part one: restoring patients to health—outcomes and indicators of advanced nursing practice in...

International Journal of Nursing Practice

2003;

9

: 356–367

Blackwell Science, LtdOxford, UKIJNInternational Journal of Nursing Practice1322-71142003 Blackwell Science Asia Pty LtdDecember 200396356367Original ArticleRestoring critical care patients’ health

C Ball and CL Cox

Correspondence: Carol Ball, Royal Free Hampstead NHS Trust, PondStreet, London NW3 2 QG, Britain. Email: [email protected]

✠

R E S E A R C H P A P E R

✠

Part one: Restoring patients to health—Outcomes and indicators of advanced nursing practice in

adult critical care

Carol Ball RGN MSc PhD

Consultant Nurse in Adult Critical Care Nursing, Royal Free Hampstead NHS Trust, London, United Kingdom

Carol L Cox RN BSc(Hons) PGDipEd MSc MEd PhD

Professor of Nursing, Advanced Clinical Practice, St Bartholomew School of Nursing and Midwifery, City University, West Smithfield,

London, United Kingdom

Accepted for publication May 2003

Ball C, Cox CL.

International Journal of Nursing Practice

2003;

9

: 356–367

Part one: Restoring patients to health—Outcomes and indicators of advanced nursing practice in adult critical care

The key characteristics of advanced nursing practice have been a subject of international debate over the past decade. Toaddress this debate, a grounded theory study was undertaken by one of the authors which sought to identify the key char-acteristics of advanced nursing practice in adult critical care. The outcome of the main study was a theory of legitimateinfluence in which enhancing patient stay and improving patient outcome represented the dual purpose of advanced nurs-ing practice in critical care. Fundamental to these factors is strategic activity. This encompasses improving patient care,facilitating continuity of care and engaging in patient education. The outcome of these strategic activities can be evaluatedthrough evidence of eased transition across complex hospital networks, patient satisfaction and enabling of independence.The findings reflect a change in the focus and delivery of care to the critically ill and their relatives by nurses practising atan advanced level. In the second paper of this series, the intervening conditions that affect the expression of legitimateinfluence will be discussed.

Key words:

adult critical care, advanced nursing practice, indicators of patient care, outcomes of patient care, restoring.

INTRODUCTION

Over the past decade, a number of significant forceshave impacted upon the profession of nursing within theUnited Kingdom (UK).

1,2

Chief among these were theemphasis placed on management (rather than leadership)

of nursing practice—a reduction in working time andtraining of junior hospital doctors

3

—and the increasingcentrality of the patient in measuring the effectiveness ofthe health service. Clinical grading was eroded and theimpact of nursing on the welfare of patients becameincreasingly invisible.

4

Simultaneously, within the interna-tional literature the concept of advanced nursing practicewas the subject of considerable debate. This was particu-larly evident in the ascendancy of the nurse practitioner(NP) movement and the demise of the more familiar

Restoring critical care patients’ health 357

advanced practice role of Clinical Nurse Specialist(CNS).

3,5–10

This paper forms the first of a two-part series describ-ing the key characteristics of the inductively-derived the-ory, Legitimate Influence—the Key to Advanced NursingPractice in Adult Critical Care

.

11

The purpose of derivingthe theory was to make evident the activity and patient-related outcome of advanced practice in adult criticalcare. Figure 1 outlines the elements that form the theory.

The theory takes the form of a scale or balance.

11

Legit-imate influence (LI) is defined in the theory by its essentialproperties ‘credibility’ and ‘advanced clinical nursingpractice’. The purpose of LI is to enhance patient stay andimprove patient outcomes, which will be articulated inthe second paper, along with the intervening conditionsoutlined in Fig. 1.

Enhanced patient stay and improved patient outcomeare achieved by the strategic activity of ‘restoring’, whichwill be the subject of the following discussion. However,the impact that nurses can make on enhanced patient stayand improved patient outcome is compromised by theintervening conditions which constrain strategic activity(Fig. 1). This is why the theory is portrayed as a balance orset of scales as there are a set of competing forces, bothnegative and positive, associated with the potential out-comes of advanced nursing practice. For a more in-depth

account of the development of the theory, please refer tothe original study.

11

Differentiating titles and roles

At this juncture in the evolution of advanced nursing prac-tice, it is important to distinguish between the varioustitles that have been used between countries because thereare differences in both interpretation and implementa-tion.

12

The two major advanced nursing practice roles arethe Clinical Nurse Specialist (CNS) and the Nurse Prac-titioner. Their key components have been outlined inTable 1.

The major role competencies of a CNS

13

are morereadily applied to the Clinical Nurse Consultant (CNC) inAustralia

14,15

and New Zealand (NZ). By contrast, inAustralia the term Clinical Nurse Specialist reflects adirect caregiver designated as competent in a specialistarea of practice by an employing authority which oftenutilizes different criteria to estimate competence.

16,17

The major areas of contention are the supposed medi-cal orientation of NPs

18–20

and the difficulties experiencedin evaluating the impact of indirect caregivers such as theCNS and CNC. It was decided that in the present researchstudy all advanced practice roles, appropriate to theparticular countries where data were gathered, wouldbe included in the sample to ascertain if the goals and

Figure 1.

Legitimate influence: The key to advanced nursing practice in adult critical care.

Potential Outcomes Increased Patient Satisfaction Independence EnabledTrajectory of Continuity

Enhancing Patient Stay----------------ÆÆImproving Patient Outcome Prepared for Transitions Clear Understanding

Intervening Conditions Strategic Activities Conflict Improving Patient Care Resistance Patient Education Overcoming Resistance Continuity Gender Bias Restoring Political Awareness Established Values

Legitimate Influence

Credibility Advanced Clinical Nursing Practice

Credibility and Advanced Clinical Nursing Practice: The Plinth of Legitimate Influence

358 C Ball and CL Cox

aspirations of these apparently different practitionerswere mutually exclusive or compatible.

Models of advanced nursing practice had been devel-oped at the inception of the current research study.

21–24

However, theoretical development, at that time, had beenbased on personal, faculty or policy assumptions whichsought to meet the exigencies of curriculum or policydevelopment. None had attempted to view advancednursing practice from the perspective of those working ina variety of advanced practice roles, specifically those ofCNS, CNC and NP. It was intended that the current studywould make explicit strategies used by advanced practicenurses to improve the processes associated with patientcare, management and outcome.

METHODS AND SUBJECTS

Methods generally employed in grounded theory researchwere chosen to meet the primary aim of the study. Thischoice is not without its critics within the literature.

25,26

However, the use of grounded theory methods provides abasis upon which social change can be enacted.

27

This wasconsistent with the aspirations of the study. Ethical clear-ance was obtained in all countries in which the study wasundertaken and written consent was obtained from allparticipants. Participants were informed that they were

free to withdraw from the study at any time withoutpenalty.

The major data collection tools utilized in this studywere interviews and participant and non-participantobservation. Interviews were used to gain the perspectiveof individuals involved in advanced nursing practice inadult critical care.

28

Participant and non-participantobservation techniques were used to observe the activityof the participants in their practice areas.

29,30

Three sequential interview schedules were employed.The first and second interview schedules were developedand utilized in the first two years of the study. Participantobservation and non-participant observation were thenused, together with the third interview schedule, to fur-ther develop and challenge the developing inductivetheory. The first interview schedule was based on thedevelopment and activity of advanced practice nurses,derived both from the literature and personal experience(Appendix I). Following analysis of the data gathered fromthe first interview, the second and third interview sched-ules addressed issues arising from the process of constantcomparative analysis.

27,30,31

Examples of the issues werethe primary focus of enhancing and improving patient stayand outcome, and the effects of various professionalgroups on the exercise of advanced nursing practice(Appendix II and III).

A formal schedule was not used to collect participantand non-participant observation data. Instead, the emerg-ing findings guided data collection. Field notes were alsowritten. Issues that arose during data collection were dis-cussed with the participant. The participant challengedthe interpretation of the data by the researcher whenthe participant felt the researcher’s interpretation wasinaccurate.

The process of constant comparative analysis alsoguided selection of the sample group. To ensure the sam-ple was representative and the characteristics of advancednursing practice enumerated, sampling criteria wereidentified which were supported by the literature

32–40

(Appendix IV).Data were collected in the UK, United States of Amer-

ica (USA), Australia, NZ and Canada over a four-yearperiod. An international perspective was sought becauseof the lack of advanced nursing practice in the UK at thetime data was collected and because its developmentseemed more apparent in the international literature.

Thirty-nine participants were recruited in total fromthe USA, Australia, NZ, the UK and Canada (Table 2).

Table 1

Role components of the two major advanced practice

roles

CNS and CNC

USA, UK, Australia, Canada

NP

USA, Australia

Building and maintaining

a therapeutic team

Direct management of patient

health

Providing emotional and

situational support

Monitoring and ensuring the

quality of health care practice

Making bureaucracy responsive

to patient and family need

Role competence

Monitoring the quality of

health care policy.

Helping role

Teaching role

Effective management of rapidly

changing situations

CNS, Clinical Nurse Specialist; CNC, Clinical Nurse Consult-

ant; NP, Nurse Practitioner; USA, United States of America; UK,

United Kingdom.


These included 13 CNSs, seven NPs, 16 CNCs, oneTrauma Nurse Coordinator, one joint NP/CNS and onejoint NP/CNC.

In the Findings section, numbers have been used toidentify participants by role and country (Table 2). Alldirect quotations in this section refer to interview data.A total of 115 h were spent in participant and non-participant observation. This included clinical practice inthe direct care of the critically ill and engagement inforums associated with the formation of policy at a localand national level. The observations made are included inthe text of the Findings section as pertinent issues fromthe interview data arise.

Analysis followed a definitive pattern.

27

It occurredconcomitantly with data collection and refined the processof data collection and theoretical sampling. To achieve anin-depth understanding of advanced nursing practice inadult critical care, three levels of analysis were utilized.These were open, axial and selective coding. Together,these produced categories and subcategories whichexpressed the purpose and strategic activity of the samplegroup.

To achieve credibility of the findings, several techniqueswere employed. These were transcript review, coanalysisand member validation. All participants were given theirtranscript for review and amendment to ensure accurate

representation. Coanalysis and debriefing took placethroughout the process of constant comparative analysis.In the first instance, the coanalyst, an expert in thegrounded theory method, reviewed a sample of tran-scripts independently and, subsequently, the derivation ofcategories was discussed. At each step of the coding pro-cess, the coanalyst also commented on and challenged theemerging findings.

Member validation involved two phases. Firstly, keyparticipants were invited to comment on and challengepublished preliminary findings.

37

The second phase ofmember validation involved discussion of the emergingfindings with a key participant. Finally, an audit trailwas developed to ensure the logical derivation of thefindings.

41,42

FINDINGS

Figure 2 indicates strategic activities that are undertakenat an advanced clinical practice level. These activities areimproving patient care, continuity of care and patient edu-cation. They contribute to the overall aim of restoring,that is, restoring the patient, if possible, to a former orimproved health status:

I have certainly learned in this role that despite excellent med-ical intervention and intense nursing focus/intervention, ifthe patient is not prepared . . . to make the transitions that weexpect them to make . . . nothing happens, health just doesnot get restored, it just doesn’t . . . (3)

Restoring patients to health can be evaluated throughspecific outcomes. The outcomes of strategic activity wereevaluated by participants and included increased patientsatisfaction, enabling of independence, ensuring a trajec-tory of continuity, ensuring the patient and relatives wereprepared for transitions and promoting a clear under-standing in patients and relatives of their current condi-tion and future abilities. Examples of the stated outcomesand potential empirical indicators for their measurementare outlined in Table 3.

A key focus of improving patient care was decreasingtrauma:

. . . impact on patients in a very meaningful way . . . so thattheir experience in hospital would be less traumatic . . . (1)

A key focus also included increased choice. For exam-ple a participant said:

Table 2

Participants by country and role

Participant Country Role

1, 34, 35, 36, 37, 38 USA NP

2, 3, 4, 5, 6, 7, 8, 9 USA CNS

12, 14, 15, 16, 17, 18, 19, 20, 21,

22, 23, 24, 25, 26, 27

Australia CNC

28 New Zealand CNC

29 New Zealand TNC

30, 31, 32, 33 UK CNS

39 Canada NP

40 Canada CNS

10 USA NP/CNS

13 Australia NP/CNC

11 Data lost Data lost

NP, Nurse Practitioner; CNS, Clinical Nurse Specialist; CNC,

Clinical Nurse Consultant; TNC, Trauma Nurse Coordinator; USA,

United States of America; UK, United Kingdom.


I gave them many more options so that their outcomes did varybut usually it was one that they were comfortable with so thewound might have taken a bit longer to heal using plan B, butit still healed but it was in . . . their area of comfort. (13)

Another participant emphasized increased efficiency:

. . . updating the patient’s care very frequently so that theydon’t have long periods of time where nothing happens tothem. (19)

There were many examples which provided supportingevidence for crossing traditional boundaries betweenmedicine and nursing. Although this was an area wheremost conflict occurred, more recently a sense of collabo-ration appeared within the data as evidenced in:

I would have the HDU (high dependency unit) resident or reg-istrar calling me, particularly in regards to patients with tra-ches (tracheostomy) because a lot of them are not skilled insome of those areas. (15)

It was apparent that boundaries were usually crossedwith the aim of improving patient care, not to make up ashortfall in medical presence:

. . . that’s the thing, it’s looking at what’s appropriate in yourunit, looking at the patient population. (33)

The perception of many of the participants was sum-marized by the following statement:

. . . you don’t stop and think ‘well it’s not my job’ . . . youknow all these kind of boundaries . . . are not real, you know,just in peoples’ heads often . . . (33)

as the definitive focus was improving patient care:

That has to be the ultimate driver because that’s ultimatelywhat makes everybody else comfortable with it, the fact that ifwe don’t do this, we’re detracting from care, and so it is thatmoving forward which provides the focus . . . that your pri-mary aim is patient care. (31)

Figure 2.

The strategic activities that contribute to restoring patients’ health.

Outcomes Aim

Improving Patient Care

Decreasing Trauma Crossing Traditional Boundaries Effective Communication

Prepared for Transition

Continuity of Care

‘Whole Package’ Follow-through

Patient Satisfaction Restoring Trajectory of Continuity

Patient Education

Learning to Cope Day-to-Day Management Education Strategies

Clear Understanding Independence Enabled

Strategic Activities


Effective communication with patients and relatives wasseen as a vital strategy in improving patient care. Advancedpractice nurses were aware of the effects of illness upon thepatient and relatives and were prepared to listen:

. . . psychological support, you know, just letting themtalk, . . . they’re very frightened, you know they’ll just speakat length about things like that and the effect on theirfamily . . . (16)

They attempt to provide understandable explanationsbased on an individual’s experience:

. . . but I often find that people will, if you can sit down awayfrom the unit, maybe go to the coffee shop or, you know, wher-ever, a bit more private, you can say things in a way that they

are not taken over by the technology. It is frightening . . .and . . . you know you can sort of say ‘just let me explain this,it does make sense and I will try and make it make sense foryou’ . . . (33)

This was associated by the participants with the need todecrease confusion and enhance the understanding ofpatients and those close to them.

Continuity of care and patient education were also inte-gral to restoring (Fig. 2). Facilitating continuity of careunderpinned the maintenance of support during hospital-ization and following discharge by ensuring patients wereperceived as a ‘whole package’ (13) and followed throughappropriately. Continuity of care across the continuum ofhospitalization, and beyond in some instances, was a con-sistent feature within the data:

Table 3

Outcomes of advanced nursing practice in adult critical care and empirical indicators

Outcomes of advanced

nursing practice

Empirical indicators

Patient satisfaction Patient satisfaction used as a measure of outcome

The impact of the role on patient satisfaction is demonstrated

A process of negotiation between the advanced practice nurse and the patient is evident

Services are altered to achieve patient satisfaction

An emphasis is placed on psychological and physical improvement

Patients are encouraged to voice issues which are of concern to them

Independence enabled Innovative education programmes which meet patients’ needs are evident

Non-traditional care is considered and action taken to maximize independence (for example, care of ventilated

patients in the community or withdrawal of treatment decisions)

Patients are involved in decision making within the hospital and in the community

Trajectory of continuity Progress towards recovery and quality of life are assessed and evaluated regularly, during hospitalization and in the

community

The management of particular problems associated with critical illness is streamlined (for example, integrated care

pathways are developed)

Patients report feeling supported during hospitalization and following discharge

Contact with the advanced practice nurse is encouraged and evident (for example, through the administration of

business cards or telephone contact numbers)

Prepared for transitions Phases of recovery which indicate a need for specific transitional arrangements are identified and patients are

prepared (for example, admission to or discharge from intensive care, need for further specialist help, such as

an occupational therapist, movement to rehabilitation, discharge home)

Patients with special needs are identified and appropriate arrangements are made to aid recovery and independence

Complications which reduce the patient’s ability to make transitions (incontinence or pressure sores) are identified

and managed proactively

Clear understanding Patients demonstrate an understanding of their health-related problems

Patients demonstrate increased feelings of control


What is the continuity? How can issues on a particularpatient be covered day to day . . . aspects are very key to howpatients comply in the future. What sort of things do they needto support them? (3)

Particular emphasis was placed on following the patientthrough the system and ensuring patients continued toprogress with recovery

I mean it is obvious that these patients shouldn’t have . . .become as ill as they had, . . . I mean there are obvious prob-lems in . . . the fact that they are getting mis-managed andthey aren’t . . . properly followed up . . . (14)

The outcomes of engaging in patient education were toenable a clear understanding of current health problemsand to enable independence within the restrictions thatcritical illness had imposed (Fig. 2). Patient educationcontinued to be a key feature throughout the process ofconstant comparative analysis and expanded to includethose closest to the patient. Open coding demonstratedthe focus of patient education was health promotion andrisk reduction. Further theoretical sampling revealedadvanced practice nurses also instigated the developmentof educational material:

My role is going to be to coordinate the production of our ownmaterial, . . . the neurosurgeon . . . he gives them the projec-tion, what I see as my role is teaching and, you know, . . .understanding . . . the tumour, where it’s located, what sortsof symptoms, to explain to them what to expect and how todeal with those symptoms. (24)

In addressing the strategic activity of the participantswithin this study, the needs of the recovering patient havebeen emphasized due to the need for brevity. However, itwould be inconsistent with the findings of the study toimply that the participants did not address the needs of thedying and bereaved. Many participants maintained contactwith relatives in the immediate period following organdonation and/or death and attempted to provide supportto the bereaved.

Contextual field notes from participant and non-participant observation revealed that there was little dif-ference between NPs, CNSs and CNCs in their desire tooptimize patient care through the strategic activity asso-ciated with restoring. Where it did differ was in the modeof delivery. Nurse Practitioners tended to engage in more

direct care whereas CNSs and CNCs were more involvedwith the strategic direction of the critical care service.

Indirect engagement was achieved though the develop-ment of care pathways:

. . . a streamlined process . . . cut down on variances . . . sowe concentrate on high volume presentation types of patients,such as drug overdose, chest pain . . . and what we did wasdevelop a clinical pathway. (10)

Direct contact was achieved through:

. . . being able to care for the patient from start to finish—having someone come in with a specific complaint, addressingtheir issues, solving the puzzle so to speak, and moving themon to a better place. (35)

However, these differences were not absolute and mightmore readily be represented by a continuum (Fig. 3).

REFLECTIONS ON THE FINDINGS

Restoring represented activity associated with improvingpatient care, facilitating continuity of care and engaging inpatient education (Fig. 2). Their combination in terms ofan intent to restore well-being was not evident within theliterature. However, the behaviours that comprised eachof these strategic activities have been represented sepa-rately (Fig. 2). The purpose of the following discussionwill be to integrate these with the results of the researchstudy.

Decreasing trauma comprised two aspects of care pro-vision—psychological and physical. Psychological caredominated the results of the study and its importance wasemphasized by both NPs and CNSs/CNCs. It included theinvolvement of patients and families in decisions regardingoptions that might be available to them. Examples of thisrelated to the comfort and convenience of a particularwound dressing, the method of securing a tracheostomyor endotracheal tube, quality of life and end-of-life deci-sions. It also involved the mobilization of social services orcharitable institutions to ensure home circumstances weresuitable and safe for discharge, and that social isolation

Figure 3.

Direct and indirect care influence of nurse practitioners

and clinical nurse specialists/consultants.

Direct Care Indirect Care

Nurse Practitioners Clinical Nurse Specialists/Consultants


was avoided if the patient desired. Psychological elementsassociated with the advanced practice role and recoveryfrom critical illness were not evident within the literature,which was dominated by the physical aspects of care.

Physical aspects of care that reduced trauma includeda reduction in the number of complications arisingfrom critical illness; for example, reducing intravenouscatheter-related infection

43

or decreasing the incidenceof pressure area formation. Literature associated with thereduction of complications in critical illness often repre-sents the work of individual nursing staff, not necessarilythat of advanced practice nurses. The role of the advancedpractice nurse would be to articulate the difference madeby nursing to the welfare of critically ill patients and todevelop strategies to achieve this.

The crossing of traditional professional boundaries,both in this study and in the literature, referred almostexclusively to advanced practice nurses undertaking func-tions previously within the domain of medicine. Thedebate this inspired has already been alluded to in theintroduction to the current study and focused on the‘medicalizing

’

of nursing.

44

It occurred both in the UK,

44

USA

45–47

and Australia.

48

However, to a large extent this isnow a redundant debate. Many nurses, not only advancedpractice nurses, are undertaking functions formally in thedomain of medicine.

3,49,50

In the field of adult critical care,these include inserting venous and arterial cannulae,interpreting chest radiographs, physical examination,weaning from ventilation and managing pain.

51

The issue, revealed in the results of this study, was notwhether a nurse can perform these psychomotor skills ina competent manner, although competence is extremelyimportant,

52

but that the performance of a particular skillshould benefit the patient and not detract from otherpatient-related responsibilities. Once patient benefit hasbeen established, then the decision to instigate the skill orintervention and its evaluation should be within thedomain of nursing. This latter aspect might fall into therealm of the advanced practice nurse indicating increasedautonomy in practice.

53

Participants in the current study determined the effec-tiveness of their communication by the ability of patientsand family members to understand the reasons for illness,how to cope with residual problems following illness,avoiding future illness or why current treatment mighthave failed, resulting in the loss of a loved one. Thisemphasis on understanding indicated an attempt toparticipate in ‘communicative action’.

54

Communicative

action implies that future activity is negotiated betweenthe advanced practice nurse and the patient and familywithout the use of power or coercion. However, compet-ing tensions were likely to effect this ideal type of com-munication,

55

where emphasis was placed on efficiencymeasures such as decreasing length of stay and complica-tion rates.

Continuity has been termed a ‘seamless web of care’ bythe American Association of Critical Care Nurses

56

andwas seen as a key feature of advanced nursing practice bythe majority of participants in the current study. This againdemonstrated the emphasis placed on restoring patientsfollowing critical illness by the participants in this research(Fig. 2). Case management was cited in this study as themain method of ensuring continuity of care, and is prev-alent within the literature.

57

The use of case managementhas been associated predominantly with the role of theCNS.

58,59

It demonstrates an indirect means of providingenhanced patient stay and improved patient outcomewhere the impact of the indirect role can be evaluated(Table 3). However, NPs also find the process of develop-ing care pathways useful in delineating scope of practiceand measures of outcome:

Together with one of the surgeons . . . put together a very niceprogramme for patients here so that everything runs verysmoothly. (1)

The work of Egloff Parr was also pertinent to the main-tenance of continuity as it identified criteria that reflecteda proactive response to patient progression following dis-charge from the intensive care unit.

57

This could be com-bined with the work of Hravnak who identified the risksassociated with adult critical care inpatient stay and thepotential impact of the advanced practice nurse in avoid-ing further deterioration and improving patient recoveryfrom critical illness.

60

Many studies have demonstrated the effectiveness ofeducation provided by advanced practice nurses in reduc-ing complication rates and increasing the ability of a per-son to deal with illness.

61–63

However, the latter studieswere not performed in the acute sector and cautionshould be exercized because of a lack of longitudinalresearch appraising the long-term impact of patient edu-cation. Even so, more recent authors

60,64,65

all suggesthealth education and patient teaching are vital compo-nents of advanced nursing practice.

It was found in this study that patient education during


a period of critical illness is impossible to provide. Patientsare not normally conscious and families are in a state ofemotional turmoil. Neither condition is conducive tolearning. However, for patients in whom critical illnessforms an accepted stage of hospitalization (for example,cardiac or vascular surgery) educational strategies can becommenced prior to admission and continued after recov-ery.

60,66,67

All patients who recover from critical illnessrequire some form of education concerning altered func-tional ability, management of prosthesis and/or enhancedcoping mechanisms in order to facilitate restoration. Theparticipants in this study attempted this through the pro-vision of information concerning the day-to-day manage-ment of individual health-related problems utilizinginnovative educational strategies.

In summary, the strategic activity undertaken byadvanced practice nurses in this study was aimed at restor-ing critically ill patients to an optimal level of function fol-lowing discharge from hospital. To achieve this, emphasiswas placed on the psychological impact of critical illnesswhile not forgetting physical needs.

It was also evident that participants in this studyembraced skills currently in the domain of medicine ifthese could be performed effectively and, thereby,enhance and expedite patient care and management.These skills were not undertaken, however, just to relievemedical staff of onerous tasks. A long-term perspective,encompassing the entire trajectory of patient stay in hos-pital, and sometimes beyond, was seen to be the remit ofadvanced practice nurses. This demonstrates a nursingresponse to services which are frequently fragmentedbecause of the nature of critical illness itself, having as itdoes a requirement for multiple specialist interventionand the complex bureaucracy frequently apparent in thedelivery of critical care.

Education was also represented as a key characteristic,particularly in the strategic development of educationalpackages and in the actual delivery of knowledge to aidcoping and day-to-day management of problems that arosefollowing critical illness. The orientation of participants inthis study did not alter as a function of their role title.

LIMITATIONS

Limitations associated with this study comprise the inclu-sion of NPs, CNSs and CNCs in the sample group, theinternational nature of data collection and the processused to determine trustworthiness (truth value) of thedata. It might be considered that the mixed nature of the

sample group could be a limitation if a separatist stancewas taken in relation to advanced nursing practice roles inadult critical care. That is to say, only one role title (suchas CNS) represents advanced nursing practice. Interest-ingly, Offredy has demonstrated how advanced practicenurses themselves often use role titles interchangeably.

38

For the purpose of the study described in this paper, it wasdetermined that it would be inappropriate to restrict thepotential representation of advanced nursing practice toone group as this would conflict with the primary aim ofthe research, which was to delineate advanced nursingpractice in adult critical care.

The international nature of the sample group mightalso be criticized. It could be suggested that naive cross-cultural comparison would make the findings of this studyirrelevant. A superficial view of advanced practice roles innursing might indeed suggest that roles do differ betweencountries. However, it has been demonstrated in thisstudy that this only appeared to be the case if health carepolicy was considered in isolation. Indeed, even in thisarea, there were more similarities than differences giventhe concentration on cost containment prevalent in theUK, Australia, NZ, Canada and the USA, despite differenthealth care delivery systems. What did not differ betweencountries were the essentially personal relationshipsbetween advanced practice nurses and their patients, andthe interpersonal structures created through strategicactivity.

CONCLUSION

This paper has described the strategic activities associatedwith the theory Legitimate Influence—the Key toAdvanced Nursing Practice in Adult Critical Care. Theoutcomes and empirical indicators of advanced nursingpractice have been explicated. These were discernedthrough the inductive process associated with groundedtheory methodology. Through implementation of the stra-tegic activities, restoration can become a reality for thepatient.

The rationale for undertaking grounded theory meth-odology was to delineate advanced nursing practice inadult critical care. Through this approach, the patient-orientated characteristics of advanced nursing practicehave been revealed. These provide a basis for the futuredevelopment of advanced nursing practice in adult criticalcare, where the effectiveness of the role can be establishedby outcomes that are sensitive to the impact of nursingitself rather than those of another discipline.


The introduction of advanced nursing practice intoadult critical care provides an opportunity for servicedelivery to be enhanced and, more importantly, the expe-rience of critical illness by patients and relatives to beimproved.

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APPENDIX IExamples of questions asked in the first

round of data collection• What actions have you taken to achieve your current

position?

• What initiatives have been taken to achieve your cur-rent role?

• What is the purpose of engaging in advanced nursingpractice?

• What could be identified as the actual or potential con-sequences of advanced nursing practice?

APPENDIX IIExamples of questions asked in the

second round of data collection• How would you describe the impact you have on

patient stay in hospital?

• How would you describe the difference you make topatient outcome?


• How do you see yourself in relation to other nurses andprofessional groups who care for the critically ill?

APPENDIX IIIExamples of questions asked in the

third round of data collection• From your experience, could you give an example

which really epitomized the advanced practice role foryou?

• What were the components of this experience whichyou really valued?

APPENDIX IVSampling criteria

• Educated, or in the process of being educated, at Mas-ters level.

• Role function is based in clinical practice, rather thanpolicy development or management.

• In possession of an advanced practice title (appropriateto the particular country), that is, nurse practitioner,clinical nurse specialist or clinical nurse consultant.

• Employed in the care of actual or potential critically illpatients.

part one: restoring patients to health—outcomes and indicators of advanced nursing practice in...

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