Nurses and Midwives Working at Advanced and Clinical Specialist Levels are Embracing their Strategic Management Roles in Delivering Innovative Healthcare

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Implications for nurse managers
The need for awareness of the importance of advanced practice and strategy innovation for nurses working in intensive care units were identified. Developing and managing strategy is a critical success factor in delivering health care to advanced level. This factor has largely remained elusive to the roles and processes being undertaken by some nurses and midwives including advanced nurse and midwife practitioners and clinical nurse specialists.

Background
The Faculty of Nursing and Midwifery, established in 1974, plays a pivotal role in leading and supporting the development of nursing and midwifery professions nationally through the delivery of transformative learning experiences, impactful research in the areas of professional development and supporting the contribution of nurses and midwives to healthcare and societal well-being (RCSI 2021). Their role in managing strategy and on how strategy education impacts of their delivery of advanced care in intensive care units is unclear. An intensive care unit (ICU) is a special department of a hospital that caters to patients with severe or lifethreatening illnesses and injuries, which require constant care, close supervision from life support equipment and medication to survive (IACCN 2020). Units may relate to general, cardiac, neurology, emergency, trauma or neonatal intensive care. ICU's are staffed by highly trained nurses. They and their professional colleagues promote excellence in the early recognition of critical illness in caring for very ill patients (Coulter-Smith and Lyte 2015). Strategic management is part of their role.

Study Design
This descriptive qualitative study took place by reviewing peer reviewed scholarly nursing and management literature, available through EBSCO, CINAHL and PUBMED data bases (2019-2022). Review of 450 titles and abstracts published during this period was undertaken to determine the profile of strategy. Following this, thematic analyses on the full text of 72 manuscripts were undertaken. English language limits were imposed. The second method used was a survey of advanced nurse and midwife needs undertaken by academic faculty with clinical nurses and midwives working in five hospitals in Ireland (n=45).

Results and Discussion
Both evidence review of the literature pertaining to strategy and survey findings identified successful practice innovations and also similar challenges affecting the role and function of advanced nurse and midwife practitioners. Findings from thematic analysis of survey results were identified.

(1) Thematic analysis of survey results
Challenges faced by advanced practice nurses from survey findings included the need for dedicated time for research and publication with greater designated support from their organisation in gathering data/specifics about the role and patient metrics. They also required dedicated administration assistance. The need for enhanced recognition of the advanced practice roles and of role autonomy within their scope of practice including the need for a recognised level of autonomy and further development of medication prescribing were reported.

Dedicated Time for Research
Participants found it difficult to have dedicated time for research and publication. They believed this was resulting in inability to research the role and develop evidence based practice. Whilst acknowledging ongoing support from their senior nursing and midwifery managers they would like to receive more designated support for dedicated research time. Participants also recognised the importance of gathering data/specifics about their role and around patient metrics and all agreed that greater administration assistance would support practice. Acknowledging that supports are available, having access to further training such as educational programmes and nursing and midwifery planning and development training days were seen as possible supports.

Recognition of the Role
Participants want their work load recognised, accepted and appreciated by the multidisciplinary team members. This could be enhanced, they believed, by researching their own roles, keeping a record of the tasks/roles undertaken over a specific period of time and collectively exploring and discussing this further in a future forum, particularly on measuring patient outcomes. There appeared to be a lack of clarity around the role.

Role Autonomy
Whilst recognising their reporting structures there is a recognised level of autonomy that needs to be accepted by the multidisciplinary team member's. They believe that some of those professionals are sometimes not comfortable with their level of advanced practice autonomy and in effect they have only semi autonomy. They acknowledged that they also have a role in informing other professions about their role and responsibilities and level of autonomy and that effective team work would contribute to patient safety and better patient outcomes. The level of autonomy of advanced nurse practitioners vis-à-vis other members of the multi-disciplinary team could be clarified as it was recognised that their autonomy was often questioned, often leading to delays in providing patient care, particularly when patient care could be compromised as a result.

Medication Prescribing
Concerns were raised in relation to prescribing. Nurses and midwives have medication prescribing authority within their scope of practice in Ireland. However, some felt they had limited medication practice prescribing and that x-ray prescribing was problematic, often leading to delays in patients receiving prescribed medication/x-rays. Participants expressed the importance of clarifying the Collaborative Practice Agreement in this respect as there appears to be different approaches being taken in different organisations.

(2)
Thematic analysis of findings from literature review Thematic analyses on the full text of 72 manuscripts was undertaken. Some themes were identified in multiple journals and are represented here in the number of times (n =) the subject matter was mentioned. Themes identified from documentary analysis of the data were: (1) Strategic roles of advanced intensive care nurses and midwives (n=26)  There are many issues pertinent to the advanced nurse practitioner role that also affect the strategic roles of intensive care nurses including the changing health needs of society and how social and cultural environments now affect the healthcare workforce. Medical and political changes and technological advances are contributing to healthcare delivery and strategic policies. Professional collaboration and nursing education changes are also influencing practice. Environmental challenges at strategic level are currently facing healthcare organisations.
It is important that these challenges are identified and that advanced nurses have the education and ability to influence plans being drawn up by senior management to ensure that environmental factors are considered. How scarce resources are prioritised and directed is critical to nursing practice [1]. A strategy is the means to achieve the ends, and is a unified comprehensive plan that ties all parts together in an integrated manner. Strategy begins with a concept of how to use the resources of the organisation most effectively in a changing environment [2]. Strategy is often described by nurses as policy, administration, guidelines, protocols or management even when undertaking strategic roles across their care delivery spectrum, yet not recognized as such [2,3]. Strategic management is a stream of decisions and actions which leads to the development of an effective strategy or strategies to help achieve corporate objectives. The strategic management process is the way in which strategists determine objectives and make strategic decisions [1]. Strategy produces advanced decision making which is critical to achieving successful outcomes. It appears that this factor has largely remained elusive to the roles and processes being undertaken by some nurses and midwives. Strategic management characteristics are concerned with the environment the nurse is working in, the types of services being delivered in the unit and on how activities taking place are matched to the environment and to resources, all of importance to the advanced nurse practitioner. Decision making is an important role and advanced nurses and midwives need to recognise the operational consequences of decisions made on their behalf within their unit and organisation and to have awareness of the future direction, values, expectations and time frames for such strategies [2].

Roles of advanced nurse and midwife practitioners
Nurses working in intensive care units are critical to care delivery. The Irish Association of Critical Care Nurses (IACCN) is a voice for excellence in Irish critical care nursing where the integral role of the specialist intensive care nurse is acknowledged, valued and at the forefront of healthcare provision and governance. The Association is committed to the professional and educational development of these nurses and of their core competencies (IACCN 2020). In the unparalleled and extraordinary public health emergency in which we find ourselves, across the world, nurses stand, as they always do, at the front line. Nurses account for more than half of all the world's health care workers providing vital services throughout the health care system. Around the world, they are demonstrating their compassion, bravery, and courage as they respond to the COVID-19 pandemic, and never has their value been more clearly demonstrated [4].
Core competencies for advanced practice are identified in the literature. Competencies include the need for autonomy in accountability for practice, use of professional judgement, ability to undertake health assessment, evaluate effectiveness of care provided, demonstrate advanced clinical decision making and professional and clinical leadership by communicating a vision for practice. Demonstrating research leadership by identifying research priorities, leading research projects, critically analysing research findings and evaluating health care audits [5] and the need to work collaboratively with other professions are all vital roles of both the advanced nurse practitioner and the specialist critical care nurse [5]. Advanced nurse practitioner are educated to empower, to become a leader and advocate for critically ill patients and their families. Williamson et al. (2012) in exploring the role of advanced nurse practitioners found that the role had evolved and their function had varied, but equally that roles and expectations lacked clarity, which in their opinion may hinder advanced nurse effectiveness and pivotal contribution to practice in using their expertise, networks and knowledge to facilitate and provide quality holistic care [6].
As with critical care nurses' patient centred care is the priority for advanced nurse practitioners. Their roles are developed in response to patient need and healthcare service requirements and they must have a vision of areas of nursing practice that can be developed beyond the current scope of nursing/midwifery practice and a commitment to the development of these areas. They promote wellness, offer healthcare interventions and advocate healthy lifestyle choices for patients, their families and carers in a wide variety of setting according to agreed scope of practice guidelines (Nursing and Midwifery Board of Ireland 2017) [5]. McDonnell et al. (2015) evaluated implementation of advanced nurse practitioner roles in an acute hospital setting and Reynolds and Mortimore (2018) spoke of the advanced practitioner as being a valuable resource from international perspectives and dimensions [7,8].
Advanced practitioners need to know what the corporate objectives being pursued in their unit and organisation are and have awareness about how these objectives are transmitted to unit staff. They need to know the strategic processes and the possible consequences for patients and staff and to ask who the decision- makers are, what influence have nurses got and importantly what decisions are nurses involved in. Planning is an important role for advanced nurses. Plans and policies are guidelines to action. They indicate how resources are to be allocated and how tasks assigned by the organisation might be accomplished [9].

Strategic leadership
Lack of strategic leadership was evident in the Institute of Medicine Report on the future of nursing, undertaken in the United States, which highlights the importance of promoting the ability of advanced practitioners to practice to the full extent of their education and training and to identify nurses' contributions to delivering safe, high-quality care [3]. Bindon was also concerned with safe practice when stating that maintaining competence is a professional responsibility for nurses and midwives [10]. Individuals are accountable for their practice yet nurses across clinical settings face the sometimes daunting challenge of staying abreast of regulatory mandates, practice changes and other strategic workplace expectations (NMBI 2017, IOM 2010), hence the need for ongoing education [3,5]. However, nurses' efforts to engage in their own development can be hampered by a lack of time, limited access to educational resources, or cost concerns [1].
Anderson (2018) explored the strategic leadership role from the perspective of changes occurring in the United Kingdom due to rising health costs and increasing demands on healthcare professionals to deliver high-quality care [11]. The author counsels that while advanced nurse practitioners can positively influence clinical outcomes and cost efficiency, they must also be adequately prepared to undertake a leadership role that includes strategic dimensions. Reynolds and Mortimore (2018) identified the significant strategic leadership role of advanced nurse practitioners in the NHS in Britain, and also discussed the difficulties advanced clinical practitioners face when taking on this new role, and how drawing on their transferable skills can help them make the transition (Reynolds and Mortimore 2021) [8,12]. In Ireland the Nursing and Midwifery Board (NMBI) are at the forefront of advanced practice regulation, development and implementation including strategic leadership (NMBI 2017) [5]. Such organisations are operating at a strategic level and have recognised advanced nurse and midwife practice roles in their processes. These studies bear out the narrative that leadership for the future requires nurse leaders to provide direction for health care organisations and also indicate that nursing leadership improves programme coordination and efficiency among team specialties, serving to help patients maximise their potential. In today's fast-paced healthcare environment managers and nurses need a resource that helps to challenge and redefine current thinking in relevant areas and to encourage innovation [1].

Role of advanced nurse practitioners in multidisciplinary teams within organisations
The role of advanced nurse and midwife practitioners in multidisciplinary teams within healthcare organisations and on their impact on patient/client care and nursing practice is recognised [13,1,14]. Needs analysis of patients, nurses and midwives is a preliminary but essential step in the delivery of care. Kilpatrick et al. (2014), in a review on team effectiveness, focused on the needs of patients and nurses by identifying a number of advantages to the addition of the advanced nurse practice role in health care teams and on the perceptions of team effectiveness [13]. Findings from the evidence review indicates that strategic processes within health care teams were dynamic and responsive to surrounding environments, but they caution that teams and perceptions of team effectiveness need to be understood in the broader context in which teams are situated, so that delivery of health care services to patients and families is improved from a strategic clinical perspective.
From an international perspective, in Latin America and the Caribbean, Bryant-Lukosius et al. (2017) examined the advanced nurse practice role in supporting universal health coverage and universal access to health [14]. Findings indicated that this role was ideally suited as part of a primary health care workforce strategy but that implementation barriers existed. To alleviate those barriers and achieve successful role implementation strong nursing leadership that aligned advanced nurse practice roles with policy priorities and collaborative primary care providers was needed.
National studies demonstrated how a strategic change in role and focus for a regional hospital department resulted in innovative improved care for patients with skin cancer [15] and in an interpretative study Kelly and Kelly (2019) explored the positive living experience of patients with ureteric stents [16]. These studies demonstrate that in the increasingly complex and often political era of health care nurses need a wide diversity of knowledge, experiences and skills to enable good decision making to take place that will have positive outcomes for patients and society. Ȍrtenblad et al. (2016) in discussing the relevance of management innovations for health care organisations says that every innovation fights a battle against the existing way of thinking and doing things in order to overcome this bias/prejudice. Innovation is presented in several recent studies, as demonstrated above [1].

Innovative nursing care: Cardiology
Studies relating to new, innovative nursing, midwifery and management areas, were identified as being strategic by their focus on strategy and its application to nursing: indications that strategy was being viewed as a nursing concept. Strategic advances for nurses, including advanced nurse practitioners working in the fields of cardiology, neurology, emergency and intensive care indicated that evidence-based innovative processes were transforming nursing care delivery and encouraging a multidisciplinary approach [17]. Exploring patient satisfaction with cardiology services in Ireland was explored by O'Toole et al. (2019) in an innovative strategic clinical development [18]. Collaboration occurred between two advanced nurse practitioners in two separate hospitals by offering evidence-based equitable service for patients presenting to emergency departments with non-acute coronary syndrome chest pain. Findings indicated high levels of patient satisfaction with this pioneering advanced nurse practice-led cardiology service that had resulted in equitable cardiology services for such patients. Davis et al. (2018) on the launching of a new strategy for single-ventricle heart defects described a hospital's synchronised, multidisciplinary team to support children with this condition and their families [17]. A systematic review undertaken by Manoj et al. (2019) identified the impact of a nurse-led elective direct current cardioversion in atrial fibrillation on patient outcomes [19]. Many patients who present to E/D with low or intermediate risk cardiac presentations can be safely managed with out-patient ambulatory diagnostics strategy. The lack of definitive outpatient pathways to safely manage these patients has a significant impact on admissions and length of stay adding to the current bed crisis and overcrowding of Emergency Department. A novel collaborative approach to this problem involved the implementation of a Cardiology ANP led Virtual Clinic outpatient ambulatory pathway which facilitates the referral of non ACS chest discomfort, rate controlled atrial fibrillation/flutter/pSVT, stable heart failure, HTN, incidental murmur, low risk collapse/syncope from the ED and provides patients with rapid access to a comprehensive range of outpatient cardiology diagnostics prior to referral to OPD when necessary [20].

Outcomes from innovation in trauma and emergency care
Emergency care settings in many countries have struggled with a high volume of service users in recent years and subsequent infection control. Breen and Rees (2018) explored barriers to implementing the Sepsis Six guidelines in an acute hospital setting [21]. Trauma care is one of the main strategic functions of nurses working in intensive care units and in emergency minor injury units where they use a broad range of strategic clinical skills to manage patients' injuries effectively, including the diagnostic decisions and management options available to them [22].
In a related emergency care study Freter et al. explored how prevention strategies may be translated into routine clinical care for the elderly with hip fractures and delirium by strategies that compared adherence to and prevalence of delirium [23]. The authors concluded that delirium-friendly pre-printed postoperative orders (PPOs) executed by regular nursing staff resulted in a significant reduction in postoperative delirium.
In a similar strategic initiative aimed at reducing trauma in spinal cord injury guidelines for rehabilitation by nurses were developed. Reynolds et al. [2018] [8] evaluated a bundle of implementation strategies through a strategic pre-program, post-program, and follow-up design. Findings indicated that this implementation strategy improved neuro-critical care nurses' knowledge of, and adherence to spinal cord injury guidelines. McBrien (2019) described how Lisfranc injury assessment and strategic management is being successfully undertaken by emergency care nurses [22].
Using a systematic approach provides advanced nurses with a collaborative and integrated theoretical and empirical approach to strategic management, in addition to incorporation of managerial and organisational skills into work processes [24,25]. Lavery and Whitaker (2018) researched the training of advanced practitioners to perform lumbar puncture, a procedure mostly undertaken by doctors that requires skill, knowledge and experience [26]. This study demonstrated how advanced nurse practitioners expanded their role to include performing lumbar puncture with resultant benefits for patients and medical colleagues. These articles provoke and stimulate nursing professionals to examine the behavioural and professional environments underpinning healthcare management in certain circumstances.

Value based strategy
The perception of nurses and midwives as having being of value to society is evident as referenced in an Irish public survey (Ipsos MRBI, 2019) and reflected in national (Veracity Index, 2019) [27] and international evidence [28] with reference to 'Who do we trust more', which identifies nurses' as the most honest and trusted professionals. Value based strategic initiatives are presented by researchers. A trauma related strategic overview was presented by Czuhajewski (2017) in evaluating the Society of Trauma Nurses (STN) (2017-2019) strategic plan relating to prevention, education, and collaboration with other health care disciplines [29]. Evaluation demonstrated that priority goals were leading to the promotion of excellence and research across the continuum of trauma care [30]. This strategy critically analysed and evaluated the value of this initiative. Value based healthcare is a good example of a strategy concept with a high recognition factor, such as adherence to guidelines [21]. A further value based UK initiative was recognised by O'Driscoll et al. [31]. These researchers explored compassion in practice by evaluating the awareness, involvement and perceived impact of a national nursing and midwifery strategy amongst healthcare professionals in NHS Trusts in England. Compassion was also identified by Quinn and Gephart (2016) [32] in implementation strategies to provide palliative care by critical care nurses in the neonatal intensive care unit. We are reminded of the emphasis that the founder of modern nursing, Florence Nightingale, placed not just on compassionate care, but compassionate care that is evidenced-based care [33].

Summary of post-forum set-up consultations
Following the formation of the ANMP Forum visits were made by the coordinator with advanced practitioner's working in the network hospitals to determine their level of satisfaction with the forum. All expressed satisfaction with consultation strategies. The following areas provide a flavour of discussions held: Framework Scope of Practice in cardiology (ANP general hospital); ANPs current research projects related to fracture of head of Fibula and high velocity injury causing fracture to the Scapula (ANP cardiology unit general hospital); extending the network to all the hospitals and community in the RCSI group; forming a support base for ANPs around research; publishing enhances their profile as professionals, the nursing profile within the hospital and leads to the advancement of patient care through the development of new initiatives (ADON general hospital); work being undertaken by nursing and midwifery planning and development including the requirements for NMBI registration: KPIs and new panel assessment (NMPD directors Dublin); Research requirements and set up with Medline and CINAHL searches and follow on EBSCO research (Librarian, RCSI); to support the development of the educational aspects of the role and in keeping up to date with ANP/AMP regulation and published research (DOM maternity hospital); The importance of improving the patient experience and the critical need for ANPs to develop a research body and to support nurses in their roles through education, teaching and evidence based research (DON general hospital);the various roles currently being undertaken by the ANPs/AMPs in the hospital including in minor injuries, respiratory and endoscopy and research projects within the network (DON general hospital) and the work being undertaking in the RCSI in collaboration with the research lead and project engineer on the Lighthouse project. This group put forward a number of possibilities for research (cANP).

Membership and Fellowship awards
Two further prestigious awards introduced by the Royal College of Surgeons (RCSI) provides advanced information through Membership of the Faculty of Nursing and Midwifery RCSI (MFNMRCSI). Membership is exclusively offered by RCSI and is a professional qualifications awarded to nurses and midwives possessing a bachelor's degree in nursing or midwifery. The award links the nurse or midwife contribution to their profession, society, patients, service users, colleagues and students. Membership offers continuous professional development, learning and networking opportunities to registered nurses and midwives [34].
The second award is the Fellowship of the Faculty of Nursing and Midwifery (FFNMRCSI) which is exclusively offered by the RCSI since 1982 and is a professional qualification offered to registered nurses and midwives possessing a Master's degree in nursing, midwifery or related/allied field or PhD with a minimum of 5 years nursing experience (Membership Handbook 2020) [35-37]. The awards identify professional development including strategy along the continuum of nursing and midwifery from bachelor to masters/PhD degrees and from professional qualification to advanced practice [39].
Both awards support lifelong learning by providing resource for professional and personal growth.
Nursing and midwifery is underpinned by rigorous scientific inquiry that provides a significant body of knowledge to advance practices, shape health policy and strategy and thus impact positively the health of people. The State of the World's Nursing Report (WHO 2020) provides the most up-to-date evidence on policy options for the global nursing workforce. Importantly, the report highlights the critical importance of engaging professionally with nurses and midwives to establish and assure the effectiveness of nursing and midwifery contributions and interventions [33]. Membership and Fellowship will provide nurses and midwives with resources to support advances in nursing and midwifery leadership, strategy, management, education, research and evidenced based clinical practices as well as networking opportunities, which will help advance professional development [40][41][42][43][44] will afford opportunities to influence current and future nursing and midwifery practices, thus supporting the delivery of efficient, effective, quality person centred care [33].

Conclusion
Extensive research is presented with references to leading research articles. Findings are timely and address the management issues being dealt with in modern healthcare. Authors discussed the relevance of their findings to nurses and midwives and to advanced nurse practice. Integrative approaches linking the topics of strategy, leadership and management were dealt with. Both quantitative and qualitative methods were used by researchers due to the multi-dimensional nature of nursing and health, sometimes singly or in combination. It is evident in the research presented here that strategy and strategic management is being utilised by nurses and midwives and that the strategic processes being utilised are appropriate and timely and contribute to improved care and better outcomes for all. It is important for healthcare organisations to facilitate practice at the level of advanced strategic leadership thereby expanding the expertise of the advanced nurse and midwife practitioner and clinical specialist in critical care units in strategic planning and development. This involvement allows the nurse to critically evaluate relevant issues within the area of advanced practice and strategic management.
The nurse manager needs to be involved in the development of strategy in order to have, or to generate influence. Through involvement managers process their understanding of a changing dynamic healthcare environment and its relevance to positive outcomes by having sufficient information of their work and environment allied to managerial capabilities to allow for effective planning to take place. Strategy may evolve through political influence, innovation, efficient strategic planning and development of controls, all of which are evident in the strategic processes employed in these studies.