The Impact of International Service-Learning on Nursing Students’ Cultural Competency

Authors: Pamela Wolfe Kohlbry PhD, RN, CNL

Abstract

Purpose

This article reports research findings on the effect of an international immersion service-learning project on the level and components of cultural competence of baccalaureate (BSN) nursing students.

Design

A triangulated methodology was used to determine changes in components and level of cultural competence pre- and postexperience. The theoretical model The Process of Cultural Competence in the Delivery of Healthcare Services was used. It identifies five central constructs in the process of becoming culturally competent: cultural awareness, cultural knowledge, cultural skill, cultural encounter, and cultural desire. The sample of 121 BSN nursing students was gathered from three southern California universities. Data were collected from 2009 to 2013.

Methods

Using the Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals-Student Version© and Cultural Self-Efficacy Scale, constructs of cultural competency were measured in pre- and posttest participants who participated in international service-learning immersion experiences. A demographic survey and open-ended qualitative questions were completed at the posttrip meeting. Mean, frequencies, and correlations with demographic data and survey data were calculated. Pre- and posttrip means were analyzed. Qualitative analysis from six open-ended questions completed at the posttest were coded and themes emerged.

Findings

The research findings demonstrated the impact of the international service-learning project on building cultural competency in nursing students. Quantitative findings revealed statistically significant differences between pre- and posttest surveys for two of the five constructs of cultural competence. Qualitative analysis supported the quantitative findings in cultural competency constructs found in the model.

Conclusions

The research findings support nursing education program use of international service-learning immersion experiences to foster cultural competence in nursing students. Findings from student participants demonstrated and articulated that these program experiences strengthen the process of becoming culturally competent. The research findings support the inclusion of international service-learning experiences with debriefing and reflective learning as effective teaching strategies. Researchers have demonstrated that poor healthcare outcomes are a result of health disparities, which are then compounded by healthcare workers not being prepared to care for clients from differing cultures. The American Association of Colleges of Nursing identified innovative ways for nursing students to develop skills in cultural competency, which included international experiences.

Clinical Relevance

In nursing education, this study demonstrated that international service-learning immersion experiences are of value as they impact and improve cultural competency. Nurses graduating with enhanced cultural understanding will contribute to decreased health disparities and improved patient care quality and safety. Further research that examines nurses’ cultural competency in the patient care setting who have had previous education in international nursing could further inform nursing education and contribute to the understanding of patient satisfaction.

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Researchers have demonstrated that a lack of cultural competence contributes to health disparities and poor health outcomes (Betancourt, Corbett, & Bondaryk, 2014; Institute of Medicine, 2002). Healthcare disparities create healthcare issues that are costly for patients and families as well as healthcare systems. This deficiency in cultural competency creates a gap between the nurse and safe patient-centered care. An essential dynamic of quality care is the nurse's level of cultural competency (Campinha-Bacote, 2013). Analysis of the impact of growth in ethnic populations and global immigration demonstrates the need for healthcare workers to be educated in cultural competency in order to decrease health disparities and achieve quality patient-centered care (Delgado et al., 2013; Vaughn, 2009; Waite & Calamaro, 2010). Healthy People 2020 (2015) highlights the need to address the social determinants of health, including cultural competency. Challenges to cultural competency, such as a deficiency in cultural understanding and skill and an absence of cultural sensitivity, have been identified (Clifford, McCalman, Bainbridge, & Tsey, 2015; Kwong, 2009; Maltby & Abrams, 2009). As nursing education prepares future nurses who are culturally sensitive and aware, consideration of effective teaching strategies that foster cultural competency is essential.
The American Nurses Association and American Association of Colleges of Nursing (AACN) Baccalaureate Essentials mandate nursing education to focus on diversity due to increased globalization with the expectation that for nurses to provide safe high-quality care requires cultural understanding and sensitivity (AACN, 2008a; Dolansky & Moore, 2013). Numerous investigators have described opportunities in nursing education to overcome cultural competency barriers by using national and/or international service-learning projects (Amerson, 2010; Bentley & Ellison, 2007; Kaddoura, Puri, & Dominick, 2014; Kardong-Edgren et al., 2010). Nursing education findings recommend various pedagogies to prepare future nurses to care for diverse individuals, families, and populations from cultures different from their own (Hughes & Hood, 2007; Jenkins, Balneaves, & Lust, 2011; Kardong-Edgren & Campinha-Bacote, 2008). Teaching strategies include a traditional format with classroom education and workshop training, reflective journaling, role play in simulation, and community service-learning projects (Gallagher & Polanin, 2015; Kohlbry & Daugherty, 2013; Kohlbry & Daugherty, 2015; Worrell-Carlisle, 2005).
The AACN (2008a) has identified three qualities of culturally competent baccalaureate nurses: (a) assessment of cultural variations; (b) cultural skill in communication and assessment; and (c) awareness of personal attitudes, culture, behaviors, and beliefs (Calvillo et al., 2009). Based on these qualities, the AACN established competencies and developed the AACN Tool Kit of Resources for Cultural Competent Education for Baccalaureate Nurses (AACN, 2008b). The tool kit, with various teaching strategies to improve cultural competency, identified experiential learning through immersion experiences within diverse communities as a recommendation.
The Quality and Safety Education in Nursing (QSEN) initiative by Robert Wood Johnson Foundation and the AACN further emphasized the need for education in cultural competency to elevate quality care. QSEN competencies were developed with cultural competence as a central aspect of patient-centered care (Disch, 2010). The QSEN knowledge, skills, and attitudes for nursing student graduates include: knowledge to “describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values”; skills to “provide patient-centered care with sensitivity and respect for the diversity of human experience”; and attitudes that “recognize personally held attitudes about working with patients from different ethnic, cultural and social backgrounds” as well as “willingly support patient-centered care for individuals and groups whose values differ from own” (Cronenwett et al., 2007, p. 123).
Nursing education, founded on evidence-based teaching practices, has a responsibility to “build the capacity of students” through experiences that foster cultural understanding (Hall & Guidry, 2013, p. e6). The nursing literature describes international cultural immersion programs of varying lengths of time and their value to help students appreciate global factors, expand their worldview, and understand different cultures (Hunt, 2007; Larson, Ott, & Miles, 2010).
Service-learning contributes to a student's development of cultural sensitivity, social justice, collaboration, and problem solving (Bosworth et al., 2006; Reising et al., 2008). The differences among service-learning, community clinical experiences, and volunteerism are discussed elsewhere (Kohlbry & Daugherty, 2013; Kohlbry & Daugherty, 2015). The reciprocal value of service-learning experiences are embedding student learning in facilitating goals of the community host country (McAuliffe & Cohen, 2005). The opportunities for collaboration with social service programs and community partners maximize learning and develop cultural competence (Pretorius & Small, 2007). For example, service-learning opportunities can be found in communities near international border areas where health conditions are often more severe than generally found beyond the distance of the border area (Kohlbry, 2011). Allen, Smart, Odom-Maryon, and Swain (2013) found a significant increase in perceived cultural competency and self-efficacy in cultural knowledge, skills, and attitudes among participants in a service-learning immersion activity in Peru.
Student learning often occurs in the reflective opportunities in the experience, such as debriefing (Laplante, 2007). It is often in the reflection process that assimilation of ideas and development of understanding around the experience take place. Debriefing is a valuable teaching tool in “cementing” the students’ learning and drawing out students’ understanding of their own worldview to help develop cultural awareness.
Research, anecdotal articles, and author experience identified that students found immersion experiences worthwhile and included comments, such as “this is why I wanted to go into nursing to make a difference” (Kohlbry & Daugherty, 2015, p. 245). However, there have been few studies of rigor to provide evidence of the effect and value of immersion service-learning on cultural competency. This article reports research findings on the effect of an international immersion service-learning project on the level and components of cultural competence of baccalaureate nursing students.

Theoretical Framework

Both the AACN's and QSEN's recommendations for cultural competency used Campinha-Bacote's (2013) model, The Process of Cultural Competence in the Delivery of Healthcare Services, as a framework for the development of cultural competence recommendations for nursing education. The model emphasized that cultural competence is a process of becoming based on cultural encounters or face-to-face experiences, motivated by cultural desire for those experiences. The five central constructs in the process of becoming culturally competent are cultural awareness, cultural knowledge, cultural skill, cultural encounter, and cultural desire. This model emphasizes the need for students to develop skills in communication and understanding of those from other cultures. It provides a framework for innovative teaching strategies for students to engage in the process. Nursing education is an important time to begin that process in a comprehensive way.

Methodology

A triangulated method using quantitative pre- and posttrip surveys and a qualitative questionnaire post-immersion experience were utilized to measure cultural competency and cultural self-efficacy. The study was conducted with nursing student participants from three universities with schools of nursing in California. Undergraduate students participated in service-learning type healthcare-focused trips, utilizing their nursing skills and collaborative abilities.

Data Collection Process

Institutional review board (IRB) approval was obtained from each participating university. Once the research was IRB approved by the participating university, the faculty leading an international trip invited the researcher to a trip-planning meeting. The researcher explained the purpose of the research and surveys, the rights of the participants, the pre- and postimmersion nature of the study, and invited students to participate. Participants were informed that their participation was not related to eligibility for the trip, class requirements, or grades. Informed consent was obtained and their confidentially was maintained. Demographic and pretrip surveys were completed. All research documents were of the paper and pencil format. Within 2 weeks of the participants’ return from the experience, they completed the posttrip surveys and the written qualitative questionnaires at a posttrip meeting. However, not all students attended the posttrip meetings; therefore, fewer posttrip responses than pre-trip responses were gathered.

Instruments

Two survey instruments were used to collect quantitative data on levels of cultural competence and cultural self-efficacy. The first tool, the Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals-Student Version (IAPCC-SV©), measured cultural competence in students and is based on Campinha-Bacote's (2013) model. The tool, found in numerous studies, was used with permission. The IAPCC-SV is a 20-item Likert 4-point scale with responses ranging from “strongly agree” to “strongly disagree.” The five constructs of the model measured are cultural awareness, cultural knowledge, cultural skill, cultural encounter, and cultural desire. The IAPCC-SV scores four levels of cultural competence. They are culturally proficient, culturally competent, culturally aware, or culturally incompetent. Cronbach's alpha reported in various studies averaged .87 (Capell, Veenstra, & Dean, 2007).
The second tool used in the study was the Cultural Self-Efficacy Scale (CSES), developed by Bernal and Froman (1993). It measures the participant's confidence level in caring individuals from different cultures, knowledge of cultural concepts, comfort in performing cultural nursing skills, and knowledge of cultural patterns among four subscale ethnic groups: African American, Hispanic, Native American, and Asian. This tool was used with permission and is in the public domain (Coffman, Shellman, & Bernal, 2004). The tool is a 30-item Likert-type 5-point scale, with 1 equaling “very little confidence” and 5 equaling “quite a lot of confidence.” An integrative review of cultural competency tools by Loftin, Hartin, Branson, and Reyes (2013) included the CSES’ Cronbach's alpha coefficient range of .86 to .98. Content validity of both tools was determined by an expert panel.
The qualitative data were gathered using an interview schedule with six open-ended questions:

• What were your expectations of the service-learning project?
• What did you learn about your perceptions of individuals from another culture?
• What were the positive experiences you remember?
• What were the challenges you remember?
• Do you feel the length of your trip was sufficient to change your worldview related to culture? If so, why; if not, why not?
• Describe new knowledge that you learned about transcultural nursing.

These questions were chosen to provide a focused review. The subsequent themes would add to the quantitative findings by “exploring different dimensions of the respondents’ experiences” (Jackson & Trochim, 2002, p. 307). The responses to the interview schedule were uploaded into Atlas.ti version 7 (Thomas Muhr Developer, Berlin, Germany). Open coding was conducted by reading over the data. Each response was reviewed, color highlighted, and carefully coded. Words and quotations were analyzed for frequency and meaning. Similar codes were grouped together. The code groups were analyzed, and reviewed for patterns and commonality, and themes emerged. Themes were examined for relationships and linkages. Demographic data were gathered from a survey on age, sex, marital status, work status, ethnicity, university, length of trip, and country visited.
Mean, frequencies, and correlations with demographic data and survey data were calculated. The pre- and posttrip surveys were grouped, as individual students were not tracked before and after trips. SPSS version 19.0 (IBM Corp., Armonk, NY, USA) was used for pre- and posttrip survey analysis for the IAPCC-SV and CSES. Qualitative data analysis of the quotations identified codes and themes using Atlas-ti version 7.

Findings and Discussion

The demographic results of the participants are summarized in Table 1. A total of 161 pretrip students and 121 posttrip students were analyzed. The majority of the participants were female (91%) and in the age range of 21 to 30 years (79%). Student ethnicity was primarily non-Hispanic White (54%). Depending on the university, the duration of the trip varied from 1 day to 3 weeks, and locations included Mexico, Belize, Lesotho, Vietnam, Jamaica, Dominican Republic, Swaziland, and Ghana.

Table 1. Demographic Results

Age ranges (years)
21–30	79%
31–40	16%
41–60	5%
Ethnicity
Hispanic American	11%
African American	2%
Other: Filipino, Pacific Islander, Asian	32%
Non-Hispanic White	54%

Age was correlated with the IAPCC-SV. Using a Spearman rho, a significant correlation (rho = 0.18) was found with the age of respondent in the cultural encounters construct (Table 2). The older the respondent, the stronger the correlation. This could be explained by the fact that with age comes more encounters, which builds the process of cultural competency. A significant correlation was found with the CSES scale and age. The CSES areas of “African American” and “Other” questions were significant at the Spearman rho < .01 (see p value) level with age of respondent (Table 3). With age potentially comes more flexibility and face-to-face encounters. Campinha-Bacote (2007) determined that more face-to-face cultural encounters influence the process in the healthcare professional in which the interactions with clients from culturally diverse backgrounds help to modify existing beliefs about a cultural group and to prevent possible stereotyping. Nursing students are novices and are more adaptable, which is reflected in the correlation of age and IAPCC-SV total score.

Table 2. Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals-Student Version Correlated With Age

Construct	Spearman's rho	p
*p < .05.
Awareness	−0.005	.93
Knowledge	0.06	.30
Skill	0.03	.66
Encounters	0.18	.00*
Desire	0.11	.06
Total	0.14	.025*

Table 3. Cultural Self-Efficacy Scale Correlated With Age

CSES Areas	Spearman's rho	p
*p < .05.
African American	0.15	.02*
Hispanic	0.07	.24
Asian	0.05	.46
Native American	0.09	.13
Other	0.17	.007*

In measuring pre- and posttrip means, both surveys demonstrated an increase in overall means in all constructs of cultural competence and cultural self-efficacy (Table 4). Significant pre- and posttest means on the IAPCC-SV survey were demonstrated on the constructs of cultural knowledge (F = 12.3, p = .001) and skill (F = 8.1, p = .005) and were significant at p = <.01. Pre- and posttest CSES means were significantly different in two of the ethnic subscales (p < .01)—African American (F = 10.2, p = .002) and Hispanic (F = 3.8, p = .05)—and on questions related to comfort in performing cultural care (F = 7.6, p = .00).

Table 4. Pre- and Postimmersion IAPCC-SV Means of Cultural Competency Constructs

	Preimmersion	Postimmersion
Construct	mean	mean	F	p
Note IAPCC-SV = Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals-Student Version. *p < .01.
Awareness	3.55	3.6	1.74	.19
Knowledge	2.9	3.08	12.3	.001*
Skill	2.94	3.11	8.1	.005*
Encounters	3.26	3.32	2.7	.10
Desire	3.56	3.61	1.08	.298

There was no significance found between pre- and posttrip levels of cultural competency. The majority of students were at the culturally competent level pre- and postexperience, with a smaller number at the culturally aware level and a few at the culturally proficient level. None were at the culturally incompetent level. While there was movement between levels on students’ post-trip surveys, several unexpected findings were noted. On several questions students rated themselves higher on the pretrip survey than on the posttrip survey. One explanation of these findings is that students have a particular mindset or worldview before their experience. After their experience, perhaps they realized that their worldview, assumptions, and understanding were more limited. This type of experience helps students expand their worldview and requires them to ask themselves if they clearly understand the needs of an individual from another culture. The finding that most students identified themselves as culturally competent before the trip may indicate that the awareness of these students was heightened by the experience.
Every posttrip participant filled out an interview survey. All survey data were reviewed. The qualitative data gathered from the interview surveys were reread, codes were established, subsequent findings were attributed to commonality and patterns, and emerging themes were identified. Each question, answer, related phrase, and quotation was color coded using the Atlas ti version 7 software and given a code label. After rereading the data and codes, similar codes were clustered or grouped together. Because of the volume of qualitative data, repeated or similar quotations and codes were reviewed for frequency, meaning, similarity, or pattern. There were numerous quotations and phrases supporting each code. The code groups were further analyzed, and six themes emerged. The six themes were examined to determine relationships and linkages. The themes and relationship among the themes were found to be reflective of Campinha-Bacote's (2013) model.
Interestingly, three of the themes—cultural knowledge, cultural skills, and cultural awareness—directly reflect the constructs described in Campinha-Bacote's (2013) model. These themes were identified in Category 1 and directly reflected model constructs. The first theme of cultural knowledge reflected student's inclusion of learning language, cultural perceptions, customs, and beliefs. In the second theme, cultural skills, students identified the need to be creative and take into account others’ cultural beliefs. The third theme of cultural awareness had some of the most frequent codes from quotations that students articulated. They described that experiences challenged their preconceptions and stereotypes of culture, and opening up their worldview. Table 5 identifies Category 1 themes and quotations with corresponding student participant and university number.

Table 5. Category 1 Themes, Supporting Student Quotations and Corresponding to Campinha-Bacote's Model Constructs: University and Student Participant Numbers Noted

Theme	Student quotations
Cultural knowledge	“Learn, connect, care, learning language, learning customs and beliefs, giving hugs, encouraging others, praying for receptive individuals, [and] giving.” (U1S401)
	“Individuals from other cultures perceive many of the same basic values as I do—family, community etc.” (U2S414)
	“Different cultures have different healthcare norms that they use and make work. It was interesting [and] educative to see how the Vietnamese healthcare system functions similarly and differently from ours.” (U1S466)
Cultural skills	“You have to keep being creative to come up with solutions that
	[will] take their beliefs into account and still try to help.” (U1S416)
	“Patience is key. Education is most effective.” (U1S474)
	“I have to work with local health beliefs and adapt accordingly.” (U1S418)
	“How to ask questions more carefully and ensure I properly interpret responses.” (U1S472)
Cultural awareness	“Keep an open and non-judgmental mind.” (U2S412)
	“I learned to not assume anything about others in another culture, because often times I was wrong.” (U3S446)
	“I learned that I grew tremendously after doing [a lot of] works at being culturally aware.” (U3S445)

The next three themes that emerged from the data were cultural sensitivity, cultural self-efficacy, and identifying cultural barriers. While these themes were not identical to the model, they support its constructs and were identified in Category 2. In the second category, the fourth theme of cultural sensitivity was identified as a greater appreciation of the value of the beliefs and opinions of other cultures about health and medication. The fifth theme described reflected self-efficacy. An example of a student response within the theme of self-efficacy described the realization that the student could make a difference, “There was a great need and feeling like I was making a difference to meet this need by working at community clinics.” The sixth theme that emerged was cultural barriers, which centered on language and gender roles. These three themes support the cultural competence model constructs of cultural encounter and cultural desire. Developing cultural sensitivity and self-efficacy contribute to building cultural desire. Through the involvement in cultural encounters, one learns about cultural barriers and how to work with those from a different culture. Table 6 identifies Category 2 themes and quotations with corresponding student participant and university number.

Table 6. Category 2 Themes, Supporting Student Quotations and Corresponding Campinha-Bacote's Model Constructs: University and Student Participant Numbers Noted

Theme	Student quotations
Cultural sensitivity	“I think this trip made me appreciate and value the beliefs and opinions of other cultures about health and medicine even more than before.” (U1S427)
	“Giving education based on their cultural beliefs.” (U1S442)
	“More patience is needed for some culture[s].” (U2S410)
Cultural self-efficacy	“I learned that things in other countries are often done very differently but it does not mean it is wrong or that care is jeopardized. I learned that other countries often provide minimal care regularly instead of full care when symptoms are horrible. I also learned that people do not go to the doctor for things unless it is interfering with how they [feel].” (U1S458)
	“Learning from the clients as much as they learned from me.” (U1S403)
	“I had expectations similar to media representations that were very often inaccurate.” (U3S448)
Cultural barriers	“Language barrier and getting services that they need.” (U2S410)
	“The gender role conflict with women being treated are lesser equal men.” (U1S404)

Limitations

One limitation of the study was the inability to determine optimal length of time for an immersion experience. A second limitation was not being able to study gender differences because of the limited number of men who participated in the study. Another limitation would be any pretrip education, orientation, or special cultural content for the international experiences that would vary according to trip, country, faculty, and university. This could prevent generalization.

Implications for Nursing Education, Practice, and Research

The findings from this research support important implications for nursing education, practice, and research. The research indicates that the teaching strategies using international service-learning immersion projects contribute to students’ cultural encounters, knowledge, skills, awareness, sensitivity, self-efficacy, and understanding of cultural barriers. These types of experiences differ from study abroad by including faculty oversight and student contributions to the healthcare in communities where the students are situated. Students are not observers of cultures; they are participants coming alongside individuals and families who live in a different culture. The students gain insight into their own responses to others’ worldviews. To enhance this learning, focused debriefings that highlight and review cultural experiences in light of cultural encounters, skills, knowledge, self-efficacy, and awareness should be fostered. These opportunities contribute to student growth and in seeking to have students understand cultural differences and barriers to providing care and support to patients from a different culture. The findings from this study support the recommendation of using international service-learning in nursing education.
Future research on patient perceptions of nurses who have participated in international service-learning projects as students is needed to further understand how this type of learning experience potentially impacts nurses’ cultural sensitivity. Research on faculty experience in international service-learning projects, methods of effective debriefing, and how these projects are integrated into the curriculum would further expand teaching strategies.

Conclusions

The research findings in this study describe the impact and value of an international immersion experience on the level of cultural competency of nursing students. Nursing education is charged with the responsibility to educate students in a way that fosters the development of cultural competency. Graduating future nurses who are experienced in the process of cultural competence have the potential to improve nursing practice and improve care.
In summary, cultural competency is a process that nursing education must initiate with effective teaching strategies such as international service-learning immersion experiences. When students have an opportunity to experience and learn in this type of setting, they are engaged in the learning process and the multifaceted experience imprints an understanding that potentially influences their future practice.

Acknowledgments

The author would like to thank Sigma Theta Tau International's Zeta Mu chapter and Phi Theta chapter for research grant funding and California State University San Marcos for funding through the University Professional Development grant.

Clinical Resources

• American Association of Colleges of Nursing. Tool kit of resources for cultural competent education for baccalaureate nurses: http://www.aacn.nche.edu/Education/pdf/toolkit.pdf
• CLAS Standards: https://www.thinkculturalhealth.hhs.gov/content/clas.asp
• Transcultural C.A.R.E Associates: http://www.transculturalcare.net/

PROFESSION AND SOCIETY

Factors Associated With Full Implementation of Scope of Practice

Authors: Freda DeKeyser Ganz PhD, RN, Orly Toren PhD, RN, Yafit FAdlon, MSc, RN

Abstract

Purpose

To describe whether nurses fully implement their scope of practice; nurses’ perceptions of future practice implementation; and the association between scope of practice implementation with professional autonomy and self-efficacy.

Design

A descriptive correlational study was conducted using a convenience sample of 145 registered nurses with post-basic certification from two Israeli university hospitals, from May 2012 to September 2013.

Methods

Five questionnaires were distributed: (a) Demographic and Work Characteristics, (b) Implementation of Scope of Practice, (c) Attitudes Towards Future Practice, (d) Practice Behavior Scale, and (e) Practice Self-Efficacy. Descriptive statistics for all demographic and questionnaire data were analyzed. Two regression models were developed, where current and future implementations were the criterion variables and demographic and work characteristics, professional autonomy, and self-efficacy were the predictors.

Findings

High levels of professional autonomy, self-efficacy, and attitudes towards future practice were found in contrast to low or moderate levels of current implementation of the full extent of scope of practice. Primary reasons associated with low implementation were lack of relevance to practice and permission to perform the practice. Significant associations were found between professional autonomy, self-efficacy, and attitudes towards future practice, but not with current implementation.

Conclusions

Nurses wanted to practice to the full extent of their scope of practice and felt able to do so but were hindered by administrative and not personal barriers.

Clinical Relevance

Even though staff nurses with post-basic certification had high levels of professional autonomy and self-efficacy, many were not implementing the full extent of their scope of practice. Similar to findings from around the world, external factors, such as administrative and policy barriers, were found to thwart the full implementation of nurses' full scope of practice. Therefore, practicing nurses should be aware of these barriers and work towards reducing them.

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Nursing scope of practice refers to those actions, functions, or procedures that nurses are legally permitted to perform. The exact range of authorized practices is based on the nurse's education, training, competencies, and experience, as well as the laws and regulations of the state, and the policies of the local institution where the practices are performed (Bryce & Foley, 2014; Queensland Nursing Council, 2005). Nursing scope of practice has been changing and expanding due to changes in the healthcare environment (Bohmer & Imison, 2013; Brodsky & Van Dijk, 2008).
The need to provide increasingly complex healthcare services at decreased costs induced countries from around the world to develop their own human resource solutions. For example, the English National Health Service instituted a national initiative changing the roles and scope of practice of physicians and nurses (Bohmer & Imison, 2013). Australia implemented initiatives further redefining and expanding the roles of enrolled and registered nurses. The Congress of the United States passed the Patient Protection and Affordable Care Act, thereby presenting a unique opportunity to improve healthcare by reforming scope of practice policies (Villegas & Allen, 2012) and encouraging nurses to practice to the full extent of their authority, especially in advanced nursing and primary care (Institute of Medicine [IOM], 2011; Kunic & Jackson, 2013).
Israel, a country in the Middle-East with socialized medicine, has also developed a solution. Over 30 years ago, the Israel Ministry of Health authorized advanced practices and procedures within the framework of post-basic certification. Certification is obtained by registered nurses who complete a course that is approximately 1 year in length and includes both theoretical and clinical content. Nurses must also pass a theoretical and clinical examination in order have post-basic certification. These courses are not given within an academic framework and initially did not require an academic degree. Areas of post-basic certification include midwifery, intensive care (neonatal, pediatric, and adult), emergency, oncology, geriatrics, and others. The scope of practice of nurses with post-basic certification is expanded from that of the registered nurse and includes a specific set of practices based on the type of certification (Ben Natan & Oren, 2011; Israel Ministry of Health, 2015; Table 1).

Table 1. Extended Practices for Nurses With Post-Basic Certification

	Type of certification
		Neonatal/pediatric
Practice	Adult ICU	ICU	Emergency	Oncology	Midwifery
Note ICU = intensive care unit; IV = intravenous.
Handheld defibrillation	√		√
Attach pacemaker electrodes and set heart rate	√		√
Set ventilator settings for weaning	√	√	√
Connect and disconnect patient to ventilator	√	√	√		√
Insertion of arterial line		√
Removal of arterial line	√	√	√	√	√
Draw blood from an arterial line	√	√	√	√	√
Administer drugs IV push	√	√	√	√	√
Administer drugs IV push to central line	√	√	√	√	√
Draw blood for type and cross-matching	√	√	√	√	√
Care of a Swan-Ganz catheter	√		√
Blood drawing for laboratory tests, including arterial blood gases	√
Drawing of mixed-venous blood from a Swan-Ganz catheter	√
Draw peripheral arterial blood from a newborn		√	√ (up to 1 year old)
Insert peripheral IV to newborn		√	√ (up to 1 year old)
Draw venous blood from newborn peripheral vein		√	√
Insert peripheral venous line on the scalp and legs of newborn		√

Only in 2009 did the Israel Ministry of Health authorize an advanced-practice role, that of nurse specialist in palliative care. Since that time, several other specialist roles have been introduced (Israel Ministry of Health, 2013, 2015). Scope of practice for the specialist role includes management of patient medications and treatments (not including hospital admission), follow up and discharge care, ordering tests (including blood tests, x-rays, and scans), and ordering referrals to consultants and the emergency department. However, the nurse and all of his or her decisions are under the authority of the physician in charge of the department (Israel Ministry of Health, 2015). Nurses must have post-basic certification in a related area of nursing in order to apply to become a specialist.
There are reports of nurses not working to the full extent of their education and training or scope of practice (IOM, 2011; D'Amour, Dubois, Dery, Clarke, Tchouaket, Blais, & Rivard, 2012). Previous studies have shown that lack of full implementation of the scope of practice might be due to internal as well as external factors. Internal factors include feelings of incompetence (McConnell, Slevin, & McIlfatrick, 2013) or personal characteristics, while external factors include organizational support (Shiu, Lee, & Chau, 2012), work environment (Oelke, White, Besner, Doran, Hall, & Giovannetti, 2008), institutional policies (McConnell et al., 2013), and local and national health policy (IOM, 2011).
Two internal factors that might be related to the full implementation of scope of practice are professional autonomy and self-efficacy. Professional autonomy can be defined as control over one's professional practice (Bahadori & Fitzpatrick, 2009). Dempster (1990) described four aspects of professional autonomy: readiness (ability, skill, and mastery), empowerment (perception of the legitimacy to practice), actualization (decision making, authority, and responsibility), and valuation (an evaluation of professional worth and quality). Kilpatrick et al. (2012) found that increased levels of professional autonomy were associated with increased implementation of scope of practice among a sample of Canadian nurse practitioners. Goldberg, Kertzman, Van Dijk, & Eisenberg (2012) also found a positive relationship between professional autonomy and attitudes towards expanding the scope of practice among a sample of Israeli nurses.
Self-efficacy in this context can be defined as the assessment that a nurse is able to perform the roles and practices within the scope of practice. Efficacy expectations are defined as the belief that one is able to successfully perform a specific task for a specific purpose. These expectations influence whether one will attempt to perform the specific tasks as well as the amount of effort that will be expended to complete them (Bandura, 1977). No study was found that investigated the relationship between self-efficacy and implementation of scope of practice. However, it would seem logical that nurses who felt that they were not able to perform a practice successfully would neither attempt to perform it nor expend a lot of effort to do so. This information might be important to policymakers when they are deciding whether to endorse the expansion of certain practices into nursing.

Significance

Nurses are expected to deliver safe, high-quality, and cost-effective care (Kunic & Jackson, 2013). However, nurses working below the full extent of their scope of practice may have lower job satisfaction and increased turnover, leading to increased costs and decreased quality of care (D'Amour et al., 2012). While one of the major conclusions of the American IOM report on the future of nursing (2011) was to promote nurses to work to the full extent of their education and training, few studies have investigated whether nurses, especially staff nurses, from other countries are having similar problems. Even fewer have determined what factors are associated with nurses implementing the full scope of their practice.

Aims

The aims of this study were to describe whether nurses worked to the full extent of their scope of practice; whether these nurses wanted to expand their scope of practice in the future; and whether demographic and work characteristics, professional autonomy, or self-efficacy were predictors of working to the full extent of the scope of practice or attitudes towards expanding scope of practice in the future.

Design

This study was a descriptive, correlational study.

Methods

Sample

The target population was Israeli nurses who had completed post-basic certification courses. The accessible population was nurses from two university hospitals. Nurses were chosen using convenience sampling of units that are expected by the Israel Ministry of Health to hire nurses with post-basic certification. The units that were included were intensive care (adult, pediatric, and neonatal units), emergency, oncology, and maternity departments. A power analysis found that a minimum of 134 subjects were needed to achieve a power of .80, with an alpha level of .05 with a moderate effect size (Cohen, 1992).

Instruments

Five instruments were used in this study: (a) Demographic and Work Characteristics Questionnaire, (b) Implementation of Scope of Practice Scale, (c) Attitudes Towards Future Practice Scale, (d) Practice Behavior Scale (Dempster, 1990), and (e) Practice Self-Efficacy Scale.

Demographic and work characteristics scale

This scale included the variables of age, sex, family status, religion and religiosity (measures of ethnicity in Israel), unit, role, experience as a nurse and on the current unit, professional education, type of post-basic course, and date of course completion.

Implementation of scope of practice scale

This scale was designed by the investigators in order to measure the level of current implementation of nursing practices that are included in the Israel Ministry of Health list of expanded practices (practices allowed only by registered nurses with post-basic certification; see Table 1). The scale consists of a list of the practices relevant to the type of post-basic certification (range: 5–13 practices). Participants are asked to describe on a Likert scale to what extent they perform each practice independently (i.e., not require a physician or other healthcare provider to perform the practice), from 1 (never) to 5 (always). Higher scores indicate a higher level of current implementation of the full extent of the nurse's scope of practice.
In the event that the participant responded with an answer in the range of 1 to 3, the participant was asked (using a checklist) why they did not perform this practice. Possible responses were no time, not have relevant knowledge or training, not enough confidence, and lack of permission or prohibited by a superior.
The questionnaire was sent to five content experts (five nurses with expertise in policy and administrative issues related to scope of practice and advanced practice) to evaluate its content validity. Only minor changes were requested in the questionnaire. Cronbach's α reliability scores ranged from .31 (for midwives) to .67 (for the emergency and pediatric intensive care groups). Test-retest reliability (data collection with a difference of three weeks) was r = .92.

Attitudes towards future practice scale

This questionnaire was also designed by the investigators and describes attitudes towards the expansion of the scope of practice in the future. The questionnaire is based on that of Brodsky and Van Dijk (2008). The original questionnaire was distributed to nurses and physicians and described attitudes towards the introduction of the advanced practice role. The current questionnaire is addressed only to nurses with post-basic certification, and several additional items were added that were relevant to the current population. The questionnaire asks respondents to describe on a Likert scale from 1 (strongly disagree) to 6 (strongly agree) their level of agreement with 15 items. The questionnaire includes items such as what is the nurse's agreement with expanding their scope of practice to include prescriptive authority or whether they agree that further expansion of their scope of practice will improve their quality of patient care. Scores can range from 15 to 90, with higher scores indicating more positive attitudes towards increasing the extent of scope of practice in the future. The questionnaire was sent to five content experts (five nurses with expertise in policy and administrative issues related to scope of practice and advanced practice) to evaluate its content validity. Only minor changes were requested in the questionnaire. Cronbach's α reliability was .92 and test-retest reliability (data collection with a difference of three weeks) was r = .99.

Practice behavior scale

This tool is a 30-item, Likert type questionnaire designed to measure professional autonomy (Dempster, 1990). The questionnaire is divided into four sections: readiness (11 items), empowerment (7 items), actualization (9 items), and valuation (3 items). Items are rated on a scale from 1 (not at all) to 5 (strongly agree). Final scores range from 30 to 150, with higher scores demonstrating higher levels of autonomy.
Written permission was granted by the author of the questionnaire for its use and translation into Hebrew. The Brislin method (1970) was used for forward and back translation. Cronbach's α for the entire scale was found to be .90, with subscale scores ranging from .69 to .85.

Practice self-efficacy scale

Self-efficacy is a concept that must be measured within a specific context; therefore, this scale was designed by the authors for this study. The scale consists of nine items that measure efficacy expectations, a type of self-efficacy. Each item measures the level to which the respondent feels he or she is able to perform a specific nursing practice. For example, “I think that I am able to interpret x-ray reports (after instruction) in an acceptable, safe and efficient manner.” Items are measured on a Likert scale from 1 (strongly disagree) to 4 (strongly agree). Higher scores indicate higher levels of efficacy expectations for the specific practice.
The questionnaire was sent to five content experts (five nurses with expertise in policy and administrative issues related to scope of practice and advanced practice) to evaluate its content validity. Cronbach's α reliability was found to be .89, while test-retest reliability (3 weeks apart) was r = .99.

Data Collection

After institutional ethical approval, the investigators received approval from the nurse managers to collect data. Some nurse managers preferred that data be collected during a staff meeting. A brief explanation was given about the study, and then nurses were asked to complete the questionnaire while one of the investigators was present to answer any questions. On other units, questionnaires were individually distributed. Questionnaires were returned to a closed envelope.

Ethical Issues

The study was approved by the ethics boards of both institutions. Questionnaires were anonymous and were distributed and stored according to the local ethics board regulations.

Statistical Analysis

Descriptive statistics were used to describe the sample and results of the questionnaires. This included mean, standard deviation, and frequency data. Associations between variables were assessed using Pearson product moment correlations. Two regression models were designed. The predictor variables for both models were professional autonomy, self-efficacy, age, sex, years of experience as a nurse, years worked on the current unit, nursing education, role, and type of post-basic certification. The criterion variable for the first model was current implementation of scope of practice while future implementation of scope of practice was used for the second model.

Results

Questionnaires were distributed to 207 nurses from 13 units in two institutions, and 145 were returned (70% response rate). The mean age of nurse participants was 43 years, with a mean of 16 years as a nurse and 10 years working on the current unit. Most nurses were women (n = 131, 90%) with an academic education (BA or MA; n = 88, 61%). For further demographic data, see Table 2.

Table 2. Demographic and Work Characteristics

Demographic characteristics			Work characteristics
Variable	n	Result	Variable	n	Result
Note ICU = intensive care unit.
Age (years)	141	M = 42.7	Experience as RN	144	M = 15.8
		SD = 9.7			SD = 9.2
		Range = 26–66			Range = 2 – 43
		Missing: 4			Missing: 1
Sex	145	Female: 131 (90.3%)	Experience on current unit	143	M = 9.9
		Male: 14 (9.7%)			SD = 7.6
					Range = 1–36
					Missing: 2
Family status	143	Married: 109 (76.2%)	Years since post-basic	140	M = 10.6
		Single: 24 (16.8%)	certification		SD = 8.6
		Divorced: 9 (6.3%)			Range = 1–36
		Other: 1 (0.7%)
		Missing: 2
Religion	144	Jewish: 131 (90.3%)	Type of certification	145	Neonatal/Pediatric ICU: 47 (32.4%)
		Muslim: 9 (6.3%)			Midwifery: 37 (25.5%)
		Christian: 3 (2.7%)			Adult ICU: 30 (20.7%)
		Other: 1 (0.7%)			Emergency: 18 (12.4%)
		Missing: 1			Oncology: 13 (9.0%)
Place of birth	140	Israel: 87 (62.1%)	Nursing education	144	BA in nursing: 68 (46.9%)
		Eastern Europe: 39 (27.9%)			MA in nursing: 20 (13.8%)
		Americas: 8 (5.7%)			MA in other field: 19 (13.1%)
		Western Europe: 4 (2.9%)			RN: 19 (13.1%)
		Africa: 2 (1.4%)			BA in other field: 18 (12.4%)
		Missing: 5
			Role	145	Staff nurse: 38 (26.2%)
					Senior nurse: 88 (60.7%)
					Nurse administratoror
					manager: 19 (13.1%)

The mean level of implementation of current scope of practice was 2.77 (standard deviation [SD] = 0.91; possible range: 1–5). The highest percentage of nurse implementation (defined as often or always) for the six practices that were common to all units was for giving an intravenous drug (IV push) (n = 96, 67%; mean [M] = 3.7, SD = 1.6). The lowest level of implementation was for removal of an arterial line (n = 63, 44%; M = 2.8, SD = 1.9). Levels of implementation for other practices are detailed in Table 3. Nurses who had certification in intensive care had the highest level of current implementation (M = 3.7, SD = 0.5), while nurses with labor and delivery post-basic certification had the lowest levels of implementation (M = 1.8, SD = 0.4). This difference was statistically significant, F(4,140) = 66.0, p ≤ .01. The majority of nurses with labor and delivery post-basic certification did not implement any of the six extended practices (57–100% of nurses), with the exception of taking blood for type and cross-matching (n = 2, 5%). This is in contrast to the finding that 8 of 12 extended practices were implemented often or always by the majority (60–97%) of intensive care unit (ICU) nurses.

Table 3. Mean Levels of Current Implementation of Scope of Practice by Type of Certification

	Type of certification, M (SD)
	Adult	Neonatal/pediatric	Emergency	Oncology	Labor and
Practice	ICU (n = 30)	ICU (n = 47)	(n = 18)	(n = 13)	delivery (n = 37)
Note ICU = intensive care unit; IV = intravenous.
Handheld defibrillation	2.5 (1.3)		2.3(1.4)
Attach pacemaker electrodes and set heart rate	2.5 (1.3)		2.6(1.4)
Set ventilator settings for weaning	4.0 (1.2)	1.8(1.2)	1.6(0.9)
Connect and disconnect patient to ventilator	4.6 (0.6)	4.0(1.5)	3.6(1.1)		1.0(0.0)
Insertion of arterial line		1.2(0.8)
Removal of arterial line	4.7 (0.6)	3.9(1.5)	1.5(1.2)	1.0(0.0)	1.1(0.7)
Draw blood from an arterial line	4.6 (1.0)	4.7(0.5)	1.4(1.0)	1.3(1.1)	1.0(1.3)
Administer drugs IV push	4.6 (1.0)	4.6(0.8)	3.0(1.6)	3.8(1.3)	2.0(1.3)
Administer drugs IV push to central line	4.4 (1.2)	4.3(1.0)	1.8(1.4)	3.7(1.4)	1.1(0.7)
Draw blood for type and cross-matching	3.5 (1.7)	3.0(1.7)	1.6(1.3)	4.4(1.2)	4.8(0.9)
Care of a Swan-Ganz catheter	2.7 (1.6)		1.1(0.5)
Blood drawing for laboratory tests, including arterial blood gases	4.7 (0.8)
Drawing of mixed-venous blood from a Swan-Ganz catheter	1.8 (1.2)
Draw peripheral arterial blood from a newborn			√ (up to 1 year old)
Insert peripheral IV to newborn		3.4(1.6)	√ (up to 1 year old)
Draw venous blood from newborn peripheral vein		2.6(1.6)	√
Insert peripheral venous line on the scalp and legs of newborn		3.0(1.6)

Nurses who did not implement a practice were asked why not, using a structured checklist. The reason most commonly cited (40% of the responses) was “other.” The most cited answers for this category were that the practice was not relevant or was uncommon. The next most cited responses were lack of permission (23%) and prohibited to practice (18%). Fewer nurses reported a lack of knowledge (14%) or lack of confidence (6%) to perform the practice.
The mean score for future implementation of extended scope of practice was 4.4 (SD = 1.0) (possible range 1–6). Highest scores were for referral to laboratory tests and their interpretation (M = 4.9, SD = 1.0) and prescriptive authority based on standardized protocols (M = 4.7, SD = 1.3). Nurses thought that extending the scope of practice was important (M = 4.8, SD = 1.4), would improve nursing care (M = 4.7, SD = 1.4), and would improve the overall quality of care (M = 4.6, SD = 1.2).
The mean level of professional autonomy was 118.8 (SD = 12.5; range: 81–145). Highest scores were the in the subscale of actualization (M = 4.4, SD = 0.5), followed by valuation (M = 4.2, SD = 0.6), readiness (M = 4.0, SD = 0.5), and empowerment (M = 3.4, SD = 0.6). No statistically significant differences were found between the different types of post-basic certification on professional autonomy or its subscales.
The mean level of self-efficacy was 3.1 (SD = 0.7; possible range: 1–4). Most nurses felt able to extend their current scope of practice (n = 86, 59%), prescribe medications (n = 103, 71%), or refer patients for laboratory tests and interpret them (n = 85, 59%). No statistically significant differences were found between the different types of post-basic certification on levels of self-efficacy.
No statistically significant associations were found between the current level of implementation of scope of practice and future levels of implementation of extended scope of practice, self-efficacy, or professional autonomy for the entire sample. However, statistically significant associations were found between current implementation of scope of practice and professional autonomy among nurses with ICU post-basic certification (r = .37, p ≤ .05) and pediatric ICU certification (r = .36, p ≤ .05). Statistically significant associations were found between future implementation of extended scope of practice and professional autonomy (r = .36, p ≤ .01) and self-efficacy (r = .75, p ≤ .01).
The majority of the shared variance in the scores for current implementation of the scope of practice (68%) was found to be significantly predicted by a model including future levels of implementation, professional autonomy, self-efficacy, and demographic variables, F(17,120) = 18.3, p ≤ .01. Only current role and type of post-basic certification were found to be significant predictors, where those in administrative roles and nurses with pediatric and ICU post-basic certifications were found to have higher levels of implementation. Other demographic and work characteristics were not found to be statistically significant predictors in the model. A similar model was built with future implementation of scope of practice as the criterion variable. This model was also found to be statistically significant, F(17,120) = 11.0, p ≤ .01, explaining 56% of the shared variance, with the variables of self-efficacy and actualization of professional autonomy statistically significant predictors. Increased levels of self-efficacy and actualization predicted higher levels of future implementation. Demographic and work characteristics were not found to be statistically significant predictors in the model.

Discussion

The nurses in this study demonstrated a wide range of implementation of the extent of their scope of practice. However, the overall mean was low to moderate, where those in the adult ICUs had a moderate-high level, pediatric ICU and oncology a moderate level, and emergency and labor and delivery a low level of implementation of the full extent of the scope of practice. It was also found that nurses had positive attitudes towards increased scope of practice expansion. Participants demonstrated a high level of self-efficacy, indicating a high ability and readiness to take on expanded practices. In addition, the participants had high levels of professional autonomy that were positively associated with attitudes towards scope of practice expansion. These results point to the readiness of nurses to expand their scope of practice.
Two primary reasons were given as to why nurses do not implement the full extent of their scope of practice. The first was lack of relevance of many of the practices to the work environment. For example, nurses working in labor and delivery or oncology have little or no reason to remove an arterial line, while almost all nurses take blood for type and cross-match. Similar results were reported by Kilpatrick et al. (2012), who found a low level of implementation among nurse practitioners for those practices that were uncommon (e.g., using defibrillators).
The second reason was the lack of permission to perform the practice by supervisors or institutional policy, where approximately one quarter of the sample described this as the reason they did not practice to the full extent of their authority. Few nurses cited lack of knowledge or time.
Nurses in this study had very positive attitudes towards expanded scope of practice, as was found in other studies (Brodsky & Van Dijk, 2008; Goldberg et al., 2012). Participants also had high levels of professional autonomy, irrespective of the type of certification. These results are also similar to findings in other studies (Cajulis & Fitzpatrick, 2007). Nurses showed high levels of self-efficacy, again without differences between types of certification. This demonstrated an across-the-board readiness and support of nurses in the field for the expansion of their scope of practice. According to Bandura (1982), this is related to a successful completion of these practices. For example, nurses in this study expressed a willingness and readiness to have prescriptive authority or referral of patients to laboratory tests, roles associated with advanced practice.
No statistically significant associations were found with current levels of implementation. These consistent results imply that predominantly external forces as opposed to internal forces seem to be related to a lack of implementation of the full extent of the scope of practice. Others have found a significant relationship between professional autonomy and implementation of scope of practice (Kilpatrick et al., 2012). One possible explanation is the differences in the healthcare systems, culture, and policies of the two countries where the research was conducted. Others have also found that as levels of professional autonomy increase, there are more positive attitudes towards expansion of scope of practice (Goldberg et al., 2012).
Two variables were found to predict the extent of implementation of the scope of practice: role and type of certification. Like Brodsky and Van Dijk (2008), those in administrative positions were more likely to have implemented their scope of practice. Such nurses are also more likely to have a higher level of commitment, levels of self-confidence, knowledge, and training. ICU nurses were also found to have higher levels of implementation. This result is consistent with the findings listed earlier that described an increased relevance of expanded practices to those who work in critical care as opposed to maternity or oncology.
Two other variables were found to positively predict future implementation: self-efficacy and actualization (a subscale of professional autonomy). While no study was found that can be related to these findings, they are consistent with Bandura's self-efficacy theory, where the higher the level of personal feelings of authority and responsibility, the higher the feeling that one is able to perform the practice and wants to perform it in the future.
It is recommended that further studies be conducted in other countries on registered nurses with different forms of education. Other factors and barriers to current and future implementation of full scope of practice such as peer and interprofessional relationships should also be investigated.
The results of this study demonstrate that nurses with post-basic certification feel willing and able to expand their scope of practice to areas associated with advanced practice. Therefore, policymakers should take advantage of this fact and promote the introduction of advanced practice in these clinical areas. Administrators and policymakers should also investigate what are the specific factors associated with administrative barriers to expanding nursing scope of practice as well as matching the expanded practices with the specific work environment.

Limitations

This study contains several limitations. First, it was conducted in only one country and in two institutions. Second, most of the questionnaires used in the study were designed by the authors. Almost all of the reliability and validity scores were within acceptable levels, except for the current level of implementation of scope of practice among labor and delivery nurses. It is possible that this score has a lower internal consistency because of the great variation in current practices across units or because most nurses did not implement most of the practices. In addition, one of the questionnaires was translated into Hebrew. While the translation was validated, there might be cultural and language differences between the two versions of the questionnaire. The response rate was 70%, which also might have led to a bias in the results. Results of this study were based on self-report, and there were no “objective” means of data collection to determine whether nurses practiced to the full extent of their scope of practice. It is also possible that other factors and barriers could be associated with implementation, such as interprofessional relationships, the work environment, or other personal characteristics, that were not investigated. Several comparisons between clinical areas were found to be statistically significant. However, it should be noted that some of the areas contained a small number of nurses, and so conclusions based on the data should be taken with caution.

Conclusions

Nurses wanted to practice to the full extent of their scope of practice and felt able to do so but were hindered by administrative barriers. Therefore, it is recommended that efforts continue to expand the scope of practice for registered nurses, that factors associated with administrative barriers be investigated and eliminated, and that further research be conducted with other nurses and in other countries to determine what factors are associated with the implementation of the full scope of practice.

Clinical Resources

• •American Nurses Association. Scope of practice: http://www.nursingworld.org/EspeciallyForYou/AdvancedPracticeNurses/Scope-of-Practice-2
• •Nursing Council of New Zealand. Scopes of practice: http://www.nursingcouncil.org.nz/Nurses/Scopes-of-practice
• •Nursing and Midwifery Board of Australia. Fact sheet: Contest of practice for registered nurses and midwives: http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/FAQ/Context-of-practice-for-registered-nurses-and-midwives.aspx