REVIEW

Clinical role of the nurse: concept analysis Maria A Mendes, Din
a ALM da Cruz and Margareth Angelo

Aims and objectives. To identify the attributes of the concept ‘clinical role of the nurse’ in the literature. Background. The concept of nurses’ clinical role is frequently mentioned in literature, but hardly explored in conceptual terms. This has implications for nursing practice and education. Design. Qualitative and descriptive study, which corresponds to the first phase in the concept development of the qualitative concept analysis method – identification of concept attributes. Methods. The critical literature analysis method was used to identify the antecedents, defining attributes and consequences of the nurse’s clinical role. A systematic literature search was undertaken in International Literature in Health Sciences, Cumulative Index to Nursing and Allied Health Literature and Latin American and Caribbean Health Sciences. Results. The clinical role was shown to be a process of complex interaction between nurse and patient, with critical thinking, informed experience and a sense of clinical autonomy as its antecedents. Consequences of nurses’ clinical role include transformations in the organisation and process of nursing practice. A theoretical proposal was elaborated for the concept of the clinical role of the nurse, identifying the defining attributes, antecedents and consequences. Conclusions. The clinical role of the nurse concept that was developed represents innovative evidence on the theme. Nevertheless, a deeper understanding of nurses’ clinical role is needed, as well as refinement of its conceptual components. This study should be integrated into a field research project, designed to illuminate how nurses manifest and articulate the concept in clinical practice. Relevance to clinical practice. Knowledge of clinical role attributes, associated with nursing competencies, can contribute to reflection on the dimensions involved in nursing practice and inform not only teaching and professional practice, but also health policies.

What does this paper contribute to the wider global clinical community?

• Unedited conceptual/theoretical •

formulation of the clinical role of the nurse. Relevant theoretical material to expand the components of the concept clinical role of the nurse.

Key words: clinical competence, clinical role, concept formation, nurse’s role, nurse–patient relations Accepted for publication: 5 December 2013

Authors: Maria A Mendes, PhD, Professor, Nursing School of the Federal University of Alfenas, Alfenas, MG; Dina ALM da Cruz, PhD, Full Professor, S~ao Paulo University Nursing School, S~ ao Paulo, SP; Margareth Angelo, PhD, Full Professor, S~ao Paulo University Nursing School, S~ao Paulo, SP, Brasil

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Correspondence: Maria A Mendes, Professor, Nursing School of the Federal University of Alfenas, Rua Augusto Teodoro, 228 – Alfenas, MG, CEP 37 130-000, Brasil. Telephone: +55 (35) 3291 3621. E-mail: [email protected]

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 318–331, doi: 10.1111/jocn.12545

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Introduction This study is focused on the idea of the clinical role. Although this expression is commonly used in daily reality, little has been explored in regard to its conceptual terms. In the literature, the concept of the clinical role of the nurse is strongly linked to the emergence of new functions or designations for nurses, including the activities of clinical nurse specialists or ‘practitioners’ and advanced nursing practice. The clinical role of the nurse concept is predominantly present in the work of British authors. In general, authors discuss this role indirectly. Only the publication entitled ‘Future clinical role of nurses in the United Kingdom’ specifically addresses the clinical role. In this article, the author expresses a personal view and discusses how to improve the quality of nursing care, along with the use of skills and talents in new, advanced ways by nurses (Mullally 2001). Even in the large number of publications in which nursing teachers’ clinical role is highlighted, the concept of the clinical role of the nurse is not evident, as in the work by Carlisle et al. (1997), Clifford (1999) and Barrett (2007). It is observed in publications that by describing or recommending behaviours, practices or experiences, the idea of clinical role is frequently present and highlighted as the essence of nursing practice (Lee 1996, Drach-Zahavy & Dagan 2002). There seems, though, to be a bias in nursing literature. Nurses’ clinical role is considered fundamental, but scientific literature contains no explicit ideas regarding the concept of a clinical role. Shewan and Read (1999) mentioned that the exploration and development of the concept of the clinical role of the nurse in scientific literature are secondary issues. And today, over a decade later, there is still little understanding regarding the concept, without explanations of the nature of this role. Many of the concerns originating in the nursing profession with regard to the development of new roles consist of the need to maintain a continuing debate, seeking coherence between the limits and responsibilities of each role, and, at the same time, to retain the essence of nursing. In this article, an analysis is presented on the concept of the clinical role of the nurse, seeking to enhance its usefulness in nursing science and practice, as well as to offer references to reflect on its dimensions, including the scope of practice, clinical autonomy levels, professional performance expectations, education and the corresponding preparation for this role. In view of the range and complexity of nursing practice, some inquiries emerge, such as ‘Does clinical role reflect © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 318–331

Clinical role of the nurse

something truly unknown, or is it a novel title for a previously practised activity?’ ‘What is the clinical role nurses perform?’ ‘What are the values, foundations, premises, attributes and skills nurses share in clinical role performance?’.

Aim and methods To identify attributes of the concept of the clinical role of the nurse presented in the literature. Concepts are ‘cognitive representations’ of a perceived reality, constituted of direct or indirect experiences, ranging from empirical and observable experiences to mental inferences; they may be relatively abstract and indirectly observable, based on situations, events or true behaviours (Morse 1995). In the function of their abstract nature, concepts are verified by determining their components, which are generally referred to as constituent elements, attributes, characteristics, properties, essential or defining aspects and criteria (Morse 1995). Qualitative concept analysis research methods have recently emerged and permit the identification of a concept’s common attributes belonging to the same category, involving the use of current data obtained through participant observation and interviews or through the use of literature as a data source (Morse 1995). The expression concept analysis, as used by Morse et al. (1996), means a questioning process that explores the maturity of concepts. The authors define a mature concept as one that is ‘welldefined, has clearly described characteristics, delineated boundaries, and documented preconditions and outcomes’ (Morse et al. 1996, p. 255). Thus, the maturity of a concept can be revealed through its internal structure, uses, representativeness and relation to other concepts. Additionally, concept analysis refers to the process of discovering, exploring and understanding concepts with a view to their development, delineation, comparison, clarification, correction or identification. Much of what entails the intrinsic role of the clinical nurse remains invisible or assumed in the eyes of practice. Nevertheless, it does take place but in a veiled way, and the nurse does not appropriate herself of it with real value and in a meaningfully consolidated manner. Therefore, the clinical role of the nurse cries out for a deep conceptual organisation. Thus, this study corresponds to the first phase in the conceptual development of the qualitative concept analysis method, which comprises three phases: identification of concept attributes, verification of attributes and identification of concept manifestations (Morse 1995). The strategy

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of critical literature analysis, as described by Morse et al. (1996) and Morse (2000), was used to extract the group of attributes from the literature that defines the concept of the clinical role of the nurse. Critical literature analysis permits exploring the different conceptions of a given concept, the contexts in which it is being used and information concerning its implicit and explicit attributes, thus contributing to the assessment of the concept’s logical coherence (Morse 2000). Concept development involves exploring a concept’s antecedents, attributes and consequences (Cowles 2000). Defining attributes are words and/or expressions used to describe the defining characteristics of the concept of interest, distinguishing it from other similar or related concepts (Walker & Avant 2005). In this case, these are the peculiarities that make up the clinical role of the nurse. Antecedents and consequences of the concept are considered as situations, events or incidents that happen a priori and a posteriori to the phenomenon of interest, respectively (Walker & Avant 1995). Antecedents and consequences may coincide or not with the defining attributes. Antecedents help to understand the social context in which the concept is generally used and allow refining the defining attributes and identifying the premises underlying the studied concept (Walker & Avant 2005). In this study, the antecedents are determining or triggering elements of the clinical role that somehow contribute to its performance and concretisation. Consequences, in turn, are perceived as resulting or deriving from the application of the studied concept. They are useful to determine ideas, variables or relationships that are frequently neglected when seeking to understand the concept (Walker & Avant 2005). The theoretical exploration process of the abstract and defining components of the clinical role of the nurse concept was carried out by one author (MAM) in the MEDLINE (International Literature in Health Sciences), CINAHL (Cumulative Index to Nursing and Allied Health Literature) and LILACS (Latin American and Caribbean Health Sciences) databases, during the month of March 2012. In the MEDLINE search, the following strategy was applied: ‘nurse’s role’ [Subject descriptor] and (‘clinical competence’) or ‘nurse clinicians’ [Subject descriptor] and (‘nursing’) or ‘nurses’ [Subject descriptor], which resulted in 110 citations. To further focus the bibliographic search, a second strategy was applied in MEDLINE, through a title search, using the expression: clinical role [Title] AND (nursing OR nurses). This second search produced 28

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citations, only one of which was repeated from the previous strategy. In addition, in CINAHL, the following strategy was applied: MW Clinical AND MW Role AND Nurses, returning 13 citations. The application of the subject descriptor ‘nurse clinicians’ in LILACS resulted in 24 citations. The four bibliographical searches produced 175 eligible citations.

Selection criteria As this literature review was designed to identify the attributes of nurses’ clinical role, all types of publications were included for reading, whether empirical or theoretical studies, which could provide defining elements of the concept of clinical role and published in Portuguese, English or Spanish. Titles and, when available, the abstracts of the 175 references were read by two authors (MAM, DALMC), to select the publications pertinent to the study’s objective. In the event of doubt, or if the abstract alone did not permit this definition, the publication was retained until the next phase, when the full texts were read. The full texts of the references selected were read, based on the abstracts, with a view to identify those papers that contained useful information to study the clinical role of nurses, that is, those texts were selected that outlined possible defining elements of nurses’ clinical role, whether antecedents, attributes or consequences. Similarly, texts in which not even one possible clinical role attribute was identified through selected reading were discarded. Any doubts were solved with the help of the third author (MA). The authors, all nurses, were responsible for the theoretical exploration process in the nursing literature, as well as for data extraction and analysis. One of the authors is experienced in cardiology, the second in family health and the third in woman’s health and medical clinical care.

Data extraction and analysis According to Morse et al. (1996), the main aims of qualitative concept analysis methods are the organisation and consolidation of data into categories, whether these derive from texts or observation. Categorisation seeks to identify attributes, together with antecedents and consequences. Thus, the contents of the remaining papers were subject to comprehensive reading and critical analysis. Text that could contribute to the study of the clinical role of the nurse concept was highlighted. These short texts were then © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 318–331

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examined, considering their contexts, to identify which elements they addressed: attributes, antecedents or consequences. The authors (MAM, DALMC, MA) developed this analysis, first separately and then jointly, with a view to reaching a consensus, based on which codes were attributed to the extracted texts. Next, to identify the conceptual boundaries of nurses’ clinical role, that is, to identify those attributes of the clinical role of the nurse concept that distinguish it from other concepts, the analysis of the outlined categories was accomplished through constant comparison. The comparison between one category and another permits the identification of defining characteristics/attributes for each concept, and this comparative technique facilitates the acknowledgement of their conceptual boundaries (Morse et al. 1996). First, the codes were compared and grouped by function of similar meanings, after which the groups were inductively labelled. Based on the assessment of similarities and variations between the groups, analytic categories and subcategories were created. As the codes had been organised under defining attributes, antecedents and consequences, the established categories maintained this organisation. The contents of the established categories were mutually compared to check their pertinence as defining attributes, antecedents or consequences. Categories that referred to the same aspect of the clinical role were linked. The categories were preliminarily labelled, based on the interpretation of the meanings for the attributes they contained. By linking similar groups of attributes and using one attribute to illustrate a group, that is, by applying synthesis and abstraction techniques, and seeking to accurately describe the concept (Morse et al. 1996), some categories changed labels several times, until a name was found that represented the meaning of the attributes they grouped, which then became permanent. For the sake of methodological rigour in this analytical phase, the authors sought mutual consensus in establishing the main categories. First, two of the authors (MAM, DALMC) elaborated the categories, which were validated by the third author (MA). Thus, if there was no consensus concerning a given category, the three authors discussed it until they reached a consensus. While reading and analysing the publications, the authors’ concern regarding nurse teachers’ clinical role was found to be clearly relevant. Then, the researchers decided not to include in this study instances directly related to teachers’ clinical role, setting them aside for future discussion. This decision was based on the observation that the context of the dimensions of teachers’ clinical role differs from the contexts of practice in other nursing areas. © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 318–331

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Results Hence, a new selection process was performed, resulting in 30 studies for analysis. The main characteristics of the 30 publications are described in Table 1: author and year, country of origin, study design and objective. The literature analysis results for the concept of the clinical role of the nurse are presented in three parts: first the defining attributes, followed by the antecedents and, finally, the consequences of the concept. The categories and subcategories of the attributes, antecedents and consequences of nurses’ clinical role, as well as the main codes and references that gave rise to the attributes, are condensed in Tables 2, 3 and 4, respectively. And, to facilitate the understanding of the categories, a summary of the titles of categories and subcategories is presented in Table 5 to analyse the antecedents, defining attributes and consequences of the clinical role of the nurse. Another result is the unedited conceptual/theoretical formulation of the clinical role of the nurse.

Defining or critical attributes According to the literature, the clinical role takes place in a space of interaction between nurse and client, whether these are individuals, families, groups or communities. Thus, the defining attribute – interaction with the client – is highlighted as a fundamental and constituent characteristic of nurses’ clinical role (Davies 1993). The clinical nurse as a being (Tornabeni & Miller 2008) is unveiled in the care relation, based on an effective interactional communication process (Jones & Cheek 2003, Lofmark et al. 2006), at the bedside (O’Brien et al. 2008) or in another health scenario; the clinical nurse may simply count as part of the medical team or as part of a multiprofessional team (Mullally 2001). Interactional targets accompany the nurse’s relation with the individual. It is the nature of these targets that distinguish the interaction that derives from the clinical role from other types of social interaction. In the literature, some interactional targets were evidenced: being responsive to the care context (Roberts-Davis & Read 2001), developing advanced nursing practice (Grindel 2005) and expert clinical practice (Mullally 2001). The development of clinical decision processes in areas identified as part of the nursing domain was also found: rest, nutrition, elimination, mobility, daily patient activities, dressings, medication administration, emotional support and referrals (Hoffman et al. 2004). Satisfaction of patient needs (Davies 1993),

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MA Mendes et al. Table 1 Characteristics of the studied publications. S~ao Paulo, 2012

Author/year

Country of origin

Type of study

Courtenay et al. (2010)

UK

Empirical

Lammon et al. (2010)

U SA

Empirical

McElhinney (2010)

UK

Empirical

Jones et al. (2010)

UK

Empirical

Vanaki and Memarian (2009) O’Brien et al. (2008)

USA UK

Empirical Empirical

Tornabeni and Miller (2008)

USA

Theoretical

Aitken et al. (2008)

Australia

Empirical

Courtenay and Carey (2008)

UK

Empirical

O’Connor et al. (2008)

Australia

Empirical

Mantzoukas and Watkinson (2007) Miles et al. (2007)

UK

Theoretical

UK

Theoretical

Chaloner (2007) Barrett (2007) Lofmark et al. (2006)

UK UK Sweden

Theoretical Theoretical Empirical

Grindel (2005) Griscti et al. (2005) Ashmore and Banks (2004) Hoffman et al. (2004) Jones and Cheek (2003)

USA Canada UK Australia Australia

Theoretical Empirical Empirical Empirical Empirical

Roberts-Davis and Read (2001) Mullally (2001)

UK

Empirical

UK

Theoretical

Cox and Ahluwalia (2000)

UK

Empirical

Clifford (1999) Carlisle et al. (1997) Forrest et al. (1996)

UK UK UK

Empirical Empirical Empirical

Lee (1996) Crotty (1993)

China UK

Empirical Empirical

Davies (1993)

Australia

Empirical

Clifford (1993)

UK

Empirical

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Aims To explore the views of patients with diabetes about nurse prescribing and the perceived advantages and disadvantages To report the strategies used and the progress made at The University of Alabama Capstone College of Nursing in the development of innovative partnerships to develop the role of the CNL in diverse clinical settings To identify the factors that influence nurse practitioners ability to practice physical examination skills in the clinical area To measure the effectiveness of training in psychopharmacology at the improvement mental health nurses’ knowledge of the subject To determine the process of acquiring clinical competency by nurses To report about students’ general perceptions of nursing as a career prior to their first clinical placement To describe the evolution and implementation of the clinical nurse leader’s role To describe the priorities of the educational outcomes of nursing post graduate programmers, specialty in critical care To examine Nurse Independent/Nurse Supplementary prescriptions for people with diabetes and the extent to which these nurses feel prepared for this role To describe the clinical aspects of the palliative care nurse consultant work in the acute hospital setting To provide clarifications about the concept of advanced nursing practice To discuss how nurses are underutilized in long-term clinical management of patients requiring antiretroviral therapy To show how ethical analysis and decision-making affect the professional role To evaluate the clinical role of nurse lecturers To compare opinions of graduating nursing students, rating their own competence, with the opinions of experienced nurses on the competence of newly-graduated nurses To discuss about Clinical Nurse Leader and the doctorate in nursing practice To explore the clinical role of nurse educator in Malta To analyze student nurses’ current skills and to compare them with earlier findings To investigate the contextual factors that influence clinical decision-making To detail the diversity that exists in contemporary nursing practice and workplaces, in Australia To identify the differences between the Specialist and the Nurse Practitioner, in order to clarify the latter’s role To discuss how to meet the call to improve the quality of nursing care, alongside the need to use nurses’ new skills and talents To discover how clinically effective nursing care is fostered among clinical nurse specialists (CNSs) and nurse practitioners (NPs) in an NHS trust in East London To conceptualize the clinical role of the nurse teacher To explore the changing role of the nurse teacher To explore the present and ideal role of the nurse teacher in the clinical area from the perspective of nurse teachers, ward/sister/charge nurses, staff nurses and student nurses To critically analyze the literature about the nurse teacher’s clinical role To describe the findings related to the clinical role activities of the nurse teacher, in Project 2000 To determine whether the observation of clinical role models leads students to discover knowledge embedded in clinical practice To examine the role of the nurse teacher in teaching, research, clinical practice and management

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Table 2 The analysis categories and subcategories, of the defining attributes of the clinical role of the nurse. S~ ao Paulo, 2012 Categories/subcategories

Main codes and references

Interaction with the client

Interactions with the client were seen as the primary purpose of the clinical nursing role (Davies 1993, p. 631) Responsiveness to the context of care (Roberts-Davis & Read 2001, p. 40); advanced nursing practice (Grindel 2005, p. 209); expert clinical practice (Mullally 2001, p. 338); decision-making in areas identified as belonging to the nursing domain, such as rest, nutrition, elimination, mobility and activities of daily living, wound dressings, administration of medications, emotional support and referrals (Hoffman et al. 2004, p. 54); maintenance of clinical leadership (O’Connor et al. 2008, p. 351, Lammon et al. 2010, p. 259); meeting of the patient’s needs (Davies 1993, p. 631); prevention of diseases such as cancer and the coronary heart disease (Mullally 2001, p. 338)

Interaction goals

Care experiences Evaluation/assessment

Diagnosis

Planning

Intervention

Care space governance

Patient-centred care

Strategies and practice of improvement the care outcome

Assessing (e.g. tissue viability) (Mantzoukas & Watkinson 2007, p. 30); involving and relying on tools of observation, questioning, vigilance and monitoring (Jones & Cheek 2003, p. 122, Courtenay et al. 2010, p. 1052); taking a systematic patient history and carry out a full physical examination (Jones et al. 2010, p. 809; Courtenay et al. 2010, p. 1051) including cardiopulmonary and neurological assessment (Roberts-Davis & Read 2001, p. 40, McElhinney 2010, p. 3178) Making diagnostic decisions based on the interpretation of clinical and other findings, such as laboratory results and X-rays (Roberts-Davis & Read 2001, p. 40); assessing patients’ needs for nursing care (Lofmark et al. 2006, p. 724); identifying patients according to early signs of disease and risk factors (Roberts-Davis & Read 2001, p. 40) Referring to other professionals (Mantzoukas & Watkinson 2007, p. 30), like the physician (Miles et al. 2007, p. 558); admitting and discharging patients according to the protocols (Mullally 2001, p. 337, Miles et al. 2007, p. 558, O’Connor et al. 2008, p. 352); planning individualized nursing care (Aitken et al. 2008, p. 75), setting priorities (Lofmark et al. 2006, p. 726) and selecting the most appropriate intervention (Ashmore & Banks 2004, p. 21); prescribing medicines and treatments to patients in specified conditions and within the agreed protocols (Jones et al. 2010, p. 805; Courtenay & Carey 2008, p. 404, Mullally 2001, p. 337) Undertaking nursing interventions (Lofmark et al. 2006, p. 724), as symptom management (O’Connor et al. 2008, p. 351), mouth care (Mullally 2001, p. 337); administering drugs (Lofmark et al. 2006, p. 724); analyzing changes in physiological parameters and appropriately intervening (Aitken et al. 2008, p. 73); realizing complex care for critically ill patients (Aitken et al. 2008, p. 73) and also those in terminal care (O’Connor et al. 2008, p. 352); performing minor surgeries, clinical and outpatient procedures (Mullally 2001, p. 337); educating (Grindel 2005, p. 209) and habilitating patients for self-care (Davies 1993, p. 631); recording of the care given to patients (Mullally 2001, p. 337) Development of clinical governance (Cox & Ahluwalia 2000, p. 1064, Aitken et al. 2008, p. 70, Lammon et al. 2010, p. 259); team management (Jones & Cheek 2003, p. 124, Tornabeni & Miller 2008, p. 610); information management (Tornabeni & Miller 2008, p. 610); setting practice standards in the unit (Grindel 2005, p. 209); maintaining a focus on quality, safety, patient’s comfort and cost effectiveness (Davies 1993, p. 629, Tornabeni & Miller 2008, p. 612, Vanaki & Memarian 2009, p. 290); leadership of the local health services (Mullally 2001, p. 337, Jones & Cheek 2003, p. 124, Vanaki & Memarian 2009, p. 287, Lammon et al. 2010, p. 259) Humanized care (Davies 1993, p. 629, Lammon et al. 2010, p. 259); focus on patient interest, inclusion and involvement in decision making regarding his care (Davies 1993, p. 629, Aitken et al. 2008, p. 75); developing a trustful relationship with the patient (Davies 1993, p. 633); compassion with the patient (Davies 1993, p. 629); respecting dignity and privacy of the patient (Davies 1993, p. 629); psychosocial care (O’Connor et al. 2008, p. 352); emphasis on the person rather than the routines (Davies 1993, p. 629); counseling the patient, his family and the staff, and defending their interests (Jones & Cheek 2003, p. 124, Grindel 2005, p. 209, O’Connor et al. 2008, p. 351, Tornabeni & Miller 2008, p. 610); family care (O’Connor et al. 2008, p. 352) Outcomes management (Lammon et al. 2010, p. 259); Challenge the status quo (Aitken et al. 2008, p. 69); critical review of practice (Aitken et al. 2008, p. 69); application of methodologies related to the evaluation of practice (Grindel 2005, p. 209); engaging in activities to enhance level of practice and quality outcomes for patients (Aitken et al. 2008, p. 73); introducing changes in practice gradually with according to contextual factors (Davies 1993, p. 633)

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MA Mendes et al. Table 2 (Continued) Categories/subcategories

Main codes and references

Evidence-based practice

Scientific underpinnings for practice (Grindel 2005, p. 209, Lofmark et al. 2006, p. 724, Mantzoukas & Watkinson 2007, p. 32, Lammon et al. 2010, p. 259); assimilation and application in clinical practice of research-based information include protocols (Tornabeni & Miller 2008, p. 610, Lammon et al. 2010, p. 259); implementation outcomes-based practice (Grindel 2005, p. 209); development of the practice alongside research and education (Mullally 2001, p. 338); consultation (Mantzoukas & Watkinson 2007, p. 30); continually adapting to meet the demands of the professional role (Davies 1993, p. 633) Fulfillment the duty of care (Aitken et al. 2008, p. 73); accountability for the health care outcomes (Tornabeni & Miller 2008, p. 610, Vanaki & Memarian 2009, p. 289); understanding of clinical activities (Aitken et al. 2008, p. 69); free of doubts instruction and interventions (Aitken et al. 2008, p. 73); recognizes unsafe practice (Aitken et al. 2008, p. 73); recognition the limitations of their practice (Miles et al. 2007, p. 558); responsibility for own actions (Aitken et al. 2008, p. 73, Vanaki & Memarian 2009, p. 288); zeal for accuracy and reliability (Lofmark et al. 2006, p. 724); acting complies with the profession’s code of ethics and code of professional conduct (Chaloner 2007, p. 40, Aitken et al. 2008, p. 73, Vanaki & Memarian 2009, p. 288) Effective participation in the health care team (Aitken et al. 2008, p. 69, Lammon et al. 2010, p. 259); interaction in a flexible and equalitarian way with the whole health care team (Davies 1993, p. 631, Vanaki & Memarian 2009, p. 289); acting as integrator and facilitator of the health care team (Davies 1993, p. 631, Lammon et al. 2010, p. 259); actively support for staff and other health professionals (Cox & Ahluwalia 2000, p. 1071, O’Connor et al. 2008, p. 354); communication and collaboration with other members of the health care team (Grindel 2005, p. 209, Tornabeni & Miller 2008, p. 611, Courtenay et al. 2010, p. 1052); focuses on interdependency of all care disciplines and the expertise of the team (Tornabeni & Miller 2008, p. 611); acting as the interface between medical and nursing care (Cox & Ahluwalia 2000, p. 1070, Mantzoukas & Watkinson 2007, p. 30) Member of a nursing profession (Tornabeni & Miller 2008, p. 610); education (Tornabeni & Miller 2008, p. 610, Vanaki & Memarian 2009, p. 288, Lammon et al. 2010, p. 259); information, guiding and teaching of workers and students (Crotty 1993, p. 461, Cox & Ahluwalia 2000, p. 1071); development of mentors and precepts students activities (Aitken et al. 2008, p. 73); mentoring of others health care professionals team (Grindel 2005, p. 209, Tornabeni & Miller 2008, p. 610)

Professional commitment, ethical awareness and zeal for accuracy and reliability

Effective, collaborative, facilitative and equalitarian interaction with the health team

Commitment to the permanent nursing formation and education

including comfort needs (Mullally 2001) and maintenance of clinical leadership (O’Connor et al. 2008), was another target found in the literature. Care experiences take place in the interactional space. In the literature, the following experiences were identified: assessing, seeking information, diagnosing, planning and intervening (Table 2). Most of the activities selected in the studies surveyed were classified under interventions. In the governance of the care interaction space, experiences were observed that belonged to unit management but, at the same time, are closely related to the care process. Although these activities deal with administrative structure, they rest on clinical components, giving rise to the expression of clinical management as clinically managing patients with chronic conditions (Mullally 2001) or managing clinical outcomes (Tornabeni & Miller 2008) based on scientific evidence (Cox & Ahluwalia 2000). This entails the idea that management at the clinic involves subjective aspects, such as the connection the nurse makes between palliative care in the community and the hospital nursing service (O’Connor et al. 2008).

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Patient-centred care is presented as a defining attribute of the clinical role, in terms of the patient’s inclusion and participation in decision-making concerning his/her care (Davies 1993, Aitken et al. 2008), development of a trust relationship with the patient (Davies 1993), feeling compassion (Davies 1993) and respect for the patient’s dignity and privacy (Davies 1993). O’Connor et al. (2008) underscore psychosocial care, emphasising the person instead of routines (Davies 1993). Defending and counselling patients, their families and the support team (Jones & Cheek 2003, Grindel 2005, O’Connor et al. 2008, Tornabeni & Miller 2008) are also identified as attributes of nurses’ clinical role regarding patient-centred care. Care outcome improvement strategies and practice also characterise the clinical role nurses play. These include challenging the status quo (Aitken et al. 2008), critically reviewing practices (Aitken et al. 2008), applying practice evaluation-related methods (Grindel 2005), developing activities to improve practice and patient outcomes (Aitken et al. 2008) and introducing changes in practice, gradually and according to contextual factors (Davies 1993). © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 318–331

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Table 3 Categories of analyse the antecedents of clinical role of the nurse. S~ ao Paulo, 2012 Categories

Main codes and references

Critical thinking

Ethical sensitivity (Chaloner 2007, p. 41); communication interpersonal skills (Jones & Cheek 2003, p. 123, Ashmore & Banks 2004, p. 20, Courtenay et al. 2010, p. 1051); clinical skills (O’Brien et al. 2008, p. 1847; Tornabeni & Miller 2008, p. 609); cognitive skills (Hoffman et al. 2004, p. 54); critical thinking and analytical skills (Mantzoukas & Watkinson 2007, p. 32, Vanaki & Memarian 2009, p. 287); clinical judgment and decision-making skills as core with clinical autonomy (Lofmark et al. 2006, p. 726, Mantzoukas & Watkinson 2007, p. 32); knowledge and skills for clinical decision making (Courtenay et al. 2010, p. 1051, Jones et al. 2010, p. 811, Tornabeni & Miller 2008, p. 612, Lofmark et al. 2006, p. 726, Jones & Cheek 2003, p. 123); management and educative capabilities (Mantzoukas & Watkinson 2007, p. 30); professional leadership (Jones & Cheek 2003, p. 124, Mantzoukas & Watkinson 2007, p. 33, Vanaki & Memarian 2009, p. 287) Clinical focus (Aitken et al. 2008, p. 75); formation with practical experiences (Lofmark et al. 2006, p. 726); clinical learning experiences (Tornabeni & Miller 2008, p. 610); practice and education to be intricately linked (Tornabeni & Miller 2008, p. 609); clinical experience (Hoffman et al. 2004, p. 55, Vanaki & Memarian 2009, p. 287, Courtenay et al. 2010, p. 1051); patient care delivery models (Tornabeni & Miller 2008, p. 609, Vanaki & Memarian 2009, p. 290); clinical leadership (Grindel 2005, p. 209, Mantzoukas & Watkinson 2007, p. 33, Tornabeni & Miller 2008, p. 612); postgraduate education centers for nursing staff and for new professionals (Miles et al. 2007, p. 557) Clinical autonomy and professional accountability (Vanaki & Memarian 2009, p. 288, McElhinney 2010, p. 3181) Mantzoukas & Watkinson 2007, p. 33); valuing the importance of the fundamentals of care to patients (Mullally 2001, p. 338); values to work role (Hoffman et al. 2004, p. 54, McElhinney 2010, p. 3180); awakening to their therapeutic potential (Aitken et al. 2008, p. 69, Vanaki & Memarian 2009, p. 289); attitude of willingness to make decisions (Hoffman et al. 2004, p. 54)

Informed experience

Clinical autonomy, professional accountability, valuation of work role and fundamentals of care to patients

Table 4 Categories of analyse the consequences of clinical role of the nurse. S~ ao Paulo, 2012 Categories

Main codes and references

Impact in the identity, development and socialisation professional

Validation of the choice professional (O’Brien et al. 2008, p. 1843); modeling of the conceptions what is nursing (O’Brien et al. 2008, p. 1843); development of particular skills and techniques (Davies 1993, p. 628); continuing professional growth (Davies 1993, p. 632); high standards of care (Mullally 2001, p. 338); better use of nurses’ skills (Jones et al. 2010, p. 810, Courtenay & Carey 2008, p. 411); growing analytic and ethical posture (Chaloner 2007, p. 41); autonomous and imputable practice (Lofmark et al. 2006, p. 722); improves job satisfaction and autonomy of nursing decisions (Jones & Cheek 2003, p. 125, Courtenay & Carey 2008, p. 411, Tornabeni & Miller 2008, p. 610); providing the good clinical role models (Davies 1993, p. 627); influence in professional socialization (Davies 1993, p. 628) Attendance to care demands (Tornabeni & Miller 2008, p. 609); resolvability in the care process (Mullally 2001, p. 337); effectively address care environment challenges (Tornabeni & Miller 2008, p. 610); safe and effective care (Mullally 2001, p. 337); holistic care (Davies 1993, p. 629); avoidance fragmentation of nursing care (Mantzoukas & Watkinson 2007, p. 30); facilitation of care and patients’ learning (Tornabeni & Miller 2008, p. 611, Courtenay et al. 2010, p. 1051); independence of patients on nursing staff (Davies 1993, p. 630); positive effect on service (O’Connor 2008, p. 350); excellence in patient care (Mullally 2001, p. 337, O’Connor 2008, p. 351); changes within the practice setting (Grindel 2005, p. 209, Tornabeni & Miller 2008, p. 609); improve patients outcomes (Tornabeni & Miller 2008, p. 611) Facilitating the accessibility to health care (Mullally 2001, p. 337) and to medicines (Courtenay et al. 2010, p. 1051); scheduled attendances without wait line (Mullally 2001, p. 337) or with reduced waiting times (Courtenay et al. 2010, p. 1050); allow for localized provision of support for adherence and education (Miles et al. 2007, p. 559); uses team resources effectively (Tornabeni & Miller 2008, p. 611); strong communication between the health professionals (Tornabeni & Miller 2008, p. 610, Courtenay et al. 2010, p. 1051); effective care in terms of cost and time (Tornabeni & Miller 2008, p. 611, Courtenay et al. 2010, p. 1050)

Improvement of quality assistance

Favouring the structure and dynamics of health work

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MA Mendes et al. Table 5 Summary table of categories and subcategories of analyse of the antecedents, defining attributes and consequences of clinical role of the nurse. S~ao Paulo, 2012 Antecedents

Defining attributes

Consequences

Critical thinking

Interaction with the client

Informed experience Clinical autonomy, professional accountability, valuation of work role and fundamentals of care to patients

Interaction goals Care experiences Evaluation/assessment Diagnosis Planning Intervention Care space governance Patient-centred care Strategies and practice of improvement the care outcome Evidence-based practice Professional commitment, ethical awareness and zeal for accuracy and reliability Effective, collaborative, facilitative and equalitarian interaction with the health team Commitment to the permanent nursing formation and education

Impact in the identity, development and socialisation professional Improvement of quality assistance Favouring the structure and dynamics of health work

Another critical attribute is evidence-based practice, with a view to assimilating, finding and applying scientific evidence in clinical practice (Grindel 2005, Lofmark et al. 2006, Mantzoukas & Watkinson 2007, Tornabeni & Miller 2008). Additionally, there is the exercise of outcome-based practice (Grindel 2005). Developing practice together with research and education (Mullally 2001), serving as consultants (Mantzoukas & Watkinson 2007) and continually adapting to professional role requirements (Davies 1993) characterise nurses’ evidence-based practice in the performance of their clinical role. Professional commitment, ethical awareness and zeal for accuracy and reliability are clinical role attributes when complying with healthcare duty (Aitken et al. 2008) and accounting for its outcomes (Tornabeni & Miller 2008). This accountability for outcomes includes the understanding of clinical activities (Aitken et al. 2008), elimination of doubts concerning instructions and interventions (Aitken et al. 2008), as well as the recognition of unsafe practices (Aitken et al. 2008) and limitations (Miles et al. 2007). Other identified attributes were being responsible for one’s actions (Aitken et al. 2008), having zeal for accuracy and reliability (Lofmark et al. 2006), working in line with professional ethics and conduct code (Chaloner 2007, Aitken et al. 2008). The attributes of nurses’ clinical role point towards effective, collaborative, facilitating and equalitarian interaction with the health team (Davies 1993, Aitken et al. 2008),

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offering support to the nursing team and other health professionals (Cox & Ahluwalia 2000, O’Connor et al. 2008), through communication and cooperation with other peers (Grindel 2005, Tornabeni & Miller 2008, Lammon et al. 2010). These attributes emphasise the interdependence of care disciplines (Tornabeni & Miller 2008), so that nurses serve as an interface between medical and nursing care (Cox & Ahluwalia 2000, Mantzoukas & Watkinson 2007). Commitment to nursing preparation and continuing education is another nursing attribute in clinical role performance, including being a member of the nursing profession (Tornabeni & Miller 2008), being an educator (Tornabeni & Miller 2008), informing, guiding and teaching workers and students (Crotty 1993, Cox & Ahluwalia 2000), in addition to developing tutor and preceptor activities (Aitken et al. 2008) and serving as a mentor for other team members (Grindel 2005, Tornabeni & Miller 2008).

Antecedents Critical thinking is an antecedent of the clinical role and involves ethical sensitivity (Chaloner 2007), interpersonal communication skills (Jones & Cheek 2003, Ashmore & Banks 2004), clinical (O’Brien et al. 2008, Tornabeni & Miller 2008), cognitive (Hoffman et al. 2004) and analytical skills (Mantzoukas & Watkinson 2007), associated with educational and management abilities (Mantzoukas & © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 318–331

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Watkinson 2007). Knowledge, accurate clinical judgment, decision-making concerning autonomy and professional clinical accountability stand out as central determinants in clinical role performance (Jones & Cheek 2003, Lofmark et al. 2006, Mantzoukas & Watkinson 2007, Tornabeni & Miller 2008, Courtenay et al. 2010), because they create a scientifically supported clinical and professional leadership style. Informed experience, understood as experience integrated in knowledge, indicates clinical interest (Aitken et al. 2008) and the development of practical clinical learning experiences (Hoffman et al. 2004, Lofmark et al. 2006, Tornabeni & Miller 2008) as antecedents of nurses’ clinical role, making education and practice intrinsically connected (Tornabeni & Miller 2008). An adequate care model (Tornabeni & Miller 2008), clinical leadership (Grindel 2005, Mantzoukas & Watkinson 2007, Tornabeni & Miller 2008, Lammon et al. 2010) and educational programs for the nursing team and for new professionals (Miles et al. 2007) similarly collaborate in clinical role development. Clinical autonomy, professional accountability, valuation of the care role and foundations (Mantzoukas & Watkinson 2007, McElhinney 2010) were identified as antecedents in the elaboration of nurses’ clinical role. The most significant contextual factor when participating in clinical decision-making is nurses’ professional valuations of their own role (Hoffman et al. 2004), as well as the valuation of care foundations (Mullally 2001), combined with nurses’ awakening to their own therapeutic potential (Aitken et al. 2008, Vanaki & Memarian 2009) and an attitude of availability for decision-making (Hoffman et al. 2004).

Consequences Consequences in the validation of one’s professional choice (O’Brien et al. 2008), modelling of conceptions concerning what nursing is (O’Brien et al. 2008), development of specific skills and techniques (Davies 1993) and continuing learning (Davies 1993) represent the impact on identity, development and professional socialisation. To illustrate the relevance of reaching the clinical role, the achievement of high care standards is underscored (Mullally 2001), as well as the better use of nurses’ skills (Courtenay & Carey 2008), including increasing analytical and ethical postures (Chaloner 2007) and the influence on the socialisation of the profession (Davies 1993). Autonomous and accountable practice (Lofmark et al. 2006), which influence nurses’ professional satisfaction and autonomy (Jones & Cheek 2003, Courtenay & Carey 2008, Tornabeni & Miller 2008) and © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 318–331

Clinical role of the nurse

offer a good clinical role model (Davies 1993), are other consequences of putting the clinical role in practice. Important effects of the clinical role nurses perform are indicated in the improvement of care quality, in line with the transformation of health outcomes and healthcare practice (Grindel 2005, Tornabeni & Miller 2008), positively influencing the service (O’Connor et al. 2008). At the same time, they are considered consequences of the response to care demands (Tornabeni & Miller 2008), responding in a safe and effective way (Mullally 2001), including problemsolving ability in the process (Mullally 2001) and in coping with challenges in the care environment (Tornabeni & Miller 2008). Other consequences lead to reflection on the value attributed to nurses’ clinical experiences, including holistic care (Davies 1993), avoiding care fragmentation (Mantzoukas & Watkinson 2007), facilitating patient care and learning (Tornabeni & Miller 2008), including patients’ independence from the nursing team (Davies 1993) and, finally, excellence in care (Mullally 2001, O’Connor et al. 2008). The final consequence of nurses’ clinical role is expressed in the enhancement of the structure and dynamics of health work, including healthcare accessibility, with scheduled appointments without queues (Mullally 2001), in addition to local support with a view to promote adherence and education (Miles et al. 2007). The optimisation of team resources (Tornabeni & Miller 2008) with strong communication among health professionals (Tornabeni & Miller 2008) and, finally, cost- and time-effective care (Tornabeni & Miller 2008) are also mentioned as consequences. The qualitative method of concept analysis permitted the construction of an unedited conceptual/theoretical formulation of the clinical role of the nurse: The constituent element of the clinical role of the nurse is the interaction between the nurse and a person, family or group, in view of the decision processes that conduct care experiences and the governance of the environment of interaction. It is characterized by evidence-based,

patient-centered

care,

continuously

seeking

to

improve care outcomes, and requires professional commitment, ethical awareness and zeal for accuracy and reliability. It is based on an effective interaction process with the health team, as well as on commitment to nursing preparation and lifelong learning. From nurses, it demands critical thinking and informed experience applied to the phenomena that patients experience, associated with clinical autonomy, professional accountability, role valuation and care foundations. As consequences, the clinical role influences identity, development and professional socialization, improvement in quality of care and enhancement of the structure and dynamics of health work.

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MA Mendes et al.

Discussion The analysis of the concept (Morse 1995) and its application favoured reflections and a deeper understanding of the meaning of nurses’ clinical role through the identification of the theoretical elements of this concept, permitting a theoretical proposal of the concept based on data from the scientific literature on the topic. The complex and multifaceted concepts such as nurses’ clinical role require the identification of the antecedents or conditions preceding the manifestation of the concept, the associated characteristics or distinct attributes, the limits outlined and the description of results related to the concept (Hupcey et al. 2001). Thus, in this study, the abstract and universal attributes of the concept of the clinical role of the nurse were identified. Besides the identification of the structural characteristics of the clinical role of the nurse concept, the results revealed new perspectives, such as the establishment of true expectations for the performance of the role, as well as for people in complementary roles and the identification of the components that inhibit or encourage the development of that role, among others. Similarly, these study results entailed significant questions, including – ‘Does the clinical role of the nurse have specific attributes in various settings and at different practice levels, like the midwife or the acute care nurse?’ ‘What is the clinical role of nurse teachers?’ pointing towards further studies. Squires (2004) defines role as a group of socially expected behaviours and the influence of the relationships resulting from how this role is performed in a given space. Data from the literature distinguished between nurses’ actions in the clinical role, such as assessing, seeking information, diagnosing, planning and intervening. These actions are behaviours expected from nurses and are imperative in clinical role performance. With the establishment of nurses’ actions in their clinical role, the question arises about the relationship between clinical practice and clinical role. If clinical practice is the practice model in which nurses also develop assessing, information seeking, diagnosing, planning and intervention, namely clinical activities, then those terms are synonymous? Could these terms be used interchangeably or not? If not, why? In that sense, the distinction between clinical practice and clinical role of the nurse is characterised as another interesting research question. A clear definition of the role, responsibilities and limits is an important part of the role performance process, as these are determining factors in the quality of the dialectic reinterpretation and reconstruction process of social reality. When people play their role consciously, appropriately and

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coherently in the moment experienced, they create ideal conditions for group functioning, besides permitting better interactions among professionals. A well-defined clinical role enhances nurses’ clinical decision-making skills; consequently, their confidence and self-conception are strengthened with a view to enhance their role performance (Pritchard 2006), so as to enhance patient care and safety. In these role dynamics, the concept of clinical credibility or empowerment emerges when nurses, themselves, and teams begin to acknowledge and value their knowledge and skills in achieving clinical outcomes. The characteristic attributes of the actions nurses perform and the interactions they have in their clinical role form model them and grant them their own design. The data indicated that the main clinical role attributes are putting the focus on the patient, having goals and intentionality regarding actions and interactions. These attributes outline the clinical role of nurses. In this respect, one can affirm that the actions nurses perform that move them away from these attributes are not characteristic of their clinical role. Clinical role performance involves not only operational components, but also expressive components, produced in the nurse’s relationship with her/his context. How nurses interact with their context influences the expressive components of the experience of the clinical role, such as how commitment to the care model adopted, for example, affects the valuation of their actions and their own sense of autonomy. Clinical role antecedents are focused on internal and subjective processes of nurses. In that sense, antecedents are understood from the nurses’ perspectives as critical thinking, informed experience and a sense of clinical autonomy as determinants of their role performance. Regarding the consequences of the clinical role, it has broad repercussions, including transformations in the organisation and process of nursing practice.

Conclusion The concept of nurses’ clinical role, developed based on data derived from the literature, represents innovative evidence on the theme, which had not been considered in any previous study. In spite of that, a deeper understanding of nurses’ clinical role is needed, as well as refinement of their conceptual components. It is important to highlight that the definition of a concept is always dynamic and subject to change when the concept is applied. Nevertheless, this research provides important evidence for the development of the concept of the clinical role of the nurse. To permit the development of that concept, these professionals need © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, 24, 318–331

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Clinical role of the nurse

to gain a voice in their daily relationships, and to recover the symbolic meaning, they attribute to the clinical role experience, in the context in which they are active. Field research should be conducted to understand how nurses manifest and articulate the concept in clinical practice, to broaden the conceptual components identified in this study.

Relevance to clinical practice The findings from the literature on the clinical role of the nurse, using the qualitative content analysis method, offer relevant theoretical material to develop this concept. The nurses’ clinical role is a complex process of interaction between the nurse and the client. Enhancing the clarity of the concept of clinical role should influence performance of the role. The practical value of greater knowledge concerning the clinical role nurses play in daily practice cannot be underestimated because human beings, as subjects, are always able to construct and reconstruct their social experiences through learning. The analysis of the roles performed grants the opportunity to consider the different standard forms of complex real-life behaviours, which include social positions and work divisions. The analysis of the concept of clinical role can also be used to improve the management and effectiveness of professional nursing services. The concept of nurses’ clinical role can contribute to reflecting on the dimensions involved in nursing practice, particularly intangible aspects of nursing care, such as clinical autonomy and judgment.

As nursing teachers are responsible for preparing students to perform their clinical role, these study results contribute to a clear articulation of the role they are expected to play, as well as of their responsibilities. In the context of teaching nursing, the attributes of the clinical role of the nurse can enhance the conception of associated competencies and specific skills, with a view to the continuous orientation and configuration of the essence of this role (Mendes & Cruz 2009). Finally, the understanding of the roles nurses play, as well as regarding the influences, expectations and limits of the social behaviour deriving from these roles, is important in informing not only teaching and nursing practice policies, but also health policies.

Disclosure The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author.html), as follows: (1) substantial contributions to conception and design or acquisition of data, or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content; and (3) final approval of the version to be published.

Funding  Pesquisa do Estado de S~ Fundacß~ ao de Amparo a ao Paulo – ao de FAPESP, Brasil, processo nº 2008/02640-9. Coordenacß~ Aperfeicßoamento de Pessoal de N
ıvel Superior – CAPES – Brasil.

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