The exploration of the lived experience of nurse facilitators

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CHAPTER 3DESCRIPTION OF THE DIVERSION PROGRAM AND LITERATURE REVIEW

INTRODUCTION

Chapter 2 discussed the research purpose and objectives, research design, research methodology, and measures of trustworthiness. A phenomenological qualitative research design that was explorative, descriptive, and contextual was developed in order to explore the lived experiences of nurse facilitators of support groups for nurses with chemical dependency in California, USA. Chapter 3 provides an in-depth examination of the regulatory power of the California Board of Registered Nursing, a history and description of the California Diversion Program, to include identification of the requirements for admission, expectations for successful completion of the program, support groups, and procedural requirements for nurse facilitators of support groups. Also, included in this chapter is the literature review for purposes of imparting the findings in other studies that are similar to this study, and to connect the present study to an ongoing dialogue with a larger audience. Another purpose for the literature review is to provide a framework from which the importance of the study will be established (Creswell 2009:25).

CALIFORNIA BOARD OF REGISTERED NURSING

The California Board of Registered Nursing (BRN) is a professional regulatory Board within the California Department of Consumer Affairs. Its primary responsibility is to protect the health and wellbeing of the public; however, it also oversees the licensing and regulation of registered nurses. The BRN‟s responsibilities are outlined in the Nursing Practice Act (California Board of Registered Nursing 2009c) which provides the BRN the authority to administer a Diversion Program (California Board of Registered Nursing 2009a).A major portion of the California BRN‟s mandate to protect the public involves the monitoring and supervision of the professional conduct of registered nurses. The BRN intercedes and controls all arbitration and outcomes when nurses falter in their responsibility to deliver safe care to the public. In cases where chemical dependency is suspected, nurses may be offered the opportunity for rehabilitation through voluntarily entrance into the Diversion Program, where direction and support is given during the recovery process (California Board of Registered Nursing 2009a).

EXECUTIVE OFFICER

The Executive Officer is appointed by the BRN and performs and accomplishes the duties as dictated by the BRN. The executive officer must be a registered nurse, and shall not be a member of the BRN (California Board of Registered Nursing 2009e).

DIVERSION PROGRAM

The Diversion Program was established in California in 1985 as a confidential voluntary rehabilitation program. It is an alternative to judicial enforcement to give nurses a chance to recover from their affliction and return to work. The goal of the Diversion Program is to protect the public by early detection and suspension from nursing practice. The program offers oversight of treatment and recovery services to nurses with chemical dependency. The Diversion Program is comprised of several sub-groups that work together to provide the services required for nurses with chemical dependency. The relationship between the Diversion Program (and its sub-groups) and the BRN is represented in Figure 3.1 (BRN 1999). The figure identifies the lines of communication as envisioned by the BRN. Beginning with the Board of Registered Nursing, the communication flows to the Executive Officer, to the Diversion Program Manager, and finally it moves horizontally through three  areas: the Diversion Evaluation Committee, the Diversion Program Contractor, and the Nurse Support Group. In the organisational chart, which depicts the envisioned ideal flow of communication, the nurse support groups are identified as an equal part of the Diversion Program

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CHAPTER 1 ORIENTATION TO THE RESEARCH PROBLEM
1.1 INTRODUCTION
1.2 BACKGROUND
1.3 BRIEF OVERVIEW OF THE CALIFORNIA DIVERSION PROGRAM 
1.4 STATEMENT OF THE PROBLEM
1.5 RESEARCH QUESTIONS
1.6 PURPOSE OF THE STUDY
1.7 RESEARCH OBJECTIVES
1.8 PARADIGMATIC PERSPECTIVE OF RESEARCH 
1.8.1 Meta-theoretical assumptions
1.8.2 Theoretical assumptions
1.8.3 Methodological assumptions
1.9 OPERATIONAL DEFINITION OF IMPORTANT TERMS 
1.10 RESEARCH OVERVIEW 
1.10.1 Pilot study
1.10.2 PHASE 1: The exploration of the lived experience of nurse facilitators
1.10.2.1 Recruitment and sample population
1.10.2.2 The interview process
1.10.2.3 Data analysis
1.10.2.4 Ethical considerations
1.10.3 PHASE 2: The formulation and description of supportive guidelines for nurse facilitators
1.11 DEFINITION OF A CONCEPTUAL FRAMEWORK
1.12 CONCLUSION
CHAPTER 2 RESEARCH DESIGN AND METHODS
2.1 INTRODUCTION 
2.2 RESEARCH PURPOSE AND OBJECTIVES 
2.3 RESEARCH DESIGN
2.3.1 Qualitative
2.3.2 Phenomenological
2.3.3 Descriptive
2.3.3.1 Bracketing
2.3.3.2 Intuition
2.3.4 Exploratory
2.3.5 Contextual
2.4 RESEARCH METHODS
2.4.1 Sample population and sampling techniques
2.4.2 Recruitment
2.4.3 Data collection
2.4.3.1 Field notes
2.4.4 Data analysis
2.4.5 Phenomenological concepts used in data collection and analysis
2.4.5.1 Merging together of various data collection strategies that were flexible and capable of adjustment during the gathering of information
2.4.5.2 Holistic understanding of the data
2.4.5.3 Researcher is intensely involved and becomes the research instrument
2.4.5.4 Ongoing interpretation of the data is required
2.4.5.5 Van Manen‟s concepts of four life themes
2.5 ETHICAL CONSIDERATIONS 
2.6 MEASURES OF TRUSTWORTHINESS
2.6.1 Credibility
2.6.2 Transferability
2.6.3 Dependability
2.6.4 Confirmability
2.6.5 Operational techniques:
2.6.5.1 Prolonged engagement and persistent observation
2.6.5.2 Triangulation
2.6.5.3 Member checking
2.6.5.4 Reflexivity
2.7 CONCLUSION
CHAPTER 3 DESCRIPTION OF THE DIVERSION PROGRAM AND LITERATURE REVIEW
3.1 INTRODUCTION 
3.2 CALIFORNIA BOARD OF REGISTERED NURSING
3.3 EXECUTIVE OFFICER
3.4 DIVERSION PROGRAM 
3.4.1 Entry into Diversion Program
3.4.2 Warning signs of chemical dependency
3.4.3 Eligibility
3.4.3.1 Cost
3.4.4 Recovery service
3.4.5 Contract terms
3.4.6 Typical contract when entering the Diversion Program
3.4.7 Typical progression through the Diversion Program
3.5 DIVERSION EVALUATION COMMITTEE
3.5.1 Responsibilities of a DEC
3.6 DIVERSION PROGRAM CONTRACTOR 
3.7 NURSE SUPPORT GROUPS
3.7.1 Support group facilitators
3.7.1.1 Criteria for approval as a facilitator
3.7.1.2 Procedural requirements
3.7.1.3 Role of facilitators
3.8 LITERATURE REVIEW
3.8.1 What is the role of nurse facilitators of nurse support groups?
3.8.1.1 Group facilitator
3.8.1.2 Nurse support group facilitator
3.8.2 Are nurse support groups essential to the success of a diversion program for nurses with chemical dependency?
3.8.2.1 Support groups
3.8.2.2 Nurse support groups
3.8.3 Are nurses with chemical dependency a danger to the safety of the public?
3.8.3.1 Chemical dependency and nurses
3.8.3.2 Diversion programs
3.8.3.2.1 Alcoholics Anonymous Twelve-Step Model
3.9 CONCLUSION
CHAPTER 4 FINDINGS AND DISCUSSION
4.1 INTRODUCTION 
4.2 DESCRIPTION OF SAMPLE
4.3 THEME 1: EXPERIENCE OF COMMUNICATION WITHIN THE DIVERSION PROGRAM
4.3.1 Nurse facilitators experience poor communication within the Diversion Program
4.3.1.1 Poor communication between nurse facilitator and the Diversion Program manager
4.3.2 Poor communication between nurse facilitator and the Diversion Program contractor
4.3.3 Little communication between the nurse facilitators and the Diversion Evaluation Committees (DEC)
4.3.4 Poor communication among nurse facilitators
4.3.4.1 Large geographical distances between them
4.3.4.2 Lack of continuity among the nurse facilitators
4.3.4.3 No networking system
4.3.4.4 Lack of guidance
4.4 THEME 2: EXPERIENCE OF THE STRUCTURE OF THE DIVERSION PROGRAM
4.4.1 Nurse facilitators‟ experience frustration with the structure of the Diversion Program
4.4.1.1 Lack of structure in the Diversion Program
4.4.1.2 Lack of consistency in the Diversion Program
4.4.1.3 Poor supervision
4.5 THEME 3: EXPERIENCE OF THEIR ROLE WITHIN THE DIVERSION PROGAM
4.5.1 Nurse facilitators experience feeling marginalised by the Diversion Program
4.5.1.1 Marginalisation of the nurse facilitators by the Diversion Program due to poor communication
4.5.1.2 Lack of orientation for new facilitators
4.5.1.3 Lack of mentoring for new nurse facilitators
4.6 THEME 4: EXPERIENCE OF FACILITATION OF SUPPORT GROUPS IN THE DIVERSION PROGRAM
4.6.1 Nurse facilitators experience a lack of acknowledgement by the Diversion Program
4.6.1.1 Unclear guidelines for facilitating support groups
4.6.2 Nurse facilitators‟ experience of support groups
4.6.2.1 A place to build support networks
4.6.2.2 Group dynamics assist in the recovery process by nurses trusting and sharing
4.6.2.2.1 Confidentiality is mandated as part of the recovery process
4.6.2.2.2 Accountability is mandated as part of the recovery process
4.6.3 Nurse facilitators experience various roles as facilitators of support groups
4.6.3.1 Communicator
4.6.3.2 Informed resource person
4.6.3.3 Educator
4.6.3.3.1 Chemical dependency disease process
4.6.3.4 Role model
4.6.3.5 Mentor
4.6.3.6 Facilitator
4.6.3.7 Change agent
4.6.3.7.1 Knowledgeable
4.6.3.7.2 Instils hope
4.6.3.7.3 Provides feedback
4.7 THE STRUCTURE OF THE DIVERSION PROGRAM AS
EXPERIENCED BY THE NURSE FACILITATORS
4.8 CONCLUSION
CHAPTER 5 GUIDELINES AND CONCEPTUAL FRAMEWORK
5.1 INTRODUCTION 
5.2 RATIONALE FOR GUIDELINES
5.3 SUPPORTIVE THEORY
5.3.1 Survey list
5.4 CONCEPTUAL FRAMEWORK 
5.5 PHASE 2: FORMULATION AND DESCRIPTION OF SUPPORTIVE GUIDELINES FOR NURSE FACILITATORS OF SUPPORT GROUPS FOR NURSES WITH CHEMICAL DEPENDENCY
5.5.1 Promote support for nurse facilitators by increasing communication within the Diversion Program
5.5.2 Facilitate support for nurse facilitators by encouraging critical action within the Diversion Program
5.5.3 Enhance support by empowering the role of nurse facilitator within the Diversion Program
5.5.4 Promote support for nurse facilitators by acknowledgement from the Diversion Program that facilitation of support groups by nurse facilitators is essential for support of nurses with chemical dependency
5.6 REVIEW OF THE DIVERSION PROGRAM APPLYING THE NEUMAN SYSTEMS MODEL
5.6.1 Input, process, and outcome
5.1 PROPOSED ORGANISATIONAL CHART FOR THE CALIFORNIA DIVERSION PROGRAM 
5.2 CONCLUSION
CHAPTER 6 CONCLUSIONS
6.1 SUMMARY 
6.2 LIMITATIONS OF THE STUDY
6.3 RECOMMENDATIONS 
6.3.1 Nursing practice
6.3.2 Diversion Program
6.3.3 Nurse facilitators
6.3.3.1 How can nurse facilitators assist in increasing communication within the Diversion Program?
6.3.3.2 How can nurse facilitators assist with making changes within the structure of the Diversion Program?
6.3.3.3 How can nurse facilitators empower their role?
6.3.3.4 How can nurse facilitators gain acknowledgement of their role as essential for support of nurses with chemical dependency?
6.4 PROPOSED ORGANISATIONAL CHART FOR THE CALIFORNIA DIVERSION PROGRAM 
6.5 FURTHER RESEARCH
6.6 CONCLUSION
BIBLIOGRAPHY
ANNEXURE A: SAMPLE INTERVIEW
ANNEXURE B: ETHICS APPROVAL FORM FROM UNISA
ANNEXURE C: CONSENT FORM FOR PARTICIPATION IN RESEARCH
ANNEXURE D: APROVAL FROM DIVERSION PROGRAM FOR RESEARCH

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