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The sub-category, characterising the nurse educator, depicts an intersect between the complexities of the role, its attributes and hidden aspects. Participant groups identified common role attributes such as support, facilitation of learning and development, communication and leadership. However, lack of knowledge of the nurse educator position resulted in difficulties in identifying the skill sets associated with the role.
Attributes ascribed to the role of teacher or educator in the literature (e.g. teaching, developing programs/sessions, assessment and evaluation, facilitator of learning) aligned to some of those appearing in this research. However, they do not explain additional attributes (e.g. clinical skills and credibility) and expectations (e.g. visibility and engagement in clinical work units), the multifaceted decision making required of nurse educators (e.g. the need to be adaptive and fit into the changing workplace context) and the increasing complexity of health care and related environments. It is broadly acknowledged that nurse educators must be able to negotiate and demonstrate flexibility if they are to be effective in helping and supporting nurse employees to demonstrate best practice standards (Billet, 2004; Challis, 2001; Gallagher, 2007; Lombard, 1990; Shanley, 2004). Yet, existing knowledge of the nurse educator role relates primarily to characteristics of the role, rather than to their contribution to the ongoing professional development needs of the nursing profession (Christiansen, 2011; Conway & Elwin, 2007; Manning & Neville, 2009; McSharry, et al., 2009; Ramage, 2004; Sayers & DiGiacomo, 2010; Shanley, 2004). The literature is simplistic in this sense, in reducing the complexity of the role to generalisations.
The issue above is arguably not constrained to the nurse educator. Other research has similarly found that nursing generally does not develop as a linear process but demands multifaceted decision making and ever-changing skill sets (Bartletts, 2005; Gallagher, 2007; Gristic & Jacono, 2006; Ramage, 2004; Shanley 2004). Nurse educator work is directly related to what nurses do and as such a nurse educator has a difficult and crucial role in assisting nurses to negotiate their health care environments (Bartletts, 2005; Conway & Elwin, 2007; Gallagher, 2007; Gristic& Jacono, 2006; Ramage, 2004; Shanley, 2004). It may be, therefore, that the complexity of the nurse educator role makes it difficult to articulate or measure.
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Indeed, and as noted, there was little participant acknowledgement of the complexities of the nurse educator position and particularly what constituted the hidden role. The hidden role referred to those functions the nurse educator undertakes primarily outside the clinical work unit. In other words, these were the elements that were not immediately visible from a clinical practice perspective but, nonetheless, were core to the educational role. Hidden roles were identified as program and session development, marking assessments, resource development, and confidential consultation support to colleagues, data entry and evaluations. Those in nurse educator positions and line managers who had formerly been nurse educators had insight into this area. The following data demonstrate understanding of nurse educator position requirements:
I think most people have a limited view and understanding of what the nurse educator does and they probably only see the public components of what an educator does at the points of time when they may be involved. Most staff don’t see what most staff do anyway, they don’t understand the role of the Nurse Unit Manager often, and they don’t understand my role or the Nurse Manager’s role. IDI LM (7). L 38.
Certainly when I go on holidays and somebody comes in and acts in my position, they just say I didn’t know that you did all this. I didn’t know that all this comes under your role. They don’t really have a concept they don’t see all the little bits and pieces and the things that you actually do so they don’t understand the role. They see me teaching but don’t see the stuff that you do behind it. IDI NE 1 (19). L 81 / 102.
Two factors underpinned this constructed reality. First and as noted above, a significant proportion of the nurse educator role is undertaken out of the clinical work unit and is thus unseen. Most nurse educators support multiple work units over the period of an eight or ten hour shift while nursing care is provided over a series of shifts and visibility of nurse educator activities may not align with the work hours of nurse clinicians. Second, the educator role may not be perceived as important as direct patient care. As evidenced by the following quote, there was a lack of appreciation of the complexity of the nurse educator role:
Everyone wants a piece of you. I didn’t realise the hours required or the diversity of the knowledge base I needed … I’m only just beginning to appreciate the full extent of the role and workload. I feel pulled from pillar to post … They can’t identify what we do but would be unhappy if we weren’t there. IDI NE 1 (12). L 133 / 239 / 253 / 258.
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One dimension of the educator role is ensuring continuity and coherency in this area of work. It has been found elsewhere (Donner et al., 2005; Neese, 2003; Siler & Kliener, 2001) that while experienced nurse educators are expected to precept and mentor new nurse educators, these activities are not routinely identified as part of workloads and in terms of outcomes. As such, it may be difficult for staff to sustain consistency. Line manager and nurse educator participants indicated that if neophyte nurse educators were not effectively transitioned into the position, they may never fully appreciate the role and would focus only on what they think the position should be. Hence, they may function according to the perceptions of others who have no clear idea thereby reducing nurse education credibility and effectiveness (Donner et al., 2005; Neese, 2003; Siler & Kliener, 2001).
Differences between models of education and support processes across facilities made it more difficult to define the nurse educator position. This added to misperceptions of role application and achievements. A nurse educator explained:
I report to a non-nurse line manager who does not really understand the role … I don’t think they know what it is like to be a nurse educator. I feel that unfortunately for them it is a visual thing. They have to see that you. I think they appreciate the fact that you work on the floor with people but they don’t realise what has to go on behind. IDI NE 1 (14). L 81 / 84 / 484.
And further:
In rural roles they are often expected to be everything to everyone and cover diverse areas in which they may not have expertise. Sometimes I think there is too much diversity and they are asked to do too much. Also there is not always equity between roles. IDI LM 1 (10). L 39.
A review of Queensland Health (2007c, 2008a, 2010a) documents also revealed marked disparities in nurse educator job descriptions, key skills and responsibilities. In seeking to address some of these issues local strategies were instituted including the introduction of a Clinical Nurse Clinical Facilitator (RN/EN Support) position aligned to each work unit to work in collaboration with a nurse educator.
The result, however, was a blurring between nurse educator and clinical nurse/clinical facilitator positions where the latter role had been implemented. Blurring of work boundaries and associated role creep gave rise to problems in
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discriminating between role responsibilities in work units/facilities. Relationships, although collegial, varied in effectiveness and confusion and some conflict over role boundaries was noted. Participants reported role ambiguity, de-valuing of the nurse educator position and instances of poor productivity among nurse educators and clinical nurse /clinical facilitator (RN/EN Support) positions. One line manager stated:
There is some confusion. The Clinical Nurse/Clinical Facilitator position should only be operational with a focus on upskilling and mandatory skills. Nurse educators should work from a more strategic perspective with a good understanding of where the organisation is going and how they can enable that…Nurse educators need clarity in their role. Clinical nurse facilitators don’t have the same knowledge and scope as nurse educators. IDI LM 1 (11). L 55 / 53.
Ambiguity surrounding the roles is reflected in the Conway and Elwin (2007) finding that comparisons of nurse educator roles in Australia are difficult when the title is used generically to explain any role that involves teaching and learning. Inconsistency in nomenclature, in turn, leads to misunderstanding where the term nurse educator is used regardless of conceptual differences over responsibilities and outcomes (Conway & Elwin, 2007; Hughes, 2005; Mackay, 1998; Mateo et al., 1998; Raja-Jones, 2002; Sayers, DiGiacomo & Davidson 2011; Squires, 1999). Related issues noted were confusion, role ambiguity and poor productivity among affected groups (Conway & Elwin, 2007; Hughes, 2005; Mackay, 1998; Mateo et al., 1998; Raja-Jones, 2002; Sayers, DiGiacomo & Davidson 2011; Squires, 1999). The two Australian studies (Conway & Elwin 2007; Sayers & DiGiacomo 2010; Sayers et al., 2011) argued that identity confusion can be explained by disparate attributes and lack of role clarity of the nurse educator and clinical nurse educator positions.
Although the position is not award-recognised in Queensland, the core attributes and responsibilities of the clinical nurse/clinical facilitator (RN/EN Support) and clinical nurse educator position, as determined by Conway and Elwin (2007, p. 191), obviously overlapped. Participants in the current research affirmed role blurring and that further consideration of the clinical nurse/clinical facilitator (RN/EN Support) position was needed.
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We should clarify the differences between the nurse educator and clinical nurse clinical facilitator roles to minimise role blurring. The nurse educators should support the clinical nurse clinical facilitator. The nurse educators problem solve and should guide and direct the new clinical nurse clinical facilitator role. However this isn’t always the case and there is some degree of role confusion between the two. IDI LM 1 (10). L 18 / 45.
If the model was working effectively it is a good model. The nurse educator should look at the more strategic picture, workforce redesign, models of care and be an infrastructure support role. The clinical nurse clinical facilitator should be doing a registered nurse enrolled nurse support role, doing the operational support, hands on, mandatory skills and then liaising more I suppose concertedly or more in depth with the nurse educator. IDI CN 1 (8). L 106.
The nurse educators sought clarity by questioning the functioning and responsibilities of the clinical nurse/clinical facilitator (RN/EN Support). Somewhat similarly, the clinical nurse/clinical facilitators (RN/EN Support) tended to compete with nurse educators for recognition and legitimation of their position. The consequence was the relative exclusion of the nurse educator from work units which had the effect of diminishing the nurse educator role. It was as though, with the insertion of the clinical nurse/clinical facilitator (RN/EN Support) position, nurse educators faced a further level of negotiation over their role. Hence, while the new position was implemented to reduce nurse educator workload the result was arguably an increase in nurse educator workload and further distortion of expectations. Two clinical nurses explained:
They are always asking the clinical facilitators if they are organising how modules are going and how you know who the new grads are. So they are sort of the prompt in making sure the clinical facilitator is doing her role correctly and that the staff get time off line and for their modules and that the clinical nurse facilitator is supporting the process and that processes are being implemented and standards are being met. Sometimes it is difficult to achieve especially when I am busy supporting new starters. IDI CN 1 (9). L 256.
There is frustration (over) the difference between the Clinical Facilitator role and the educator role and where you can sort of integrate them (to) support each other and make the best combination. IDI CN 1 (5). L 12.
Nonetheless, the clinical nurse/clinical facilitator (RN/EN Support) position was also perceived as valuable because it allowed the nurse educator to focus on more strategic activities and addressed some concerns about nurse educator visibility. A nurse unit manager explains:
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I use the clinical facilitator to cover work that used to be done by the educator as this role gives the work unit one person in their own environment that they can go to. My clinical facilitator works closer with me than the nurse educator. IDI NUM 2 (10). L 203 / 207.
It was also the case that views on the nurse educator role were primarily drawn from interactions with individual educators rather than the collective or job descriptions. The personality traits of the educators shaped the meanings that participants attributed to the position. The following quotes reflect the ways in which the nurse educator role was conceived:
It depends on the personality of the educator. If they use their personality in a therapeutic way they build trust with the staff, they get to know the staff members, they know what is happening. IDI CN 1 (1). L 256.
I think it really depends on the person in the role. I have seen some excellent nurse educators about and I’ve had a lot of contact with them and feel very supported by them but I have seen other areas where you kind of do wonder what actually goes on and how they contribute to education. IDI CN 1 (8). L 53.
While the nurse educator participants, and line manager participants who had been nurse educators, were able to express more in-depth insight into the attributes and responsibilities of the nurse educator there was a distinct lack of awareness across the other groups of the comprehensive nature of the position. There existed, however, clear views about visible characteristics of the educator.