As the demand for high-quality healthcare soars, the need for specialist nurses is also increasing. Well-trained, skilled nurses are assets for any healthcare organisation. Those with advanced skills can make complex decisions and provide world-class, good-value healthcare. Although nursing is a well-established profession, the term ‘specialist nurse’ is still not clearly defined (Pulcini et al, 2010; Jokiniemi and Miettinen, 2020; Decock et al, 2022), and the role of a specialist nurse varies between countries. However, according to Debout (2021) and Decock (2022), there are minimal data on nurses' specific roles in Europe.
Background
Following objection by a medical association in Malta, the term ‘specialist nurse’ was replaced by ‘practice nurse’ to include all specialist and practice development nurses.
Debout (2021) noted that political, local and country-based policies and cultural beliefs heavily influence nursing. Specialist nurses in Malta work in dedicated areas including surgery, diabetes, cardiovascular diseases, primary healthcare, infection control, tissue viability, diabetes and continence care.
However, recruiting nurses to specialised areas when there is no standard academic and practical training pathway is problematic. Even though Malta's educational system now offers a master's degree in nursing and specialist pathways, much more still needs to be done to regulate the profession and bring it in line with chapter 464 of the Maltese Healthcare Professions Act of 2003. Under this law, nurses must be registered with the Council of Nursing and Midwifery. By November 2023, 10 years since the title ‘specialist nurse’ was abandoned, there is still no designated place on the national register for practice nurses.
This study outlines the challenges specialist nurses face in Malta and sheds light on ways they can advance their careers and services to patient care.
Methodology
A qualitative case study approach was used to explore the views of the participants. A conceptual framework was drawn from the literature and models of advanced nursing practice, namely Hamric's (1989) model of advanced practice roles, Manley's conceptual framework (1997) and the transformational advanced professional practice (TAPP) model of Elliott and Walden (2015). This framework is embedded in Merriam's (1998) pragmatist approach to qualitative case study design, which promotes the context of the case to be examined and explained. Figure 1 shows the framework used.
Case study outline
The study was carried out between 2013 and 2015 in three phases (Table 1).
Table 1. Case study
| Phase | Data source | Population | Sample size | Tools |
|---|---|---|---|---|
| Phase I | Survey | Specialist nurses | n=27 | Questionnaire adapted from Ball (2005) and Reed et al (2007) |
| Phase II | Interviews | Specialist nurses | n=9 | Interview guide |
| Phase III | Focus groups | Stakeholders: multidisciplinary | n=7 | Focus group guide |
| Nurse directors and senior managers | n=8 | |||
| Consultants | n=6 | |||
| Staff nurses | n=7 |
In phase I, a basic understanding of the specialist nurse's job responsibilities, recruitment process and management norms was gained. This gave a descriptive indication of perceptions of their competency and educational preparation, as well as of support by the organisation and other staff.
Phase II was conducted by interviewing specialist nurses employed by Malta's National Health Service. These interviews collected data on their years of work as a nurse and as a specialist, sex and role. The analysis was carried out concurrently with the data collection (Rabiee, 2004) and was completed after nine interviews, since no new themes emerged at this point as data and theoretical saturation had been achieved. Lincoln and Guba (1985) called this ‘informational redundancy’, which denotes that no new concepts or dimensions for themes could be identified.
In phase III, focus groups were carried out with the specialist nurses' stakeholders, who were hospital colleagues from diverse health professions. Phases II and III were based on the literature review and the data collected from phase I.
Ethical considerations
For each study phase, the ethical and organisational approvals required were obtained and all the participants' identities were kept anonymous. All eligible participants were provided with information about the purpose of the study and procedure and were asked for their written informed consent before the interview or focus group was held. They were also informed about data confidentiality and that they could withdraw from the study at any time with no repercussions.
Sampling
Potential participants were contacted via their work emails. Sampling in this case study was done using two main types of purposive sampling (Patton, 2002; Palinkas et al, 2015). For the survey, the total population sample was the entire population of specialist nurses in Malta at the time; the majority were based in the only general hospital and three were in other areas (n=27). A homogeneous purposive sampling technique was used for the interviews: a sample (n=9) of specialist nurses were interviewed.
For the four focus groups, stakeholders were grouped according to their profession (Table 1). The aim was to achieve samples that shared the same or similar characteristics and backgrounds. As Patton (2002) explained, homogeneous sampling is used when the research question being addressed is specific to the characteristics of the group of interest, with the results then being examined in detail. Participants were selected to maintain diversity while they answered a standard set of questions based on their shared and unique experiences. To avoid any bias, the groups and participants selected were thoroughly checked for balance after each phase to ensure objectivity.
Demographics and backgrounds
The highest number of specialist nurses were infection control nurses, with three working in a general hospital and one working in primary care. There were three breast care nurses working in a general hospital, two breast screening nurses working in primary healthcare and two nurses working in stoma care and diabetes each. The rest were working in other clinical areas (Table 2). The average period of employment as a specialist nurse was 6.4 years and most (n=23) were employed at an acute general hospital. There were more female (n=17) than male (n=10) specialist nurses. The age range was 30 to 60 years, with most aged 40 to 49 years. A high proportion were postgraduates (n=12), followed by diploma holders (n=8); none had a PhD. Ten years on, the situation is different in terms of numbers; there were 27 specialist nurses in 2013 compared to more than 120 in 2023.
Table 2. Specialist nurse demographics
| Variable | n | |
|---|---|---|
| Place of employment | General hospital | 23 |
| Primary healthcare | 3 | |
| Elderly residence | 1 | |
| Age | 30–39 | 4 |
| 40–49 | 17 | |
| 50–60 | 6 | |
| Sex | Male | 10 |
| Female | 17 | |
| Whether post established before taking up post | Yes | 8 |
| No | 19 | |
| Whether they attend to patients | Yes | 21 |
| No | 6 | |
| Qualifications | Diploma | 8 |
| Postgraduate diploma | 7 | |
| First degree | 4 | |
| Master's degree | 12 |
Since 2015, no other study has been carried out on specialist nurses in Malta. Moreover, the 120 nurses are now called practice nurses and, as specialist nurses have been grouped with practice development nurses, the exact number today is more difficult to ascertain.
Findings: themes
Roles and attributes
From the survey, it was established that clinical work took up less than 50% of the specialist nurses' time. About 18% of their total time was devoted to education and training for staff, patients and relatives, while 14% was dedicated to management. In addition, equipment procurement and organising consultants' clinics consumed a great deal of their time. Although the majority of specialist nurses understood the importance of research in their jobs, only 7% of their time was dedicated to research. Specialist nurses said their extended roles included: haematological sample analysis; educating patients and their families; and treatment follow-ups.
The stakeholders described the specialist nurses as subject-matter experts, helpful and continually supportive caregivers.
All specialist nurses said their role had expanded in recent decades; however, it was evident that some had more freedom and autonomy than others, and this hinted at unclear hospital policies.
This was also an issue regarding referrals. Although all participants agreed they should be given autonomy, it was evident that they were not practising autonomously since they experienced several referrals being rejected.
Specialist nurse roles, attributes, development and influences on progress are summarised in Table 3.
Table 3. Specialist nurse roles, attributes, development and influences on progress
| Theme 1. Roles and attributes | ||
|---|---|---|
| Research question: how do specialist nurses in Malta explain their roles, development and experience, and do these concur with those of their stakeholders? | Objectives | |
| Specialist nurses and stakeholders: areas of agreement | Stakeholder perspectives | |
| Expert practitioner, educationalistCase manager, professional leader, transformational leaderExtended and expanded rolesAdministrative and procurement roles should be deployed to other workersProvider of high-quality, evidenced-based and person-centred care | Consultants: specialist nurses can take on more financial responsibilityConsultants: some specialist nurses are afraid to take on more responsibility to increase autonomyConsultants: with the right education and training, specialist nurses can become consultant nursesDirectors/managers: specialist nurses need to be more business minded | Explore the scope of services offered by specialist nursing throughout MaltaIdentify roles and services provided by specialist nurses |
| Whole package: education (master's degree) and training, experience and personality. Interpersonal skills: assertive, approachable, passionateTeam player, motivatedLove their job and positive | Multidisciplinary group: diplomacy was valued but specialist nurses should be open rather than diplomatic; diplomacy was felt as being dishonest | Explore the attributes of a specialist nurse |
| Theme 2. Development of specialist nurses | ||
|
Directors and consultants did not mention having one manager to direct specialist nursesBurnout was not mentioned | Explore the specialist nurses' and their stakeholders' experience of their developmentProvide a profile of specialist nursesProvide a historical background of their development |
| Theme 3. Influences on the advancement of specialist nursing practice | ||
Paucity of support from:
|
Consultants do not regard medical dominance as an influence on advancement of the specialist nurse role but see a lack of training and structure in nursingConsultants, managers and the multidisciplinary group did not mention bedside care as an influencing factor to specialist nurse development | Explore the influences on the advancement of specialist nursing practiceExplore what factors supported or hindered specialist nurses' progress (some aspects discussed in theme 2) |
This study found that specialist nursing as a profession must include aspects of an expert practitioner, educator, researcher and consultant. This view is similar to that put forth by Hamric's (1989) model and Manley's (1997) conceptual framework as well as in Sastre-Fullana et al's (2014) review on international systematics and the TAPP model in the US (Elliott and Walden, 2015).
An area this study highlighted was the need for professional leadership in nursing. There is a serious requirement for formulating new standards and clarity in guidelines for procedures and services. This finding was similar to those of international studies conducted in the UK (Ball, 2005), Australia (Ramis et al, 2013) and globally (Pulcini et al, 2010); nurse leadership and a research mentality need improving worldwide (Delamaire and Lafortune, 2010).
Notwithstanding this, the lack of time to conduct audits, evaluation and research was a common complaint among the specialist nurses. Again, similar observations had been made previously in international studies (Begley et al, 2010; Delamaire and Lafortune, 2010; Bryant-Lukosius et al, 2010). Day-to-day work, running clinics, high workloads and financial constraints served as major hindrances. Additionally, the work generated by equipment purchases and clinic administration created a burden of hidden non-clinical duties that consumed a lot of their time. Similar trends were documented in the UK and Australia by Belling et al (2008) and Ramis et al (2013) respectively. These additional jobs were seen as exerting undue pressure on specialist nurses that could lead to professional burnout, especially since these are not clearly mentioned in national or international specialist nurse roles. Therefore, one of the recommendations to the Maltese authorities is to introduce specialists specifically for equipment purchase and also appoint staff to carry out administrative jobs and so that the specialist nurses are not overburdened.
All participants, both specialist nurses and their stakeholders, emphasised the importance of having a good education to at least at master's level with additional specialist clinical training. Finance-related, leadership and negotiating skills and knowledge were also highlighted. An international survey by Delamaire and Lafortune (2010) examined nursing practices and their developments in 12 countries (Australia, Belgium, Canada, Cyprus, the Czech Republic, Finland, France, Japan, Ireland, Poland, the UK and the US) and concluded that training and education are the primary requirements for advanced practice. While these requirements are specific to countries, they can vary between employers in the same country. Nowadays, a postgraduate qualification education is a mandatory requirement for specialist nurses in the US (National Association of Clinical Nurse Specialists, 2004). However, such formal higher degrees are not mandatory in many European countries (Decock et al, 2022).
Finally, interpersonal communication and diplomacy were perceived as essential attributes. However, one participant stated she would opt for someone who was not diplomatic because she associated this with being less honest:
‘I would go for someone who is not diplomatic… Most of the problems we have in Malta, are because of abuse of diplomacy. We lack honest people! We want people who know when to act… If I had to choose between honesty and diplomacy, I would choose honesty.’
Multidisciplinary team member
This comment could be related to a cultural aspect and merits more investigation since it could be attributed to professionals being afraid to voice their concerns and thus perceived as not being honest.
In spite of this, the findings were congruent with Coates and Gilroy's (2012: 30) description of specialist nurses' attributes of having a ‘big heart, broad shoulders and be approachable’.
Development of specialist nurses
In this study, all participants acknowledged progress and development within nursing in Malta in relation to specialist nurse advancement. However, there was a unanimous impression that management was not supportive enough and there was a lack of strategic planning, training and development within this nursing community. Most specialist nurses felt that they were ‘thrown in the deep end’, with some blaming the consultants or the organisation and others blaming political changes, their union and policies.
Another shortcoming in the development of these positions was that the selection process for advanced nurse roles was not transparent enough. It was emphasised that the promotion and selection process needed substantial improvement to attract good candidates. Most nurses felt that there was a lack of meritocracy in the system. This was identified as one of the major hindrances in their development. Some stakeholders said that professional experience, passion for the role and the ability to work independently should be sought in a potential candidate.
Notwithstanding these issues, these nurses were pioneers in their areas of expertise and, despite having a challenging career, they seemed to have a positive mindset towards their profession. Some felt grateful since previously they had only two options to channel their career: educator or manager. Having the opportunity to become a specialist nurse motivated them to stay in clinical practice, close to the patient and family and still progress in their career.
Most of them said that the motivation to grow came from their determination to perform better and improve healthcare. One participant highlighted the importance of transformational changes brought by the specialist nurses in the wards that reached patients.
Overall, this study revealed high job satisfaction among specialist nurses, which Mills and Blaesing (2000) stated, could be related to professional pride and status in society. In the UK, Read et al (2001) also mentioned the satisfaction of personal development associated with the role.
Despite these positive perceptions, there was evidence that these nurses felt powerless and, at times, burnt out, finding their working environment fairly demotivating. Similar observations were seen by Galea (2014) in the general nursing population of Malta. This leads to the final theme of the study, which concerns the wider influences on the advancement of specialist nursing practice in this country.
Influences on the advancement of specialist nursing practice
In spite of the very positive views on the roles and practice of Maltese specialist nurses, a number of barriers to their development were identified. The lack of understanding and support for their role and the paucity of evaluation of their practice and services were seen as major barriers. Additional areas affecting their advancement included organisational, legal and political systems, which were seen to affect leadership and power in nursing and therefore achieving the aims of increasing the status of nursing and providing good-quality care.
There was unanimous agreement that the development of specialist nurses needed to be ‘seen’, since nurses do not become specialists overnight. Evidence of progress in education, training and competence was thought to increase the credibility of specialist nurses. This is supported by Manley (1997: 187) who stated: ‘To operate successfully… and to develop the expertise, skills and processes required will involve more than merely undertaking a theoretical course.’
As Manley (1997) further explained, the biggest challenge is the identification of practice outcomes as a basis for accreditation since theoretical and academic results are much easier to recognise. Therefore, using a model to offer guidance on the introduction and monitoring of these roles to determine how they would be implemented and assessed in practice is recommended in the literature (Elliott and Walden, 2015). One such model was described by the Scottish Executive Health Department (2005) in its position paper, Framework for Developing Nursing Roles:
‘Bolstered by appropriate education and management support, [nurses] can extend, expand and develop their roles to enhance their skills, knowledge and professional identity, strengthen their influence on the design, delivery and evaluation of services, and increase their impact on improving the health and well-being of the people of Scotland.’
Scottish Executive Health Department: 2005: V
Although one may criticise this as being grandiose, Kucera et al (2010) found that advanced nurse practitioners had the ability to be innovative and leaders who could advance nursing practice while keeping the nurse-patient relationship central to their role. Moreover, the strength of using a model is that it would facilitate strategic evaluation of the impact of advanced practice roles in Malta.
Finally, this study highlighted the power struggles in nursing and the hierarchical system that does not involve specialist and general nurses in matters on either an organisational or professional level. This was seen to be hampering the morale and standard of nursing within Malta's National Health Service (Buttigieg 2012; Johns Hopkins University, unpublished report, 2012; Dalli, unpublished report, 2014).
One medical consultant in a focus group pointed out that the ‘power distance culture’ in Malta discourages people from taking responsibility. This consultant further explained that specialist nurses in Malta who were well trained and actively embraced responsibility were seen as being arrogant or ‘pushy’. As Spratley et al (2000) explained, nurses' lack of power may be rooted in societal expectations since nurses may be more reluctant than most to discuss power because nursing is predominately a female profession and women have not been socialised to exert power (Rafael, 1996).
Manojlovich (2005) explained that nurses' power may arise from three components: a workplace that has the requisite structures that promote empowerment; a psychological belief in one's ability to be empowered; and acknowledgement that there is power in the relationships and caring that nurses provide.
Other elements that need to be examined in Malta include the dominant patriarchal ideology of the Roman Catholic identity (Darmanin, 2009) and the position of women in society. Darmanin (2013), an associate professor at the Faculty of Education at the University of Malta, explained that empowerment of women is still a contentious issue in Malta. Although the situation is improving and there has been a fast-growing increase in women in the labour market (National Statistics Office, 2023), Demarco (2022) stated that the disparity between men and women, especially regarding economic opportunities, health and leadership, remains glaringly wide, on both global and European scales, and especially in Malta. This inequality between the sexes is confirmed by the latest Global Gender Gap Report published by the World Economic Forum (2022). This could be because of the effects of earlier social and economic planning that remain evident in the participation of women and in the segmentation and segregation in the labour market that still prevail (Darmanin, 2009).
Conclusion
This study is the only research done on specialist nurses in Malta and, although data collection ended in 2015, it highlights the barriers and factors that influence nurses' development.
The core components of the specialist nurse position in Malta correlate with international roles, which include expert practitioner, educator, researcher and consultant.
It was evident that specialist nurses managed to go beyond establishing themselves but it seems that they now need to prove their worth by providing cost-effective and high-quality care autonomously. Their stakeholders need to be brought on board to make the case for specialist nursing positions to remain permanent, and the development of advanced nursing practice roles should follow a model or conceptual framework to guide and evaluate competence and development.
Finally, further research is needed to determine the quality of specialist nurses from different perspectives and hear the voices of those involved in receiving services. Moreover, additional areas affecting specialist nurses, including organisational and political systems, role evaluation and power in nursing, merit further attention to challenge attitudes and systems to promote high-quality care.
KEY POINTS
- The roles of a specialist nurse can include being an expert practitioner, educator, researcher and consultant
- Many specialist nurses are the only people in that role where they work so may not have time to participate in research
- A lack of standardised courses to prepare nurses for the specialist nurse role is problematic; such training will allow them to share and develop good practice
- A postgraduate qualification at least at master's level with additional specialised clinical training as well as finance-related knowledge, leadership and negotiating skills are vital to the role of a specialist nurse
CPD reflective questions
- What qualities do specialist nurses need to develop their services?
- What common factors hinder the advancement of European specialist nurses ?
- What are the legal and ethical implications around specialist nurses being appointed without a recognised pathway that includes education and competence? Should specialist nurse training follow a similar path to that for doctors?