HEALTH POLICY AND SYSTEMS
The Future of the Clinical Nurse Specialist Role in Finland Krista Jokiniemi, MSc, RN1 , Kaisa Haatainen, PhD, RN2 , Riitta Meretoja, PhD, RN3 , & Anna-Maija Pietila, ¨ PhD, RN4 1 Doctoral student, University of Eastern Finland, Faculty of Health Sciences, Department of Nursing Science, and Assistant Head Nurse, Kuopio, Finland 2 Docent, University of Eastern Finland, and Patient Safety Manager, Kuopio University Hospital, Kuopio, Finland 3 Docent, Universtity of Turku, and Development Manager, Corporate Headquarters, Hospital District of Helsinki, Uusimaa, Helsinki, Finland 4 Professor, University of Eastern Finland, Faculty of Health Sciences, Department of Nursing Science, Social and Health Care Services, Kuopio, Finland
Key words Clinical nurse specialist, advanced practice nurse, advanced practice nursing, expert panel, policy Delphi design Correspondence Krista Jokiniemi, Haltijankatu 15, 70840 Kuopio, Finland. E-mail: [email protected] Accepted: August 25, 2014 doi: 10.1111/jnu.12109
Abstract Purpose: To identify and examine the expert panelists’ visions on the future implementation of the clinical nurse specialist (CNS) role in Finland. Design and Methods: A policy Delphi design was conducted in 2013. A purposive sampling method was used to recognize expert panelists in the areas of advanced practice nursing (APN), healthcare management, and advanced practice nurse education. Three iterative Web-based survey rounds were conducted (n = 25, n = 22, n = 19). Both qualitative and quantitative methods were used to analyze the data. Findings: The expert panelists envisioned the future of the CNS role in Finland. This study portrayed the CNS role in Finland as generally consistent with the international role. CNS have comprehensive skills and knowledge that they use to guide and develop nursing practice; however, several threats may affect their role achievement. The existing national consensus, contradiction, and ambivalence related to CNS roles were revealed through the examination of the results, thus pointing out the areas for consideration when further developing these roles and role policies. Conclusions: This is the first national study to examine the implementation of the CNS role in Finland. Expert panelists’ views regarding the CNS role will be valuable in the forthcoming national policy formulation process. Although the policy Delphi design is not often utilized, this study reveals that it is very well suited to guide and inform national and international APN policy development. Clinical Relevance: This study contributes to CNS role development and describes the methods facilitating the essential policy formulation process.
The increased demands of contemporary health care have created a need for nursing to strengthen the quality and safety of practice and reexamine its clinical roles (Delamaire & Lafortune, 2010; Sheer & Wong, 2008). In order to respond to these requirements, advanced practice nursing (APN) roles have evolved over the years and are currently a global trend of the nursing profession (Delamaire & Lafortune, 2010; Kleinpell et al., 2014; Pulcini, Jelic, Gul, & Loke, 2010; Ruel & Motyka, 2009; Sheer & Wong, 2008). Although the nomenclature and generic definitions of an advanced practice nurse 78
vary between and even within countries (Baldwin, 2013; Dowling, Beauchesne, Farrelly, & Murphy, 2013; Hutchinson, 2014; International Council of Nurses ¨ Kylma, ¨ & Haatainen, [ICN], 2014; Jokiniemi, Pietila, 2012; Lewandowski & Adamle, 2009; Pulcini et al., 2010), it is generally agreed that APN is carried out by autonomous, experienced practitioners who possess an advanced level of skills and knowledge acquired through graduate nursing education (ICN, 2014). An APN role is actualized through advanced nursing, specialization, and expansion of scope of practice, which underpin Journal of Nursing Scholarship, 2015; 47:1, 78–86. C 2014 Sigma Theta Tau International
Jokiniemi et al.
nurses’ activities in advanced clinical practice, practice development, education, consultation, research, and clinical leadership (Bryant-Lukosius, DiCenso, Browne, & Pinelli, 2004; Dowling et al., 2013; Duke, 2012; Gardner, 2013; Hanson & Hamric, 2003; Hutchinson, 2014; Jokiniemi et al., 2012; Roche, 2013). Role specialization and expansion provide advanced practice nurses with their secondary title, such as clinical nurse specialist (CNS; Ruel & Motyka, 2009). CNS will lead change in three impactful areas: direct patient care, nursing practice, and systems (Lewandowski & Adamle, 2009; National Association of Clinical Nurse Specialists, 2004; Patten & Goudreau, 2012). Several factors, such as healthcare reform, the requirement for evidence-based practice (EBP), and the proliferation of Magnet hospital status, offer opportunities for strengthening the CNS role worldwide (Patten & Goudreau, 2012). Although the CNS role has gained support in recent years, it appears to be, out of all advanced practice nursing roles, the least clearly defined (Dowling et al., 2013; Kilpatrick et al., 2013). Currently many countries develop or reexamine their CNS roles or educational curricula (Arslanian-Engoren, 2011; Baldwin, 2013; Dias et al., 2013; Doody, 2011; ¨ in press; Kleinpell et al., Jokiniemi, Haatainen, & Pietila, 2014; Livneh, 2011; Roberts, 2011; Wong et al., 2010). However, the pace of and readiness for role implementation vary from country to country (Bryant-Lukosius & DiCenso, 2004; Delamaire & Lafortune, 2010; Sheer & Wong, 2008); thus, differing approaches have been taken to develop these roles in various countries. Often the rigidity and slowness of healthcare systems and regulation to change have led to the ad hoc formulation of advanced nursing roles; hence, many countries are retrospectively working toward policy formulation to support role implementation (Bryant-Lukosius et al., 2004). Variation in CNS practice and lack of uniform policies regulating CNS and other APN roles represent barriers to the accurate identification and optimal functioning of these practitioners (Furlong & Smith, 2005; Kilpatrick et al., 2013; Patten & Goudreau, 2012; Rounds, 2013). Therefore, considerable effort and collaboration of the central healthcare agents, organizations, legislators, educational institutions, and other stakeholders are required to increase clarity and common understanding related to CNS roles to support policy formulation and role implementation. The recognition of APN roles and titles is a rather recent development in Finland; however, the patterns of specialty practice have existed since the early 1900s and ¨ of specialist nurse education since the 1970s (Fagerstrom & Glasberg, 2011; Jokiniemi et al., in press). The Finnish higher education system consists of two complementary Journal of Nursing Scholarship, 2015; 47:1, 78–86. C 2014 Sigma Theta Tau International
Clinical Nurse Specialist Role in Finland
sectors: universities and polytechnic institutions. The universities’ mission is to conduct scientific research and provide instruction and postqualification education based on it. Polytechnic institutions, in turn, train professionals in response to labor market needs. The entry requirement to both APN education systems is a bachelor’s degree in nursing (Ministry of Education and Culture, 2014). Despite the history of specialist level practice and existing APN educational programs, advanced-level nursing roles have not been nationally conceptualized in a Finnish context, authorized by the National Supervisory Authority for Welfare and Health, or regulated by the government. The role of the CNS was first established within hospital care in Finland at the beginning of 2000 (Meretoja, 2002). The goal of the CNS role is to assure quality of care, support the staff’s and organization’s strategic work, and implement EBP (Jokiniemi et al., in press). Furthermore, certified nurse midwife and certified nurse anesthetist roles do exist in Finland (Malin & Hemminki, 1992; Vakkuri, Niskanen, Meretoja, & Alahuhta, 2006), but educational and other APN requirements of these roles are not equivalent to the international APN role requirements. Without formal regulation, policies, and protected titles, APN roles, such as the CNS, have been defined by individual organizations, creating the emergence of unnecessary variation in roles and thus compelling the need for national role conceptualization and standardization. The increasing interest in APN roles highlights the importance for nurses and the nursing profession to understand the language and concepts involved in order to communicate with each other, clients, and stakeholders (Bryant-Lukosius et al., 2004; Ruel & Motyka, 2009; Spross & Lawson, 2013). Furthermore, national regulation and policies are needed to facilitate role recognition, curriculum design, and effective role implementation and evaluation, yet there is scarce international research available to inform or assess APN policy formulation. This article reports on a study utilizing a policy Delphi design (de Loe, 1995; Turoff, 2002). Although the Delphi method is widely mentioned in the healthcare literature (McKenna, 1994; Powell, 2003), the policy Delphi design has not been utilized much in APN policy formulation studies.
Aims and Objectives The aim of this study was to identify and examine the expert panelists’ visions on future CNS role implementation, and to generate questions as well as supporting and opposing views for further exploration. The research questions were: 79
Clinical Nurse Specialist Role in Finland
r r r
How do the expert panelists define the future CNS role and its competencies? What are the expert panelists’ supporting and opposing views regarding the future CNS role attributes and implementation? What are the most probable threats for CNS role implementation in the future?
Jokiniemi et al.
expertise). The “expertise on APN role” received the highest mean score of 3.32, with 48% of panelists rating themselves as having a lot of expertise. The “expertise on healthcare workforce development” received the second highest mean score of 3.12. The lowest mean score of 2.44 was found in “international APN expertise.”
Data Collection Rounds
Methods and Materials Policy Delphi Design A policy Delphi design (de Loe, 1995; Turoff, 2002), a variant of the conventional Delphi, was selected. It is similar to the full Delphi in terms of procedure and intent (Keeney, Hasson, & McKenna, 2006). The policy Delphi design is considered a “decision-facilitating” tool (Powell, 2003; Turoff, 2002), which seeks all possible viewpoints and explores factors underlying disagreement (Linstone & Turoff, 2011; Turoff, 2002). Since it does not aim for consensus but explores the various opinions (Powell, 2003; Turoff, 2002), it is an effective method to inform the decision-making process within the policy formulation process (de Loe, 1995). Given the newness associated with the CNS roles in Finland, as well as the study aim of aspiring information for the basis of policy formulation, it was appropriate to use a design that highlights a broad range of options rather than aim for a consensus on one or a few options (de Loe, 1995).
Participants A purposive sampling method was used to recruit 10 to 50 participants, which has been suggested as an appropriate number of experts in a policy Delphi panel (de Loe, 1995; Turoff, 2002). Participant recruitment was planned to ascertain a high level of expertise on the APN roles and thus aid in miscellaneous information gathering. The inclusion criteria of expert panelists were (a) being a member in an interest group of APN, APN education, or healthcare management, and (b) having expertise in the area of APN, APN education, APN management, healthcare workforce development, or international APN. The nursing practice directors at five university hospitals, the National Institute of Health and Welfare, Ministry of Social Affairs and Health, nursing trade organization, and universities of applied sciences that have APN programs were contacted to obtain recommendations. Overall, 35 expert panelists were recommended and asked to participate. The interest groups were evenly represented. The panelists were asked to self-rate their expertise on a scale of 1 (little expertise) to 4 (a lot of 80
Three iterative policy Delphi rounds were conducted between June and October 2013 by using Web-based online survey and analysis software. A time estimate of answering each of the rounds varied between 20 and 40 min. Approximately 2 weeks were given to answer each questionnaire, and if no response was received, reminders were sent a few days before the due date. To alleviate response exhaustion, the topics observed were divided between the rounds. The subsequent questionnaires were sent only to the panelists who had answered the previous questionnaire; thus, the policy Delphi study can be seen as a cumulative process building on the preceding panelist contribution. The response rate was 71% (n = 25) in the first round, 63% (n = 22) in the second, and 54% (n = 19) in the third round. In the first round, open-ended questions following the study questions were used to direct the data gathering. By doing this, the panelists were allowed to bring in their timely views of the CNS roles, which might be more accurate and precise than items formed based on the literature. The second and third rounds consisted mainly of 4-point Likert-type questions (de Loe, 1995; Turoff, 2002), where statements formed based on the first round, thus illustrating the views of the panelists, were presented for rating. In ranking the statements, the panelists were asked to identify the likelihood or desirability of statements, or judge items in terms of their importance relative to others. A maximum of two response choices were asked at one time. The response choices ranged from totally disagree to totally agree, very undesirable to very desirable, very unlikely to very probable, or very unimportant to very important. In addition to rating each of the statements, panelists were asked to make additional suggestions, comments, or questions on statements to minimize respondent bias (de Loe, 1995; Keeney, Hasson, & McKenna, 2006) and to expose arguments behind ratings. The statement ratings were examined in order to measure whether the panel supported, opposed, or was ambivalent toward an option, or whether no clear picture of support emerged (de Loe, 1995). Based on the measurements, the items that had high consensus in response were omitted in subsequent rounds. Items that had a low consensus level or generated major opposing views were further examined in the next round (Rayens, 2000). Journal of Nursing Scholarship, 2015; 47:1, 78–86. C 2014 Sigma Theta Tau International
Clinical Nurse Specialist Role in Finland
Jokiniemi et al.
To ensure content and face validity (Mead & Moseley, 2001), all three questionnaires were pretested with six professionals from outside the research setting. These professionals were identified by the research team using the same inclusion criterion as the original study participants. In addition to completing the email questionnaires, the experts in the pretesting phase were asked to give specific feedback about the policy Delphi process, including the time taken to complete the questionnaires, preferred method of rating, and question understandability and comprehensibility. Minor alterations were made to the questionnaires according to the feedback.
Data Analysis The policy Delphi method includes the careful management and analysis of both qualitative and quantitative data. The data produced by the open-ended questions were analyzed by qualitative content analysis, and statements significant to study design were formed for panelist rating. The quantitative data acquired through statement ratings were analyzed by using the Statistical Package for the Social Sciences (version 19.0; SPSS Inc., Chicago, IL, USA), with the aim of identifying how much the panel agreed or disagreed with each of the statements. To detect any differences between the respondent categories, the respondent ratings were also analyzed using the KruskalWallis test. To analyze the quantitative data, each rating set was examined according to mean, rating distribution, and consensus level (de Loe, 1995). Mean scores were examined in order to assess the multiple statement preference. Consensus was examined, according to de Loe’s (1995) suggestion, to be high, medium, low, or none, indicating the degree to which the group was able to agree on a given issue. In addition to consensus examination, further examination of each rating distribution was needed to observe whether the panelists’ consensus opposed or supported each statement. An example of the rating distribution and consensus levels can be seen in Table 1. To interpret Table 1, it can be seen that “advanced clinical nursing” as a future CNS role domain attained a low consensus level; thus, just over 60% of the ratings fell into two contiguous categories. Furthermore, the consensus on CNS “leadership” domain is medium, with 74% of answers being in two contiguous categories. Nevertheless, when further examining the leadership ratings, it was noted that the majority of ratings were in scale point 1 or 2; thus, here, medium consensus lay in opposition, although only weak, for this role domain being included in the future CNS role. Journal of Nursing Scholarship, 2015; 47:1, 78–86. C 2014 Sigma Theta Tau International
Table 1. Rating Distribution, Level of Consensus, and Support on CNS Role Domains Which domains should CNS work include in the future?
Ratings on scalea 1 2 3 4
Consensus
Support
Advanced clinical nursing Education Practice development Consultation Research Clinical leadership
4 0 0 0 1 3
None High High High High Medium
WS SS SS SS SS WO
4 1 0 0 1 9
4 8 2 7 9 5
7 10 17 12 8 2
a 1 = very undesirable; 2 = undesirable; 3 = desirable; 4 = very desirable. Note: CNS = clinical nurse specialist; High = 70% of ratings are in one category or 80% in two contiguous categories; Medium = 60% of ratings are in one category or 70% in two contiguous categories; Low = 50% of ratings are in one category or 60% in two contiguous categories; None = 75% of ratings on point 3 or 4); WS = weak support (>50–75% ratings on point 3 or 4); WO = weak opposition (
The Future of the Clinical Nurse Specialist Role in Finland Krista Jokiniemi, MSc, RN1 , Kaisa Haatainen, PhD, RN2 , Riitta Meretoja, PhD, RN3 , & Anna-Maija Pietila, ¨ PhD, RN4 1 Doctoral student, University of Eastern Finland, Faculty of Health Sciences, Department of Nursing Science, and Assistant Head Nurse, Kuopio, Finland 2 Docent, University of Eastern Finland, and Patient Safety Manager, Kuopio University Hospital, Kuopio, Finland 3 Docent, Universtity of Turku, and Development Manager, Corporate Headquarters, Hospital District of Helsinki, Uusimaa, Helsinki, Finland 4 Professor, University of Eastern Finland, Faculty of Health Sciences, Department of Nursing Science, Social and Health Care Services, Kuopio, Finland
Key words Clinical nurse specialist, advanced practice nurse, advanced practice nursing, expert panel, policy Delphi design Correspondence Krista Jokiniemi, Haltijankatu 15, 70840 Kuopio, Finland. E-mail: [email protected] Accepted: August 25, 2014 doi: 10.1111/jnu.12109
Abstract Purpose: To identify and examine the expert panelists’ visions on the future implementation of the clinical nurse specialist (CNS) role in Finland. Design and Methods: A policy Delphi design was conducted in 2013. A purposive sampling method was used to recognize expert panelists in the areas of advanced practice nursing (APN), healthcare management, and advanced practice nurse education. Three iterative Web-based survey rounds were conducted (n = 25, n = 22, n = 19). Both qualitative and quantitative methods were used to analyze the data. Findings: The expert panelists envisioned the future of the CNS role in Finland. This study portrayed the CNS role in Finland as generally consistent with the international role. CNS have comprehensive skills and knowledge that they use to guide and develop nursing practice; however, several threats may affect their role achievement. The existing national consensus, contradiction, and ambivalence related to CNS roles were revealed through the examination of the results, thus pointing out the areas for consideration when further developing these roles and role policies. Conclusions: This is the first national study to examine the implementation of the CNS role in Finland. Expert panelists’ views regarding the CNS role will be valuable in the forthcoming national policy formulation process. Although the policy Delphi design is not often utilized, this study reveals that it is very well suited to guide and inform national and international APN policy development. Clinical Relevance: This study contributes to CNS role development and describes the methods facilitating the essential policy formulation process.
The increased demands of contemporary health care have created a need for nursing to strengthen the quality and safety of practice and reexamine its clinical roles (Delamaire & Lafortune, 2010; Sheer & Wong, 2008). In order to respond to these requirements, advanced practice nursing (APN) roles have evolved over the years and are currently a global trend of the nursing profession (Delamaire & Lafortune, 2010; Kleinpell et al., 2014; Pulcini, Jelic, Gul, & Loke, 2010; Ruel & Motyka, 2009; Sheer & Wong, 2008). Although the nomenclature and generic definitions of an advanced practice nurse 78
vary between and even within countries (Baldwin, 2013; Dowling, Beauchesne, Farrelly, & Murphy, 2013; Hutchinson, 2014; International Council of Nurses ¨ Kylma, ¨ & Haatainen, [ICN], 2014; Jokiniemi, Pietila, 2012; Lewandowski & Adamle, 2009; Pulcini et al., 2010), it is generally agreed that APN is carried out by autonomous, experienced practitioners who possess an advanced level of skills and knowledge acquired through graduate nursing education (ICN, 2014). An APN role is actualized through advanced nursing, specialization, and expansion of scope of practice, which underpin Journal of Nursing Scholarship, 2015; 47:1, 78–86. C 2014 Sigma Theta Tau International
Jokiniemi et al.
nurses’ activities in advanced clinical practice, practice development, education, consultation, research, and clinical leadership (Bryant-Lukosius, DiCenso, Browne, & Pinelli, 2004; Dowling et al., 2013; Duke, 2012; Gardner, 2013; Hanson & Hamric, 2003; Hutchinson, 2014; Jokiniemi et al., 2012; Roche, 2013). Role specialization and expansion provide advanced practice nurses with their secondary title, such as clinical nurse specialist (CNS; Ruel & Motyka, 2009). CNS will lead change in three impactful areas: direct patient care, nursing practice, and systems (Lewandowski & Adamle, 2009; National Association of Clinical Nurse Specialists, 2004; Patten & Goudreau, 2012). Several factors, such as healthcare reform, the requirement for evidence-based practice (EBP), and the proliferation of Magnet hospital status, offer opportunities for strengthening the CNS role worldwide (Patten & Goudreau, 2012). Although the CNS role has gained support in recent years, it appears to be, out of all advanced practice nursing roles, the least clearly defined (Dowling et al., 2013; Kilpatrick et al., 2013). Currently many countries develop or reexamine their CNS roles or educational curricula (Arslanian-Engoren, 2011; Baldwin, 2013; Dias et al., 2013; Doody, 2011; ¨ in press; Kleinpell et al., Jokiniemi, Haatainen, & Pietila, 2014; Livneh, 2011; Roberts, 2011; Wong et al., 2010). However, the pace of and readiness for role implementation vary from country to country (Bryant-Lukosius & DiCenso, 2004; Delamaire & Lafortune, 2010; Sheer & Wong, 2008); thus, differing approaches have been taken to develop these roles in various countries. Often the rigidity and slowness of healthcare systems and regulation to change have led to the ad hoc formulation of advanced nursing roles; hence, many countries are retrospectively working toward policy formulation to support role implementation (Bryant-Lukosius et al., 2004). Variation in CNS practice and lack of uniform policies regulating CNS and other APN roles represent barriers to the accurate identification and optimal functioning of these practitioners (Furlong & Smith, 2005; Kilpatrick et al., 2013; Patten & Goudreau, 2012; Rounds, 2013). Therefore, considerable effort and collaboration of the central healthcare agents, organizations, legislators, educational institutions, and other stakeholders are required to increase clarity and common understanding related to CNS roles to support policy formulation and role implementation. The recognition of APN roles and titles is a rather recent development in Finland; however, the patterns of specialty practice have existed since the early 1900s and ¨ of specialist nurse education since the 1970s (Fagerstrom & Glasberg, 2011; Jokiniemi et al., in press). The Finnish higher education system consists of two complementary Journal of Nursing Scholarship, 2015; 47:1, 78–86. C 2014 Sigma Theta Tau International
Clinical Nurse Specialist Role in Finland
sectors: universities and polytechnic institutions. The universities’ mission is to conduct scientific research and provide instruction and postqualification education based on it. Polytechnic institutions, in turn, train professionals in response to labor market needs. The entry requirement to both APN education systems is a bachelor’s degree in nursing (Ministry of Education and Culture, 2014). Despite the history of specialist level practice and existing APN educational programs, advanced-level nursing roles have not been nationally conceptualized in a Finnish context, authorized by the National Supervisory Authority for Welfare and Health, or regulated by the government. The role of the CNS was first established within hospital care in Finland at the beginning of 2000 (Meretoja, 2002). The goal of the CNS role is to assure quality of care, support the staff’s and organization’s strategic work, and implement EBP (Jokiniemi et al., in press). Furthermore, certified nurse midwife and certified nurse anesthetist roles do exist in Finland (Malin & Hemminki, 1992; Vakkuri, Niskanen, Meretoja, & Alahuhta, 2006), but educational and other APN requirements of these roles are not equivalent to the international APN role requirements. Without formal regulation, policies, and protected titles, APN roles, such as the CNS, have been defined by individual organizations, creating the emergence of unnecessary variation in roles and thus compelling the need for national role conceptualization and standardization. The increasing interest in APN roles highlights the importance for nurses and the nursing profession to understand the language and concepts involved in order to communicate with each other, clients, and stakeholders (Bryant-Lukosius et al., 2004; Ruel & Motyka, 2009; Spross & Lawson, 2013). Furthermore, national regulation and policies are needed to facilitate role recognition, curriculum design, and effective role implementation and evaluation, yet there is scarce international research available to inform or assess APN policy formulation. This article reports on a study utilizing a policy Delphi design (de Loe, 1995; Turoff, 2002). Although the Delphi method is widely mentioned in the healthcare literature (McKenna, 1994; Powell, 2003), the policy Delphi design has not been utilized much in APN policy formulation studies.
Aims and Objectives The aim of this study was to identify and examine the expert panelists’ visions on future CNS role implementation, and to generate questions as well as supporting and opposing views for further exploration. The research questions were: 79
Clinical Nurse Specialist Role in Finland
r r r
How do the expert panelists define the future CNS role and its competencies? What are the expert panelists’ supporting and opposing views regarding the future CNS role attributes and implementation? What are the most probable threats for CNS role implementation in the future?
Jokiniemi et al.
expertise). The “expertise on APN role” received the highest mean score of 3.32, with 48% of panelists rating themselves as having a lot of expertise. The “expertise on healthcare workforce development” received the second highest mean score of 3.12. The lowest mean score of 2.44 was found in “international APN expertise.”
Data Collection Rounds
Methods and Materials Policy Delphi Design A policy Delphi design (de Loe, 1995; Turoff, 2002), a variant of the conventional Delphi, was selected. It is similar to the full Delphi in terms of procedure and intent (Keeney, Hasson, & McKenna, 2006). The policy Delphi design is considered a “decision-facilitating” tool (Powell, 2003; Turoff, 2002), which seeks all possible viewpoints and explores factors underlying disagreement (Linstone & Turoff, 2011; Turoff, 2002). Since it does not aim for consensus but explores the various opinions (Powell, 2003; Turoff, 2002), it is an effective method to inform the decision-making process within the policy formulation process (de Loe, 1995). Given the newness associated with the CNS roles in Finland, as well as the study aim of aspiring information for the basis of policy formulation, it was appropriate to use a design that highlights a broad range of options rather than aim for a consensus on one or a few options (de Loe, 1995).
Participants A purposive sampling method was used to recruit 10 to 50 participants, which has been suggested as an appropriate number of experts in a policy Delphi panel (de Loe, 1995; Turoff, 2002). Participant recruitment was planned to ascertain a high level of expertise on the APN roles and thus aid in miscellaneous information gathering. The inclusion criteria of expert panelists were (a) being a member in an interest group of APN, APN education, or healthcare management, and (b) having expertise in the area of APN, APN education, APN management, healthcare workforce development, or international APN. The nursing practice directors at five university hospitals, the National Institute of Health and Welfare, Ministry of Social Affairs and Health, nursing trade organization, and universities of applied sciences that have APN programs were contacted to obtain recommendations. Overall, 35 expert panelists were recommended and asked to participate. The interest groups were evenly represented. The panelists were asked to self-rate their expertise on a scale of 1 (little expertise) to 4 (a lot of 80
Three iterative policy Delphi rounds were conducted between June and October 2013 by using Web-based online survey and analysis software. A time estimate of answering each of the rounds varied between 20 and 40 min. Approximately 2 weeks were given to answer each questionnaire, and if no response was received, reminders were sent a few days before the due date. To alleviate response exhaustion, the topics observed were divided between the rounds. The subsequent questionnaires were sent only to the panelists who had answered the previous questionnaire; thus, the policy Delphi study can be seen as a cumulative process building on the preceding panelist contribution. The response rate was 71% (n = 25) in the first round, 63% (n = 22) in the second, and 54% (n = 19) in the third round. In the first round, open-ended questions following the study questions were used to direct the data gathering. By doing this, the panelists were allowed to bring in their timely views of the CNS roles, which might be more accurate and precise than items formed based on the literature. The second and third rounds consisted mainly of 4-point Likert-type questions (de Loe, 1995; Turoff, 2002), where statements formed based on the first round, thus illustrating the views of the panelists, were presented for rating. In ranking the statements, the panelists were asked to identify the likelihood or desirability of statements, or judge items in terms of their importance relative to others. A maximum of two response choices were asked at one time. The response choices ranged from totally disagree to totally agree, very undesirable to very desirable, very unlikely to very probable, or very unimportant to very important. In addition to rating each of the statements, panelists were asked to make additional suggestions, comments, or questions on statements to minimize respondent bias (de Loe, 1995; Keeney, Hasson, & McKenna, 2006) and to expose arguments behind ratings. The statement ratings were examined in order to measure whether the panel supported, opposed, or was ambivalent toward an option, or whether no clear picture of support emerged (de Loe, 1995). Based on the measurements, the items that had high consensus in response were omitted in subsequent rounds. Items that had a low consensus level or generated major opposing views were further examined in the next round (Rayens, 2000). Journal of Nursing Scholarship, 2015; 47:1, 78–86. C 2014 Sigma Theta Tau International
Clinical Nurse Specialist Role in Finland
Jokiniemi et al.
To ensure content and face validity (Mead & Moseley, 2001), all three questionnaires were pretested with six professionals from outside the research setting. These professionals were identified by the research team using the same inclusion criterion as the original study participants. In addition to completing the email questionnaires, the experts in the pretesting phase were asked to give specific feedback about the policy Delphi process, including the time taken to complete the questionnaires, preferred method of rating, and question understandability and comprehensibility. Minor alterations were made to the questionnaires according to the feedback.
Data Analysis The policy Delphi method includes the careful management and analysis of both qualitative and quantitative data. The data produced by the open-ended questions were analyzed by qualitative content analysis, and statements significant to study design were formed for panelist rating. The quantitative data acquired through statement ratings were analyzed by using the Statistical Package for the Social Sciences (version 19.0; SPSS Inc., Chicago, IL, USA), with the aim of identifying how much the panel agreed or disagreed with each of the statements. To detect any differences between the respondent categories, the respondent ratings were also analyzed using the KruskalWallis test. To analyze the quantitative data, each rating set was examined according to mean, rating distribution, and consensus level (de Loe, 1995). Mean scores were examined in order to assess the multiple statement preference. Consensus was examined, according to de Loe’s (1995) suggestion, to be high, medium, low, or none, indicating the degree to which the group was able to agree on a given issue. In addition to consensus examination, further examination of each rating distribution was needed to observe whether the panelists’ consensus opposed or supported each statement. An example of the rating distribution and consensus levels can be seen in Table 1. To interpret Table 1, it can be seen that “advanced clinical nursing” as a future CNS role domain attained a low consensus level; thus, just over 60% of the ratings fell into two contiguous categories. Furthermore, the consensus on CNS “leadership” domain is medium, with 74% of answers being in two contiguous categories. Nevertheless, when further examining the leadership ratings, it was noted that the majority of ratings were in scale point 1 or 2; thus, here, medium consensus lay in opposition, although only weak, for this role domain being included in the future CNS role. Journal of Nursing Scholarship, 2015; 47:1, 78–86. C 2014 Sigma Theta Tau International
Table 1. Rating Distribution, Level of Consensus, and Support on CNS Role Domains Which domains should CNS work include in the future?
Ratings on scalea 1 2 3 4
Consensus
Support
Advanced clinical nursing Education Practice development Consultation Research Clinical leadership
4 0 0 0 1 3
None High High High High Medium
WS SS SS SS SS WO
4 1 0 0 1 9
4 8 2 7 9 5
7 10 17 12 8 2
a 1 = very undesirable; 2 = undesirable; 3 = desirable; 4 = very desirable. Note: CNS = clinical nurse specialist; High = 70% of ratings are in one category or 80% in two contiguous categories; Medium = 60% of ratings are in one category or 70% in two contiguous categories; Low = 50% of ratings are in one category or 60% in two contiguous categories; None = 75% of ratings on point 3 or 4); WS = weak support (>50–75% ratings on point 3 or 4); WO = weak opposition (
