Exploring the scope of expanding advanced nursing practice in nurse-led clinics: a multiple-case study

Authors

  • Ann T.Y. Shiu,

    1. Ann T.Y. Shiu PhD RN Associate Professor The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong
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  • Diana T.F. Lee,

    1. Diana T.F. Lee PhD RN Chair Professor of Nursing and Director The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong
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  • Janita P.C. Chau

    1. Janita P.C. Chau PhD RN Associate Professor The Nethersole School of Nursing, The Chinese University of Hong Kong, Shatin, Hong Kong
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A.T.Y. Shiu: e-mail: annshiu@cuhk.edu.hk

Abstract

shiu a.t.y., lee d.t.f. & chau j.p.c. (2011) Exploring the scope of expanding advanced nursing practice in nurse-led clinics: a multiple-case study. Journal of Advanced Nursing68(6), 1780–1792.

Abstract

Aim.  This article is a report on a study to explore the development of expanding advanced nursing practice in nurse-led clinics in Hong Kong.

Background.  Nurse-led clinics serviced by advanced practice nurses, a common international practice, have been adopted in Hong Kong since 1990s. Evaluations consistently show that this practice has good clinical outcomes and contributes to containing healthcare cost. However, similar to the international literature, it remains unclear as to what the elements of good advanced nursing practice are, and which directions Hong Kong should adopt for further development of such practice.

Methods.  A multiple-case study design was adopted with six nurse-led clinics representing three specialties as six case studies, and including two clinics each from continence, diabetes and wound care. Each case had four embedded units of analysis. They included non-participant observation of nursing activities (9 days), nurse interviews (N = 6), doctor interviews (N = 6) and client interviews (N = 12). The data were collected in 2009. Within- and cross-case analyses were conducted.

Results.  The cross-case analysis demonstrated six elements of good advanced nursing practice in nurse-led clinics, and showed a great potential to expand the practice by reshaping four categories of current boundaries, including community-hospital, wellness–illness, public–private and professional-practice boundaries. From these findings, we suggest a model to advance the scope of advanced nursing practice in nurse-led clinics.

Conclusion.  The six elements may be applied as audit criteria for evaluation of advanced nursing practice in nurse-led clinics, and the proposed model provides directions for expanding such practice in Hong Kong and beyond.

What is already known about this topic

  •  The practice model of nurse-led clinics serviced by advanced practice nurses is a global trend.
  •  International literature shows that this practice model has good impact on patient outcomes and contributes to containing healthcare cost.
  •  Few investigations have been conducted on elements of good advanced nursing practice in nurse-led services and directions for expanding such services.

What this paper adds

  •  Empirical findings on six elements of good advanced nursing practice in nurse-led clinics.
  •  Empirical findings on reshaping four categories of boundaries for expanding advanced nursing practice in nurse-led clinics.
  •  A model has been developed from the empirical findings for expanding the scope of such practice.

Implications for practice and/or policy

  •  The empirical findings on the elements of good advanced nursing practice of nurse-led clinics can be used as audit criteria for accreditation/evaluation of nurse-led clinics in Hong Kong and internationally in settings where nurses hold similar roles.
  •  The proposed model provides directions for expanding such practice and their corresponding policy and educational development to support the expanding scope of advanced nursing practice in Hong Kong and beyond.

Introduction

The development of advanced practice (AP) nurses, an important milestone in the professional development of the nursing discipline in the 20th century (Lewandowski & Adamle 2009), has become a global trend in the 21st century (Sheer & Wong 2008, Lewis et al. 2009, Pulcini et al. 2010). Nurse-led clinics serviced by AP nurses, a common international practice, have been adopted in Hong Kong since 1990s. Evaluations (HA HK 2000, Twinn et al. 2005, Wong & Chung 2006) consistently show that this practice model has good clinical outcomes and contributes to containing healthcare cost. However, similar to the international literature (Bonsall & Cheater 2008), it empirically remains unclear as to what elements of good advanced nursing practice (ANP) are, and how the profession can further develop such practice. Research in this area would have particular application value to healthcare systems in Hong Kong and internationally in maximizing the contribution of nurse-led work to quality healthcare, and to the nursing profession in advanced role development.

Background

Despite the global trend of adopting ANP in hospital and community settings to ensure accessibility to quality healthcare, the development has not been uneventful (Sheer & Wong 2008, Lewis et al. 2009, Pulcini et al. 2010). In particular, to match with the evolution of the healthcare environments and client care needs, the essential practice characteristics of AP nurses, including roles and responsibilities, have been constantly reshaping, leading to the need of AP nurses to continuously define and redefine the scope of their practice to administrators, healthcare professionals and clients to ensure clear understanding (Bonsall & Cheater 2008, Lewandowski & Adamle 2009). Corresponding education and legal issues surrounding the evolution of ANP have emerged, which require AP nurses to undertake higher levels of postgraduate nursing education and to work through the legislative systems to enact or amend regulations so as to enable the evolution of practice (Phillips 2009, Swider et al. 2009). Such effort in redefining the scope of practice and working through the issues are considered as healthy, developmental and contributing to the professional development of nursing discipline, healthcare reform and cost containment (Sheer & Wong 2008, Pulcini et al. 2010).

In Hong Kong, the practice model of nurse-led clinics serviced by AP nurses, which is a formalized and structured healthcare delivery model to support follow-up care after the acute phase of disease (Wong & Chung 2006), has been adopted by the Hospital Authority (HA) of Hong Kong since the 1990s (HA 2000), with such practice expanding from hospital to primary care setting in 2002 (Twinn et al. 2005). The HA is a statutory body responsible for managing Hong Kong’s public hospitals and their services to the community. HA reported 1·3 million patient discharges and 8 million specialist outpatient clinic attendances in 2008/2009.

AP nurses in nurse-led clinics in Hong Kong, similar to international practice (Pulcini et al. 2010), manage client care independently with the support of multidisciplinary teams. Postgraduate prepared AP nurses were introduced in 1995. Accreditation of nurse-led clinics has become mandatory since mid 2000s. Evaluations on nurse-led clinics in Hong Kong, similar to international research (Carey & Courtenay 2007, McLoughney et al. 2007, Lewis et al. 2009, Morgan et al. 2009), consistently show that this practice model has good impact on client outcomes and contributes to containing healthcare cost (HA HK 2000, Chang & Wong 2001, Wong 2001, 2002, 2004, Twinn et al. 2005, Wong et al. 2005, Wong & Chung 2006).

Contrary to the wealth of publications about the substantive areas of ANP and an increasing body of research on the impact of nurse-led services on clinical outcomes, there are few studies examining the elements of process of care that constitute good ANP (Bonsall & Cheater 2008). Some related empirical findings on the positive aspects of ANP can be identified, for example, using a holistic approach to client care (Wong & Chung 2006, Bhattacharya et al. 2007, Edward et al. 2008), improving community–hospital interface (Canam 2005, Stephen 2007), involving family in the care (Canam 2005) and initiating innovative interventions (Stephen 2007). While these findings extend our understanding, the available research-based information is fragmented and a systematic empirical exploration of such elements has been lacking.

ANP roles have been expanding rapidly in western countries such as Australia, USA, Canada and the UK due to the corresponding introduction of policies and models of healthcare delivery (Department of Health, UK 2006, Phillips 2009, Pulcini et al. 2010). In Hong Kong, in line with the international trend and responding to the changing healthcare environments, a move in healthcare delivery is currently underway to extend the services to disease prevention and to develop service models that offer sustainable quality services, prioritization of services and reduction of avoidable hospitalization (HA HK 2008, 2009). The nurse-led practice model has been developing in this healthcare context and healthcare provision. However, similar to the international literature (Bonsall & Cheater 2008), there is a gap as to what are the elements of good ANP in nurse-led clinics in Hong Kong, and how ANP should be further developed so as to fully capitalize the contributions of AP nurses to ensure increased access to quality healthcare.

The study

Aim

This study aimed to investigate elements of good ANP in nurse-led clinics in Hong Kong and to suggest directions for expanding such practice.

Design

A multiple-case study design (Yin 2003) with two phases was adopted. Six nurse-led clinics representing three specialties were employed as six case studies, including two clinics each from continence (CC1 and CC2), diabetes (DC1 and DC2) and wound care (WC1 and WC2). Each case had four embedded units of analysis, which were the four main data sources to be examined, including non-participant observation of nursing activities (Phase one), and nurse, doctor and client interviews (Phase two). The observation aimed to collect a snap shoot of ANP in the clinics to validate and supplement the interview data. Figure 1 illustrates the study design.

Figure 1.

 Multiple-case study design.

Clinical context of the study site

The three specialties – CC, DC and WC, were purposively sampled because research (Wong & Chung 2006) indicates that these specialties of nurse-led clinics in Hong Kong demonstrate the most impact on patient outcomes, and an in-house survey of the HA in 2008 showed that they are the most common nurse-led work. The six clinics were nominated by HA to represent a range of specialty ANP development. The year of establishment of the clinics ranges from 1985 (DC2, 24 years) to 2003 (WC1, 6 years). They spread over the three main geographical regions in Hong Kong. These clinics are hospital-based. Nursing staff headcounts range from one (CC1, CC2, WC1 and WC2) to six (DC2). AP nurses attained a master’s degree nursing education or above with corresponding specialty training. The length of working as AP nurse in the designated clinics ranges from 2 months (WC2) to 14 years (DC2). Nurse prescribing, authorized by the chief of medical service, is provided across the three specialties in the form of laxative prescription in CC, titration of insulin dosages in DC and dressing prescription in WC.

Participants

Purposive sampling was used to recruit one AP nurse who had the most working experience in each nurse-led clinic. The AP nurse was then requested to nominate two patients/carers and one doctor from the clinic who had the best understanding of the nature of the nurse-led work, giving a total of 24 participants including six AP nurses (nurse participants), nine clients and three carers (client participants), and six doctors (doctor participants) for the study. Table 1 displays the demographical data of the participants.

Table 1.   Demographical characteristics: nurse, doctor and client participants.
Nurse
Clinic*SexYear of experience as a RNYear of experience in advanced nursing practiceHighest education qualificationSpecialty training
CC1F2512Master’s degreeYes
CC2F2511PhDYes
DC1M101Master’s degreeYes
DC2F2514Master’s degreeYes
WC1M225Master’s degreeYes
WC2F100·2Master’s degreeYes
Doctor
ClinicSexRankYear of experience in specialtySpecialtyYear of experience with the nurse-led clinic
CC1MConsultant27Geriatrics15
CC2MSenior medical officer17Obstetrics and Gynaecology7
DC1MSenior medical officer12Diabetes and Endocrinology1
DC2FProfessor of Medicine and Consultant20Diabetes and Endocrinology, Clinical Pharmacology20
WC1MAssociate Consultant13Surgery13
WC2MAssociate Consultant8Surgery5
Client
ClinicClientSex/AgeYear under the care of the advanced practice nurseHighest education levelDiagnosis
  1. *CC, continence clinic; DC, diabetes clinic; WC, wound clinic.

  2. The patient’s mother.

  3. The patient’s daughter.

  4. §The patient’s son.

CC1C1F/518SecondaryDetrusor-sphincter dyssynergia
C2F/394PrimaryUrge incontinence, Primary nocturnal enuresis
CC2C1F/444SecondaryStress incontinence
C2F/723SecondaryStress incontinence, Hypertension
DC1C1F/374SecondaryGestational diabetes
C2F/411SecondaryGestational diabetes
DC2C1F/6916No formal educationDiabetes, Hypertension, Breast cancer with mastectomy
C2F/6520PrimaryDiabetes, Deranged renal function, Cataract
WC1C1M/820·1No formal educationDiabetes, Foot ulcer
C2F/320·1UniversityWound abscess, breast cancer
WC2C1F/550·1PrimaryRectum cancer, adeno-carcinoma
C2§M/522No formal educationVenous ulcer

Data collection

The data were collected in 2009. Two qualitative methods of data collection were employed. In phase one, non-participant observation using an open-ended observation schedule was conducted to observe the nursing activities of nurse participants. The observation schedule was adopted from a previous study to evaluate healthcare delivery models in Hong Kong (Twinn et al. 2005). The research assistant observed the nursing activities by entering notes on the observation schedule every 10 minutes, noting down ‘who’, ‘what’, ‘when’, ‘which’, ‘where’ and ‘how’ of the activity being observed. One and a half days were randomly selected for the observation in each nurse-led clinic, giving a total of 9 days of observation data.

In phase two, in-depth interviews were used to explore the perceptions of nurses, clients and doctors on elements of good ANP and the scope of role development in ANP in nurse-led clinics. Although three separate semi-structured interview guides were developed from the literature for nurse, client and doctor participants, the topics to be examined were similar, reflecting the research aim of the study. Three major areas were explored, namely examples of good ANP, elements contributed to the good ANP and areas of ANP for further expansion. Audio-recorded interviews lasting from 40 to 60 minutes were conducted in a room with privacy and at a time and location convenient for participants. Interview data were transcribed verbatim into Word documents.

Ethical considerations

The study was approved by an ethical committee of a university. Prior to data collection, participants were given an information sheet about the purpose and nature of the study, and written consent was obtained. Participants were explained of their right to refuse participation at any time without giving any reason. Client participants were explained that refusing to participate would not have any impact on the care they obtained from the clinic or other HA services. For non-participant observation, although the main focus was on the nursing activities, those in contact with nurse participants were also observed, and their consent was obtained.

Data analysis

In line with the multiple-case study design, data were analysed in two levels. The first was the individual case level, within-case analysis, whereby the data from the four embedded units were merged and triangulated to provide an understanding on the scope of role development in ANP in each of the three specialties. Within-case analysis involved the use of thematic content analysis of the qualitative data from observations and interviews. To ensure the rigour of data analysis, the process focused on ensuring the validity and reliability in the development of themes (Miles & Huberman 1994). All researchers generated themes independently and then compared the outcome of their analysis. No major differences were identified during this process. The second level of analysis, cross-case analysis, allows the identification of similarities and differences of the six cases, whereby we merged the data to obtain convergent findings.

Results

The cross-case analysis demonstrated two themes: good ANP in nurse-led clinics and expanding ANP in nurse-led clinics. These two themes contributed to the understanding of the scope of expanding ANP in nurse-led clinics. Table 2 lists the themes and their sub-themes.

Table 2.   Main themes in nurse-led clinics.
1. Good advanced nursing practice (ANP) in nurse-led clinics
Elements of good ANP1. A holistic approach to client care
2. Client- and family centred care
3. Integrated teamwork
4. Community–hospital interface
5. Evidence-based practice
6. Innovative practice
Factors contributing to good ANP1. Professional preparation
2. Professional attributes and clinical expertise
3. Organizational culture
2. Expanding ANP in nurse-led clinic
Reshaping current boundaries1. Community-hospital boundaries
2. Wellness–illness boundaries
3. Public–private boundaries
4. Professional-practice boundaries
Facilitating and hindering factors to ANP role expansion1. Stakeholder awareness of ANP roles in nurse-led clinics
2. Public awareness of ANP roles in nurse-led clinics
3. Provision of advanced specialty education programs
4. Organizational support
5. Multi-disciplinary collaboration
6. The changing healthcare context and healthcare provision

Good ANP in nurse-led clinics

This theme has two sub-themes: elements of good ANP and factors contributing to good ANP. Six elements and four factors emerged from the data.

Elements of good ANP

A holistic approach to client care.  Observation and interview data validated each other to indicate that a holistic approach to client care is an element of good ANP in the nurse-led clinics. Observation data showed that AP nurses adopted comprehensive assessment to develop a holistic understanding of patients’ life context. In addition to physiological aspect of care, psychosocial support to patients and their caregivers prominently featured in nursing consultation. For instance, it was observed that AP nurses in CC clinics assessed patients’ sexuality and provided appropriate interventions; AP nurses in DC clinics successfully intervened patients’ suicidal ideations; and AP nurses in WC clinics introduced patients and their family caregivers to support groups. Doctors identified that ‘the AP nurse spends more time in managing clients’ psychosocial needs... put herself in their shoes’ (WC2-D58). One patient’s feedback summed up the impact of such care provision on her outlook of living with the disease (CC1-C1-4):

When I first came here, I felt that I had nothing... no future... she [the AP nurse] talked to me... so caring... I feel OK now.

Client- and family-centred care.  This element featured prominently in the observation and interview data. AP nurses stated their respect of each client as an unique individual. This comment exemplified AP nurses’ thought (DC1-N62):

There isn’t any protocol or manual that you must or could adhere to, rather what we provide to patients and their family members should depend on their needs.... even deciding when is the appropriate time to discuss a specific topic is related to individual situation.

Doctors perceived such element of care provision ‘as more likely to meeting clients’ individual needs’ (CC2-D32). Clients perceived that such element of ANP had positive impact on their mental health (e.g. CC1-C1-4, DC2-C1-34) and self-management ability (e.g. WC2-C1-206, DC2-C1-18).

Integrated teamwork.  This element featured prominently in the observation and interview data. Doctors identified AP nurses as the central agent who cultivated the integrated teamwork spirit and fostered close alliance in the multi-disciplinary team, with one stating that such teamwork has matured to a state of ‘automation’ (DC2-D8-10). While clients’ perception of integrated teamwork was not obvious, they perceived ANP as well-supported by multi-disciplinary teams, with one stating that (DC2-C2-97):

She [the AP nurse] was of the opinion that I should change to another medication due to... She immediately called the doctor... to see whether it should be changed.

Community–hospital interface.  AP nurses initiated and established collaboration with the community, ranging from a beginning to close partnership level. AP nurses in CC and WC clinics reached out to residential and primary healthcare settings to offer nursing consultation (CC1-D38, WC1-N53). AP nurses in DC clinics displayed an obvious position in mobilizing community resources (e.g. non-governmental organizations) for community-dwelling clients. The doctor in DC2 highly regarded AP nurses’ contributions to community–hospital interface by citing the ‘shared care programme’, whereby it also contributed as a platform for ‘technology transfer’ (DC2-D10) to enhance quality healthcare in the community (DC2-D6):

The clinic organizes training programmes to physicians and nurses in the community... our AP nurses demonstrate the explanation of the clinical reports to patients [technology transfer]... refer almost half of our patients for their follow-up care in community clinics... these patients are then monitored by our AP nurses every one to two years.

Evidence-based practice.  Evidence-based disease management protocols were used in the clinics. One AP nurse illustrated the link between conducting research and engaging in evidence-based practice to enhance treatment effectiveness (CC1-N50):

I had conducted a study to estimate the prevalence and treatment of constipation.... discussed the findings with the doctors... [Based on the findings] dose reduction has been recommended for appropriate patients along side with an evidence-based assessment protocol.

Innovative practice.  Initiating innovative programmes emerged from the data as a statistically significant element of good ANP. For instance, one AP nurse initiated the ‘continence care ambassador scheme’ to transfer evidence-based practice to ward nurses in geriatric settings (CC1-N78). An example, cited by one doctor, illustrated that innovative practice of the nurse-led clinic contributed to advancing the model of care for the specialty in Hong Kong (DC2-D30):

The clinic started the ‘diabetes management and complication screening programme’ [over 15 years ago],... At that time, I worked with X [the AP nurse] to [test out the programme]... we then published the self-developed education kit... protocols... In addition, we initiated the ‘diabetes registry’, the ‘shared care programme’... all these are now adopted as standard care by diabetes teams in Hong Kong.

Factors contributing to good ANP

Professional preparation.  Specialty training and postgraduate level of nursing education are perceived as supporting the provision of elements of care processes characterizing good ANP. Constant and regular professional update was regarded as essential by nurse, client and doctor participants. For example, one AP nurse said that, ‘we shouldn’t be satisfied with current attainment. We strive to provide better nursing care; we still need to move forward to obtain opportunities for learning’ (WC1-N51). The exposure to a wide variety of clinical environment was also regarded as facilitating AP nurses’ competency and confidence in leading the nurse-led service (CC1-N95).

Professional attributes and clinical expertise.  Autonomy, accountability and expertise in clinical decision-making as professional attributes facilitating the element of good ANP in nurse-led clinics were evident in the fact that AP nurses developed clinical guidelines and patient care protocols for Hong Kong (CC1-N50, WC1-N47) and international healthcare community (DC2-N63). Clients acknowledged AP nurses’ professional attributes and clinical expertise (DC1-C1-30, DC1-C1-38). Doctors regarded AP nurses’ professional attributes and clinical expertise as contribution to the achievement of treatment effectiveness, with one stating that, ‘without the professional input of AP nurses..., I could see no way in healing these patients by doctors alone’ (DC2-D14).

Organizational culture.  The HA advocates the value of evidence-based practice, organizing workshops on such practice and providing funding to support clinical research. This value has created a research culture in nurse-led clinics to improve services. Doctors always facilitated nursing research to support evidence-based practice by mobilizing resources (DC2-D20). The HA also cultivates a culture of collaborative multi-disciplinary teamwork, issuing yearly awards to the best practice teams. Such culture helped to facilitate the integrated teamwork spirit in the nurse-led clinics.

Expanding ANP in nurse-led clinics

This theme has two sub-themes: reshaping current boundaries and facilitating and hindering factors to ANP role expansion (Table 2). Four categories of boundaries and six factors emerged from the data.

Reshaping current boundaries

Findings indicate that there is great potential to expand ANP in nurse-led clinics by reshaping four categories of current boundaries. Of note is that these boundaries may exist in our mentality or clinical settings, and are interrelated.

Community-hospital boundaries.  Currently, most nurse-led clinics are hospital-based and ANP is clinic-based. Findings reported in the above indicate that ANP in DC clinics has been leading the way to build close community partnership and make innovative practice in the community, which has become regular practice in the DC specialty. Findings suggest that the community–hospital interface could further be strengthened with AP nurses working as central coordinators to ensure seamless healthcare. The doctor of DC2 stated that (DC2-D10, D36, D38):

The care is now fragmented.... I believe that there must be a central coordinator with appropriate networking... we need AP nurses with a macro view... sorting patients according to their conditions and needs... to different levels of healthcare... and coordinate a quality assurance system.

Wellness–illness boundaries.  Reshaping the above boundaries is related to the provision of ANP along the wellness–illness continuum. Findings indicate that AP nurses have already started practising along this continuum. For instance, AP nurses advised patients and their families on health promoting behaviour and organized ‘fun run campaign’ in the community. Findings suggest that the wellness–illness boundaries could be further reshaped. For example, in addition to coordinating and networking the resources between community and hospital settings, AP nurses might provide preventive education to the whole community at large (DC2-N49). Doctors suggested upstream initiatives such as using nurse-led clinics to screen the public for risk factors such as obesity for early intervention (DC1-D108, DC2-D12). Doctors believed that AP nurses in Hong Kong had the competence to act as the first point of contact alongside general physician (DC1-D48).

Public–private boundaries.  Currently, nurse-led clinics are located in the public sector. AP nurses in DC clinics have started to test out a systematic referral system with the private sector as a means to shorten waiting list to HA services. Findings suggest that the public–private boundaries can be reshaped with AP nurses taking on a central role in a model of public–private interface (DC2-D40):

We should not take care of all the cases in the public sector... to ensure the quality of healthcare of the private market... we can capitalize on AP nurses’ expertise to enhance the public-private interface... a nurse-led coordinating centre... to address specific issues such as referral and quality assurance systems.

Professional-practice boundaries.  To assume such expanded roles by reshaping the boundaries described in the above, current professional-practice boundaries should be correspondingly reshaped. One such boundary is the development of clinical expertise in one specialty only. Findings suggest that AP nurses can be supported to manage more complicated cases, for example, patients with multiple co-morbidities using an evidence-based protocol agreed on by the multi-disciplinary team. Findings showed that AP nurses in DC clinics have already made their way to reshape this clinical expertise boundary by providing one-stop care to patients who have got co-morbidities such as hypertension, stroke, renal and eye-sight problems.

Another boundary to reshape is the nursing authority in nurse prescribing and nurse referral. Reshaping this authority will also facilitate the crossing of the one specialty only practice boundary and enhance continuity of care. Moreover, the success in reshaping the nursing authority to make referral is synergetic for reshaping the community-hospital boundaries and public–private boundaries, whereby AP nurses supported by evidenced-based protocols are empowered to move clients between primary and secondary settings and between the pubic-private sectors.

Facilitating and hindering factors to ANP role expansion

Stakeholder awareness of ANP roles in nurse-led clinics.  The stakeholders included doctors, patients and nurses. Their awareness of ANP roles in nurse-led clinic was perceived as either facilitating or hindering ANP expansion. This awareness was different among the three specialties. In DC clinics, it was regarded as a facilitating factor. As a well-established specialty since late 1980s, stakeholders’ awareness of the ANP roles and their significant contribution were high (DC2-D14, DC2-P2-73). However, in CC and WC clinics, it was perceived as a major barrier hindering ANP development. The AP nurse in CC2 said that (CC2-N66), ‘some doctors question if continence care could help to improve patients’ quality of life’. The lack of awareness was perceived as relating to ambiguous roles and responsibilities of the AP nurses (CC1-N120). For instance, AP nurses of WC clinics were always called to do general wound dressing in wards (WC2-N24).

Public awareness of ANP roles in nurse-led clinics.  All participants regarded the public awareness of ANP roles in nurse-led clinics as crucial to the expansion of ANP (DC1-D54, CC2-C2-156, WC-2-C1-45), but participants also perceived this as being a hindering factor. ANP roles in nurse-led clinic are not commonly known by the public unless they had attended such services (WC2-C1-45).

Provision of advanced specialty education programmes.  Participants regarded this factor as a determinant for further expansion of the ANP. While doctors did not have any resistance to expanding the scope of ANP in nurse-led clinics, they perceived professional knowledge enhancement as a prerequisite (CC1-D38, DC2-D4, WC2-D160). Doctors were mostly concerned with the knowledge base of AP nurses in domains of medical practice such as nurse prescribing (DC1-D54). While client participants have well accepted the ANP, they perceived the need to advance nurses’ knowledge for further expanding their roles such as nurse prescribing to enhance patient confidence (CC1-C2-64).

Organizational support.  Nurse, client and doctor participants considered the lack of organizational support to resolve nursing shortages as a hindering factor (CC1-N44, DC1-C1-46, WC1-D53). In CC and WC clinics, this barrier was very obvious because the AP nurse was the only nursing staff of the clinic and they ‘sometimes feel very lonely’ (CC1-N44).

Findings indicate that the lack of a long-term plan on AP nurses’ career advancement is a hindering factor. This is also related to nursing shortages and the HA manpower structure (CC2-N40, WC2-N24). One doctor linked career advancement and nursing shortages to define challenges for expanding ANP roles (DC2-D48):

If there is no nursing staff available to support the AP nurse after promoting to [the post of] nurse consultant... how could one manage all the expanded roles?

Multi-disciplinary collaboration.  The close collaboration with multi-disciplinary teams is fundamental to the expansion of ANP roles. This finding is evident in the above, especially with it maturing to a stage of integrated teamwork.

The changing healthcare context and healthcare provision.  The changing healthcare context in Hong Kong, such as ageing society, the prevalence of long-term conditions and inadequate healthcare resources, demands appropriate changes in healthcare provision (HA HK 2008, 2009). This poses challenges (e.g. nursing shortages) and opportunities (e.g. new model of nurse-led work) to the reshaping of the current boundaries for the expansion.

Discussion

Limitations of the study

This study is limited by the short period of non-participant observation of the ANP and a small sample of participants. However, the study design resulted with rich data from nurse, client and doctor perspectives. Moreover, findings from the four embedded units of analysis (interview and observation data) of the six case studies triangulated to validate and complement (Silverman 2010) each other to provide a comprehensive understanding of the research aim. The concordance between the interview and observation data strengthens the confidence in the analytical generalization of the findings (Yin 2003, Silverman 2010), the goal of which is to expand and generalize findings to theory, rather than numerical figures as in statistical generalization. Such findings will inform further development of this practice model in Hong Kong and internationally in settings with similar healthcare context and healthcare provision.

Different stages of specialty ANP development

The cross-case analysis identifies different stages of ANP development across specialties, in terms of the structure and process of care delivery that characterize the maturity of the ANP development. This finding is consistent with the international literature, which suggests that evaluating this aspect must take into consideration the background and context of care delivery (Dunn et al. 2006, Gardner et al. 2006).

Findings show that DC clinics are the most well-equipped and well-staffed across the three specialties. The high level of organizational support and integrated teamwork is in part related to the long history of establishment of this specialty, which was initiated in 1985. It is also related to the clinical leadership of the AP nurses and the length of practice dedicated to the specialty. In terms of process of care, one obvious difference that emerged from the comparison of the three specialties is that AP nurses in DC clinics have taken the lead to reshape community hospital and professional-practice boundaries. The literature highlights a main differentiation in the capability between AP nurses and nurse consultants being the competence to work across primary, secondary and tertiary levels of the system of care (Costa 2003, McSherry et al. 2007, Stephen 2007). Our findings also extend the literature on the importance of organizational support to ANP development (Woodward et al. 2006, O’Baugh et al. 2007, Bonsall & Cheater 2008) to indicate the crucial role of the combination of professional expertise, integrated teamwork and organizational support to the expanded role development of ANP in nurse-led clinics, and have implications for directions of further expansion of this practice model.

Stakeholders’ acceptance with role expansion of ANP

Findings indicate that both doctors and clients, along with AP nurses, accept and make suggestions for further role expansion of ANP in nurse-led clinics. This acceptance is in line with the international trend (Williams et al. 2005, Bailey et al. 2006, Bonsall & Cheater 2008). These stakeholders, however, identify nursing shortages as a major barrier, which again is consistent with international scene (Avery 2008, Bonsall & Cheater 2008) and has implications for organizational support. Furthermore, AP nurses, doctors and clients suggest that there should be corresponding professional education programmes to support this development, especially in relation to nurse prescribing, similar to the international development (Carey & Courtenay 2007, Bellary et al. 2008, Bonsall & Cheater 2008). This finding has implications for designing appropriate academic programmes, and adds to the current reflection on what constitutes disciplinary knowledge as the foundation for doctoral education to support such expanded practice (Banks-Wallace et al. 2008).

A lack of clarity of the ANP roles in nurse-led clinics was expressed as a factor hindering the expansion of nurse-led work. The literature underlines that role confusion of ANP is a barrier to realizing the full potential of ANP roles and impacting on healthcare delivery (Bryant-Lukosius et al. 2004, Gardner et al. 2007).

A model to advance the scope of ANP in nurse-led clinics

Our findings indicate six elements of good ANP in nurse-led clinics in Hong Kong. While they are consistent with international literature (Canam 2005, Bhattacharya et al. 2007, Carey & Courtenay 2007, Stephen 2007, Bonsall & Cheater 2008, Edward et al. 2008), our findings extend the literature by systematically examining the elements that characterize good ANP in nurse-led clinics, especially those in Hong Kong. We suggest that these elements can be used as audit criteria to identify the maturity level of the nurse-led clinics. Our findings indicate that some AP nurses in Hong Kong have been leading the way to cross the community hospital and professional-practice boundaries. Given that the four categories of boundaries are interrelated and interdependent, it is envisaged that successful reshaping of these boundaries will result in synergetic effects that will further capitalize on nurse-led clinics’ contributions to respond proactively to the ever changing healthcare context.

On the basis of our findings, we propose a model to advance the scope of ANP in nurse-led clinics (Figure 2). In the centre of the model are the six elements of good ANP, which constitute the foundation for expanding ANP roles. The elements are surrounded by the four categories of boundaries, which are pivotal to further ANP expansion. The model provides directions for expanding such practice and the corresponding policy, and education development to support the expanded practice in Hong Kong. Specifically, we recommend four major areas for expansion (Table 3). We also suggest enabling factors to support the expanded roles (Table 4). Furthermore, we suggest that the model is relevant to international community in settings with similar clinical and healthcare context.

Figure 2.

 A model to advance the scope of advanced nursing practice in nurse-led clinics. *ANP, advanced nursing practice.

Table 3.   Four major areas for expansion.
1. Triaging patients according to their clinical conditions and needs to allocate them to different levels of healthcare. This involves the authorization of experienced advanced practice (AP) nurses to move patients between primary, secondary and tertiary levels of the healthcare system
2. Setting up nurse-led services in the community to screen the public who are at risk of developing chronic diseases and give appropriate nursing interventions to maximize positive health
3. Setting up nurse-led clinics alongside family physicians in the community to provide primary health care. The AP nurses become the first point of contact between the public and the healthcare system
4. Setting up nurse-led services to coordinate patients who attend both the Hospital Authority and private medical services. It involves the coordination of the public–private interface and the management of a quality assurance system of the private medical services
Table 4.   Enabling factors to support the expanded roles.
Enhanced organizational support1. Providing a clear career pathway for advanced practice (AP) nurses
2. Implementing a long-term plan to reduce nursing shortages
3. Promoting role clarity of different levels of AP nurses
4. Offering clear organizational policy on nurse prescribing
5. Providing appropriate skill mix and facilities in the establishment of the nurse-led clinics
Strengthened advanced nursing practice (ANP) governance1. Using the six elements of good ANP as audit criteria to identify the maturity level of nurse-led clinics
2. Delineating the professional code of practice for nurse prescribing and ensuring the appropriate legislation
3. Developing a multi-disciplinary agreed mode of the expanded ANP
4. Establishing guidelines on education programme development to equip nurses to take on various expanded roles, especially in the areas of nurse prescribing, management of multiple co-morbidities, and leadership ability
Heightened public awareness of the roles and ANP in nurse-led clinics1. Use of popular media to inform the public about the AP nurses’ credentials, the services of the nurse-led clinics, the referral system and the multi-disciplinary team support

Conclusion

This was a multiple-case study, and findings were merged from the three major stakeholders’ perspectives, including nurses, clients and doctors. The most significant contributions of the study include the identification of elements of good ANP in nurse-led clinics in Hong Kong and the development of the model to advance the scope of ANP in nurse-led clinics, which provide pointers for successful role expansion of ANP in nurse-led clinics in Hong Kong and internationally in settings with similar clinical context. The six elements are: a holistic approach to client care, client- and family centred care, integrated teamwork, community–hospital interface, evidence-based practice and innovative practice. Future research should examine the clinical and professional contributions of the expanded ANP roles.

Acknowledgements

We thank the staff of the Hospital Authority, Hong Kong, especially the leadership of Chief Manager (Nursing), Ms Sylvia Fung, for their support to the study. Special thanks go to the research assistants who collected the data and those who participated.

Funding

This was a collaborative study between the Hospital Authority of Hong Kong and the Nethersole School of Nursing, The Chinese University of Hong Kong. The study was funded by the latter.

Conflict of interest

No conflict of interest has been declared by the authors.

Author contributions

AS and DL were responsible for the study conception and design. AS, DL and JC performed the data analysis, provided administrative, technical or material support and supervised the study. AS were responsible for the drafting of the manuscript. DL and JC made critical revisions to the paper for important intellectual content.

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