1. INTRODUCTION:

Changes in social environment, such as population aging, disease diversification and consumer-oriented medical care require medical environments such as health maintenance, health promotion, disease prevention and rehabilitation in consideration of the status of individual people. It is the professional nursing system that has emerged as one of the strategies to cope with new medical environments and provide quality medical services¹. Medical care subjects and families demand more segmented and individualized nursing care which is more suited to their conditions rather than uniform care. Specialization of nursing is not only a demand from field of nursing but also from a natural reaction, dynamic change according to social demands².

And the necessity of quality nursing is increasing due to the provision of customer-oriented quality nursing services and the expectation of reduced national healthcare cost³. In Korea, the law of nurse specialist was first established in 2000 by specifying ‘nurse specialist’ in the medical laws. In 2003, qualification and education of nurse specialist were enacted in the enforcement regulations of medical laws and notification of the Ministry of Health Welfare. In 2006, the regulations for nurse specialist’s qualification including the expansion of professional nursing areas to 13 areas were enacted and being executed⁴. They contribute to national insurance finance by reducing medical costs and also have made a number of contributions to health care system including the improvement of patients’ satisfaction, quality of life about the medical services and increasing the job satisfaction level of general nurses and doctors⁵. Nevertheless, details of nursing services which are provided by nurse specialist in Korea are ambiguous¹, and job regulations or roles of them are not established yet³. Therefore, actual job and related experiences of the nurse specialists system should be identified within healthcare environment in Korea and nursing delivery³.

Previous studies about nurse specialist include the roles and execution behaviors of critical patient nurse specialist⁶, roles and functions of elderly nurse specialist⁷, job analysis of tumor nurse specialist and medical charge condition analysis^8,9.

Regarding the researches about clinical nurse specialist on the other hand, most researches are about the role perception and job satisfaction including recognition of clinical nurse specialist¹⁰, medical team and patient’s satisfaction for job execution¹¹, job satisfaction of clinical nurse specialist.¹². There are very few follow-up studies after clinical nurse specialist area was recognized legally, and therefore, it is difficult to collect diverse data about personal satisfaction, problems and alternatives for various duties and roles.

In order to improve the quality of the clinical nurse specialist, it is necessary to conduct the research based on the experiences of those who actually work. Additionally for stable settlement and growth of the system, researches about clinical nurse specialists’ experiences are required who are actually working during their job execution process.

Purpose of this study is to deeply understand clinical nurse specialists by studying the meanings of their experiences. This study tried to focus on the research phenomena with the question of “what is the structure of clinical nurse specialist’s experience?” This study is to identify the experiences of clinical nurse specialists in depth and to help establish their effective roles.

2. MATERIALS AND METHODS:

2.1. Study design:

This research is a qualitative study using Colazzi's approach to identify clinical nurse specialist's experiences in depth and describe the meanings.

2.2. Data collection and procedure:

Study participants were six clinical nurse specialists who agreed to participate in the research at A University Hospital in Korea. Data collection period was 6 months from August 2015 to February 2016, and the interviews were conducted at the place that the subjects suggested and felt most comfortable. Interviews began with the question like "Please tell me about your experiences as a clinical nurse specialist" and the interview time was 1-2 hours and the number of interviews was 1-2 times.

2.3. Selection and characteristics of study subjects:

Clinical nurse specialist in this study is an experienced nurse who has nurse license at A University Hospital and has more than 3 years of working experience in nursing practice and is recognized as a clinical nurse specialist in the hospital. All 6 study participants were female and their ages ranged from 29 to 46 years and the average age was 34 years. All participants had master’s degree in education level, 4 participants were married and 3participants had no religion. Nursing career ranged from 3 to 15 years, with the average of 6 years. Current working career as a CNS ranged from 2 to 7 years with the average of 4 years.

2.4. Protection and ethical consideration for study subjects:

Research agreement was provided that commits the interview contents should not be used except research purpose, participants’ status and personal information and be treated anonymously and explains the participants have the right to refuse research participation if they want during the interview. After the participants were given the time to fully examine the contents of the research agreement, they signed on two copies of agreement and the participant and researcher each kept one copy.

3. RESULTS:

Extracted data which were acquired from original raw data by 6 research participants could be structured into 20 meanings, 6 topics and 2 categories(as shown in table 1).Study results showed that the participants felt the fear of work, burden about patient's condition, alienation due to the lack of belonging and the pressure about self-development. However, in the aspects of duties and relationships, they determine to become the top.

Table 1.Lived experience of CNS>

Categories

Theme clusters

Suppressed mental distress

Fear about work

Burden on patient’s conditions

Alienation due to lack of belonging

Pressure about self development

Determine to become a main character on the big stage

Determine to become a top in the duty

Determine to become a top in the relationship

Following study results are the description of category about potential mental distress, category about the determination to become a main character on the big stage and all collected topics included here.

3.1. Category ; Suppressed mental distress:

3.1.1. Fear about work:

Most participants could not avoid the difficulty in executing their duties. Because they started a new duty as professional clinical nursing with lack of sufficient training period or duty takeover and consultants while they were working. Participants who became a CNS for the first time in the department didn’t have a counseling counterpart. Because they had no seniors, and even though they had senior CNSs, they had same difficulty in counseling because most of them already left the hospital. On the other hand, when there were multiple CNSs in the same department, it was possible to share the emotions, but it was difficult to seek the advices about their duties because the assigned duties are different each other.

Participants' roles were mainly the contribution to the improvement of nursing quality, cooperation with doctors' work, cooperation with other departments and educators, administrative works and counseling. Despite the difficulties to execute these various new roles at the same time, the guidelines were not sufficient.

Some participants pointed out the lack of understanding about in-depth knowledge and duties was due to the factthat clinical nurse specialists' theoretical and practical training and qualification tests are not specific but too general. In addition, immediate starting duty without education or training in the hospital was also an element that gives the difficulty to adapt to their new duties.

'Our exam questions are too broad. I just know general things now. But, I think I have too many actual things I have to know in details. I think it is a problem to start working by myself on the first day without orientation.(Participant 2)’

3.1.2. Burden on patient’s conditions:

Initially, some participants experienced general fear about what they had not done in the past. And some of participants who conducted prescription duty expressed the worries and fear about side effects and post-treatments because they didn’t have protective devices. The burden was biggest when they made prescriptions by themselves, and the biggest reason was no protective devices or regulations against wrong prescription.

As the clinical nurse specialist executed co-operation duties for doctors and made in-depth education about the disease, the patients greatly relied on the participants and the participants always had burden for that.

'I think the first thing is the hardest in everything. There is a lot of mental stress. It is a fear whether I could do it well. Especially, I was a little surprised at first because our department makes prescription. And, I also had fear what should I do if goes wrong and who could help me? If I get used some extent, I have a stress about patient's conditions(Participant 3).

'If a patient dies in the course of treatment, there is a big aftermath. Normally, if you have a problem, you go to the outpatient department and ask for help to your professor. They come to us too. The patients are also relying on us. If it goes wrong, the patients come to me first. There are many times when I feel stressed because I feel burdened by such things(Participant 1).

3.1.3. Alienation due to lack of belonging:

All participants were working with general nurses with strong cohesion, but after becoming a clinical nurse specialist, general nurses did not understand the distress of those who executed discriminatory duties. And they felt distance each other, experienced an alienation and expressed they are lonely. One participant said she felt alienated to be left alone due to the absence of belonging when she talked with the person who listens to or understands her problems and she expressed as follows. 'I think we always feel concerned to be alienated. We feel alienated even if we have 3 CNSs in the ward. I wonder where I belong and feel a little bit lonely. (Participant 6)'

3.1.4. Pressure about self-development:

Most participants experienced the pressure to improve their academic skills and abilities due to their own and external expectations. They needed to acquire or maintain a certificate related to the work in the academic field.

They had to study by themselves and pay attention to new medical changes and studying English was also a must. They made every effort to improve skills of presentation, research and education. They had to study by themselves and pay attention to new medical changes and studying English was also a must. They made every effort to improve skills of presentation, research and education.

'I feel stressed that I am lacking in something even if I am 100% satisfied with my job. I think I have to be smart because I have to teach the patients, do a lot of research and have too much to do, but I think I cannot follow it myself. I have to grow fast(Participant 1).

3.2. Category ;Determine to become a main character on the big stage :

3.2.1. Determine to become a top in the duty:

Most participants worked hard to get the job done and constantly attended the conference, planned to acquire a degree or qualification for self-development. When they were adapted by the efforts of studying by themselves and making their own handbooks, they actively executed their duties by expanding their work areas like to develop the education, computer program and books or strengthening their specialty area further. When they could participate in the treatment method, contribute to the quality of nursing through comprehensive management and their satisfaction about patient’s nursing service increased through sufficient training, explanation and management, they could feel rewarded and proud of their duties This is because the quality of nursing education is improved and prompt response for patient’s requests becomes possible. Therefore, this seems to contribute to the improvement of reliability and satisfaction about nursing.

In other words, participants executed the duties of professional nursing and cooperation with doctors to take care of the patients. And most participants were actively executing and leading their duties when they took the job. Participants said that professional nursing works were mainly to teach the patients and caregivers. And they frequently visited and carefully taught the patients with responsibility for a long time so that the patients could understand with deep knowledge for a long time. And they said that the education was done before and after the treatment, tests, surgery and at the time of medication, discharge and patient assessment. And, if the patients appealed to their problems, they immediately solved the problems.

'In many duties I do, I feel more power and confidence when I teach or explain. So, I study and practice to know how to educate them better and explain logically ... and I would like to be compensated or recognized from the outside as much as I work hard. For example, when we acquire a qualification, we would like to have a corresponding salary increase.(Participant 4)

3.2.2. Determine to become the top in the relationship:

Participants made efforts to establish and maintain new relationships with the nurses, doctors and patients. Because of the expectations and responsibilities according to their duties, they were not only cautious about words and actions but also made efforts to have confidence and intimacy to the participants. For this purpose, almost all participants were engaged to get a professional recognition from doctors and tried to narrow emotional distance from nurses.

In particular, they conducted high quality education for the patients and tried to make the patients aware of the concept and roles about clinical nurse specialist. And, when they introduced themselves, they said they were a person who is doing a little more professional works and explained their specific duties to raise the awareness of clinical nurse specialists. With these efforts, the number of visiting the participants increased when the patients were uncomfortable or had questions. Because they had the opportunity to frequently visit the patients to check and talk about their conditions or problems, they are the person who can understand the patients most with high reliability.

'When the patients talk to me, I explain to the patient that I know the situation well and I can help whenever needed. Because I frequently visit and ask their conditions or inconvenience, I have a lot of opportunities to talk. I am recognized as the highest reliable person who understands the patient(Participant 5).

4. DISCUSSION:

Study results showed that the participants felt the fear of work, burden about patient's condition, alienation due to the lack of belonging and the pressure about self-development. However, in the aspects of duties and relationships, they determine to become the top. Regarding the roles of professional nurse, they are professional nursing practitioner, educator, researcher, leader, counselor and partner ⁴. According to the ¹³about clinical medical practitioners’ quality, the qualities of doctors and nurses were identified to be knowledge, clinical experience and working capability in order. In the research about CNS by Leem (2003), the qualities were professional knowledge, working capability and clinical experiences in order.

Participants in this study also executed various duties for the patients and families including the education, counseling and coordination for doctors' duties related to prescriptions, tests, treatments, administrative supports related to program development, quality improvement activities, medical research supports, nursing study and etc. However, at the early stage, there was a big difficulty due to the lack of understanding about the duties. This suggests that the clinical nurse specialist starts to work as a professional nurse without systematic curriculum even though they should perform their tasks with higher level of expertise than general nurses in certain special areas of nursing. As a way to overcome these difficulties, participants used a strategy to study by themselves and create their own hand books. Because in-depth knowledge about nurse specialist area helps them perform their duties most reasonably and effectively, it is desirable that in-depth knowledge about their assigned duties should be provided through the education and training before starting the jobs¹⁴. Leem (2003) mentioned that more than 1 year of training period in the field is required. Participants in this study reported that the lack of expertise was also due to the problems of the curriculum. In order that the professional nurses could perform true advanced nursing practice, systematic education to secure comprehensive and necessary competence is required¹¹.And the development of specialists is required who have professional capability through in-depth clinical training¹⁰.

According to the study by Kim et al(2003), nurse specialist is expected to have the qualities like in-depth clinical knowledge, foresee ability about patient’s health, disease and responses against nursing intervention, clinical analysis and correct clinical judgment. This shows specialist nurses should have clear difference from general nurses. In this way, along with clinical nurse specialist’s objective qualities like academic background and working career, clear definition of roles and professional insights in relevant field, individual personal qualities seem to positively affect the formation and maintenance of the relationship with related groups. According to a qualitative study about the duties and difficulties of clinical nurse specialists by Darmony (2005), it is reported that clinical nurse specialists experience a feeling of pressure about their roles for about three years, which is caused by too high self-expectation.

Participants in this study also felt much pressure against the expectation and patient’s conditions. But they tried to overcome the difficulties by controlling the stress and more actively executing their duties. Almost all of the participants overcame the difficulties by actively working and improving the relationships. Participants in this study felt bigger rewards when the satisfaction with nursing services was improved especially through education, explanation and management. This self-development, reward and pride are expected to have a significant effect on the improvement of clinical nurse specialist’s job satisfaction. Additionally in the study of Kim et al. (2003) and Cho, Cho, Kwon, Seo and Baek (2011), patient’s satisfaction with clinical nurse specialists was also high when they were educated and explained, and these findings are consistent with our study results.

Participants felt stress and pressure about patient's condition. In particular, they felt most burdened with patient's condition at prescription because there is no legal protection devices or regulations. Even in the case of United States, prescription work is a constant issue¹⁵. Clinical nurse specialist’s prescription in our country is conducted by the supervision, delegation or protocols by the doctors in relevant medical institutions. In order to protect nurse specialists and patients, improve the quality and satisfaction of nursing interventions, active nursing efforts are required to prepare legal regulations and education curriculum because there is no legal regulation yet¹.

Additionally in order that the roles of clinical nurse specialist could be clearly established, it is necessary to investigate the contents of the duties in detail and standardize their roles and tasks in the medical system as well as in the nursing field. It is considered necessary to connect with the nursing department. It is the nursing department that plays the most important role in proposing the usefulness of professional nurses in the hospital and establishing the system for utilization. If the nursing department will not make efforts to understand and utilize the professional nurses, the use of professional nurses will not be achieved in practice. In addition, when the nurses in nursing field understand the meanings and roles of professional nurses and support, professional nursing system will develop and this will lead to the development of nursing profession³

5. CONCLUSION:

Previous studies have limitations to comprehensively understand clinical nurse specialist’s experiences. Therefore in this study, a qualitative study was conducted to identify in-depth experiences of clinical nurse specialists through individual interviews. Study results showed that the participants suffered from the fear about their duties, burden about patient's conditions, alienation due to the lack of belonging and pressure about self-development. However, the participants seemed to be determined to be the top in terms of duties and relationship. They are adapting themselves using the strategy to learn working process, improve relationship and work hard for self-development. Results of this study can be used as basic data to understand the experiences of clinical nurse specialists. The researcher suggests the study of role and job development through the participation observation of clinical nurse specialist’s roles and related execution behaviors.

6. REFERENCES:

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Received on 12.12.2017 Modified on 24.12.2017

Research J. Pharm. and Tech. 2018; 11(3): 857-862.

DOI: 10.5958/0974-360X.2018.00159.2

The Lived Experience of Clinical Nurse Specialist: A Phenomenological Study