School of Nursing and Midwifery Centre for Cardiovascular and Chronic Care The role of the nurse educator in acute care hospitals Australia Jan Maree Sayers This thesis is presented for the Degree of Doctor of Philosophy of Curtin University November 2013 Declaration To the best of my knowledge and belief this thesis contains no material previously published by any other person except where due acknowledgment has been made. This thesis contains no material, which has been accepted for the award of any other degree or diploma in any university. Jan Maree Sayers Date 28th November, 2013 i Abstract The health of our society is dependent upon continually developing and sustaining a knowledgeable nursing workforce. The challenges of educating nurses within the tertiary sector in Australia to meet immediate and future workforce needs are well understood. Conversely, the nurse educator role in continuing nurse education and pr ofessional development in acute care hospitals is relatively unknown. Implicit in the development of nursing workforce education models in the acute care sector is an understanding of the role and scope of practice of the nurse education workforce. Within the current health workforce reform agenda clinical education and c ontinuing professional development have high priority, as do opportunities for role and scope of practice redesign. This mandate has provided the impetus for this study. The nurse educator position is an advanced nursing role integral to continuing professional education and development. Nurse educators provide clinical leadership within the acute care environment. Role ambiguity may impede their work and influence nurse educator identity, visibility and contribution when nursing roles are being challenged by health and workforce reform. The Nurse Educators in Acute Care Hospitals (NEACH) study has explored the role, scope of practice and performance standards of nurse educators in acute care hospitals in Australia. The NEACH study examined social, policy and organisational barriers nurse educators face enacting their roles facilitating clinical and professional education to nurses in hospitals. Role theory and sy mbolic interactionism underpinned the NEACH study, design, methods and interpretation of the data. A mixed method research design was chosen for this study to allow the investigation of multidimensional facets of the nurse educator role, and t o incorporate the socio-cultural context of the contemporary hospital environment. The methodological approaches included a group interview with key stakeholders, a questionnaire with embedded validated psychometric measures, as w ell as investigator developed items appropriate to the Australian context and research questions. ii Item generation for the questionnaire was informed by a c omprehensive review of the published literature, policy documents and key informant consultations. The researcher developed the Activities and Competencies of Nurse Educator (ACONE) scale which provides a framework for future role development and performance criteria as well as a legitimate tool for self- assessment of nurse educator performance. The survey was administered by snowball and targeted sampling. The completion rate was 95% (n = 425 completed all items). Of those who reported having a postgraduate education qualification only 21.9% (n= 93) had this qualification at a M asters level; 65.1% (n=274) had par ticipated in performance review within the preceding twelve months and 69.6% (n=272) reported their role was not linked to clinical or outcome indicators. Qualitative data revealed role ambiguity and confusion were identified as impacting on nurse educator role expectations and responsibilities, as well as role visibility, role overload and stress. Whilst some educators perceive they were valued in the workplace, a greater number expressed that the role is devalued within their organisation. Logistic regression analysis was undertaken and a model for higher nurse educator regard of the practice environment emerged. This model demonstrates that nurse educators who have a Mast ers qualification, have their professional development and learning needs identified and have regular meetings with their line manager, are more likely to have a more favourable view of their workplace and perform intended domains of the nurse educator roles. Issues in sampling and responder bias need to be considered in interpreting these data. Changing dynamics in professional education require nurse educators to actively drive the transformation of workforce education. Through engaging in policy and de bate to develop dynamic, innovative models of continuing education and pr ofessional development it is likely that there will be improvements in patient outcomes and safety. As workforce is one of the critical issues in health care service reform it is important to ensure that the nurse educator role is well defined and clarified in the Australian health care system. A national, standardised approach to role description and scope of practice for nurse educators is required to achieve this. Without validation iii and support, nurse educators may disengage from their roles and workplaces or perform inadequately. Further research to elucidate the impact of the role of the nurse educator on education, practice change and pat ient outcomes is essential. It is acknowledged that nurse academics and professional nursing alliances may be influential in providing opportunities for nurse educators to define and redesign their role and advance specialty development. This thesis has focussed on the role and contribution of nurse educators to nurse education in acute care hospitals in Australia. The study has highlighted role ambiguity, conflict and e rosion and pr actice limitations. The competencies (ACONE scale) for role development and use as a tool for self- assessment of performance by nurse educators, has be en developed and tested. The identification of these anomalies and i mplementation of the ACONE tool may enable nurse educators individually and collectively and the nursing profession, to have a broader perspective of the nurse educator role in hospitals and contextually within nursing education and healthcare. iv Dedication This thesis is dedicated to my family. To my husband Peter, (who sadly passed away before the outcome of my studies was known) for his generous spirit and heartfelt love supporting my endeavours at every stage of this journey. - May He Rest in Peace - To my son Daniel and my daughter Laura - I could not have attempted nor completed this work without your unfailing love and encouragement. v Acknowledgments ‘To go quickly is to go alone. To go far, go together.’ An African Proverb. I have not walked this journey alone but have been pleased to be supported by some inspirational role models along the way. I would like to acknowledge Professor Patricia Davidson, my principal supervisor, who introduced me to the world of possibilities that embarking on my PhD would provide. To Dr. Michelle Di Giacomo, my co-supervisor, thank you for believing in me, for your unfailing good humour and words of wisdom. A special thanks to Associate Professor Yenna Salamonson, a gifted teacher, patient and kind colleague who provided expert coaching in the art and craft of statistical analysis and interpretation. To Nicole Sidoti, for taking the time to assist with editing this thesis from the far reaches of London – I am truly grateful. To my fellow students, Hui, Jane, Jo, and Vix, it has been a privilege to know you and work alongside you during our respective PhD journeys. I am indebted to you all for your friendship and unfailing support. vi Publications Arising from this Thesis Based on Status / Publication Chapter Permissions* One Published. Sayers, J., Di Giacomo, M. (2010). The nurse /Permission educator role in Australian Hospitals: granted to use Implications for policy. Collegian, 17,(2), July. paper in thesis. * 77-84. Two Published. Sayers, J., Di Giacomo, M. and Davidson, P.M. /Permission (2011). The nurse educator role in the acute granted to use care setting in Australia: important but poorly paper in thesis.* understood. Australian Journal of Advanced Nursing. 28,(4), 44-51. * Refer to Appendix 9 for permission documents. vii Conference Presentations Arising from this Thesis Peer Reviewed Nurse Educators in Acute Care Hospitals, Australia (Poster Presentation), Conference, Malta, May, 2011. State of the Nation: Nurse Educator Practice in Australia, International Nurse Education Conference (NETNEP), Sydney. April, 2010 Birds on the Wire – Lessons from the Field – Utilising the Web Based Survey as a qualitative tool in nursing research. International Networking for Education in Healthcare Conference, Cambridge, England. September, 2009. The Nurse Educator role in Australian Hospitals: Implications for health policy. International Networking for Education in Healthcare Conference, Cambridge, England. September, 2009. A Brave New World – from Chaos to Leadership Challenge, 13th National Nurse Education Conference, Sydney, September, 2008. viii Table of Contents Declaration i Abstract ii Dedication v Acknowledgements vi Publications Arising from this Thesis vii Conference Presentations Arising from this Thesis viii Table of Contents ix List of Tables xii List of Figures xiii Appendices xiv Abbreviations xv Glossary xvi Glossary References xvii Chapter 1 – Introduction 1 1.1 Introduction 1 1.2 Study Aims 3 1.3 Background to the Study 3 1.3.1 The Australian healthcare system 4 1.3.2 Health demographics of the Australian population 4 1.3.3 Health funding 4 1.3.4 Health workforce funding 5 1.3.5 Scholarship funding to support professional education 6 1.3.6 Health care and workforce challenges 6 1.3.7 Changing models of care 6 1.3.8 Australia’s health workforce 7 1.4 The role of the nurse educator in the health workforce 7 1.4.1 Historical perspectives of the nurse educator role in Australia 8 1.5 Policy in support of nurse educator practice 9 1.6 Study method 10 1.7 Thesis organisation 11 1.8 Significance 13 1.9 Summary and conclusions 14 1.10 References 15 Chapter 2 – Literature Review 19 2.1 Introduction 19 2.2 Part 1: Background – Issues in the contemporary health care System 19 2.2.1 Health reform 2.2.2 Health workforce reform 20 2.2.3 Workforce education and reform 21 2.2.4 Competency to practice 21 2.3 Part 2: Method – Integrative Literature Review 24 2.3.1 Search strategy 24 2.3.2 Inclusion criteria 25 2.4 Findings 25 2.4.1 The role of the nurse educator in the contemporary health care system 26 2.4.2 The impact of nurse education on patient outcomes 30 2.4.3 Key challenges facing the nurse educator role 31 ix