to the RNS role. The core components of the RNS role may vary locally as the RNS responds to community needs, however, there are a number of consistencies in RNS practice. The RNS is mostly involved in direct patient care, which includes nurse-led clinics and autonomous after-hours work. In this role advanced assessment and diagnosis skills are used to treat patients and are sometimes combined with other roles such as allied health and administrative activities due to a lack of other professionals in the rural setting.

The RNS practices collaboratively with other members of the healthcare team, medical staff and the wider healthcare team. Nursing and medical staff have a long history of difficult relationships (Hamric et al., 2009). Lack of role clarity affects the ability of the RNS to communicate effectively with the wider health team as others may not have clear expectations of the RNS. Poor communication inhibits

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effective collaboration, which then prevents efficient healthcare in rural areas (Ross, 2001; World Health Organisation, 2010). RNS skills are underpinned by an advanced knowledge base which are necessary due to the demands of the rural health population and the isolation within which the RNS practices. Completing postgraduate study can be difficult due to isolation, travel and access to appropriate course content. However, postgraduate study is well utilised, and recognized as essential by the RNS. Further education is a requirement for the RNS, to enable them to meet the diverse needs of a rural population. The RNSs felt that engaging in postgraduate education to gain the NP qualification would enhance services to the community by giving participants the ability to prescribe medication.

There is a noticeable lack of professional leadership in the position descriptions and the RNSs descriptions of their own practice, possibly relating to the lack of role clarity and poor role recognition which participants found frustrating. Role recognition is important in the unique rural context. Role recognition will also provide acknowledgment of the further education gained by the RNS in order to use advanced assessment skills to provide a broad range of treatments in clinics and on-call settings. Role recognition would distinguish the role of the RNS from other health professionals and would provide communities with clear expectations of the RNS. Particpants within this study felt that gaining NP qualifications may provide an increased role recognition.

In the next chapter, Conclusions, the thesis will be summarized and recommendations that have arisen from this discussion will be presented.

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6. Conclusion

6.1 Introduction

In this chapter, the main findings of this study will be summarized. This study was undertaken in response to the question “What are the core descriptors of the Rural Nurse Specialist role in New Zealand?” The rural population requires the Rural Nurse Specialist to deliver advanced nursing practice across a wide range of presentations (specialist generalist) which requires appropriate and accessible postgraduate and continuing education and collaborative practice. Part of the RNS role is to provide facilitation of movement within the health system which requires role clarity in order to support collaborative practice. The RNS also provides leadership for their communities in health service design and delivery which requires appropriate and accessible postgraduate and continuing education.

RNSs provide independent patient care including assessment, diagnosis and treatment. In order to provide independent patient care it is important that RNSs have postgraduate education. RNSs perceive the NP role to be better recognised than the RNS role, and all were considering furthering their advanced practice by becoming a NP.

6.2 Summary of findings

6.2.1 Direct patient care provision

Direct patient care was considered the priority in their Rural Nurse Specialist practice for all participants. Four of the five Rural Nurse Specialist position descriptions from the DHBs also placed importance on direct patient care. Activities in this category included patient assessment, diagnosis and treatment of patient presentations across the lifespan. Participants believed they were specialist generalists as they managed a wide range of patient presentations using advanced nursing skills. The term specialist generalist also incorporated flexibility to extend their practice to provide some administrative and allied health support services to the rural community as required.

6.2.2 Postgraduate education engagement

Treatment or referral to another health professional was made based on clinical judgement skills developed through postgraduate study. All participants felt that their advanced nursing skills were not recognized by other health professionals, patients or health managers, due to a lack of role recognition for the RNS role.

6.2.3 RNS to NP role

All participants aspired to the NP role, believing that this role would provide stronger role recognition. The RNS role is difficult to define, as neither rural, nor rural nurse or rural nurse specialist are consistently defined in the literature. Poor role recognition led to lack of financial remuneration, difficulty collaborating with other health professionals and poor access to appropriate education. However, despite participants perceiving the NP role as beneficial due to the ability to prescribe, there are still barriers to gaining NP

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qualifications. Barriers include difficulties accessing postgraduate education due to isolation, and the lack of funding for education (Maw, 2008).

6.2.4 Conceptual model of findings

The core components of the Rural Nurse Specialist Role in New Zealand are conceptualized in the flowchart as seen in Figure 2. Direct patient care is provided independently and the types of activities carried out in this aspect of the role are labelled in Box 1. Overall direct patient care is performed using the advanced assessment treatment and diagnostic skills which form part of the RNS’s advanced nursing practice.

Ongoing postgraduate education is required to gain assessment, treatment and diagnostic skills, which allow the RNS to provide independent patient care. Ongoing postgraduate education also contributes to advanced nursing practice by providing skills, as well as opportunities for professional development. The RNS may not be viewed by funding providers or education providers as having a requirement for education due to a lack of role recognition.

Poor role recognition affects the RNSs ability to provide patient care, as collaboration is a key part of the RNS role. Therefore, as poor role recognition creates a barrier to effective collaboration, patient care is then impacted. A lack of recognition of the RNS role led participants to the belief that the NP role may provide more role recognition enhancing collaboration and patient care.

Figure 2: The core components of the Rural Nurse Specialist role in New Zealand

1. Independent patient care- Clinics- On-call work- Specialist-General Role- Collaboration with otherhealth professionals

2. Ongoing postgraduate education

- Priority to maintainpostgraduate education

- Professional development

3. Gaining NP quali�cation- Prescription rights- Role recognition

Independentassessment,treatment

& diagnosis

AdvancedNursingPractice

Poor RoleRecognition

} =

To enhance collaboration Prevented by pooraccess to

Creates barriersto access

Creates barriers tocollaboration

To enhance

Gain andmaintain skills

To maintain

Creates apercieved need for

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6.3 Use of method

The descriptive exploratory method was used to provide a description of the core components of the RNS role. This method provided the researcher with the ability to analyse both document analysis and data from the interviews for use in the research. Data collected in this study were categorised using the Modified Strong Model of Advanced Practice (Gardner et al., 2007) as a framework. The Modified Strong Model of Advanced Practice (Gardner et al., 2007) provided five categories which are used to describe advanced nursing practice (Gardner et al., 2007). The categories provided include direct patient care, support of systems, education, research and professional leadership (Gardner et al., 2007). This framework was initially used as a guideline during data content analysis in Phase One. During Phase Two after the initial coding and analysis the data were placed into the framework provided by the Modified Strong Model of Advanced Practice (Gardner et al., 2007). Utilising this framework provided overall unity between the data from Phase One and Two as the data were placed into the same categories, enabling clarity from the findings. During the discussion this framework provided a good basis for information from both Phase One and Two to be discussed together within the same category.

6.4 Limitations

Limitations are identified within research to demonstrate the trustworthiness of the research and allow the reader to decide if the research is transferable (Speziale & Carpenter, 2003). This research was conducted in New Zealand. In Phase One the sample was collected from five DHBs, which potentially excludes areas where the RNS is employed by a non-DHB organisation. While collecting position descriptions during Phase One it became evident that many of the organisations did not have a clear understanding of the title RNS. Participating organisations often requested clarification of the role, which created difficulties in obtaining postition descriptions. While a sample population from both the North and South Islands created good transferability within New Zealand, findings from New Zealand may not be applicable to other countries where there may be different requirements of the RNS from both the community and their own regulatory body. During Phase Two data saturation was reached after interviewing four participants. This number is low, however the rich data from Phase Two tells a story which may be considered the lived experience of the current core descriptors of the RNS role. From the findings within Phase One and Phase Two the following recommendations are made by the researcher.

6.5 Recommendations for nursing practice

6.5.1 Interprofessional education

Health professionals need more education about the nurse specialist role, in order to improve role recognition and more interprofessional education needs to be provided at undergraduate and postgraduate levels. This could include the RNS travelling to regional hospitals to meet other health professionals they consult with regularly or use communication technology to attend education sessions.

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6.5.2 Expanded role

All participants felt that gaining NP qualification would enhance their practice through prescription rights. Employers and RNSs may want to consider utilizing the expanded scope of practice in order to give RNS the ability to prescribe within set parameters. The Nursing Council of New Zealand (2013) is currently developing a framework to allow nurse prescribing in specialist areas which is well supported by organisations within the rural sector.

6.5.3 Professional leadership

There was a lack of discussion around professional leadership and research in Phase One and Phase Two of this study. If the RNSs were more active within professional organisations, they would potentially be more visible to other health professionals. This could assist in having the role recognised as well as alleviating some aspects of professional isolation. It is recommended that RNSs are encouraged by employers and professional organisations to participate in professional leadership. Professional organisations may want to consider a sector for RNSs within their organisation and employers can assist in making conferences and meetings accessible by providing leave as able.

6.6 Recommendations for nursing education

6.6.1 Barriers to education

Postgraduate education for RNS is important and strategies to gain access to education need to be actioned urgently. While the use of communicative technology such as online videoconferencing to provide postgraduate education is used at present, methods to reach those with less broadband access needs to be considered.

6.6.2 Career pathway

The RNS role needs to be promoted in order to recruit and retain rural nurses. Undergraduate nursing student placements in rural settings are required. The voluntary bonding scheme is currently used within hospitals which have difficulty recruiting and retaining staff (Ministry of Health, 2015). This scheme is facilitated by Health Workforce New Zealand and participants receive annual payments as an incentive to be bonded to work in an area for a certain amount of time (Ministry of Health, 2015). This concept could be used for experienced nurses completing postgraduate study appropriate for the RNS role.

6.7 Recommendations for nursing research

6.7.1 RNS vs NP role

Further research to examine the role of the RNS within the New Zealand health system, practicing collaboratively with other health professionals such as NPs, GPs and practice nurses would assist in role clarity.

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6.7.2 Prescribing rights

Further research could also be undertaken into prescribing rights for the RNS and how this will affect accessibility to health care.

6.7.3 Rural health outcomes

Further research into the impact of the RNS on rural health outcomes and their role in promoting accessible healthcare within the rural setting needs to be completed. Gaps remain in identifying the health needs of the rural community. Identifying these health needs will influence the core components of the RNS and the impact of the care provided by the RNS.

6.7.4 Community perception

Research into the patient experience of the RNS role would be able to inform workforce planning of the effectiveness of the RNS role. The communities perception of the RNS and if they consider a RNS an effective health provider, needs investigation.

6.8 Chapter summary

In conclusion, in this study a descriptive exploratory approach was used to investigate the core descriptors of the RNS role within New Zealand. Useful descriptors of advanced nursing practice in independent patient care utilising advanced assessment, diagnosis and treatment were found. Engaging in postgraduate education is a priority and a current lack of professional leadership were also findings of this study. RNSs are flexible and may also integrate core skills from other health professionals who are less accessible to the rural population. The RNS role is expanding to assist with the shortage of GPs within the rural area. Because of this expansion, the NP may be considered more suitable for the role than the RNS. However, there are barriers to providing NP training, therefore expansion of the RNS role into providing medication prescriptions may need to be considered. Other recommendations include an increase in professional leadership in order to increase the visibility of the RNS, further interprofessional education to enhance collaboration and innovative techniques to improve access to postgraduate education.

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7. ReferencesACC. (2008, Feb). Primary response in medical emergencies (PRIME) - Operating Guidelines. Retrieved

April 2015, from Primary response in medical emergencies (PRIME): hhttp://www.acc.co.nz/for-providers/ contracts-and-performance/all-contracts/PRD_CTRB112774

Adair, V., Coster, H., & Adair, A. (2013). Report on a study of an innovative model of rural health care: the Dargaville experience. Cambridge, New Zealand: New Zealand Institute of Rural Health.

American Nursing Association. (2015). John Hopkins nursing evidence based practice. Retrieved April 2014, from Nursing World: http://www.nursingworld.org/Research-toolkit/Johns-Hopkins-Nursing-Evidence- Based-Practice

Armstrong, S. (2008). Exploring the nursing reality of the sole on-call primary health care rural nurse interface with secondary care doctors. In J. Ross (Ed.), Rural nursing: aspects of practice (pp. 225-246). Dunedin, New Zealand: Rural Health Opportunities.

Australian College of Emergency Nursing. (2015). Courses. Retrieved May 2015, from Australian College of Emergency Nursing .

Australian Health Practitioner Regulation Agency. (2010). Registration standard for endorsement for scheduled medicines registered nurses (rural and isolated practice). Retrieved April 2015, from Nursing and midwifery board of Australia: http://www.nursingmidwiferyboard.gov.au/Registration-and-Endorsement/Endorsements-Notations/Registration-standard-for-endorsement.aspx

Barber, M. (2007). Exploring the complex nature of rural nursing. Kai Tiaki, 13(22), 22.

Bonney, A., Knight-Bilington, P., Mullan, J., Moscova, M., Barnett, S., Iverson, D., . . . Hespe, C. (2015). The telehealth skills, training and implementation project: an evaluation protocol. Journal of Medical Internet Research, Research Protocols, 4(1). doi:10.2196/resprot.3613

Bonsall, K., & Cheater, F. (2008). What is the impact of advanced primary care nursing roles on patients, nurses and their colleagues? A literature review. International Journal of Nursing Studies, 45, 1090-1102. doi:10.1016/j.ijnurstu.2007.07.013

Bourke, L., Humphreys, J., Wakerman, J., & Taylor, J. (2012). Understanding rural and remote health: a framework for analysis in Australia. Health & Place, 496-503. doi:10.1016/j.healthplace.2012.02.009

Brown, J., Hart, A. M., & Burman, M. (2009). A day in the life of rural advanced practice nurses. The Journal for Nurse Practitioners, 5(2), 108-114.

Brown, L., Eckhoff, M., Lindley, G., & Jones, S. (2002). A handbook for new and locum rural nurses. Christchurch, New Zealand: Centre for Rural Health.

Bushy, A. (2002). International perspectives on rural nursing: Australia, Canada, USA. Australian Journal of Rural Health, 10, 101-104.

70

Canadian Nurses Association. (2015). Becoming an rn. Retrieved May 2015, from Canadian Nurses Association: http://www.cna-aiic.ca/en/becoming-an-rn

Castledine, G. (2004) New nursing roles: Deciding the future for Scotland. Generalist and specialist nurses complementary or conflicting roles. Retrieved April 2015 from http://www.gov.scot/Publications/2004/04/19201/35586

Coleman, D., & Lynch, U. (2006). Professional isolation and the role of clinical supervision in rural and remote communities. Journal of Community Nursing, 20(3), 35-37. Retrieved April 2015 from http://www.gov.scot/ Publications/2004/04/19201/35586

College of Emergency Nurses New Zealand. (2014). Courses run by CEENZ. Retrieved May 2015, from New Zealand Nurses Organisation.

Crooks, K. (2004). Is rural nursing a specialty? Online Journal of Rural Nursing and Health Care, 4(1) 1-3.

Dillon, D. (2008). Rural contexts - islands. In J. Ross, Rural nursing: Aspects of care (pp. 19-29). Dunedin, New Zealand: Rural Health Opportunities.

Donald, F., Bryant-Lukosis, D., Martin-Misener, R., Kaaslainen, S., Kilpatrick, K., Carter, N., . . . DiCenso, A. (2010). Clinical nurse specialists and nurse practitioners: Title confusion and lack of role clarity. Advanced Practice Nursing, 23, 189-210.

Duffield, C., Gardner G., Chang, A., & Catling-Paull, C. (2009). Advanced nursing practice: A global perspective. Collegian, 16, 55-62. doi:10.1016/j.colegn.2009.02.001

Elo, S., & Kyngäs, H. (2007). The qualitative content analysis process. Journal of Advanced Nursing, 62(1), 107-115. doi:10.1111/j.1365-2648.2007.04569.x

Elo, S., Kääriäinen, M., Kanste, O., Pölkki, T., Utriainen, K., & Kyngäs, H. (2014). Qualitative content analysis: a focus on trustworthiness. Sage Open, 4, 1-10. doi:10.1177/2158244014522633

Farmer, J., Prior, M., & Taylor, J. (2012). A theory of how rural health services contribute to community sustainability. Social Science & Medicine, 75, 1903-1911. doi:10.1016/j.socscimed.2012.06.035

Fitzgerald, R. (2008). Rural nurse specialists: Clinical practice and the politics of care. Medical Anthropology, 27(3), 277-282.doi: 10.1080/01459740802222757

Fitzwater, A. (2008). The impact of tourism on a rural nursing practice. In J. Ross (Ed.), Rural nursing aspects of practice (pp. 136-143). Dunedin, New Zealand: Rural Health Opportunities.

Fitzwater, A. (2009). Nurse Practitioners a healthy future for New Zealand. Retrieved May 2015, from Ministry of Health: https://www.health.govt.nz/system/files/documents/publications/nurse-practitioners-a-healthy- future-for-nz.pdf

Flick, U. (2009). An introduction to qualitative research (4th ed.). Hamburg, Germany: Sage.

Gardner G., Chang, A. M., Duffield, C., & Doubrovsky, A. (2013). Delineating the practice profile of advanced practice nursing: A cross-sectional survey using the modified strong model of advanced practice. Journal of Advanced Nursing, 69(9), 1931-1942.

71

Gardner, G., Chang, A., & Duffield, C. (2007). Making nursing work: Breaking through the role confusion of advanced practice nursing. Journal of Advanced Nursing, 57(4), 382-391. doi:10.1111/j.1365- 2648.2006.04114.x

Goodyear-Smith, F., & Janes, R. (2008). New Zealand rural primary health care workforce in 2005: More than just a doctor shortage. Australian Journal of Rural Health., 16(1),40-46doi:10.1111/j.1440-1548.2007.00949.x

Granehiem, U., & Lundman, B. (2004). Qualitative content analysis in nursing research: Concepts, procedures and measures to achieve trustworthiness. Nurse Education Today, 24(2) 105-112. doi:10.1016/j.nedt.2003.10.001

Hamric, A., Spross, J., & Hanson, C. (2009). Advanced practice nursing: An integrative approach (4th ed.). St Louis: Saunders Elsevier.

Harding, T., & Whitehead, D. (2013). Analysing data in qualitative research. In Schneider, Z., Whitehead, D., Lo-Biondo-Wood, G., & Haber, J. Nursing and midwifery research: Methods and appraisal for evidence based practice (4th ed.). Sydney, Australia: Elesiver.

Hauenstein, E., Glick, D., Kane, C., Kulbok, P., Barbero, E., & Cox, K. (2014). A model to develop advanced practice nurses for rural settings. Journal of Professional Nursing, 1-29. doi:10.1016/j. profnurs.2014.04.001

Haydon-Clarke, J., McKinlay, E., & & Moriarty, H. (2011). Health needs assessment and nurse-led health care services of a small island community: Methodology and results of a pilot study of the health status of residents of Stewart Island, New Zealand. Online Journal of Rural Nursing and Health Care, 11(1), 80-97.

Health and Disability Ethics Committee. (2013). Does your research require HDEC review. Retrieved June 2014, from Health and Disability Ethics Committee: https://ethics.health.govt.nz/applying-review

Hegney, D., McCarthy, A., & Pearson, A. (1999). Effects of size of health service on scope of rural nursing practice. Collegian, 6(4), 21-4

Higgens, A. (2008). Collaboration to improve health provision: advancing nursing practice and interdisciplinary relationships. In J. Ross (Ed.), Rural nursing: Aspects of practice (pp. 215-224). Dunedin, New Zealand: Rural Health Opportunities.

Holloway, I. (2008). A-Z of qualitative research in healthcare (2nd ed.). Singapore: Blackwell Publishing.

Holloway, K. (2009, June). Glossary of terms. Retrieved April 2015, from College of Nurses: http://www.nurse.org. nz/national-nursing-organisation-nno.html

Holloway, K. (2012). The New Zealand nurse specialist framework: Clarifying the contribution of the nurse specialist. Policy, Politics & Nursing Practice, 1-7. doi:10.1177/1527154412459083

72

Hounsgaard, L., Jensen, A., Wilche, J., & Domer, I. (2013). The nature of nursing practice in rural and remote areas of Greenland. International Journal of Circumpolar Health, 368-365. doi:10.3402/ijch.v72i0.20964

Howie, L. (2008). Contextualised nursing practice. In J. Ross (Ed.), Rural nursing; Aspects of care (pp. 37-49). Dunedin, New Zealand: Rural Health Opportunities.

Hunsberger, M., Baumann, A., Blythe, J., & Crea, M. (2009). Sustaining the rural workforce; Nursing perspectives on worklife challenges. The Journal of Rural Health, 17-25.

International Council of Nurses. (2009). ICN framework of competencies for the nurse specialist. Geneva, Switzerland: International Council of Nurses.

Jamieson, I. (2008). The mobile operating theatre project. In J. Ross (Ed.), Rural nursing aspects of practice (pp. 81- 98). Dunedin, New Zealand: Rural Health Opportunities.

Janes, R. (2006). New Zealand Rural Primary Care After-hours Survey: 3. Finding workable solutions to providing rural after-hours care. Wellington: NZ Rural General Practice Network. Retrieved April 2015, from http://www.rgpn.org.nz/index.htm

Jukkala, A. M., Henly, S., & Lindeke, L. (2008). Rural perception of continuing professional education. The Journal of Continuing Education in Nursing , 39(12), 555-563. Retrieved March 2015

Kenny, A., & Allenby, A. (2013). Barriers to nurses providing psychosocial care in Australian rural context. Nursing and health sciences, 15, 194-200. doi:10.1111/nhs.12014

Krippendorf, K. (1989). Content analysis. International encyclopedia of communications, 1. (E. Barnouw, W. Schramm, G. Gerbener, T. Worth, & L. Gross, Eds.) New York: Oxford University Press. Retrieved April 2015, from http://repository.upenn.edu/asc_papers

Kulig, J., Kilpatrick, K., Moffitt, P., & Zimmer, L. (2013). Rural and remote nursing practice: An updated documentary analysis. University of Lethbridge. Lethbridge, Canada.

Lancaster, G. (2011). Postgraduate diploma [advanced nursing] primary health care-rural. Survey results. New Zealand Institute of Rural Health. Retrieved November 2014, from http://www.nzirh.org.nz/resources- publications/

Lee, H., & Winters, C. (2004). Testing rural nursing theory: Perceptions and needs of service providers. Online Journal of Rural Nursing and Healthcare, 4(1), 51-63.

Litchfield, M., & Ross, J. (2000). The role of rural nurses national survey. Christchurch, New Zealand: Centre for Rural Health.

Long, K., Scharff, J., & Weinert, C. (1997). Advanced education for the rural nurse generalist. Journal of Nursing Education, 36(2), 91-94.

Lopez, V., & Whitehead, D. (2013). Sampling data and data collection in qualitative research. In Schneider, Z., Whitehead, D., Lo-Biondo-Wood, G., & Haber, J. Nursing and midwifery research: Methods and apprasial for evidence based practice (4th ed.). Sydney, Australia: Elsevier.

73

Lowe, G., Plummer, V., O’Brien, A. P., & Boyd, L. (2012). Time to clarify - the value of advanced practice nursing roles in health care. Journal of Advanced Nursing, 68(3), 677-685. doi:10.11111/j.1365-2648.2011.05790.x

MacLeod, M., Browne, A. J., & Leipert, B. (1998). Issues for nurses in rural and remote Canada. Australian Journal of Rural Health, 6, 72-78.

MacLeod, M., Kulig, J., Stewart, N., Pitblado, J. R., Banks, K., D’Arcy, C., . . . Bentham, D. (2004, September). The nature of nursing practice in rural and remote Canada. Retrieved May 2014, from Canadian Health Services Research Foundation: www.chrsf.ca

Maw, H. (2008). The challenge of developing primary health care nurse practitioner roles. In J. Ross (Ed.), Rural nursing aspects of care (pp. 201 - 214). Dunedin, New Zealand: Rural Health Opportunities.

Mbemba, G., Gagnon, M.-P., Pare, G., & Cote, J. (2013). Interventions for supporting nurse retention in rural and remote areas: An umbrella review. Human resources for health, 11(44), 1-9. Retrieved from http://www. human-resources-health.com/content/11/1/44

Mills, J., Birks, M., & Hegney, D. (2010a). The status of rural nursing in Australia: 12 years on. Collegian, 17(1), 30-37.

Mills, J., Francis, K., Birks, M., Coyle, M., Henderson, S., & & Jones, J. (2010b). Registered nurses as members of interprofessional primary health care teams in remote or isolated areas of Queensland: Collaboration, communication and partnerships in practice. Journal of Interprofessional Care, 24(5), 587-596.

Ministry of Health (2012a) Our history and current position. Retrieved June 2015 from Ministry of Health http://www.health.govt.nz/about-ministry/ministry-business-units/maori-health-business-unit/our-history-and-current-position

Ministry of Health. (2012b). Standing order guidelines. Wellington, New Zealand.

Ministry of Health. (2014, February 21). PRIME services. Retrieved March 21, 2015, from Ministry of Health: http://www.health.govt.nz/new-zealand-health-system/key-health-sector-organisations-and-people/naso-national-ambulance-sector-office/emergency-ambulance-services-eas/prime-services

Ministry of Health. (2015). Voluntary bonding scheme. Retrieved May 2015, from Ministry of Health: http://www. health.govt.nz/our-work/health-workforce/voluntary-bonding-scheme

Moffatt, J., & Eley, D. (2010). The reported benefits of telehealth for rural Australians. Australian Health Review, 34, 276-281. doi:10.1071/AH09794

Moorfield. (2015). Te Aka Online Māori Dictionary. Retrieved March 2015, from Māori Dictionary: http://www. maoridictionary.co.nz/search?idiom=&phrase=&proverb=&loan=&keywords=maori

National Council of State Boards of Nursing. (2015). Boards and regulation. Retrieved May 2015, from National Council of State Boards of Nursing: https://www.ncsbn.org/boards.htm

74

National Health Committee. (2010). Rural health challenges of distance opportunities for innovation. Retrieved 2014, from http://www.nhc.health.govt.nz

National Nursing Centers Consortium. (2014). The future of nursing across the globe event summary and white paper. Philadelphia: National Nursing Centres Consortium. Retrieved May 2015, from http://www.nncc. us/images_specific/pdf/GlobalAPNSymposiumFINAL.pdf

National Nursing Organisation. (2014, April). Report from the National Nursing Organisations to Health Workforce New Zealand. Retrieved April 2015, from College of Nurses: http://www.nurse.org.nz/national-nursing- organisation-nno.html

New Zealand Institute of Rural Health . (2011). The rural health indicators project. Report 2 comparison of five district health boards. Retrieved from New Zealand Institute of Rural Health: http://www.nzirh.org.nz/wp-content/uploads/2012/10/Report-2-Comparison-of-Five-District-Health-Boards-Executive- Summary-only3.pdf

New Zealand Institute of Rural Health. (2008, June). Discussion paper for moving forward in rural health. New Zealand. Retrieved November 2014, from http://www.nzirh.org.nz/wp-content/uploads/2011/12/ DPweb.pdf

New Zealand Institute of Rural Health. (2008, June). Moving forward in rural health. Retrieved 2014, from New Zealand Institute of Rural Health: http://www.nzirh.org.nz/resources-publications/

New Zealand Institute of Rural Health. (2011). The rural health indicators project-report two comparison of five District Health Boards. Retrieved June 2014, from New Zealand Institute of Rural Health: http://www. nzirh.org.nz/rural-health-indicators/

New Zealand Nurses Organisation. (2014). NZCPHCN executive committee. Retrieved May 2015, from New Zealand College of Primary Health Care Nurses: http://www.nzno.org.nz/groups/colleges/college_of_ primary_health_care_nurses/executive

New Zealand Rural General Practice Network. (n.d). About Us. Retrieved May 2015, from New Zealand Rural General Practice Network: http://www.rgpn.org.nz/About-Us.aspx

Nexøe, J., Skifte, E., Niclasen, B., & Munck, A. (2012). Audit report from Greenland on nurses’ tasks and perceived competency. Rural and Remote Health, 1-6. Retrieved May 2014, from http://www.rrh.org.au

Nursing and Midwifery Board of Australia. (2015, March). Registration as a Nurse or Midwife. Retrieved May 2015, from Nursing and Midwifery Board of Australia: http://www.nursingmidwiferyboard.gov.au/ Codes-Guidelines-Statements/FAQ/Registration-nurse-or-midwife.aspx

Nursing Council of New Zealand. (2008, September). Competencies for the nurse practitioner scope of practice. Retrieved May 2015, from Nursing Council of New Zealand: http://www.nursingcouncil.org.nz/

Nursing Council of New Zealand. (2010). Registered Nurse Scope of Practice. Retrieved April 2015, from Nursing Council of New Zealand: http://www.nursingcouncil.org.nz/Nurses/Register-as-a-nurse

75

Nursing Council of New Zealand. (2011, January). Guideline: Expanded practice for registered nurses. Retrieved May 2014, from Nursing Council of New Zealand: www.nursingcouncil.org.nz

Nursing Council of New Zealand (2012). Guidelines: Professional boundaries. Retrieved June 2015 from http://www.nursingcouncil.org.nz/Publications/Standards-and-guidelines-for-nurses

Nursing Council of New Zealand (2013). Analysis of submissions concerning registered nurse prescribing. Retrieved June 2015 from Nursing Council of New Zealand http://www.nursingcouncil.org.nz/Publications/Consultation-documents/Analysis-of-submissions-concerning-registered-nurse-prescribing

Nursing Council of New Zealand. (2013). The New Zealand nursing workforce. Retrieved May 2015, from Nursing Council of New Zealand: http://www.nursingcouncil.org.nz/Publications/Reports

Polit, D., & Beck, C. (2004). Nursing research: Principles and methods. United States of America: Lippincott Williams & Wilkins.

Pope, C. & Mays, N. (2006). Qualitative research in healthcare (3rd ed.). Oxford, United Kingdom: Blackwell Publishing Ltd.

Prior, M., Farmer, J., Godden, D., & Taylor, J. (2010). More than health: the added value of health services in remote Scotland and Australia. Health & Place, 16, 1136-1144. doi:10.1016/j.healthplace.2010.07.005

Revell, S. (2013). What are the information needs of patients receiving procedural sedation in the Emergency Department. A descriptive exploratory study. (Unpublished Master’s Thesis). Napier, New Zealand: Eastern Institute of Technology.

Roberts, D., Hibberd, P., Lewis, C. A., & Turley, J. (2014). The unique contribution of community clinical nurse specialists in rural Wales. British Journal of Community Nursing, 19(12), 601-607.

Roberts, J. (2009). Characteristics of the clinical nurse specialist role in New Zealand. (Master’s Thesis). Napier, New Zealand: Eastern Institute of Technology.

Roberts, J., Floyd, S., & Thompson, S. (2011). The clinical nurse specialist in New Zealand: how is the role defined. Nursing Praxis in New Zealand, 27(2), 24-34.

Roberts, K., & Taylor, B. (2002). Nursing research processes an Australian perspective (2nd ed.). Singapore: Thomson.

Robertson, A. (2008). Rural women and maternity services. In Rural nursing aspects of practice (pp. 179-197). Dunedin, New Zealand: Rural Health Opportunities.

Ross, J. (1999). Development of the advanced role of rural nurses in New Zealand. Australian Journal of Rural Health, 253-257.

Ross, J. (2001). Dimensions of team effectiveness in rural health. Christchurch, New Zealand: Centre for Rural Health.

Ross, J. (2008) Rural nursing aspects of practice. Dunedin, New Zealand: Rural Health Opportunities.

76

Sandelowski, M. (2010). What’s in a name? Qualitative description revisited. Research in Nursing and Health, 33, 77-84. doi:10.1002/nur.20362

Sedgwick, M., Grigg, L., & Dersch, S. (2014). Deepening the quality of clinical reasoning and decision making in rural hospital nursing practice. Rural and Remote Health, 14(2858), 1-12. Retrieved December 2014, from http://www.rrh.org.au

Sheer, B., & Wong, F. (2008). The development of advanced nursing practice globally. Journal of Nursing Scholarship, 40(3), 204-211.

Sommerfeldt, S. (2013). Articulating nursing in an interprofessional world. Nurse Education in Practice, 13, 519- 523. doi:10.1016/j.nepr.2013.02.014

Speziale, H., & Carpenter, D. (2003). Qualitative research in nursing (3rd ed.). United States of America: Lippincott Williams & Wilkins.

St John. (2015). The PRIME Programme. Retrieved March 2015, from St John: http://prime.stjohn.org.nz/about/ default.aspx

Stasa, H., Cashin, A., Buckley, T., & Donoghue, J. (2014). Advancing advanced practice-clarifying the conceptual confusion. Nurse Education Today, 356-361. doi:10.1016/j.nedt.2013.07.012

Statistics New Zealand. (2012). Defining an urban and rural New Zealand. Retrieved May 2015, from Statistics New Zealand: http://www.stats.govt.nz/browse_for_stats/Maps_and_geography/Geographic-areas/ urban-rural-profile.aspx

Stemler, S. (2001). An overview of content analysis. Practical Assessment Research & Evaluation, 7(17). Retrieved April 21, 2015, from http://PAREonline.net/getvn.asp?v=7&n=17

Tolich, M., & Davidson, C. (2011). An introduction to research methods: Getting started. Malaysia: Pearson.

Vaismoradi, M., Turunen, H., & Bondas, T. (2013). Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nursing and Health Sciences, 15, 398-405. doi:10.1111/nhs.12048

Whitehead, D. (2013). Common qualitative methods. In Schenider, Z., Whitehead, D., Lo-Biondo-Wood, G., & Haber, J. Nursing and midwifery research: Methods and appraisal for evidence based practice (4th ed.). Australia: Elsevier.

Wilkinson, J. (2015). Nurses’ reported use of standing orders in primary health care setting. Journal of Primary Health Care, 7(1), 34-41.

Wong, S., & Regan, S. (2009). Patient perspectives on primary health care in rural communities: Effects of geography on access, continuity and efficiency. Rural and Remote Health, 9(1142), 1-11. Retrieved from www.rrh.org.au

World Health Organisation. (2010). Framework for action on interprofessional education and collaborative practice. Retrieved May 2015, from World Health Organisation: http://whqlibdoc.who.int/hq/2010/ WHO_HRH_HPN_10.3_eng.pdf?ua=1

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Appendix 1. Email request to human resources26.09.2014

To whom it may concern

My name is Jennie Bell and I am undertaking research as a requirement for the Master of Nursing course at the Eastern Institute of Technology (EIT). One of the purposes of this research is to develop a set of core descriptors for the Rural Nurse Specialist role.

Phase One of the data collection involves an analysis of a range of different position descriptions for the Rural Nurse Specialist role (or similar) from around New Zealand.

I am writing to request a copy of the position description your DHB uses for a Rural Nurse Specialist or similar. This study has received ethical approval from the Eastern Institute of Technology, reference number 39/14.

If you have any concerns please contact me:

Jennie Bell, jenniebell2611@gmail.com or 0273034831 My supervisor is also available for queries:

Ruth Crawford, rcrawford@eit.ac.nz or 06 974 8000 Ext. 5401 Jennie Bell, MN student

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Appendix 2. Email from a DHB describing equivalent role to Rural Nurse Specialist

Hi Jennie

I have received your contact from HR. I am afraid we don’t have a title of “rural nurse specialist”. We have Clinical Nurse Specialist – Medical Outreach who are based at the DHB and travel out. We also have 7 Nurse Practitioner’s – rural nursing. They are self-employed or employed by the iwi providers in A, B and the very C. Our PHO’s have GP practice nurses who would be the closest thing to a specialist in rural nursing. Our A and B hospitals also are specialists in rural nursing but don’t have the title.

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Appendix 3. Informational flyerHello,

My name is Jennie Bell and I am currently conducting research through the Eastern Institute of Technology (EIT). The aim of this study is to identify core descriptors of the Rural Nurse Specialist role in New Zealand.

I would like to interview nurses practising in a rural/remote setting in New Zealand. The nurse may have the title Rural Nurse Specialist, or something similar.

Participation in the study will involve a 30-45 minute phone interview at a convenient time for the participant.

If you would like to know more, or are interested in participating in this study, please contact me by email jenniebell2611@gmail.com or phone/text 0273034831.

Thank you Jennie Bell MN Student

This research has been approved by the EIT Research, Ethics & Approval Committee on 11.09.2014, ref. no. 39/14

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Appendix 4. Newsletter request

Are you currently practising as a Rural Nurse Specialist (or similar) in New Zealand??

If the answer is yes, I would love to hear from you!!

My name is Jennie Bell and I am completing my Master of Nursing degree at the Eastern Institute of Technology (EIT). I am undertaking research into the core descriptors of the Rural Nurse Specialist role. The purpose of this study is to identify the core descriptors of the Rural Nurse Specialist role in New Zealand.

I am looking for participants for my study. If you are practising in a rural/remote area in a Rural Nurse Specialist Role (or similar, you may have a different job title), I would love to hear from you.

Participating in this study would involve a telephone conversation with me at a time of your choosing. The phone call may take between 30-45 minutes.

If you are interested in participating in this study or have any questions please email me at jenniebell2611@gmail.com, or phone/text me on cell phone 0273034831 for more information.

Thank you

Jennie Bell

MN Student

This study has been approved by the EIT Research Ethics & Approvals Committee on 11.09.2014, ref. no. 39/14.

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Appendix 5. Consent Form

CONSENT FORM

Project Title: Role descriptors of the Rural Nurse Specialist in New Zealand

Researcher: Jennie Bell

I have read and I understand the Information for Research Participants sheet dated 12/06/2014 for volunteers taking part in this study. I have had the opportunity to discuss this study and am satisfied with the answers I have been given.

I understand I am able to withdraw all of my information until 31/12/2014

I understand that taking part in this study is voluntary (my choice) and that I may withdraw from the testing at any time and this will in no way affect my employment.

I understand that my participation in this study is confidential and that no material which could identify me will be used in any reports on this study.

I have had time to consider whether to take part, and know who to contact if I have any questions about the study.

I agree to take part in this research

Yes No

I consent to my interview/activity being videotaped/audiotaped

I wish to receive a summary of the results

Signed: _______________________________________________

Name: ________________________________________________

Signature of Research Participant’s Support Person (if applicable)

_________________________________________________

Date: _____________________

Witness: _______________________________________________

I/We as researcher(s) undertake to maintain the confidentiality of information gather during the course of this research.

Signed_________________________________________________

Dated______________________

This study has been approved by the Research Ethics and Approval Committee on 11 September 2014 Reference 39/14

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Appendix 6. Information for participants

Information for Research Participants

Date: 12/06/14

Project Title: Core Descriptors of Rural Nurse Specialist in New Zealand

To: Rural Nurse Specialist

Researcher(s): Jennie Bell

Affiliation: Eastern Institute of Technology

Description of the research:

This research is being completed as a requirement of a Masters of Nursing. There is currently no overall consistent descriptor of the role of the Rural Nurse Specialist. This research aims to identify common themes throughout New Zealand that describe the role of the Rural Nurse Specialist in an attempt to understand the complex role. This will help future nurses in deciding a career path, identify skills required to be a Rural Nurse Specialist and help with future workforce planning. This will also help other health professionals understand your role as a Rural Nurse Specialist.

What will participating in the research involve?

You will be asked to participate in a phone interview taking 30-45 minutes at a time of your choosing. This will involve questions around your current role, your journey to becoming a Rural Nurse Specialist and what kind of tasks you undertake on a daily basis. I am interested in learning about any challenges you face in your practice. The questions address care delivery, qualifications and aspects of care. The information will be digitally recorded and transcribed. This will be stored on a secure laptop. After the interview a copy of the transcript will be sent for you to review and you are welcome to have a copy of the final thesis. If you are interested or have any questions please contact me with the following email address: jenniebell2611@gmail.com.

What are the benefits and possible risks to you in participating in this research?

Benefits: You are able to contribute to having the complex role of the Rural Nurse Specialist better understood.

This research is confidential and any identifying information will not be published in the final results.

Your rights:

You do not have to participate in this research if you do not wish to.

If you are a patient or under the care of students or staff from EIT, you can withdraw from the research at any time.

Once you have completed the research you have a two month period within which you can withdraw any information collected from you.

You are welcome to have a support person present (this may be a member of your family/whanau or other person of your choice)

You may request a summary of the completed research

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Confidentiality:

This information will be stored on a secure computer. All identifiable information about you will not be made available to any other people without your written consent. The raw data will be stored for 6 months following publication of the thesis.

If you wish to participate in this research, or if you wish to know more about it, please contact

Contact Person: Jennie Bell Email address:

jenniebell2611@gmail.comEIT School/Section: Master of NursingHome phone # 03 732 4405Mobile phone # 027 303 4831

Supervisor Name(s):

(if applicable)

Ruth Crawford

Kathy Holloway

Email address:

rcrawford@eit.ac.nzWork phone # 5401

Head of School/Manager: Rachael VernonWork phone # 5037 Email address

rvernon@eit.ac.nz

For any queries regarding ethical concerns, please contact:

Chair, Research Approvals Committee, EIT. Ph. 974 8000

This study has been approved by the Research Ethics and Approvals Committee on 11.09.2014 Reference 39/14

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Appendix 7. Interview scheduleHello (name) it is Jennie Bell here I am calling to interview you for my research into the Rural Nurse Specialist role in NZ, You know I am completing a Master’s degree through the Eastern Institute of Technology and part of this is conducting research into the core descriptors of the Rural Nurse Specialist Role. I have sent you the information sheet for participants and Consent form. Do you have any questions about the study or the interview process? Just a reminder to return the signed Consent form to me in the Stamped addressed envelope I sent you.

Is this still a good time to talk to you?

As part of my research I will be recording this interview. All the information you give me will be completely confidential and there will be no identifying data such as your name, location or employer in the study.

Are you happy with this process? Do you have any other questions about the research process? To start with I will ask you a little bit about yourself.

How many years/months have you been practising as a registered nurse? Please tell me about your journey to becoming a Rural Nurse Specialist?

What do you consider are essential aspects of your work as a Rural Nurse Specialist? What do you spend most of working day doing (in terms of time)?

So you have described xxxxx and xxxxx as essential aspects of your role. How do these aspects align with your current position description?

What are some of the more challenging aspects of your role? What administration duties are required as part of your role?

Please tell me about the relevance of health, safety and quality audits in your practice as Rural Nurse Specialist.

I notice in Rural Nurse Specialist job descriptions that I have been reading, there is an emphasis on RNS caring for themselves. Please tell me about this aspect of your role.

Have you previously completed or are you presently undertaking postgraduate study? If so, what is the qualification you are working towards?

Tell me about the relevance/importance of post graduate study to your current nursing position?

Is there anything else regarding the rural nurse specialist role in New Zealand that you would like to discuss with me?

Thank you for your participation in this study.

When I have completed all the interviews I will summarise my findings. I would appreciate you reviewing my findings and giving me feedback regarding my interpretations. Are you willing to review my findings to check accuracy?

Thank you Bye.

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Appendix 8. Transcriber confidentiality

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Appendix 9. Research approval

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Appendix 10. Health and Disability Ethics Committees flowchart

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Appendix 11. Ethics approval

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Appendix 12. Summary of findings

Summary of Findings

This is a brief summary of the preliminary findings of my Master of Nursing research into “What are the core components of a Rural Nurse Specialist (RNS) in New Zealand?” The study commenced in September, 2014. Prior to data collection in 2014, the study was approved by Research Ethics and Approval Committee on 11/09/2014 (Reference 39/14).

These findings are presented to the participants in this study. I would appreciate participants reviewing these findings, in particular focusing on these three questions:

Do the findings reflect your understanding of the core components of the rural nurse specialist role?

Is there anything more you think should be added to any of the domains or the additional themes?

Is there anything else that you think now on reflection that you would like to have added to your discussion with me?

This further feedback will add another layer to the data already collected.

The interview data were analysed using the Modified Strong Model of Advanced Practice (Gardner, Chang, & Duffield, 2007). This framework was developed in order to categorise activities completed by nurses in advanced practice (Gardner, et al., 2007).

The Modified Strong Model of Advanced Practice has five domains: direct comprehensive care, support of systems, education, research and professional leadership in publication (Gardner, et al., 2007).

Direct comprehensive care

Direct comprehensive care refers to activities carried out with patients (Gardner et al., 2007). This is the domain which linked to the majority of findings from the interviews. Participants discussed nurse-led clinics, on-call/acute work and the use of advanced assessment skills to assess, treat and diagnose patients. Treatments were often given using standing orders with referrals to other health centres when patients are unable to be treated by the nurse.

Support of systems

Support of systems are activities the nurse does to facilitate patient movement throughout the health system (Gardner et al., 2007). A large component of this domain was collaboration and the importance of working with the wider health team. This included ambulance staff, practice nurses, nurse practitioners, GPs, secondary care consultants and allied health staff. Three participants also carried out a large number of quality activities such as audits and health and safety checks.

Education

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Education is related to both the education received by the nurses and the education they provide to other staff and patients (Gardner et al., 2007). All participants had completed a clinical master’s degree. All participants felt that further study to complete the Nurse Practitioner (NP) programme would be beneficial. The reasons for completing this programme included the ability to prescribe and support the GP, and further to provide further services to the community. The NP role is already clearly recognised in New Zealand. Education was also completed informally through consultations and collegial relationships with GPs.

Patient education with the community, with the family and whānau and individual patients, was identified as a large component of the RNS role. The education provided varied according to the needs of the community, but emphasis was put on developing community relationships in order to provide relevant appropriate education.

Research

Research was the use of up-to-date research within practice and professional leadership and publications are related to the nurse’s involvement in professional organisations outside of their employer (Gardner et al., 2007).

Research was utilised to develop policies within the local practice and to remain up-to -date with best practice. Keeping up to date with research was seen as a priority due to the broad scope of practice and intermittent nature of presentations within this role. Keeping up-to-date with research was considered by participants as important to maintain safety within their nursing practice.

Professional development and leadership

Professional development and leadership refers to the involvement of the nurse in organisations outside of the employers’ organisation (Gardner, et al., 2007). Professional development and leadership can be stressful as reported by the participants. One participant talked about current active professional leadership outside her current organisation. This was helpful for providing support for herself and other RNS as well as giving educational opportunities.

Additional themes

Stress Management

Stress management is important due to the lack of privacy, exposure to trauma, and physical safety concerns within this role. Each participant had a different approach, but all had strategies to deal with stress. These strategies include counselling/clinical supervision, self-awareness of stress triggers, setting clear professional and personal boundaries, trying to go away for weekends and ensuring friends and family knew whereabouts or accompanied if appropriate.

Role recognition

This role was considered to be unrecognised by professional bodies and other health professionals. This led to lack of financial remuneration, general disillusionment with the system and difficulties interacting with other members of the team or locums. In general participants perceived that patients were satisfied with services provided by the participants.

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Thank you

I would like to thank the participants in this study. I welcome your feedback on these preliminary findings.

Jennie Bell

MN student, EIT

April 2015

Contact details: jenniebell2611@gmail.com Phone: 0273034831

You can also contact my Supervisors:

Dr Ruth Crawford, rcrawford@eit.ac.nz, 027 418 4968

Dr Kathryn Holloway, phone kathryn.holloway@whitiriea.ac.nz 027 477 4719