Temas destacados por los stakeholders

This action research project examined the attributes and features of the role of the CNL within one District Health Board in New Zealand. The research objectives were twofold: to explore how the evolution of the CNL role could be further informed; and to establish what CNLs considered would support improvement for them in their role. The questions from these objectives were what is the role and who should define it? The study was based on the principles of action research; it involved participation, and had a strong emphasis on democracy and action. Seven nurses, active in the Clinical Nurse Leader role and from a variety of practice settings, consented to be part of the research. They would define the role and add to the discussion on its evolution and support.

The project was divided into two phases. Phase One was a face-to-face interview with each of the CNLs about their experience as a clinical nurse leader. Phase Two involved these seven CNLs joining with me to form an action research group. This group met on a monthly basis for ten months to work as an action research group with the data derived from the interviews.

Key aspects of the context of this research were the DHB where the CNLs were employed and the position of nursing and nursing leadership within New Zealand. The DHB is a crown agent charged with responding and giving effect to health related policy from the New Zealand government. The focus of each DHB is to utilise their allocated resource to improve, advance and safeguard the health of their population (New Zealand Health and Disability Act, 2000). The Clinical Nurse Leader functions within one specific clinical setting and is some management layers away from the board that governs the District Health Board function. The CNLs are responsible for leading and managing nursing teams, for the maintenance of clinical standards in their area, and for giving effect to how nurses deliver on and comply with DHB policy. They are the conduit for the patient-related information, the key person that patient, family members, managers and the multidisciplinary team approach or contact. Essentially, when they are there they are expected to know what is going on in their area for their patients and, if they do not possess such details, know where the details can be obtained. When they are not there they are accountable for what goes on in their absence. Although the DHB where the research was carried out employs approximately 5,000 people, the CNL is a recognisable face of the organisation. The public knows that where there are patients, there will be someone, usually a nurse who is in charge whether it be a ward, clinic or mobile team. The function of the CNL role is typically described within the organisation position description and Chapter One described one such example. This example described the CNL as having 10 areas which they were accountable for, with 69 performance measures which their performance is evaluated against. The selection process for appointment into the role, subsequent orientation plus ongoing professional development of each CNL varied in length and content across the DHB.

The professional and situational context which the CNLs practice within has altered significantly over the past 30 years. Since 2001 all nursing programmes preparing for Registered Nurse status have been delivered by tertiary education providers with the newly graduating nurse having a degree (Keith & Peat Marwick, 2001). The expectations of the skill set of the registered nurse and of the CNL have also changed. Increasingly there is a

skills as well as being able to undertake quality assessment. As the CNLs in this research attested, these skills are necessary to demonstrate being accountable for how nursing services impact on the health dollar. This added fiscal responsibility can be traced back to the country’s health reforms of the 1990s. This era marked a significant change in the delivery of health care. DHBs were to operate based on a cost competitive market model and as a result of this change in operation, senior nurse positions like the Director of Nursing and the then Charge Nurse were reviewed.

Whilst the change to the delivery to health care has altered so too has the patient profile that access services within the DHBs. CNLs, in conjunction with their nursing teams, increasingly care for aging communities and increasing complex social situations of some patients. These changing patient profiles have seen physical infrastructure altered to include standard notification within hospitals that verbal or physical abuse will not be tolerated from the public. In addition, CNLs in remote rural settings lead and educate their teams on personal safety.

Findings from the Phase One interviews with the CNL revealed themes relating to the role, attributes, skills and knowledge requirements of the Clinical Nurse Leader. Some of the themes were representative of struggle and uncertainty, others were not. Some were directly opposite to each other (e.g. exciting/enjoyable compared to hard work/emotionally draining) demonstrating both the tensions and triumphs of being in the role. 24 themes were identified; this large number of themes is a standalone representation as to the complexity of the CNL role.

In Phase Two the action research group was established. The 24 themes were presented as a list at the second meeting to start the group action and reflection. Four of the nine meetings concentrated on the reality of practice and the tension caused by the leadership plus management mix within the role. The role was one of leadership, management and patient care. The group agreed that a supportive role alongside the CNL would be useful, for example an associate, as the present ability to achieve all that the organisation expected of the role was constrained. This constraint, or the reality of practising in the role, could be

lessened by removal of accountabilities deemed not to be a priority, like the typing of long documents.

The last two meetings were concerned with preparation and ongoing professional development for the Clinical Nurse Leader. Their own professional development, the group established, was essential support for those in the role. The group agreed on a preparation and professional development proposal that would be put to the DHB where the research had been completed. This proposal included individual assessment by the CNL of their learning needs against the organisational position description. The proposal would also recommend that the DHB establish a senior nurse lounge, and set up an intranet site as a mechanism for CNL communication. This intranet site would profile each Clinical Nurse Leader employed by the DHB. In addition the CNL could have their respective nursing team explore what was their understanding of the role. The expectation of the group was that the proposal was to be progressed independent of the thesis.