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Structural and Process Factors That Influence Clinical Nurse Specialist Role Implementation

Kilpatrick, Kelley PhD, RN; Tchouaket, Eric PhD; Carter, Nancy PhD, RN; Bryant-Lukosius, Denise PhD, RN; DiCenso, Alba PhD, RN

doi: 10.1097/NUR.0000000000000182
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Purpose/Objectives: The aim of this study was to examine the influence of structure and process on clinical nurse specialist (CNS) role implementation.

Design: We conducted a secondary analysis of cross-sectional survey data.

Setting: The study was performed in Canada.

Sample: The authors included 445 of 471 questionnaires (94.5%) of graduate-prepared CNSs.

Methods: Based on Donabedian’s framework, we conducted a secondary analysis of CNS responses using hierarchical regression. The internal consistency of the 6 CNS role dimensions and team dynamics subscales was excellent.

Results: The use of a framework to guide CNS role implementation influences all the role dimensions. Employer understanding of the CNS role, working in an urban catchment area, specialty certification, and more years in a CNS role had a direct positive influence on team dynamics. Full-time employment exerted a direct negative influence on this dimension. Furthermore, team dynamics (as a mediator variable), seeing patients in practice, and having an office in the clinical unit exerted a direct positive influence on the clinical dimension. Having an annual performance appraisal and a job description exerted a direct negative influence on the clinical dimension. Employer understanding, working in an urban area, full-time employment, and specialty certification had an indirect effect on the clinical dimension. Accountability to a nonnurse manager exerted a direct negative influence on the education dimension. The research and scholarly/professional development dimensions were influenced by more years in a CNS role. Accountability to a nurse manager exerted a direct positive influence on the organizational leadership dimension; unionization and seeing patients in practice had a direct negative influence on this dimension. Seeing patients in practice and full-time employment exerted a direct positive influence on the consultation dimension.

Implications: The identification of structures and processes that influence CNS role implementation may inform strategies used by providers and decision makers to optimize these roles across healthcare settings and support the delivery of high-quality care.

Author Affiliations: Assistant Professor, Faculty of Nursing, Université de Montreal, Affiliate Faculty, Canadian Centre for Advanced Practice Nursing Research, and Researcher, Hôpital Maisonneuve–Rosemont Research Centre, Montréal, Quebec (Dr Kilpatrick); Assistant Professor, Department of Nursing, Université du Québec en Outaouais, Saint-Jérôme, Québec (Dr Tchouaket); Assistant Professor, School of Nursing, McMaster University, and Affiliate Faculty, Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario (Dr Carter); Associate Professor, School of Nursing and Department of Oncology, McMaster University, and Codirector, Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario (Dr Bryant-Lukosius); and Professor Emeritus, School of Nursing and Department of Clinical Epidemiology & Biostatistics, McMaster University, and Senior Advisor, Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario (Dr DiCenso), Canada.

All authors made significant contributions to the article.

The project was supported by the Canadian Nurses Association and the Office of Nursing Policy, Health Canada. K.K. received a junior 1 researcher award from the Fonds de recherche du Québec-Santé.

The authors report no conflicts of interest.

Correspondence: Kelley Kilpatrick, PhD, RN, Faculty of Nursing, Universite de Montreal, Hôpital Maisonneuve-Rosemont Research Centre, CSA-RC-Aile bleue, Room F121 5415 boul. l’Assomption, Montréal, Quebec, Canada H1T 2M4 (kelley.kilpatrick@umontreal.ca).

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