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An Exploration of Specialist Nurses in Malta: a Qualitative Case Study

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An Exploration of Specialist Nurses in Malta: a Qualitative Case Study 1 An Exploration of Specialist Nurses in Malta: A Qualitative Case Study Corinne Ward A thesis submitted in partial fulfilment of the requirements of Bournemouth University for the degree Doctor of Philosophy May 2016 Bournemouth University 2 Copyright Statement This copy of the thesis has been supplied on condition that anyone who consults it is understood to recognise that its copyright rests with its author and due acknowledgement must always be made of the use of any material contained in, or derived from, this thesis. 3 An Exploration of Specialist Nurses in Malta: A Qualitative Case Study Corinne Ward A thesis submitted in partial fulfilment of the requirements of Bournemouth University for the degree Doctor of Philosophy May 2016 Bournemouth University 4 An exploration of specialist nurses in Malta: A qualitative case study Corinne Ward Abstract The concept of specialist nursing and advanced nursing practice has been extensively debated in the literature internationally but to date no consensus exists on the preparation, titling and regulation of these nurses worldwide. The introduction of specialist nurses in Malta in 2003, now titled ‘practice nurses’, was seen as an evolution in nursing practice and launched in response to gaps in services and developments in health policy. This was perceived as a much needed career advancement option for nurses; an alternative to traditional administrative/educational roles; and a drive towards improving patient access and quality care. However there was still a paucity of information and evaluation of the nurses’ role in Malta. The aim of this study was to explore the perceptions of the roles, development and preparation of specialist nurses in Malta, an island with its own historical, political and social context. Using a qualitative case study design, a deep understanding of the complex issues surrounding specialist nurses was gained from multiple data sets using purposive sampling techniques. Data included a survey of the total specialist nurse population (N=27), in-depth interviews with a group of specialist nurses (N=9) and four focus groups with key professionals and policy stakeholders (total N=28). Data were collected between 2013 and 2015 and analysed using thematic analysis. The main themes that emerged from the findings including concepts of advanced nursing practice, role boundaries, preparation, regulation and autonomy to practice. In spite of the very positive views on the roles and practice of these specialist nurses, a number of barriers to their future development were exposed. Barriers comprised the lack of understanding and support for their role and the paucity of evaluation research on their role. Additional areas affecting their advancement included the organisational and political systems that were seen to affect leadership, and power in nursing to achieve the ultimate aim of consistent provision of good quality nursing care. The study provides the first research- based insights into the role and development of specialist nurses in Malta, and concludes by highlighting the need for a legally accepted set of definitions, preparation and evaluation of the specialist nurse role from a national policy perspective. 5 Contents Copyright Statement ..................................................................................................................................... 2 Contents ............................................................................................................................................................. 5 List of Figures ................................................................................................................................................ 11 List of Tables .................................................................................................................................................. 12 Acknowledgements ..................................................................................................................................... 13 1. Introduction .......................................................................................................................................... 14 1.1. Definition of a Specialist Nurse ............................................................................................. 14 1.2. International Background ....................................................................................................... 15 1.3. The nature of the problem and the research aims ........................................................ 16 1.4. The Research Study ................................................................................................................... 17 1.5. The Maltese Context .................................................................................................................. 17 1.5.1 The Maltese Healthcare System .......................................................................................... 18 1.5.2 Nursing in Malta – an overview .......................................................................................... 19 1.5.3 Context to the development of Specialist Nursing in Malta ..................................... 24 1.6. Organisation of this Thesis ..................................................................................................... 26 2. Literature review................................................................................................................................. 28 2.1. Introduction .................................................................................................................................. 28 2.2. Background to the study .......................................................................................................... 28 2.3. Literature Search ........................................................................................................................ 29 2.4. Concepts ......................................................................................................................................... 32 2.4.1 Advanced Nursing Practice .................................................................................................. 33 2.4.2 Titles .............................................................................................................................................. 33 2.4.3 Clinical Nurse Specialist / Specialist Nurse .................................................................... 36 2.4.4 The Role of Specialist Nurses ............................................................................................... 38 2.4.5 Qualities and preparation of a Specialist Nurse ........................................................... 42 2.4.6 Being an expert ......................................................................................................................... 45 2.4.7 Leadership................................................................................................................................... 47 2.4.8 Autonomy to Practice ............................................................................................................. 49 2.5. The International Development of Advanced Nursing Practice ............................... 52 2.6. Nurses’ Position within the Healthcare Team ................................................................. 54 2.7. Specialist Nurse Development in Malta ............................................................................. 55 2.8. Political Commitment ............................................................................................................... 57 6 2.9. Regulation ..................................................................................................................................... 58 2.10. Resources and the Value of Specialist Nurses ............................................................. 60 2.11. Career Structure/Framework ........................................................................................... 62 2.12. Conclusion ................................................................................................................................. 64 3. Methodology.......................................................................................................................................... 66 3.1. Introduction .................................................................................................................................. 66 3.2. Focus of the Study ...................................................................................................................... 66 3.3 Philosophical Underpinnings....................................................................................................... 67 3.3.1 Constructivist paradigm .................................................................................................. 67 3.3.2 Methodological Rationale ............................................................................................... 69 3.3.3 Merriam’s Orientation to Case Study Research ..................................................... 71 3.4 Frame of Reference .................................................................................................................... 72 3.4.1 Case study literature ......................................................................................................... 74 3.4.2 Reflexivity ............................................................................................................................
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