Saied Hashemi,Leila Karimi,Seyed Tayeb Moradian,Abbas Ebadi,Amir Vahedian-Azimi,Jamileh Mokhtari-Nouri
Identifying Structure, Process and Outcome Factors of the Clinical Specialist Nurse: A Scoping Review Study
Clinical nurse specialist,outcome,process,structure
Background: In order to achieve the major goals of transformation in the health care system, organizing and developing the existing potential properly play a pivotal role. The objective is to conduct a scoping review to describe available extent of literatures about scattered structure, process, and outcome factors of the clinical specialist nurse and redesign those as three cohesive and interconnected factors. Materials and Methods: A scoping review of studies was conducted from 1970 to June 20, 2020, focusing on the structure, process, and outcome factors of the clinical specialist nurse from six databases. Results: Forty-six studies were carried out. Structure (individual characteristics, intra-organizational, and governance factors), process (professional interactions, and roles and duties of a specialist nurse), and outcome (patient and family, nurse, and organizational outcomes) factors were identified. Conclusions: With the correct knowledge of the factors, it is possible to achieve the desired therapeutic, organizational, and professional results of nursing by providing the necessary fields in the structure, process, and outcomes. The identification of structures, processes, and outcomes that influence clinical nurse's role implementation may inform strategies used by providers and decision makers to optimize these roles across healthcare settings and guarantee the delivery of high-quality care.
Identifying Structure, Process and Outcome Factors of the Clinical Specialist Nurse: A Scoping Review Study

In order to achieve the major goals of transformation in the health care system, organizing and developing the existing potential properly play a pivotal role. The objective is to conduct a scoping review to describe available extent of literatures about scattered structure, process, and outcome factors of the clinical specialist nurse and redesign those as three cohesive and interconnected factors.

A scoping review of studies was conducted from 1970 to June 20, 2020, focusing on the structure, process, and outcome factors of the clinical specialist nurse from six databases.

Forty-six studies were carried out. Structure (individual characteristics, intra-organizational, and governance factors), process (professional interactions, and roles and duties of a specialist nurse), and outcome (patient and family, nurse, and organizational outcomes) factors were identified.

With the correct knowledge of the factors, it is possible to achieve the desired therapeutic, organizational, and professional results of nursing by providing the necessary fields in the structure, process, and outcomes. The identification of structures, processes, and outcomes that influence clinical nurse's role implementation may inform strategies used by providers and decision makers to optimize these roles across healthcare settings and guarantee the delivery of high-quality care.

Through time, the health care system has undergone significant changes due to demographic and cultural diversities, technological advances, changes in disease patterns, and community expectations of how health care services provided.[1] Due to this, many decision-makers in the health care system have forced countries to develop specialized nursing roles to meet the needs of society[2] and improving the quality of care.[3] A clinical specialist nurse, known as a registered nurse with a master's or doctoral degree who uses knowledge, skills, evidence, and scientific research as a trainer, researcher, consultant, and leader, provides safe, high-quality, and cost-effective care for the patients.[45] The results of a systematic review study of Donald et al.[6] entitled “the Impact of nurses' specialist on long-term care” showed that the use of specialist nurses has associated with increasing quality of health care, job, and family satisfaction. Descriptive study of Lamb entitled “ability of the leadership role of nurses specialist” showed that the specialist nurses have a high level of leadership power and with this ability, they provide better conditions in terms of care and quality services for the patients.[5] However, after more than 60 years of activity of the clinical specialist nurse as one of the four types of specialist nurses[78] and as a part of the health care system, the performance of specialist nurses in organizations is still different in spite of their determined role.[4] Despite the efforts made by the community of specialist nurses to increase the understanding of others and differentiate this role from other nurses,[7] in some cases, this role in the health care system is used incorrectly and contradictory.[7] Studies show that using the role of the clinical specialist nurse correctly in the health care system has led to a reduction in patient mortality and improving the quality of care.[39] Therefore, by employing a clinical specialist nurse, followed by improving the quality of care, mortality can be greatly reduced, but assessing the care is necessary to improve the quality of care.[10] Assessing the quality of care shows how health programs are implemented and identifies program deficiencies so that problems can be addressed.[11] There are several models for evaluating the quality of care;[12] the most widely used model in measuring and evaluating the quality of care is evaluation of services in terms of structure, process, and outcome[10] and was introduced in 1980 by Donabedian.[13] According to this model, the assessment path of care quality starts from the structure, then moves towards the process, and finally ends in the outcome. Structure means describing the physical, organizational, and other characteristics of the care delivery system, process means the method and how to provide care, and outcome means the impact of services on the health status of patients and people.[13] Some studies examined only the structural and process factors,[14] some the outcome of the role of the clinical specialist nurse,[15] and one study has briefly been referred to structural, process, and outcome factors.[4] Therefore, our objective was to conduct a scoping review to describe available extent literatures about scattered structure, process, and outcomes factors of clinical specialist nurse and redesign those as three cohesive and interconnected factors.

Scoping studies are used to review related articles to identify extent of a concept.[10] The scoping review study was conducted from 1970 to June 20, 2020, which deals with a wide range of articles related to the intended goals and on the role of the clinical specialist nurse based on the provided framework by the Joannah Briggs institute,[16] created by Arksey and Omalley.[17] Research strategy was set up based on the Joannah Briggs institute framework.[16] The research strategy consists of three steps: In the first step, a limited study was performed at the Scopus database to find keywords by analyzing the words in the title and abstract of the retrieved articles. In the second step, the study was performed based on the specified keywords, and in the third step, the list of sources of the retrieved articles was also investigated. The following databases have been used to search for published articles: Persian databases such as MagIran, Iran Medex, and SID, and English articles such as Scopus, PubMed, and Web of science. All related Persian and English accessible articles that have a good score in quality appraisal (≥60% for each appraisal tool of total score) were considered as inclusion criteria. Duplicate titles and non-related titles to clinical specialist nurse were also excluded from the study [Figure 1]. To choose from articles, first, the survey of articles was done by three researchers separately, and then the obtained titles were examined and consensus was reached. After removing duplicates and irrelevant articles, the titles and then the abstracts of the articles were reviewed by two researchers based on the relevance to the research question and then the articles with inclusion criteria screened for the next step [Figure 1]. Finally, the full text of the remaining articles was reviewed according to inclusion criteria. The quality of final selected articles was evaluated separately by three researchers. CASP tool was used to evaluate qualitative articles, STROB tool was used for quantitative articles, and PRISMA tool was used to evaluate meta-analysis and systematic articles.[1819] For qualitative articles, a score of 6 or higher of CASP (total score 10) was considered as good. STROBE tool (total score 22) was selected for quantitative articles, and a score of 15 or higher was regarded as good. For a systematic review, a score 18 or higher of PRISMA (total score 27) was assumed good [Table 1]. In cases of disagreement, discussion was continued until a final agreement between the three researchers was reached. After reviewing 6 databases, a total of 22,719 abstracts were gathered. Duplicate articles were removed and 15,435 articles were remained. After screening the titles and abstract, only 115 articles were related to the research question in which the full text of them was reviewed. After reviewing the full-text of articles according to the inclusion and exclusion criteria, finally 46 articles were selected for the final review [Figure 1]. An adapted form of the Joannah Briggs Institute was used for data extraction, which was related to scoping studies.[16] After reviewing and comparing the findings of each article, the initial themes were formed, then all the themes were reviewed and discussed among the members of research teams; any changes also were applied as needed.[62]

Researchers tried to act in an unbiased way to analyze the retrieved data of articles. Ethics committee of Bagiyatallah University of Medical Sciences approved this study (Project code: IR.BMSU.REC.REC.1399.288).

Based on the extracted codes, three factors including structure (individual characteristics, intra-organizational, and governance factors), process (professional interactions, roles, and responsibilities of the specialist nurse), and outcome (patient and family, nurse, and organizational) were selected. The themes were explained as follows:

These factors determine the necessary conditions to promote the role of the nurse toward clinical specialist nurse.[45] Sub-categories of individual characteristics includes: evidence-based practice (15-time), clinical judgment (2-time), Decision-making power (4-time), problem-solving ability (3-time), moral characteristics, empathy, responsibility (6-time), professional competence (Knowledge, attitude, professional and specialized skills, and technical ability) (12-time), systematic thinking (1-time), job commitment (1-time), work experience (5-time), having certificate of a clinical specialist nurse (7-time), having at least a master's degree (18-time), independent performance (2-time), critical thinking (3-time) and having a multifaceted nature of education, research, management, leadership, and clinical (4-time). Sub-categories of intra-organizational factors include scientific promotion and specialized knowledge (4-time), explanation the scope of activities in the specialized and managerial field (complex decision-making power, moral, department management, team and health, and safety and quality assurance) (6-time), approval of specialized nursing courses by organizations for professional competence (7-time), budgeting (10-time), having experienced professors in various fields (4-time), specifying the structure and standards of education (7-time), editing specialized educational curriculum (12-time), explaining and clarifying the role of specialist nurse (15-time), determining facilitating factors and barriers (6-time), having an organizational chart (manpower) (7-time), need for expertise according to the context and culture (5-time), understanding the importance and role of clinical specialist nurse by officials (5-time), and provision of nurse welfare facilities (private room, meeting place for specialist nurse) (1-time). Sub-categories of governance factors include determining the rules and regulations (9-time), support of government institutions (11-time), and determining the educational requirements and creating a culture of the importance of the role (6-time).

Process factors have been expressed through practice, participation, and working relationships of team members, including doctors and other nurses.[63] Sub-categories of professional interactions are communication with the patient and his family (21-time), education to the patient and their family (10-time), communication with other members of treatment team (28-time), communication with team members for independent prescription (2-time), submission integrated and coordinated care with treatment team (4-time), cooperation and gaining trust for effectiveness (2-time), partnership with team to solve the problem (3-time), and participation in meetings and conferences with team members (5-time). Sub-categories of “duties of a clinical specialist nurses” are management and leadership roles (19-time), supervision to provide a calm and respectful environment and treatment (7-time), support and recognition of new nurses (4-time), implementation and use of scientific evidence in the clinic (6-time), the role of care depending on the patient's needs (3-time), the role of diagnosis, treatment and prevention (6-time), community needs assessment (1-time), the role of education, research and clinical (18-time), Policy making (1-time), the responsibility of clinical specialist nurse for action taken (4-time), training of general nurses and medical staff (12-time), and gaining new and up-to-date experiences in care (6-time).

These factors explain the effects of employing a clinical specialist nurse according to the results of treatment measures.[52] The sub-categories of “Patient and family outcomes” are as follows: increasing patient satisfaction (9-time), prevention of patient readmission to hospital (4-time), reducing mortality (5-time), complication prevention and control (5-time), reduction of staying time in hospital (5-time), improving the quality of services and clinical care of nurse (15-time), encouragement and involving patient to self-care (increase treatment adherence)(5-time), meeting the patient's physical and environmental needs (2-time), reducing the patient's medical expenses (19-time), availability of care and clinical specialist nurse (6-time), training and emotional support of patients and their families (9-time), and decreasing anxiety (3-time). The sub-categories of “nurse outcomes” include increasing job satisfaction (5-time), professional, specialized qualification promotion (4-time), and the formation (employment) of clinical specialist nurse (2-time). The sub-categories of “organizational outcomes” are as follows: increasing the credibility of organization and attracting nurses (1-time), preventing leaving the job (2-time), reducing organizational costs (7-time), promoting organization (5-time), and improving organizational performances (2-time).

Due to the complexity of the process of playing the role of a clinical specialist nurse, identifying and recognizing the factors are of particular importance;[64] therefore, this study was conducted to describe available extent of literatures about scattered structure, process, and outcome factors of clinical specialist nurse and redesign those as three cohesive and interconnected factors; then, the authors applied results of this study to provide more evidence supporting the structure, process, and outcome factors to clarify the role of clinical specialist nurse. One of the strengths of the current study is the process of searching for articles without considering the time period, reviewing abstracts and titles of articles, and evaluating the quality of articles by three researchers separately. All authors also endorsed the extracted themes and the number of times that were repeated in the articles. Weaknesses of the study include the omission of non-English and non-Persian articles and the impossibility of properly evaluating narrative review articles due to the lack of qualitative evaluation tools. Moreover, the authors did not search in some databases like EMBASE, Cochrane, and CINAHL due to lack of access to those sites. One of the subcategories was individual characteristics as having a degree/license of specialist nurse, recognizing the role of specialist nurse, systemic thinking, evidence-based performance, management, and leadership[1445] that is consistent with our study findings; moreover; the results of the included studies showed that due to the complex situation and extensive changes in health care services, clinical specialist nurse should be able to update their knowledge, professional skills, and technical abilities by continuing to study at the postgraduate level, which are important and the main pillars of the personal characteristics of a clinical specialist nurse because a clinical specialist nurse plays a pivotal role in the delivery of evidence-based practice, and specific competency guidance has been established to facilitate critical care nursing practice and education development in many developed countries.[6566] Another subcategory is an organizational factor which defines the scope of activity of clinical specialist nurse and clarifies the role of the nurse.[4] Based on the current study, even though they have the necessary characteristics to play the role of a clinical specialist nurse, these persons should be supported by the organization and the organization should create educational and organizational structures with a correct understanding of the role of clinical specialist nurse, training specialized nurses, removing existing barriers by using relevant educational curriculum, and experienced professors fitted to the context and culture of the country. Some authors believed that redesigning the job description, documenting role-specific activities, and capturing role-sensitive outcomes have a key role in successfully establishment of the clinical specialist nurse role and could sufficiently differentiate from other nursing roles.[7] Final subcategory is governing factor, to the best of the authors' knowledge, for the first time, this concept has been introduced as a separate subcategory in current study; although review of the literatures demonstrated, the factor in other studies has differently labeled as determining laws and regulations[14] and the support of government institutions.[22] Professional interactions, roles, and responsibilities of clinical specialist nurse are the subcategories of process factor that is consistent with the study of Kilpatrick et al.[45] (2016) which expresses interactive factors such as communication and acquaintance of clinical specialist nurse with other members of treatment team, cooperation, and gaining trust for effectiveness and partnership with treatment team to solve the problem, and the role of management and leadership, but do not mention the interactions of clinical specialist nurse and treatment team with the patient and the patient's family to provide integrated and coherent care. However, recently, it is stated that a small variability was found in the comparison of using from a clinical specialist nurse in core competency in the spheres of patient, nursing, organization, and scholarship.[67] Another noteworthy issue that has been neglected is the knowledge of a clinical specialist nurse about his/her roles and responsibilities as a manager, leader, researcher, clinical educator than general nurses, providing care according to the need and accepting responsibility before evidence-based treatment for the patient in order to establish these interactions, because Poulton believes how to care by treatment team as a process leads to the realization of more than a quarter of the effectiveness of occupational therapy;[68] one of the most guiding studies for better performing the roles and responsibilities is Contandriopoulos and their colleagues study that demonstrated five themes which includes planning, role definition, practice model, collaboration, and team support.[69] Patient and their family, nurse, and organization outcomes were extracted, which refers to the importance of the role of clinical specialist nurse in organizational outcome that is consistent with other quantitative and qualitative studies.[5054] However, in aforementioned studies, only the effect of the role of clinical specialist nurse on the patient is considered and its influence on preventing from leaving the job of medical staff and consequently improving performance and reducing costs of the organization has not been considered. The outcomes that bring about job satisfaction, formation, and promotion of professional and specialized qualifications for nurses are not discussed. Some authors declared that current guidelines should form the foundation for such evaluations of clinical specialist nurse roles; the proposed role-specific considerations which clarifies application of standard guidelines sections to such evaluation of clinical specialist nurse could strengthen the quality and comprehensiveness of future evaluations of these roles.[4270] One of the main limitations of the present study was lack of access to the EMbase website and lack of access to interviews with specialist nurses abroad.

Considering the involving factors in structure, process, and outcome area of clinical specialist nurse role can guarantee the key to successful establishment of the clinical specialist nurse role and sufficiently differentiate it from other nursing roles, having lasting effect on the patient life, their family, the organization, and even the clinical specialist nurse. Moreover, with the correct knowledge of aforementioned factors, it is possible to achieve the desired therapeutic, organizational, and professional results of nursing by providing the necessary fields in the structure, process, and outcome that may inform strategies used by providers and decision makers to optimize these roles across healthcare settings and support the delivery of high-quality care.

Baqiyatallah University of Medical Sciences

Nothing to declare.