title: How clinical nurse and midwifery consultants optimise patient care in a tertiary referral hospital.
abstract: OBJECTIVE
  To develop new insights into the phenomenon of clinical nurse/midwifery consultant clinical effectiveness in a tertiary referral hospital.
  
  
  BACKGROUND
  International studies identify the pivotal role clinical nurse/midwifery consultants play in patient outcomes. There remains, however, a significant deficit in our knowledge of how these, or other advanced practice nurses and midwives, apply their extensive experience, ontological understandings and tacit knowledge to the enhancement of patient outcomes in complex healthcare environments.
  
  
  METHODS
  This study was underpinned by the principles of Heideggerian hermeneutic phenomenology.
  
  
  METHODS
  Recruitment involved expressions of interest distributed hospital-wide to clinical nurse/midwifery consultants. Inclusion criteria specified a minimum of three years' experience. Fifteen clinical nurse/midwifery consultants, representing a broad range of specialties, were interviewed. Preliminary descriptive analysis of transcribed data was followed by in-depth hermeneutic analysis.
  
  
  RESULTS
  The findings comprise four themes: walking beside the patient, anticipating the unexpected, pushing through barriers and leading within a complex system. These themes highlight how clinical nurse/midwifery consultants significantly influence pre-existing trajectories of patient care delivery through context-appropriate strategies.
  
  
  CONCLUSIONS
  This study introduces new insights into the meanings advanced practice nurses and midwives develop from their engagements with patients and how these meanings inform clinical decisions. The paper accomplishes this by drawing on Heideggerian philosophical concepts such as ontological understandings, authenticity and care. It also casts light on the participants' shared understandings of how to synergise expectations within the team.
  
  
  CONCLUSIONS
  The significance of this paper lies in the uncovering of ontological understandings and tacit knowledge of how consultant nurses and midwives optimise patient care delivery in challenging situations. The findings indicate, however, that the value of these internationally established roles is yet to be fully realised. The paper concludes by recommending strategies to assist newly appointed clinical nurse/midwifery consultants transition into these demanding autonomous roles.
authors.affiliation: Diabetes & Endocrinology Ambulatory Care Centre, Westmead Hospital, Wentworthville, NSW, Australia.
authors.forename: Christine
authors.initials: C
authors.lastname: Atsalos
authors.forename: Karen
authors.initials: K
authors.lastname: Biggs
authors.forename: Sabine
authors.initials: S
authors.lastname: Boensch
authors.forename: Fiona Lee
authors.initials: FL
authors.lastname: Gavegan
authors.forename: Susan
authors.initials: S
authors.lastname: Heath
authors.forename: Marlene
authors.initials: M
authors.lastname: Payk
authors.forename: Grace
authors.initials: G
authors.lastname: Trapolini
mesh_terms: D000328:Adult; D001315:Australia; D003253:Consultants; D003266:Continuity of Patient Care; D003430:Cross-Sectional Studies; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008880:Midwifery; D009722:Nurse Practitioners; D009723:Nurse-Patient Relations; D057184:Practice Patterns, Nurses'; D011247:Pregnancy; D015397:Program Evaluation; D062606:Tertiary Care Centers
keywords: advanced practice; clinical effectiveness; clinical nurse/midwifery consultant; continuity of care; hermeneutics; leadership; nurse-patient relationship; patient-centred approach; phenomenology; tacit knowledge