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• Research article
• Open access
• Published: 14 June 2021

Nurses in the lead: a qualitative study on the development of distinct nursing roles in daily nursing practice

• Jannine van Schothorst–van Roekel 1 ,
• Anne Marie J.W.M. Weggelaar-Jansen 1 ,
• Carina C.G.J.M. Hilders 1 ,
• Antoinette A. De Bont 1 &
• Iris Wallenburg 1  

BMC Nursing volume  20 , Article number:  97 ( 2021 ) Cite this article

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Transitions in healthcare delivery, such as the rapidly growing numbers of older people and increasing social and healthcare needs, combined with nursing shortages has sparked renewed interest in differentiations in nursing staff and skill mix. Policy attempts to implement new competency frameworks and job profiles often fails for not serving existing nursing practices. This study is aimed to understand how licensed vocational nurses (VNs) and nurses with a Bachelor of Science degree (BNs) shape distinct nursing roles in daily practice.

A qualitative study was conducted in four wards (neurology, oncology, pneumatology and surgery) of a Dutch teaching hospital. Various ethnographic methods were used: shadowing nurses in daily practice (65h), observations and participation in relevant meetings (n=56), informal conversations (up to 15 h), 22 semi-structured interviews and member-checking with four focus groups (19 nurses in total). Data was analyzed using thematic analysis.

Hospital nurses developed new role distinctions in a series of small-change experiments, based on action and appraisal. Our findings show that: (1) this developmental approach incorporated the nurses’ invisible work; (2) nurses’ roles evolved through the accumulation of small changes that included embedding the new routines in organizational structures; (3) the experimental approach supported the professionalization of nurses, enabling them to translate national legislation into hospital policies and supporting the nurses’ (bottom-up) evolution of practices. The new roles required the special knowledge and skills of Bachelor-trained nurses to support healthcare quality improvement and connect the patients’ needs to organizational capacity.

Conclusions

Conducting small-change experiments, anchored by action and appraisal rather than by design , clarified the distinctions between vocational and Bachelor-trained nurses. The process stimulated personal leadership and boosted the responsibility nurses feel for their own development and the nursing profession in general. This study indicates that experimental nursing role development provides opportunities for nursing professionalization and gives nurses, managers and policymakers the opportunity of a ‘two-way-window’ in nursing role development, aligning policy initiatives with daily nursing practices.

Peer Review reports

The aging population and mounting social and healthcare needs are challenging both healthcare delivery and the financial sustainability of healthcare systems [ 1 , 2 ]. Nurses play an important role in facing these contemporary challenges [ 3 , 4 ]. However, nursing shortages increase the workload which, in turn, boosts resignation numbers of nurses [ 5 , 6 ]. Research shows that nurses resign because they feel undervalued and have insufficient control over their professional practice and organization [ 7 , 8 ]. This issue has sparked renewed interest in nursing role development [ 9 , 10 , 11 ]. A role can be defined by the activities assumed by one person, based on knowledge, modulated by professional norms, a legislative framework, the scope of practice and a social system [ 12 , 9 ].

New nursing roles usually arise through task specialization [ 13 , 14 ] and the development of advanced nursing roles [ 15 , 16 ]. Increasing attention is drawn to role distinction within nursing teams by differentiating the staff and skill mix to meet the challenges of nursing shortages, quality of care and low job satisfaction [ 17 , 18 ]. The staff and skill mix include the roles of enrolled nurses, registered nurses, and nurse assistants [ 19 , 20 ]. Studies on differentiation in staff and skill mix reveal that several countries struggle with the composition of nursing teams [ 21 , 22 , 23 ].

Role distinctions between licensed vocational-trained nurses (VNs) and Bachelor of Science-trained nurses (BNs) has been heavily debated since the introduction of the higher nurse education in the early 1970s, not only in the Netherlands [ 24 , 25 ] but also in Australia [ 26 , 27 ], Singapore [ 20 ] and the United States of America [ 28 , 29 ]. Current debates have focused on the difficulty of designing distinct nursing roles. For example, Gardner et al., revealed that registered nursing roles are not well defined and that job profiles focus on direct patient care [ 30 ]. Even when distinct nursing roles are described, there are no proper guidelines on how these roles should be differentiated and integrated into daily practice. Although the value of differentiating nursing roles has been recognized, it is still not clear how this should be done or how new nursing roles should be embedded in daily nursing practice. Furthermore, the consequences of these roles on nursing work has been insufficiently investigated [ 31 ].

This study reports on a study of nursing teams developing new roles in daily nursing hospital practice. In 2010, the Dutch Ministry of Health announced a law amendment (the Individual Health Care Professions Act) to formalize the distinction between VNs and BNs. The law amendment made a distinction in responsibilities regarding complexity of care, coordination of care, and quality improvement. Professional roles are usually developed top-down at policy level, through competency frameworks and job profiles that are subsequently implemented in nursing practice. In the Dutch case, a national expert committee made two distinct job profiles [ 32 ]. Instead of prescribing role implementation, however, healthcare organizations were granted the opportunity to develop these new nursing roles in practice, aiming for a more practice-based approach to reforming the nursing workforce. This study investigates a Dutch teaching hospital that used an experimental development process in which the nurses developed role distinctions by ‘doing and appraising’. This iterative process evolved in small changes [ 33 , 34 , 35 , 36 ], based on nurses’ thorough knowledge of professional practices [ 37 ] and leadership role [ 38 , 39 , 40 ].

According to Abbott, the constitution of a new role is a competitive action, as it always leads to negotiation of new openings for one profession and/or degradation of adjacent professions [ 41 ]. Additionally, role differentiation requires negotiation between different professionals, which always takes place in the background of historical professionalization processes and vested interests resulting in power-related issues [ 42 , 43 , 44 ]. Recent studies have described the differentiation of nursing roles to other professionals, such as nurse practitioners and nurse assistants, but have focused on evaluating shifts in nursing tasks and roles [ 31 ]. Limited research has been conducted on differentiating between the different roles of registered nurses and the involvement of nurses themselves in developing new nursing roles. An ethnographic study was conducted to shed light on the nurses’ work of seeking openings and negotiating roles and responsibilities and the consequences of role distinctions, against a background of historically shaped relationships and patterns.

The study aimed to understand the formulation of nursing role distinctions between different educational levels in a development process involving experimental action (doing) and appraisal.

We conducted an ethnographic case study. This design was commonly used in nursing studies in researching changing professional practices [ 45 , 46 ]. The researchers gained detailed insights into the nurses’ actions and into the finetuning of their new roles in daily practice, including the meanings, beliefs and values nurses give to their roles [ 47 , 48 ]. This study complied with the consolidated criteria for reporting qualitative research (COREQ) checklist.

Setting and participants

Our study took place in a purposefully selected Dutch teaching hospital (481 beds, 2,600 employees including 800 nurses). Historically, nurses in Dutch hospitals have vocational training. The introduction of higher nursing education in 1972 prompted debates about distinguishing between vocational-trained nurses (VNs) and bachelor-trained nurses (BNs). For a long time, VNs resisted a role distinction, arguing that their work experience rendered them equally capable to take care of patients and deal with complex needs. As a result, VNs and BNs carry out the same duties and bear equal responsibility. To experiment with role distinctions in daily practice, the hospital management and project team selected a convenience but representative sample of wards. Two general (neurology and surgery) and two specific care (oncology and pneumatology) wards were selected as they represent the different compositions of nursing educational levels (VN, BN and additional specialized training). The demographic profile for the nursing teams is shown in Table  1 . The project team, comprising nursing policy staff, coaches and HR staff ( N  = 7), supported the four (nursing) teams of the wards in their experimental development process (131 nurses; 32 % BNs and 68 % VNs, including seven senior nurses with an organizational role). We also studied the interactions between nurses and team managers ( N  = 4), and the CEO ( N  = 1) in the meetings.

Data collection

Data was collected between July 2017 and January 2019. A broad selection of respondents was made based on the different roles they performed. Respondents were personally approached by the first author, after close consultation with the team managers. Four qualitative research methods were used iteratively combining collection and analysis, as is common in ethnographic studies [ 45 ] (see Table  2 ).

Shadowing nurses (i.e. observations and questioning nurses about their work) on shift (65 h in total) was conducted to observe behavior in detail in the nurses’ organizational and social setting [ 49 , 50 ], both in existing practices and in the messy fragmented process of developing distinct nursing roles. The notes taken during shadowing were worked up in thick descriptions [ 46 ].

Observation and participation in four types of meetings. The first and second authors attended: (1) kick-off meetings for the nursing teams ( n  = 2); (2) bi-monthly meetings ( n  = 10) between BNs and the project team to share experiences and reflect on the challenges, successes and failures; and (3) project group meetings at which the nursing role developmental processes was discussed ( n  = 20). Additionally, the first author observed nurses in ward meetings discussing the nursing role distinctions in daily practice ( n  = 15). Minutes and detailed notes also produced thick descriptions [ 51 ]. This fieldwork provided a clear understanding of the experimental development process and how the respondents made sense of the challenges/problems, the chosen solutions and the changes to their work routines and organizational structures. During the fieldwork, informal conversations took place with nurses, nursing managers, project group members and the CEO (app. 15 h), which enabled us to reflect on the daily experiences and thus gain in-depth insights into practices and their meanings. The notes taken during the conversations were also written up in the thick description reports, shortly after, to ensure data validity [ 52 ]. These were completed with organizational documents, such as policy documents, activity plans, communication bulletins, formal minutes and in-house presentations.

Semi-structured interviews lasting 60–90 min were held by the first author with 22 respondents: the CEO ( n  = 1), middle managers ( n  = 4), VNs ( n  = 6), BNs ( n  = 9, including four senior nurses), paramedics ( n  = 2) using a predefined topic list based on the shadowing, observations and informal conversations findings. In the interviews, questions were asked about task distinctions, different stakeholder roles (i.e., nurses, managers, project group), experimental approach, and added value of the different roles and how they influence other roles. General open questions were asked, including: “How do you distinguish between tasks in daily practice?”. As the conversation proceeded, the researcher asked more specific questions about what role differentiation meant to the respondent and their opinions and feelings. For example: “what does differentiation mean for you as a professional?”, and “what does it mean for you daily work?”, and “what does role distinction mean for collaboration in your team?” The interviews were tape-recorded (with permission), transcribed verbatim and anonymized.

The fieldwork period ended with four focus groups held by the first author on each of the four nursing wards ( N  = 19 nurses in total: nine BNs, eight VNs, and two senior nurses). The groups discussed the findings, such as (nurses’ perceptions on) the emergence of role distinctions, the consequences of these role distinctions for nursing, experimenting as a strategy, the elements of a supportive environment and leadership. Questions were discussed like: “which distinctions are made between VN and BN roles?”, and “what does it mean for VNs, BNs and senior nurses?”. During these meetings, statements were also used to provoke opinions and discussion, e.g., “The role of the manager in developing distinct nursing roles is…”. With permission, all focus groups were audio recorded and the recordings were transcribed verbatim. The focus groups also served for member-checking and enriched data collection, together with the reflection meetings, in which the researchers reflected with the leader and a member of the project group members on program, progress, roles of actors and project outcomes. Finally, the researchers shared a report of the findings with all participants to check the credibility of the analysis.

Data analysis

Data collection and inductive thematic analysis took place iteratively [ 45 , 53 ]. The first author coded the data (i.e. observation reports, interview and focus group transcripts), basing the codes on the research question and theoretical notions on nursing role development and distinctions. In the next step, the research team discussed the codes until consensus was reached. Next, the first author did the thematic coding, based on actions and interactions in the nursing teams, the organizational consequences of their experimental development process, and relevant opinions that steered the development of nurse role distinctions (see Additional file ). Iteratively, the research team developed preliminary findings, which were fed back to the respondents to validate our analysis and deepen our insights [ 54 ]. After the analysis of the additional data gained in these validating discussions, codes were organized and re-organized until we had a coherent view.

Ethnography acknowledges the influence of the researcher, whose own (expert) knowledge, beliefs and values form part of the research process [ 48 ]. The first author was involved in the teams and meetings as an observer-as-participant, to gain in-depth insight, but remained research-oriented [ 55 ]. The focus was on the study of nursing actions, routines and accounts, asking questions to obtain insights into underlying assumptions, which the whole research group discussed to prevent ‘going native’ [ 56 , 57 ]. Rigor was further ensured by triangulating the various data resources (i.e. participants and research methods), purposefully gathered over time to secure consistency of findings and until saturation on a specific topic was reached [ 54 ]. The meetings in which the researchers shared the preliminary findings enabled nurses to make explicit their understanding of what works and why, how they perceived the nursing role distinctions and their views on experimental development processes.

Ethical considerations

All participants received verbal and written information, ensuring that they understood the study goals and role of the researcher [ 48 ]. Participants were informed about their voluntary participation and their right to end their contribution to the study. All gave informed consent. The study was performed in accordance with the Declaration of Helsinki and was approved by the Erasmus Medical Ethical Assessment Committee in Rotterdam (MEC-2019-0215), which also assessed the compliance with GDPR.

Our findings reveal how nurses gradually shaped new nursing role distinctions in an experimental process of action and appraisal and how the new BN nursing roles became embedded in new nursing routines, organizational routines and structures. Three empirical appeared from the systematic coding: (1) distinction based on complexity of care; (2) organizing hospital care; and (3) evidence-based practices (EBP) in quality improvement work.

Distinction based on complexity of care

Initially, nurses distinguished the VN and BN roles based on the complexity of patient care, as stated in national job profiles [ 32 ]. BNs were supposed to take care of clinically complex patients, rather than VNs, although both VNs and BNs had been equally taking care of every patient category. To distinguish between highly and less complex patient care, nurses developed a complexity measurement tool. This tool enabled classification of the predictability of care, patient’s degree of self-reliance, care intensity, technical nursing procedures and involvement of other disciplines. However, in practice, BNs questioned the validity of assessing a patient’s care complexity, because the assessments of different nurses often led to different outcomes. Furthermore, allocating complex patient care to BNs impacted negatively on the nurses’ job satisfaction, organizational routines and ultimately the quality of care. VNs experienced the shift of complex patient care to BNs as a diminution of their professional expertise. They continuously stressed their competencies and questioned the assigned levels of complexity, aiming to prevent losses to their professional tasks:

‘Now we’re only allowed to take care of COPD patients and people with pneumonia, so no more young boys with a pneumothorax drain. Suddenly we are not allowed to do that. (…) So, your [professional] world is getting smaller. We don’t like that at all. So, we said: We used to be competent, so why aren’t we anymore?’ (Interview VN1, in-service trained nurse).

In discussing complexity of care, both VNs and BNs (re)discovered the competencies VNs possess in providing complex daily care. BNs acknowledged the contestability of the distinction between VN and BN roles related to patient care complexity, as the next quote shows:

‘Complexity, they always make such a fuss about it. (…) At a given moment you’re an expert in just one certain area; try then to stand out on your ward. (…) When I go to GE [gastroenterology] I think how complex care is in here! (…) But it’s also the other way around, when I’m the expert and know what to expect after an angioplasty, or a bypass, or a laparoscopic cholecystectomy (…) When I’ve mastered it, then I no longer think it’s complex, because I know what to expect!’ (Interview BN1, 19-07-2017).

This quote illustrates how complexity was shaped through clinical experience. What complex care is , is influenced by the years of doing nursing work and hence is individual and remains invisible. It is not formally valued [ 58 ] because it is not included in the BN-VN competency model. This caused dissatisfaction and feelings of demotion among VNs. The distinction in complexities of care was also problematic for BNs. Following the complexity tool, recently graduated BNs were supposed to look after highly complex patients. However, they often felt insecure and needed the support of more experienced (VN) colleagues – which the VNs perceived as a recognition of their added value and evidence of the failure of the complexity tool to guide division of tasks. Also, mundane issues like holidays, sickness or pregnancy leave further complicated the use of the complexity tool as a way of allocating patients, as it decreased flexibility in taking over and swapping shifts, causing dissatisfaction with the work schedule and leading to problems in the continuity of care during evening, night and weekend shifts. Hence, the complexity tool disturbed the flexibility in organizing the ward and held possible consequences for the quality and safety of care (e.g. inexperienced BNs providing complex care), Ultimately, the complexity tool upset traditional teamwork, in which nurses more implicitly complemented each other’s competencies and ability to ‘get the work done’ [ 59 ]. As a result, role distinction based on ‘quantifiable’ complexity of care was abolished. Attention shifted to the development of an organizational and quality-enhancing role, seeking to highlight the added value of BNs – which we will elaborate on in the next section.

Organizing hospital care

Nurses increasingly fulfill a coordinating role in healthcare, making connections across occupational, departmental and organizational boundaries, and ‘mediating’ individual patient needs, which Allen describes as organizing work [ 49 ]. Attempting to make a valuable distinction between nursing roles, BNs adopted coordinating management tasks at the ward level, taking over this task from senior nurses and team managers. BNs sought to connect the coordinating management tasks with their clinical role and expertise. An example is bed management, which involves comparing a ward’s bed capacity with nursing staff capacity [ 1 , 60 ]. At first, BNs accompanied middle managers to the hospital bed review meeting to discuss and assess patient transfers. On the wards where this coordination task used to be assigned to senior nurses, the process of transferring this task to BNs was complicated. Senior nurses were reluctant to hand over coordinating tasks as this might undermine their position in the near future. Initially, BNs were hesitant to take over this task, but found a strategy to overcome their uncertainty. This is reflected in the next excerpt from fieldnotes:

Senior nurse: ‘First we have to figure out if it will work, don’t we? I mean, all three of us [middle manager, senior nurse, BN] can’t just turn up at the bed review meeting, can we? The BN has to know what to do first, otherwise she won’t be able to coordinate properly. We can’t just do it.’ BN: ‘I think we should keep things small, just start doing it, step by step. (…) If we don’t try it out, we don’t know if it works.’ (Field notes, 24-05-2018).

This excerpt shows that nurses gradually developed new roles as a series of matching tasks. Trying out and evaluating each step of development in the process overcame the uncertainty and discomfort all parties held [ 61 ]. Moreover, carrying out the new tasks made the role distinctions become apparent. The coordinating role in bed management, for instance, became increasingly embedded in the new BN nursing role. Experimenting with coordination allowed BNs prove their added value [ 62 ] and contributed to overall hospital performance as it combined daily working routines with their ability to manage bed occupancy, patient flow, staffing issues and workload. This was not an easy task. The next quote shows the complexity of creating room for this organizing role:

The BNs decide to let the VNs help coordinate the daily care, as some VNs want to do this task. One BN explains: ‘It’s very hard to say, you’re not allowed.’ The middle manager looks surprised and says that daily coordination is a chance to draw a clear distinction and further shape the role of BNs. The project group leader replies: ‘Being a BN means that you dare to make a difference [in distinctive roles]. We’re all newbies in this field, but we can use our shared knowledge. You can derive support from this task for your new role.’ (Field notes, 09-01-2018).

This excerpt reveals the BNs’ thinking on crafting their organizational role, turning down the VNs wishes to bear equal responsibility for coordinating tasks. Taking up this role touched on nurse identity as BNs had to overcome the delicate issue of equity [ 63 ], which has long been a core element of the Dutch nursing profession. Taking over an organization role caused discomfort among BNs, but at the same time provided legitimation for a role distinction.

Legitimation for this task was also gained from external sources, as the law amendment and the expert committee’s job descriptions both mentioned coordinating tasks. However, taking over coordinating tasks and having an organizing role in hospital care was not done as an ‘implementation’; rather it required a process of actively crafting and carving out this new role. We observed BNs choosing not to disclose that they were experimenting with taking over the coordinating tasks as they anticipated a lack of support from VNs:

BN: ‘We shouldn’t tell the VNs everything. We just need this time to give shape to our new role. And we all know who [of the colleagues] won’t agree with it. In my opinion, we’d be better off hinting at it at lunchtime, for example, to figure out what colleagues think about it. And then go on as usual.’ (Field notes, 12-06-2018).

BNs stayed ‘under the radar’, not talking explicitly about their fragile new role to protect the small coordination tasks they had already gained. By deliberately keeping the evaluation of their new task to themselves, they protected the transition they had set into motion. Thus, nurses collected small changes in their daily routines, developing a new role distinction step by step. Changes to single tasks accumulated in a new role distinction between BNs, VNs and senior nurses, and gave BNs a more hybrid nursing management role.

Evidence-based practices in quality improvement work

Quality improvement appeared to be another key concern in the development of the new BN role. Quality improvement work used to be carried out by groups of senior nurses, middle managers and quality advisory staff. Not involved in daily routines, the working group focused on nursing procedures (e.g. changing infusion system and wound treatment protocols). In taking on this new role BNs tried different ways of incorporating EBP in their routines, an aspect that had long been neglected in the Netherlands. As a first step, BNs rearranged the routines of the working group. For example, a team of BNs conducted a quality improvement investigation of a patient’s formal’s complaint:

Twenty-two patients registered a pain score of seven or higher and were still discharged. The question for BNs was: how and why did this bad care happen? The BNs used electronic patient record to study data on the relations between pain, medication and treatment. Their investigation concluded: nurses do not always follow the protocols for high pain scores. Their improvement plan covered standard medication policy, clinical lessons on pain management and revisions to the patient information folder. One BN said: ‘I really loved investigating this improvement.’ (Field notes, 28-05-2018).

This fieldnote shows the joy quality improvement work can bring. During interviews, nurses said that it had given them a better grip on the outcome of nursing work. BNs felt the need to enhance their quality improvement tasks with their EBP skills, e.g. using clinical reasoning in bedside teaching, formulating and answering research questions in clinical lessons and in multi-disciplinary patient rounds to render nursing work more evidence based. The BNs blended EBP-related education into shift handovers and ward meetings, to show VNs the value of doing EBP [ 64 ]. In doing so, they integrated and fostered an EBP infrastructure of care provision, reflecting a new sense of professionalism and responsibility for quality of care.

However, learning how to blend EPB quality work in daily routines – ‘learning in practice’ –requires attention and steering. Although the BNs had a Bachelor’s degree, they had no experience of a quality-enhancing role in hospital practice [ 65 ]. In our case, the interplay between team members’ previous education and experienced shortcomings in knowledge and skills uncovered the need for further EBP training. This training established the BNs’ role as quality improvers in daily work and at the same time supported the further professionalization of both BNs and VNs. Although introducing the EBP approach was initially restricted to the BNs, it was soon realized that VNs should be involved as well, as nursing is a collaborative endeavor [ 1 ], as one team member (the trainer) put it:

‘I think that collaboration between BNs and VNs would add lots of value, because both add something different to quality work. I’d suggest that BNs could introduce the process-oriented, theoretical scope, while VNs could maybe focus on the patients’ interest.’ (Fieldnote, informal conversation, 11-06-2018).

During reflection sessions on the ward level and in the project team meetings BNs, informed by their previous experience with the complexity tool, revealed that they found it a struggle to do justice to everyone’s competencies. They wanted to use everyone’s expertise to improve the quality of patient care. They were for VNs being involved in the quality work, e.g. in preparing a clinical lesson, conducting small surveys, asking VNs to pose EBP questions and encourage VNs to write down their thoughts on flip over charts as means of engaging all team members.

These findings show that applying EPB in quality improvement is a relational practice driven by mutual recognition of one another’s competencies. This relational practice blended the BNs’ theoretical competence in EBP [ 66 ] with the VNs’ practical approach to the improvement work they did together. As a result, the blend enhanced the quality of daily nursing work and thus improved the quality of patient care and the further professionalization of the whole nursing team.

This study aimed to understand how an experimental approach enables differently educated nurses to develop new, distinct professional roles. Our findings show that roles cannot be distinguished by complexity of care; VNs and BNs are both able to provide care to patients with complex healthcare needs based on their knowledge and experience. However, role distinctions can be made on organizing care and quality improvement. BNs have an important role organizing care, for example arranging the patient flow on and across wards at bed management meetings, while VNs contribute more to organizing at the individual patient level. BNs play a key role in starting and steering quality improvement work, especially blending EBP in with daily nursing tasks, while VNs are involved but not in the lead. Working together on quality improvement boosts nursing professionalization and team development.

Our findings also show that the role development process is greatly supported by a series of small-change experiments, based on action and appraisal. This experimental approach supported role development in three ways. First, it incorporates both formal tasks and the invisible, unconscious elements of nursing work [ 49 ]. Usually, invisible work gets no formal recognition, for example in policy documents [ 55 ], whereas it is crucial in daily routines and organizational structures [ 49 , 60 ]. Second, experimenting triggers an accumulation of small changes [ 33 , 35 ] leading to the embeddedness of role distinctions in new nursing routines, allowing nurses to influence the organization of care. This finding confirms the observations of Reay et al. that nurses can create small changes in daily activities to craft a new nursing role, based on their thorough knowledge of their own practice and that of the other involved professional groups [ 37 ]. Although these changes are accompanied by tension and uncertainty, the process of developing roles generates a certain joy. Third, experimenting stimulated nursing professionalization, enabling the nurses to translate national legislation into hospital policy and supporting the nurses’ own (bottom-up) evolution of practices. Historically, nursing professionalization is strongly influenced by gender and education level [ 43 ] resulting in a subordinate position, power inequity and lack of autonomy [ 44 ]. Giving nurses the lead in developing distinct roles enables them to ‘engage in acts of power’ and obtain more control over their work. Fourth, experimenting contributes to role definition and clarification. In line with Poitras et al. [ 12 ] we showed that identifying and differentiating daily nursing tasks led to the development of two distinct and complementary roles. We have also shown that the knowledge base of roles and tasks includes both previous and additional education, as well as nursing experience.

Our study contributes to the literature on the development of distinct nursing roles [ 9 , 10 , 11 ] by showing that delineating new roles in formal job descriptions is not enough. Evidence shows that this formal distinction led particularly to the non-recognition, non-use and degradation [ 41 ] of VN competencies and discomforted recently graduated BNs. The workplace-based experimental approach in the hospital includes negotiation between professionals, the adoption process of distinct roles and the way nurses handle formal policy boundaries stipulated by legislation, national job profiles, and hospital documents, leading to clear role distinctions. In addition to Hughes [ 42 ] and Abbott [ 67 ] who showed that the delineation of formal work boundaries does not fit the blurred professional practices or individual differences in the profession, we show how the experimental approach leads to the clarification and shape of distinct professional practices.

Thus, an important implication of our study is that the professionals concerned should be given a key role in creating change [ 37 , 39 , 40 ]. Adding to Mannix et al. [ 38 ], our study showed that BNs fulfill a leadership role, which allows them to build on their professional role and identity. Through the experiments, BNs and VNs filled the gap between what they had learned in formal education, and what they do in daily practice [ 64 , 65 ]. Experimenting integrates learning, appraising and doing much like going on ‘a journey with no fixed routes’ [ 34 , 68 ] and no fixed job description, resulting in the enlargement of their roles.

Our study suggests that role development should involve professionalization at different educational levels, highlighting and valuing specific roles rather than distinguishing higher and lower level skills and competencies. Further research is needed to investigate what experimenting can yield for nurses trained at different educational levels in the context of changing healthcare practices, and which interventions (e.g., in process planning, leadership, or ownership) are needed to keep the development of nursing roles moving ahead. Furthermore, more attention should be paid to how role distinction and role differentiation influence nurse capacity, quality of care (e.g., patient-centered care and patient satisfaction), and nurses’ job satisfaction.

Limitations

Our study was conducted on four wards of one teaching hospital in the Netherlands. This might limit the potential of generalizing our findings to other contexts. However, the ethnographic nature of our study gave us unique understanding and in-depth knowledge of nurses’ role development and distinctions, both of which have broader relevance. As always in ethnographic studies, the chances of ‘going native’ were apparent, and we tried to prevent this with ongoing reflection in the research team. Also, the interpretation of research findings within the Dutch context of nurse professionalization contributed to a more in-depth understanding of how nursing roles develop, as well as the importance of involving nurses themselves in the development of these roles to foster and support professional development.

We focused on role distinctions between VNs and BNs and paid less attention to (the collaboration with) other professionals or management. Further research is needed to investigate how nursing role development takes place in a broader professional and managerial constellation and what the consequences are on role development and healthcare delivery.

This paper described how nurses crafted and shaped new roles with an experimental process. It revealed the implications of developing a distinct VN role and the possibility to enhance the BN role in coordination tasks and in steering and supporting EBP quality improvement work. Embedding the new roles in daily practice occurred through an accumulation of small changes. Anchored by action and appraisal rather than by design , the changes fostered by experiments have led to a distinction between BNs and VNs in the Netherlands. Furthermore, experimenting with nursing role development has also fostered the professionalization of nurses, encouraging nurses to translate knowledge into practice, educating the team and stimulating collaborative quality improvement activities.

This paper addressed the enduring challenge of developing distinct nursing roles at both the vocational and Bachelor’s educational level. It shows the importance of experimental nursing role development as it provides opportunities for the professionalization of nurses at different educational levels, valuing specific roles and tasks rather than distinguishing between higher and lower levels of skills and competencies. Besides, nurses, managers and policymakers can embrace the opportunity of a ‘two-way window’ in (nursing) role development, whereby distinct roles are outlined in general at policy levels, and finetuned in daily practice in a process of small experiments to determine the best way to collaborate in diverse contexts.

Availability of data and materials

The data generated and analyzed during the current study is not publicly available to ensure data confidentiality but is available from the corresponding author on reasonable request and with the consent of the research participants.

Abbreviations

Bachelor-trained nurse

Vocational-trained nurse

Evidence-based Practices

Allen D. Nursing and the future of ‘care’ in health care systems. J Health Serv Res Policy. 2015;20(3):129–30. https://doi.org/10.1177/1355819615577806 .

Article   PubMed   Google Scholar  

NHS England. Leading change, adding value. A framework for nursing, midwifery and care staff. 2016. https://www.england.nhs.uk/wp-content/uploads/2016/05/nursing-framework.pdf . Accessed 11 Nov 2020.

Institute of Medicine (IOM). The future of nursing; Leading change, advancing Health. Washington (DC): National Academies Press; 2011.

Google Scholar  

World Health Organization (WHO). Gloabal strategic directions for strengthening nursing and midwifery 2016–2020. Geneva: WHO Press; 2016.

Dawson AJ, Stasa H, Roche MA, et al. Nursing churn and turnover in Australian hospitals: nurses perceptions and suggestions for supportive strategies. BMC Nurs. 2014;13:11. https://doi.org/10.1186/1472-6955-13-11 .

Article   PubMed   PubMed Central   Google Scholar  

Hayes LJ, O’Brien-Pallas L, Duffield C, et al. Nurse turnover: a literature review–an update. Intern J Nurs Stud. 2012;49(7):887–905. https://doi.org/10.1016/j.ijnurstu.2011.10.001 .

Article   Google Scholar  

Persson U, Carlson E. Conceptions of professional work in contemporary health care—Perspectives from registered nurses in somatic care: A phenomenographic study. J Clin Nurs. 2019;28(1–2):201–8. https://doi.org/10.1111/jocn.14628 .

Senek M, Robertson S, Ryan T, et al. Determinants of nurse job dissatisfaction-findings from a cross-sectional survey analysis in the UK. BMC Nurs. 2020;19(1):1–10. https://doi.org/10.1186/s12912-020-00481-3 .

Jacob ER, McKenna L, D’Amore A. The changing skill mix in nursing: considerations for and against different levels of nurse. J Nurs Manag. 2015;23(4):421–6. https://doi.org/10.1111/jonm.12162 .

Sermeus W, Aiken LH, Van den Heede K, et al. Nurse forecasting in Europe (RN4CAST): Rationale, design and methodology. BMC Nurs. 2011;10:6. https://doi.org/10.1186/1472-6955-10-6 .

de Bont A, van Exel Job, Coretti S, Ökem ZG, Janssen M, Hope KL, Ludwicki T, Zander B, Zvonickova M, Bond C, Wallenburg I. Reconfiguring health workforce: a case-based comparative study explaining the increasingly diverse professional roles in Europe. BMC Health Serv Res. 2016;16(1).

Poitras ME, Chouinard MC, Fortin M, et al. How to report professional practice in nursing? A scoping review. BMC Nurs. 2016;15(1):31. https://doi.org/10.1186/s12912-016-0154-6 .

Jones ML. Role development and effective practice in specialist and advanced practice roles in acute hospital settings: systematic review and meta-synthesis. J Adv Nurs. 2005;49(2):191–209. https://doi.org/10.1111/j.1365-2648.2004.03279.x .

Ranchal A, Jolley MJ, Keogh J, et al. The challenge of the standardization of nursing specializations in Europe. Int Nurs Rev. 2015;62(4):445–52. https://doi.org/10.1111/inr.12204 .

Article   CAS   PubMed   Google Scholar  

Lowe G, Plummer V, O’Brien AP, et al. Time to clarify–the value of advanced practice nursing roles in health care. J Adv Nurs. 2012;68(3):677–85. https://doi.org/10.1111/j.1365-2648.2011.05790.x .

Fealy GM, Casey M, O’Leary DF, et al. Developing and sustaining specialist and advanced practice roles in nursing and midwifery: A discourse on enablers and barriers. J Clin Nurs. 2018;27(19–20):3797–809. https://doi.org/10.1111/jocn.14550 .

Aiken LH, Sermeus W, Van den Heede K, et al. Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ. 2012;344;e1717. https://doi.org/10.1136/bmj.e1717

Lu H, Zhao Y, While A. Job satisfaction among hospital nurses: A literature review. Intern J Nurs Stud. 2019;94:21–31. https://doi.org/10.1016/j.ijnurstu.2019.01.011 .

Duffield C, Roche M, Twigg D, et al. Adding unregulated nursing support workers to ward staffing: Exploration of a natural experiment. J Clin Nurs. 2018;27(19–20):3768–79. https://doi.org/10.1111/jocn.14632 .

Chua WL, Legido-Quigley H, Ng PY, et al. Seeing the whole picture in enrolled and registered nurses’ experiences in recognizing clinical deterioration in general ward patients: A qualitative study. Intern J Nurs Stud. 2019;95:56–64. https://doi.org/10.1016/j.ijnurstu.2019.04.012 .

van Oostveen CJ, Mathijssen E, Vermeulen H. Nurse staffing issues are just the tip of the iceberg: a qualitative study about nurses’ perceptions of nurse staffing. Intern J Nurs Stud. 2015;52(8):1300–9. https://doi.org/10.1016/j.ijnurstu.2015.04.002 .

Saville CE, Griffiths P, Ball JE, et al. How many nurses do we need? A review and discussion of operational research techniques applied to nurse staffing. Intern J Nurs Stud. 2019;97:7–13. https://doi.org/10.1016/j.ijnurstu.2019.04.015 .

Vatnøy TK, Sundlisæter Skinner M, Karlsen T, et al. Nursing competence in municipal in-patient acute care in Norway: a cross-sectional study. BMC Nurs. 2020;9:70. https://doi.org/10.1186/s12912-020-00463-5 .

De Jong JHJ, Kerstens JAM, Sesink EM, et al. Deskundigheidsbevordering en professionalisering. In: Handboek verpleegkunde. Houten: Bohn Stafleu van Loghum; 2003. p. 396–421. https://doi.org/10.1007/978-90-313-9699-3_13 .

Lalleman P, Stalpers D, Goossens L, et al. RN2Blend: meerjarig onderzoek naar gedifferentieerde inzet van verpleegkundigen. Verpleegkunde. 2020;1:4–6.

Endacott R, O’Connor M, Williams A, et al. Roles and functions of enrolled nurses in Australia: Perspectives of enrolled nurses and registered nurses. J Clin Nurs. 2018;27(5–6):e913–20. https://doi.org/10.1111/jocn.13987 .

Jacob E, Sellick K, McKenna L. Australian registered and enrolled nurses: Is there a difference? Intern J Nurs Pract. 2012;18(3):303–7. https://doi.org/10.1111/j.1440-172X.2012.02037.x .

Matthias AD. Educational pathways for differentiated nursing practice: a continuing dilemma. In: Lewenson SB, McAllister A, Smith KM, editors. Nursing History for Contemporary Role Development. New York: Springer Publishing Company; 2017. p. 121–40.

Boston-Fleischhauer C. Another Look at Differentiating Nursing Practice. J Nurs Adm. 2019;49(6):291–3. https://doi.org/10.1097/NNA.0000000000000754 .

Gardner G, Duffield C, Doubrovsky A, et al. Identifying advanced practice: a national survey of a nursing workforce. Intern J Nurs Stud. 2016;55:60–70. https://doi.org/10.1016/j.ijnurstu.2015.12.001 .

Duffield C, Twigg D, Roche M, et al. Uncovering the disconnect between nursing workforce policy intentions, implementation, and outcomes: Lessons learned from the addition of a nursing assistant role. Policy Polit Nurs Pract. 2019;20(4):228–238. https://doi.org/10.1177/1527154419877571

Terpstra D, Van den Berg A, Van Mierlo C, et al. Toekomstbestendige beroepen in de verpleging en verzorging: rapport stuurgroep over de beroepsprofielen en de overgangsregeling. 2015. http://www.nfu.nl/img/pdf/Rapport_toekomstbestendige-beroepen-in-de-verpleging-en-verzorging.pdf

Bohmer RM. The hard work of health care transformation. N Engl J Med 2016;375(8):709–11. doi: https://doi.org/10.1056/NEJMp1606458

Ellström PE. Integrating learning and work: Problems and prospects. Hum Res Dev Q. 2001;12(4):421–35. https://doi.org/10.1002/hrdq.1006 .

Lyman B, Hammond E, Cox J. Organizational learning in hospitals: A concept analysis. J Nurs Manag. 2019;27:633–46. https://doi.org/10.1111/jonm.12722 .

van Schothorst J, van Roekel AM,  Weggelaar-Jansen JWM, de Bont A, Wallenburg I. The balancing act of organizing professionals and managers: An ethnographic account of nursing role development and unfolding nurse-manager relationships. J Professions an Orga. 2020;7(3):283–99.

Reay T, Golden-Biddle K, Germann K. Legitimizing a New Role: Small Wins and Microprocesses of Change. Acad Manag J. 2006;49(5):977–98. https://doi.org/10.5465/amj.2006.22798178 .

Mannix J, Wilkes L, Jackson D. Marking out the clinical expert/clinical leader/clinical scholar: perspectives from nurses in the clinical arena. BMC Nurs. 2013:12;12. https://doi.org/10.1186/1472-6955-12-12

Nelson-Brantley HV, Ford DJ. Leading change: a concept analysis. J Adv Nurs. 2017;73(4):834–46. https://doi.org/10.1111/jan.13223 .

Boamah SA. Emergence of informal clinical leadership as a catalyst for improving patient care quality and job satisfaction. J Adv Nurs. 2019;75(5):1000–9. https://doi.org/10.1111/jan.13895 .

Abbott A. Linked ecologies: States and universities as environments for professions. Sociol Theory. 2005;23(3):245–74. https://doi.org/10.1111/j.0735-2751.2005.00253.x .

Hughes D. Nursing and the division of labour: sociological perspectives. In: Allen D, Hughes D, editors. Nursing and the Division of Labour in Healthcare. Hampshire and New York: Palgrave Macmillan; 2017. p. 1–21.

Ayala RA. Towards a Sociology of Nursing. Palgrave Macmillan; 2020.

Chua WF, Clegg S. Professional closure. Theory Soc. 1990;19(2):135–72.

Roper JM, Shapira J. Ethnography in nursing research. Thousand Oaks: Sage Publications; 2000.

Book   Google Scholar  

Polit DF, Beck CT. Nursing research: Generating and assessing evidence for nursing practice, 8th Edition. Philadelphia: Wolters Kluwer Health/ Lippincott Williams & Wilkins; 2008.

Atkinson P, Hammersley M. Ethnography: Principles in practice. New York: Routledge; 2007.

Draper J. Ethnography: Principles, practice and potential. Nurs Stand. 2015;29(36):36–41. https://doi.org/10.7748/ns.29.36.36.e8937 .

Allen D. The invisible work of nurses: Hospitals, organisation and healthcare. The Invisible Work of Nurses: Hospitals, Organisation and Healthcare. Oxfordshire and New York: Routledge; 2014.

Lalleman P, Bouma J, Smid G, et al. Peer-to-peer shadowing as a technique for the development of nurse middle managers clinical leadership: An explorative study. Leader Health Serv. 2017;30(4):475–90. https://doi.org/10.1108/LHS-12-2016-0065 .

Atkins S, Lewin S, Smith H, et al. Conducting a meta-ethnography of qualitative literature: lessons learned. BMC Med Res Methodol. 2008;8:21. https://doi.org/10.1186/1471-2288-8-21

Houghton C, Casey D, Shaw D, et al. Rigour in qualitative case-study researh. Nurse Res. 2013;20(4):12–7. https://doi.org/10.7748/nr2013.03.20.4.12.e326 .

Denzin NK, Lincoln YS, editors. The Sage handbook of Qualitative research. Thousands Oak: Sage; 2011.

Creswell JW, Miller DL. Determining validity in qualitative inquiry. Theory Pract. 2000;39(3):124–30. https://doi.org/10.1207/s15430421tip3903_2 .

Baker L, Observation. A complex research method. Library Trends. 2006;55(1):171–89.

Kanuha VK. “Being” native versus “going native”: Conducting social work research as an insider. Social Work. 2000;45(5):439–47. https://doi.org/10.1093/sw/45.5.439 .

Dwyer SC, Buckle JL. The space between: On being an insider-outsider in qualitative research. Intern J Qual Methods. 2009;8(1):54–63. https://doi.org/10.1177/160940690900800105 .

Star SL, Strauss A. Layers of silence, arenas of voice: The ecology of visible and invisible work. Comp Support Coop Work. 1999;8(1–2):9–30. https://doi.org/10.1023/A:1008651105359 .

Allen DA, Lyne PA. Nurses’ flexible working practices: some ethnographic insights into clinical effectiveness. Clin Effective Nurs. 1997;1(3):131–8. https://doi.org/10.1016/S1361-9004(97)80048-9 .

Allen D. Translational mobilisation theory: a new paradigm for understanding the organisational elements of nursing work. Intern J Nurs Stud. 2018;79:36–42. https://doi.org/10.1016/j.ijnurstu.2017.10.010 .

Arrowsmith V, Lau-Walker M, Norman I, et al. Nurses’ perceptions and experiences of work role transitions: a mixed methods systematic review of the literature. J Adv Nurs. 2016;72(8):1735–50. https://doi.org/10.1111/jan.12912 .

Apker J, Propp KM, Ford WSZ, et al. Collaboration, credibility, compassion, and coordination: professional nurse communication skill sets in health care team interactions. J Prof Nurs. 2006;22(3):180–9. https://doi.org/10.1016/j.profnurs.2006.03.002 .

Currie G, Koteyko N, Nerlich B. The dynamics of professions and development of new roles in public services organizations. The case of modern matrons in the English NHS. Public Adm. 2009;87(2):295–311. https://doi.org/10.1111/j.1467-9299.2009.01755.x .

Skela-Savič B, Hvalič-Touzery S, Pesjak K. Professional values and competencies as explanatory factors for the use of evidence-based practice in nursing. J Adv Nurs. 2017;73(8):1910–23. https://doi.org/10.1111/jan.13280 .

FURÅKER C. Registered Nurses’ views on their professional role. J Nurs Manag. 2008;16(8):933–41. https://doi.org/10.1111/j.1365-2834.2008.00872.x .

Stokke K, Olsen NR, Espehaug B, et al. Evidence based practice beliefs and implementation among nurses: a cross-sectional study. BMC Nurs. 2014;13(1):8.

Abbott A. The system of professions: an essay on the expert division of labor. Chicago: The University of Chicago Press; 1988.

Clegg SR, Kornberger M, Rhodes C. Learning/becoming/organizing. Organization. 2005;12(2):147–67. https://doi.org/10.1177/1350508405051186 .

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Acknowledgements

The authors would like to thank all participants for their contribution to this study.

The Reinier de Graaf hospital in Delft, who was central to this study provided financial support for this research.

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Jannine van Schothorst–van Roekel, Anne Marie J.W.M. Weggelaar-Jansen, Carina C.G.J.M. Hilders, Antoinette A. De Bont & Iris Wallenburg

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van Schothorst–van Roekel, J., Weggelaar-Jansen, A.M.J., Hilders, C.C. et al. Nurses in the lead: a qualitative study on the development of distinct nursing roles in daily nursing practice. BMC Nurs 20 , 97 (2021). https://doi.org/10.1186/s12912-021-00613-3

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Best Nursing Research Topics for Students

What is a nursing research paper.

• What They Include
• Choosing a Topic
• Best Nursing Research Topics
• Research Paper Writing Tips

Writing a research paper is a massive task that involves careful organization, critical analysis, and a lot of time. Some nursing students are natural writers, while others struggle to select a nursing research topic, let alone write about it.

If you're a nursing student who dreads writing research papers, this article may help ease your anxiety. We'll cover everything you need to know about writing nursing school research papers and the top topics for nursing research.  

Continue reading to make your paper-writing jitters a thing of the past.

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A nursing research paper is a work of academic writing composed by a nurse or nursing student. The paper may present information on a specific topic or answer a question.

During LPN/LVN and RN programs, most papers you write focus on learning to use research databases, evaluate appropriate resources, and format your writing with APA style. You'll then synthesize your research information to answer a question or analyze a topic.

BSN , MSN , Ph.D., and DNP programs also write nursing research papers. Students in these programs may also participate in conducting original research studies.

Writing papers during your academic program improves and develops many skills, including the ability to:

• Select nursing topics for research
• Conduct effective research
• Analyze published academic literature
• Format and cite sources
• Synthesize data
• Organize and articulate findings

About Nursing Research Papers

When do nursing students write research papers.

You may need to write a research paper for any of the nursing courses you take. Research papers help develop critical thinking and communication skills. They allow you to learn how to conduct research and critically review publications.

That said, not every class will require in-depth, 10-20-page papers. The more advanced your degree path, the more you can expect to write and conduct research. If you're in an associate or bachelor's program, you'll probably write a few papers each semester or term.

Do Nursing Students Conduct Original Research?

Most of the time, you won't be designing, conducting, and evaluating new research. Instead, your projects will focus on learning the research process and the scientific method. You'll achieve these objectives by evaluating existing nursing literature and sources and defending a thesis.

However, many nursing faculty members do conduct original research. So, you may get opportunities to participate in, and publish, research articles.

Example Research Project Scenario:

In your maternal child nursing class, the professor assigns the class a research paper regarding developmentally appropriate nursing interventions for the pediatric population. While that may sound specific, you have almost endless opportunities to narrow down the focus of your writing. 

You could choose pain intervention measures in toddlers. Conversely, you can research the effects of prolonged hospitalization on adolescents' social-emotional development.

What Does a Nursing Research Paper Include?

Your professor should provide a thorough guideline of the scope of the paper. In general, an undergraduate nursing research paper will consist of:

Introduction : A brief overview of the research question/thesis statement your paper will discuss. You can include why the topic is relevant.

Body : This section presents your research findings and allows you to synthesize the information and data you collected. You'll have a chance to articulate your evaluation and answer your research question. The length of this section depends on your assignment.

Conclusion : A brief review of the information and analysis you presented throughout the body of the paper. This section is a recap of your paper and another chance to reassert your thesis.

The best advice is to follow your instructor's rubric and guidelines. Remember to ask for help whenever needed, and avoid overcomplicating the assignment!

How to Choose a Nursing Research Topic

The sheer volume of prospective nursing research topics can become overwhelming for students. Additionally, you may get the misconception that all the 'good' research ideas are exhausted. However, a personal approach may help you narrow down a research topic and find a unique angle.

Writing your research paper about a topic you value or connect with makes the task easier. Additionally, you should consider the material's breadth. Topics with plenty of existing literature will make developing a research question and thesis smoother.

Finally, feel free to shift gears if necessary, especially if you're still early in the research process. If you start down one path and have trouble finding published information, ask your professor if you can choose another topic.

The Best Research Topics for Nursing Students

You have endless subject choices for nursing research papers. This non-exhaustive list just scratches the surface of some of the best nursing research topics.

1. Clinical Nursing Research Topics

• Analyze the use of telehealth/virtual nursing to reduce inpatient nurse duties.
• Discuss the impact of evidence-based respiratory interventions on patient outcomes in critical care settings.
• Explore the effectiveness of pain management protocols in pediatric patients.

2. Community Health Nursing Research Topics

• Assess the impact of nurse-led diabetes education in Type II Diabetics.
• Analyze the relationship between socioeconomic status and access to healthcare services.

3. Nurse Education Research Topics

• Review the effectiveness of simulation-based learning to improve nursing students' clinical skills.
• Identify methods that best prepare pre-licensure students for clinical practice.
• Investigate factors that influence nurses to pursue advanced degrees.
• Evaluate education methods that enhance cultural competence among nurses.
• Describe the role of mindfulness interventions in reducing stress and burnout among nurses.

4. Mental Health Nursing Research Topics

• Explore patient outcomes related to nurse staffing levels in acute behavioral health settings.
• Assess the effectiveness of mental health education among emergency room nurses .
• Explore de-escalation techniques that result in improved patient outcomes.
• Review the effectiveness of therapeutic communication in improving patient outcomes.

5. Pediatric Nursing Research Topics

• Assess the impact of parental involvement in pediatric asthma treatment adherence.
• Explore challenges related to chronic illness management in pediatric patients.
• Review the role of play therapy and other therapeutic interventions that alleviate anxiety among hospitalized children.

6. The Nursing Profession Research Topics

• Analyze the effects of short staffing on nurse burnout .
• Evaluate factors that facilitate resiliency among nursing professionals.
• Examine predictors of nurse dissatisfaction and burnout.
• Posit how nursing theories influence modern nursing practice.

Tips for Writing a Nursing Research Paper

The best nursing research advice we can provide is to follow your professor's rubric and instructions. However, here are a few study tips for nursing students to make paper writing less painful:

Avoid procrastination: Everyone says it, but few follow this advice. You can significantly lower your stress levels if you avoid procrastinating and start working on your project immediately.

Plan Ahead: Break down the writing process into smaller sections, especially if it seems overwhelming. Give yourself time for each step in the process.

Research: Use your resources and ask for help from the librarian or instructor. The rest should come together quickly once you find high-quality studies to analyze.

Outline: Create an outline to help you organize your thoughts. Then, you can plug in information throughout the research process. 

Clear Language: Use plain language as much as possible to get your point across. Jargon is inevitable when writing academic nursing papers, but keep it to a minimum.

Cite Properly: Accurately cite all sources using the appropriate citation style. Nursing research papers will almost always implement APA style. Check out the resources below for some excellent reference management options.

Revise and Edit: Once you finish your first draft, put it away for one to two hours or, preferably, a whole day. Once you've placed some space between you and your paper, read through and edit for clarity, coherence, and grammatical errors. Reading your essay out loud is an excellent way to check for the 'flow' of the paper.

Helpful Nursing Research Writing Resources:

Purdue OWL (Online writing lab) has a robust APA guide covering everything you need about APA style and rules.

Grammarly helps you edit grammar, spelling, and punctuation. Upgrading to a paid plan will get you plagiarism detection, formatting, and engagement suggestions. This tool is excellent to help you simplify complicated sentences.

Mendeley is a free reference management software. It stores, organizes, and cites references. It has a Microsoft plug-in that inserts and correctly formats APA citations.

Don't let nursing research papers scare you away from starting nursing school or furthering your education. Their purpose is to develop skills you'll need to be an effective nurse: critical thinking, communication, and the ability to review published information critically.

Choose a great topic and follow your teacher's instructions; you'll finish that paper in no time.

Joleen Sams is a certified Family Nurse Practitioner based in the Kansas City metro area. During her 10-year RN career, Joleen worked in NICU, inpatient pediatrics, and regulatory compliance. Since graduating with her MSN-FNP in 2019, she has worked in urgent care and nursing administration. Connect with Joleen on LinkedIn or see more of her writing on her website.

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The Importance of Nursing Research

Nursing research has a tremendous influence on current and future professional nursing practice, thus rendering it an essential component of the educational process. This article chronicles the learning experiences of two undergraduate nursing students who were provided with the opportunity to become team members in a study funded by the National Institute of Nursing Research. The application process, the various learning opportunities and responsibilities performed by the students, and the benefits and outcomes of the experience are described. The authors hope that by sharing their learning experiences, more students will be given similar opportunities using the strategies presented in this article. Nursing research is critical to the nursing profession and is necessary for continuing advancements that promote optimal nursing care.

Throughout the 21st century, the role of nurse has evolved significantly. Nurses work in a variety of settings, including the hospital, the classroom, the community health department, the business sector, home health care, and the laboratory. Although each role carries different responsibilities, the primary goal of a professional nurse remains the same: to be the client's advocate and provide optimal care on the basis of evidence obtained through research.

Baccalaureate programs in the United States prepare students for entry-level nursing positions. The focus is to care for individuals throughout the human life span. Knowledge is acquired from textbooks, classroom and Web-based instruction, simulation, and clinical experiences. The goal of all programs is for students to graduate as safe, entry-level professionals, having received a well-rounded exposure to the nursing field. Students are exposed to evidence-based nursing practice throughout their curriculum; however, the allocated time for nursing research is often limited. Many programs require only one 3-credit hour course for nursing research. This amount of time is limited, despite the broad spectrum of nursing research and its influence on current and future nursing care.

Research is typically not among the traditional responsibilities of an entry-level nurse. Many nurses are involved in either direct patient care or administrative aspects of health care. Nursing research is a growing field in which individuals within the profession can contribute a variety of skills and experiences to the science of nursing care. There are frequent misconceptions as to what nursing research is. Some individuals do not even know how to begin to define nursing research. According to Polit and Beck (2006) , nursing research is:

systematic inquiry designed to develop knowledge about issues of importance to nurses, including nursing practice, nursing education, and nursing administration. (p. 4)

Nursing research is vital to the practice of professional nursing, and the importance of its inclusion during undergraduate instruction cannot be overemphasized. Only with exposure and experience can students begin to understand the concept and importance of nursing research.

The purpose of this article is to describe undergraduate students’ experiences of becoming aware of and participating in a federally funded research study from the National Institute of Nursing Research. As a part of funding for the study, which was an AREA award ( A cademic R esearch E nhancement A ward, R15 mechanism), there were designated opportunities for student involvement. The primary aim of the research study was to investigate the effects of gene-environment interactions on risk factors of preclinical cardiovascular disease in a cohort of 585 young adults who all had a positive family history of cardiovascular disease (i.e., essential hypertension or premature myocardial infarction at age 55 or younger in one or both biological parents or in one or more grandparents), verified in the medical record. Specific genes examined included cytochrome P-450, family 1, subfamily A, polypeptide 1; cytochrome P-450 2A; glutathione S-transferase mu 1; and glutathione S-transferase theta 1. Cardiovascular-dependent measures were diastolic blood pressure, endothelium-dependent arterial vasodilation, left ventricular mass indexed for body size, systolic blood pressure, and total peripheral resistance. The effects of ethnicity and gender were also explored.

Learning Opportunity

The learning process began with the principal investigator (M.S.T.) of the study visiting the junior class (class of 2007) of baccalaureate students at the Medical College of Georgia. This particular student group was chosen due to their academic standing because they would have the chance to take full advantage of learning directly from a nurse researcher for one full year before graduation. The principal investigator briefly presented and discussed the growing field of nursing research, the advancements made by nursing research, and the critical role of nursing research to nursing practice. The principal investigator also presented an overview of the funded research study and extended an invitation to students to apply for two part-time positions on the grant that were designed specifically for nursing student involvement. Students recognized the excellent opportunity and were intrigued with the future possibilities. They understood this option was unique and appeared to be a great pathway for becoming an active participant in learning the nursing research process through involvement in an official nursing research study.

The principal investigator established objective criteria for the application process. The criteria included writing a maximum 1-page essay sharing the reasons why the students wanted to join the research project as a team member and also sharing their personal and professional goals for involvement in the study. Many students were interested; thus, it was a very competitive process. The principal investigator reviewed the essays and selected approximately 10 prospective individuals for an interview. The interview was an extension of the essay. At the interview, the principal investigator further described the positions, provided a detailed overview of the grant, and had the opportunity to gain a better understanding of the student candidates. The students were encouraged to ask questions to further understand the expectations of the prospective opportunity. The interview also provided the students with increased exposure to the study's goal and more familiarization with the expectations of the funded positions.

After the interview process was completed, two individuals were selected, per the grant specifications. The selected individuals described the interview process as a positive experience that helped solidify their desire to become involved in the research study. The principal investigator emphasized that this job opportunity was designed to be a learning experience in which the students would be guided through the entire research study process and become members of a multidisciplinary team. Time responsibilities for each student included approximately 6 hours per week. The principal investigator communicated clearly that the nursing baccalaureate program was the first priority for the students, and thus provided a flexible work schedule.

Research Study Experience

The students began working in early april 2006. The first step in the work experience included 6 weeks of funded orientation. This was their first exposure to the research process; thus, it was important for the students to be provided with a strong foundation. Orientation included attending a team meeting and being introduced to the members of the multidisciplinary team (i.e., biostatistician, cardiologist, geneticists, nurse researcher, and psychologist, all of whom served as co-investigators, and the genetic laboratory personnel); reviewing the grant application; completing the Collaborative Institutional Training Initiative (CITI) (2000) ; completing the Roche educational program on genetics; and touring the worksite facilities. Reviewing the grant gave the students a better understanding of the specific aims and objectives of the study and the intended procedures of the genetic laboratory work in which the students would be involved. The complexity of the grant required the principal investigator to further explain and clarify specific details. The CITI training, which is required by the institution's Office of Human Research Protection, was completed online and took approximately 5.5 hours. The CITI program was presented in a tutorial format, and satisfactory completion of numerous quizzes was required. The task was tedious and time consuming, but valuable and essential, as it increased the awareness of the established codes of conduct for research. At the conclusion of the CITI training, the students understood the necessary policies and procedures for maintaining security and confidentiality of human subjects, the legal and ethical issues regarding the research process, and the essential procedures for research conduct.

Although the students had a basic understanding of genetics, they completed the Roche Genetics Education Program (2004) to gain a deeper understanding. The program was direct and easy to navigate and was excellent for all learning styles, as it contained both visual and auditory explanations. The explanations covered both basic and complex genetic concepts. Through the use of the genetics program, the students were able to comprehend abstract genetic details and to further understand the importance and influence of genetics on personal health. To conclude the orientation process, students were taught basic laboratory procedures, such as polymerase chain reaction and restrictive enzyme digestion, which were used to perform genotyping for the study. After these procedures had been observed several times, the students were given the opportunity to acquire hands-on experience with these laboratory techniques. Each of these components of the orientation process provided the students with the needed foundation for becoming involved in the research study.

After approximately 2 months of orientation, the students were ready to begin working in the genetics laboratory. One of the primary responsibilities of the students would be to further learn and become confident with genotyping techniques. The laboratory was shared among research personnel of several funded studies, with various research experiments being conducted concurrently. The students, under the supervision of the principal investigator and geneticist (H.Z.), also worked with experienced research assistants to perform the genotyping. The students maintained a daily log describing the laboratory genotyping procedures and experiments, and these logs were reviewed at team meetings. Although the actual procedure for polymerase chain reaction seemed straightforward, the students quickly learned that quality control must be used. Sometimes during genotyping, the DNA samples did not produce results. The students discovered that there are numerous contributing factors to successful polymerase chain reaction, such as quality of DNA templates, primer specifications, temperature settings, gel conditions, pipette measuring accuracy, and general laboratory techniques. Even the slightest error could result in permanent DNA sample loss, major experiment failure, or DNA sample contamination.

The students met with the research team members frequently to discuss and troubleshoot potential solutions and problem solve techniques that would foster improving the success rate and productivity of the genotyping. From the laboratory experience, the students learned that every detail must be considered and addressed precisely and meticulously when conducting experiments. Sometimes the process became frustrating, but the students soon discovered that patience and persistence were the most important attributes for a laboratory researcher to possess. The laboratory experience was an excellent hands-on learning opportunity. The students no longer viewed research as strictly information gathered from a journal or textbook, but rather as a physical act that required extreme concentration, dedication, and determination.

After spending numerous months in the laboratory performing the required genotyping, the students had the opportunity to be exposed to another role of a nurse researcher. They performed literature reviews regarding the study. Although the students had written papers in their nursing school program that required literature citations, they were not familiar with all of the library resources available to them. In no time, the students learned which library and online resources had the most validity and what would be the most relevant to their study. The literature search results provided the students and principal investigator with information on new studies that had been conducted on gene-environment interactions regarding tobacco smoke exposure and cardiovascular disease. From the literature review experience, the students learned the importance of being selective and time efficient. Often when a search was first begun, thousands of articles were listed, but the students learned the importance of narrowing the searches to the specific areas of focus. After the students completed their searches, they met with the principal investigator, who provided direction on the articles identified as the most relevant to the study.

The students continued working with the principal investigator during data review, analysis, and preparation of dissemination of the results (i.e., the publishing process). They helped to prepare an abstract submission of the study presented at an international meeting ( Tingen et al., 2007 ). They also helped with the preparation of manuscripts of the study results. By the conclusion of their work experience, the students will have been exposed to and participated in the entire research process.

Benefits and Outcomes

From the students’ perspectives, this opportunity was extremely beneficial. Prior to this experience, the students were not familiar with nursing research. Their original perception of research was that it was conducted by people with chemistry, biology, biochemistry, and genetic degrees in laboratories at major universities. They now realize that nursing and research can be combined and that optimal nursing care is dependent on the latest research findings. In addition, the students believe this opportunity has been beneficial in learning that nurse researchers are valuable to nurses in other settings. For example, one of the long-term goals of this research study is to develop appropriate interventions for children who are more susceptible to and at risk for the harmful effects of tobacco smoke due to their genetic heritage. The information obtained by a nurse researcher can be disseminated to nurses who work directly with the individuals to whom the research applies. Practice that has shown to be effective through research allows nurses to better advocate for patients and provide the best possible care. Although the majority of nurses who provide patient care will be consumers of nursing research, implementing evidence-based nursing practice is crucial to provide optimal nursing care. Information from nursing research has the potential to directly impact the care provided to patients in all health care settings.

Now that the students have had the opportunity to become more familiar with nursing research through involvement as team members, they recognize that their future professional possibilities are endless. Nursing research is an emerging and growing field in which individuals can apply their nursing education to discover new advancements that promote evidence-based care. They learned the research process and the important roles that each team member plays during the study phases of conception, design, implementation, analysis, and dissemination. Each aspect of the research process is important and contributes to the overall success of the study.

The students also discovered the benefit of trying new things. Prior to this experience, they had little exposure to the research process and nursing research. Consequently, they had to be receptive to learning and recognize that acquiring new knowledge was a gradual process. At times, the students felt anxious because all aspects were new, but they realized that without trying, they would never advance and feel comfortable with the research process. As the students reflected, they thought this was an excellent growing experience professionally, scholastically, and personally. In addition, this opportunity benefited the students’ peers through discussions and their sharing of work responsibilities, the research process, and the importance of evidence-based practice. As future nurses, the students are strong proponents of nursing research, and this experience has also broadened their horizons regarding future professional growth and opportunities. In addition, they have a better understanding of the importance of scientific evidence to support their clinical practice. As a result, the students thought that a stronger emphasis should be placed on nursing research in undergraduate baccalaureate education and that more students should have the opportunity to participate as team members in nursing research studies.

The students were almost one full year into nursing school and thought they had learned about all of the possibilities for their futures when they were first presented with this learning opportunity. They knew their future options were numerous and included working in acute care and community settings. They also realized they could further their education and pursue graduate degrees to include a master's degree and become an administrator, educator, clinical nurse specialist, nurse anesthetist, or nurse practitioner, or potentially pursue a doctorate. They did not know there was an emerging and growing field in which their nursing education could be applied and furthered—the area of research and the role of becoming a nurse researcher. Prior to this experience, students perceived their possibilities for a professional career in nursing were tremendous. Now by being involved in the entire process of conducting a federally funded research study, they realized their future professional possibilities are limitless.

The authors of this paper hope that by sharing their experience, they will encourage both nursing faculty and nursing students to not only introduce the research process into the nursing curriculum, but also to consider making nursing research a tangible and more integrated process. They think that a more beneficial approach to the introduction of research may be achieved through incorporating research-related content into each nursing course throughout the educational process. This could be conducted in addition to the current curriculum plan of many schools of nursing that require a single and concentrated 3-hour research course with a goal of research becoming a positive experience for students that is enthusiastically received as a new learning opportunity. In addition, students who are involved as team members in a funded research study may be provided with scheduled classroom opportunities for making progress reports to their peers. Also, the students could field questions regarding the research project and their experiences. These activities may foster increased learning and interest about research among the students’ classmates.

As nursing students are the future members of the nursing profession, and for the profession to continue to advance, nursing research must be the foundation of comprehensive, evidence-based clinical practice. This may only occur with increased exposure to nursing research. Therefore, it is critical that the future members of the nursing profession be exposed to, develop an appreciation for, and become more involved in nursing research, and thus incorporate its outcomes into the delivery of optimal professional nursing practice.

Acknowledgments

The lead author was awarded a grant (NR008871) from the National Institutes of Health, National Institute of Nursing Research.

• Collaborative Institutional Training Initiative [April 14, 2006]; Office of Human Research Protection. The Medical College of Georgia. 2000 from http://www.mcg.edu/Research/ohrp/training/citi.html .
• Polit DF, Beck CT. Essentials of nursing research: Methods, appraisal, and utilization. 6th ed. Lippincott Williams & Wilkins; Philadelphia: 2006. [ Google Scholar ]
• Roche Genetics Education Program [May 10, 2006]; Education. 2004 from http://www.roche.com/research_and_development_r_d_overview/education.htm .
• Tingen MS, Ludwig DA, Dong Y, Zhu H, Andrews JO, Burnett AH, et al. Tobacco smoke exposure and genetics: Youth at risk for cardiovascular disease.. Proceedings of the 13th Annual Meeting of the Society for Research on Nicotine and Tobacco.2007. p. 39. [ Google Scholar ]

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Always a Nurse

A profession for a lifetime.

Sanford, Kathleen D. DBA, RN, FACHE, FAAN

CommonSpirit Health, Chicago, Illinois.

Correspondence: Kathleen D. Sanford, DBA, RN, FACHE, FAAN, CommonSpirit Health, 444 W. Lake St, Ste 2500, Chicago, IL 60606 ( [email protected] ).

The author declares no conflict of interest.

A single career in nursing may encompass numerous and very different positions. Nurses are aware they can select from a variety of specialties, as they choose to learn additional skills or pursue new opportunities. Today's nurses use their intelligence, experience, and holistic concern for all people in more diverse arenas than ever before. This article is followed by a series of first-person accounts of jobs that may not, on first consideration, look like nursing roles. These professionals have not left nursing. They have carried their healing energy, grounding in the nursing process, as well as a desire to improve the well-being of others with them, because they are nurses.

WHAT, exactly, is a nurse? Is he or she simply a person who graduated from an accredited school of nursing? Or, are nurses persons who successfully passed, in the United States at least, one of the state boards of nursing examinations? Does pursuing a career outside of what has historically been considered mainstream health care mean that an individual should no longer identify with the profession? Or, is a nurse only a nurse when his or her professional role involves direct patient (or direct client) interactions and care?

For most of the public, the primary visual image of nurses is probably a group of (mostly) women dressed in scrubs, who perform a variety of personal care or technical procedures in a hospital or clinic setting. Some older individuals may still envision women in white uniforms. Others, who have recently interacted with them outside of acute care, might include both men and women in business clothes, military uniforms, or laboratory coats in their description. They may have encountered nurses in homes, schools, office buildings, birthing centers, rehabilitation centers, prisons, drugstores, or freestanding urgent care and emergency facilities.

All of these depictions have one thing in common: all the nurses in these environments are seen in roles that involve direct interactions with those they are serving. In other words, it is recognized that nurses work in a variety of settings, but very few people would associate an image of, say, a virtual clinician or an executive in an office with “nurse.”

Nurses themselves might recognize the emergence of the virtual role as an appropriate specialty for their profession. However, some may not accept that a person who no longer provides personal care is still performing the role of a nurse. (The exceptions to this may be nurses in public health positions or college professors who are part of educating nurses in schools of nursing.) Gail Latimer, MSN, RN, FACHE, FAAN, recipient of the 2019 American Organization for Nursing Leadership (AONL) Lifetime Achievement Award, referred to this way of thinking when she was interviewed at the AONL annual meeting. She stated that some colleagues could not understand why she would go to work for a large information technology (IT) company. They told her she was “going to the dark side.” Gail, who has helped a myriad of nurses understand how technology can help patients and their caregivers, said, “Innovation is happening in industry. Nurses need to take jobs there. Who better than Florence Nightingale's professional descendants to bring the lamp of caring to the world in every way? We are able to light the corners while carrying the badge that we once touched patients.”

Some nurses whose career journeys include jobs outside of the public's conception of the prototypical nurse may agree they are “no longer caregivers.” Many, however, continue to see themselves as nurses. They are proud of their nursing roots and realize that their successes, their belief systems, and the very core of their beings are the results of being a lifetime member of a very special profession: Nursing.

THE MANY FACES OF NURSING IN HEALTH CARE

Nurses can be found in a variety of health care organization roles that do not include individual hands-on patient care. These include positions in management, executive practice, education, quality, patient experience, safety, human resources, recruiting, infection control, advocacy, chaplaincy, finance, care management, medical records, audit, insurance, strategy, supply chain, legal affairs, communications, compliance, and any number of other “business” activities. Hospitals and others have long recognized the value of unique skills that nurses bring to “non-nursing” jobs.

Management and executive roles filled by nurses may either be nursing specific (such as shift supervisors, unit managers, or chief nurse executives) or general health care management (such as chief executive officers [CEOs], chief operation officers, or formal leaders of non-nursing departments). Management is a specialty, a distinction that not all nurses recognize. Those who manage (and lead) well have defined characteristics, well documented in management literature. In fact, there is a large body of management theory and researched evidence-based practices for formal leaders. 1 The failure of many nurses and nurse educators to recognize nursing management and nurse executive practice as a specialty that needs specialized education and experience has resulted in some poorly prepared nurse managers. Since managers have position power that affects culture, morale, nurse engagement (and therefore patient engagement), turnover, quality, and any number of practice environment factors, this has been detrimental to the profession, individuals, and entire organizations. It has led to the placement of great clinical specialists into a new specialty for which they are inadequately prepared. Sometimes, they are neither ready to competently perform their management jobs nor ready to advocate for their nursing colleagues and patients. In some cases, their lack of preparation or suitability to the role has reinforced perceptions of other health care leaders that nurses are not interested in, or able to manage, budgets or finances. In addition, if nursing management was widely recognized as a specialty that is just as legitimate as medical, surgical, behavioral health, or critical care, perhaps, more nurses would understand that nurses in formal leadership positions have not “left” nursing ( Table 1 ).

Nurse CEOs are even more likely to be seen as no longer belonging to the nursing profession. Some have allowed their licenses to lapse; some do not use “RN” after their names. This is in stark contrast to physician CEOs, who consistently identify themselves as “doctors” (MD or DO). Others recognize that their nurse experience has enriched their professional lives and should give them more credibility as individuals who know that they are leading a clinical enterprise, not just a business that happens to provide health care. They are proud to claim nursing and to have other know that they have touched patients and can relate to the challenges faced by caregivers ( Table 2 ).

“Nurses as hospital administrators” is not a new phenomenon. In fact, historians Margarete Arndt and Barbara Bigelow have published several articles about the history of hospital management, as described in Table 3 .

A third group of nurses who are sometimes accused of having “left” nursing (and “joined” medicine) are those who have selected advanced practice specialties. Although they are educated in schools of nursing, have nursing licenses, have “nurse” in their specialty titles (nurse midwife, nurse anesthetist, nurse practitioner, etc), and are under the jurisdiction of state boards of nursing, they are sometimes not identified with the profession. By definition, physicians and advanced nurse practitioners are not the same:

Doctors, at their core, are scientists; they study diseases and how to cure them. Nurse practitioners, at their core, are healers. The vast majority began their careers as registered nurses, and focus their care on wellness of the whole body and mind. That's not to say that doctors never take a more holistic approach to health, or that Nurse Practitioners don't use scientifically tested treatments—there's plenty of overlap—but their basic approach to patient care differs at the philosophical level. 2

In addition, their biggest professional support continues to come from nursing organizations and nurse leaders who advocate for them and for laws/regulations that allow them to practice at the top of their licenses ( Table 4 ).

NURSES IN ROLES OUTSIDE OF TRADITIONAL HEALTH CARE

While most nurse leaders recognize the natural fit between nurses and health care roles that do not quite fit the stereotypes, many members of the public do not realize the variety of ways that nursing is practiced. They might be surprised to learn that there are organizations such as The American Association of Nurse Attorneys (TAANA) and the National Nurses in Business Association (NNBA).

They may know that nursing specialties include hospice, camp, cruise ship, public health, dialysis, correctional (prison), and flight nursing. These roles are still considered hands-on. Some community members may have crossed paths with nurses who are health coaches or who serve as occupational nurses, with responsibility for the health and safety of workers in industry. It is less likely that they are aware that nurses serve as informaticists, who combine the sciences of nursing and analytics; telehealth clinicians, who triage patients and help them discern next steps for care they may need; forensic nurses, with special training in protection of evidence, who care for the victims of trauma or violence in the criminal justice system; case managers, who coordinate an individual's care across the confusing landscape of a fragmented health system; or nurse writers, who compose educational/academic materials, author articles for journals or magazines, write history books, or even develop television and movie scripts that involve health care.

Nurses perform all of these roles and more. Some are also lobbyists for patients and the professionals who care for them. Some serve on boards, where they can bring the voice of these groups to decision tables. Others have determined that their knowledge and passion for healing individuals, communities, and nations can be most influential when they serve as elected officials. Table 5 describes nurse who have served (or are currently serving in) the Congress of the United States.

THE PAST, PRESENT, AND FUTURE FOR NURSING

There are multiple books that chronicle the history of nursing. Some record the life stories of individual nurses, such as Mary Eliza Mahoney, Edward Lynn, Clara Barton, John Hogan, Catherine McCauley, Walt Whitman, Juan Ciudad, and, of course, Florence Nightingale. Others, such as in the beautiful book by Patricia Donahue, Nursing, the Finest Art: An Illustrated History , 15 trace the history of a profession essential to the well-being of humanity.

The calendar is about to turn to the year 2020, which has been declared the Year of the Nurse and Midwife by the World Health Organization. Governments around the world have endorsed this, recognizing that the goal of universal health care will not be accomplished without these professionals. 2020 is also the 200th anniversary of the birth of Florence Nightingale and the third year of the international “Nursing Now” campaign, which has a goal of increasing worldwide health by improving the profile and status of nurses. Acknowledging the variety of roles that nurses play in their quest for universal “wellness” can help with that objective.

Today's nurses continue to use their intelligence, skill, experience, passion, and holistic concern for all people in more diverse arenas than ever before. This article is followed by a series of first-person accounts of jobs that might not, at first consideration, look like nursing roles. The nurse authors of these narratives are a very small sample of those who have pursued education and opportunities that took them away from the bedside, but who retain their identity as nurses. Every one of them speaks about how their nursing education (including training based on the Nursing Process—see Table 6 ) and experience as direct caregivers have provided the foundation for their lives and current work. They have not “left” their profession. They have carried nursing—embodied by their intellect, healing energy, love, and desire to improve the wellness of the world—with them ... because they are nurses.

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