Decision aids for female BRCA mutation carriers: a scoping review.

OBJECTIVES: Women who inherit a pathogenic BRCA1 or BRCA2 mutation are at substantially higher risk of developing breast and ovarian cancer than average. Several cancer risk management strategies exist to address this increased risk. Decisions about which strategies to choose are complex, personal and multifactorial for these women. Decision aids (DAs) are tools that assist patients in making health-related decisions. The aim of this scoping review was to map evidence relating to the development and testing of patient DAs for cancer unaffected BRCA mutation carriers. DESIGN: Scoping review conducted according to the Joanna Briggs Institute's (JBI's) scoping review methodological framework. DATA SOURCES: MEDLINE, EMBASE, CINAHL, Web of Science. No restrictions applied for language or publication date. A manual search was also performed. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies on DAs for cancer risk management designed for or applicable to women with a pathogenic BRCA1 or BRCA2 mutation who are unaffected by breast or ovarian cancer. DATA EXTRACTION AND SYNTHESIS: Data were extracted using a form based on the JBI instrument for extracting details of studies' characteristics and results. Data extraction was performed independently by two reviewers. Extracted data were tabulated. RESULTS: 32 evidence sources relating to development or testing of 21 DAs were included. Four DAs were developed exclusively for cancer unaffected BRCA mutation carriers. Of these, two covered all guideline recommended risk management strategies for this population though only one of these was readily available publicly in its full version. All studies investigating DA effectiveness reported a positive effect of the DA under investigation on at least one of the outcomes evaluated, however only six DAs were tested in randomised controlled trials. CONCLUSION: This scoping review has mapped the landscape of the literature relating to developing and testing, DAs applicable to cancer unaffected BRCA mutation carriers.

Multidisciplinary user experience of a newly implemented electronic patient record in Ireland: An exploratory qualitative study.

BACKGROUND: Implementation of an Electronic Patient Record (EPR) in a key milestone in the digital strategy of modern healthcare organisations. The implementation of EPR systems can be viewed as challenging and complex. OBJECTIVE: The aim of the study was to investigate user perspectives and experiences of the implementation of an Electronic Medical Record in a major academic teaching hospital, with simultaneous 'go-live' across the whole hospital taking place. METHODS: Focus groups and individual in-depth interviews were conducted with stakeholders and users (n = 105), approximately nine months post-EPR implementation. The study explored EPR users' perceptions using an extended theoretical framework of the DeLone and McLean Information Systems Success Model (2003), which measured information systems, system quality, information quality, service quality, use/perceived usefulness & user satisfaction and net benefits. RESULTS: Staff engagement and satisfaction was high and the EPR is accepted as the new standard way of completing care. There was agreement that the EPR affords transparency, and greater accountability. There was some concern expressed regarding impact of the EPR on interprofessional and patient/provider interactions and communication. Physicians reported the inputting of social history through free text as an issue of concern and time consuming. The Big Bang approach with mandatory conversion was key to the successful adoption of EPR. There was consensus across professional and administrative respondents that there was no appetite to return to paper-based records. CONCLUSION: The successful roll out of the EPR reflects the digital readiness of healthcare providers and organisations. The potential for unintended consequences on work process requires continual monitoring. A key future benefit of the EPR will be the capacity to reach a broader understanding and analysis of variation in processes and outcomes within healthcare organisations. It is clear that skills in data analytics will be needed to mine data successfully.

Youths with asthma and their experiences of self-management education: A systematic review of qualitative evidence.

AIMS: To identify and synthesize the available evidence of youths with asthma and their experience of self-management education. DESIGN: Systematic literature review of qualitative studies with meta-synthesis of findings. DATA SOURCES: We searched five databases, CINAHL Complete, Embase, MEDLINE (EBSCO) PsycINFO, ASSIA and the Global Index Medicus (formerly the WHOLIS). Initial search in September 2019 and updated in July 2020 and July 2022. REVIEW METHODS: The systematic review was conducted in accordance with the JBI methodology for systematic reviews of qualitative evidence. Qualitative data were extracted, meta-summarized and then meta-synthesized. RESULTS: Eighteen studies were identified for inclusion in this review and three themes were identified: The theory and practice gap, contemporary health-seeking preferences and the psychosocial impacts of living with asthma. CONCLUSION: The needs of youths with asthma are specific and must be measurable against the change in asthma outcomes for this group. They have unmet self-management educational needs that stakeholders, involved in their care and support, should address. Education and practice policy should focus on youth-centric approaches. Through meaningful engagement with youths, stakeholders can identify their support needs, requirements and preferences to successfully underpin the theory and practice of self-management education. IMPACT: This review synthesized evidence of youths with asthma and their experiences of self-management education, highlighting their specific self-management information needs. The findings highlight several implications for healthcare professionals in education, practice and research. This age profile is under-explored and further research into this population would work towards filling the theory and practice gap and highlighting the identified psychosocial issues faced by this group.

"I'm not being serviced; I'm being cared for": A mixed methods study of patients' and nurses' perceptions of community oncology nursing delivered by a Community Intervention Team.

PURPOSE: Many patients do not have access to community oncology nursing care in a primary setting and are completely reliant on tertiary hospital care. The aim of this study is to gain an understanding of oncology patients' and nurses' perceptions of community oncology nursing, delivered by an urban Community Intervention Team (CIT) in Ireland. METHODS: A descriptive, concurrent mixed methods approach was used which included semi-structured interviews with 14 oncology patients and an online survey of 27 hospital and community nurses. Thematic analysis and descriptive statistics were used to analyse the data. RESULTS: Six broad themes captured patients' views. Right care related to patients' satisfaction with the range of care available. Right place reflected positive views of the physical setting and the option for homecare for those that needed it. Right time represented patients' comments about the increased appointment efficiency, flexibility, and availability of the service out-of-hours, compared to hospital-based care. Right people was based on patients' portrayals of community cancer nurses as professional, confident, friendly, reassuring and relatable. Integration and communication reflected the communication between the services and patients' impressions of how the services were integrated together. The last theme was improvements to the CIT service. Hospital nurses reported satisfaction with the CIT service while CIT nurses responses suggest the need for better communication with hospital partners. CONCLUSION: Patients had positive perceptions of the service provided by the CIT. Both hospital and community cancer nurses were satisfied with the service and reported that they would like to see an expansion of community oncology nursing services delivered by the CIT.

Ambulatory outpatient venous surgery service: An examination of patient satisfaction and experiences.

BACKGROUND: This study aimed to ascertain patients' experience of the out-patient venous service being provided,; identify the level of patient satisfaction with the service and identify areas for further improvement and development. METHOD: A prospective descriptive quantitative study. A questionnaire was distributed to all patients who used the service between June 2017 and March 2018. A total of 195 questionnaires was distributed with 162 valid questionnaires returned; response rate of 83%. RESULTS: This study found high satisfaction levels with endovenous ablation procedures, with concomitant phlebectomy, in the ambulatory outpatient setting and patient experiences of the service are overwhelmingly positive. CONCLUSION: Study findings support the management of ambulatory outpatient varicose vein endovenous ablation procedures as a feasible alternative to day surgery theatre settings and is the blueprint for future management of varicose vein surgery in Ireland.

Decision aids for female BRCA mutation carriers: a scoping review protocol.

INTRODUCTION: Women who inherit a pathogenic mutation in Breast Cancer Susceptibility Genes 1 or 2 (BRCA1 or BRCA2) are at substantially higher risk of developing breast and ovarian cancer than the average woman. Several cancer risk management strategies exist to address this increased risk. Decisions about which risk management strategies to choose are complex, personal and multifactorial for these women. This scoping review will map evidence relevant to cancer risk management decision making in BRCA mutation carriers without a personal history of cancer. The objective is to identify and describe the features of patient decision aids that have been developed for BRCA mutation carriers. This information may be beneficial for designing new decision aids or adapting existing decision aids to support decision making in this population. METHODS AND ANALYSIS: This scoping review will be conducted according to the Joanna Briggs Institute's scoping review methodological framework. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist will be used for guidance. Studies on decision aids for women with a BRCA mutation who are unaffected by breast or ovarian cancer will be considered for inclusion. Five electronic databases will be searched (MEDLINE, EMBASE, Cochrane Library, CINAHL, Web of Science) with no restrictions applied for language or publication date. Studies for inclusion will be selected independently by two review authors. Data will be extracted using a predefined data extraction form. Findings will be presented in tabular form. A narrative description of the evidence will complement the tabulated results. ETHICS AND DISSEMINATION: Ethical approval for conducting this scoping review is not required as this study will involve secondary analysis of existing literature. Findings will be published in a peer-reviewed journal and presented at relevant conferences.

Use of mHealth apps by nurses in the management of chronic wounds: a scoping review protocol.

OBJECTIVE: The objective of this scoping review is to explore the existing literature related to nurses' use of mHealth apps in the management of chronic wounds and chart if and how these apps are being evaluated. INTRODUCTION: mHealth technology is increasingly used within health care facilities. There is now a variety of wound care apps available to support nurses delivering wound care. These promise many benefits, but little is known about their use. INCLUSION CRITERIA: Studies involving nurses of all grades, in all clinical settings using mHealth apps in the care and management of chronic wounds will be included. Criteria used to evaluate these apps will also be considered. The context will be all primary care, hospital, and community settings, which includes general practice, nurse-led clinics, public health services, nursing and care homes, and all hospital settings. There will be no limit on the geographical setting of the research. All studies and reports that focus on qualitative, quantitative, and mixed methods will be included, as will text and opinion papers and published gray literature. METHODS: An initial search of MEDLINE, CINAHL, and Embase will be undertaken to identify index terms. This will be followed by an analysis of the text words contained in the title. A search of commercial app stores (eg, Apple's App Store and Google's Play Store) will not be carried out. A data extraction form will be used and piloted on the first 10 articles. Results will be reported in tabular form and presented in a PRISMA flow diagram.

Who is failing who? A survey exploration of the barriers & enablers to accurate decision making when nursing students' competence is below required standards.

Healthcare practice supports the achievement of programme learning outcomes for nursing students internationally. Within this context the issue of reluctance to fail nursing students, when warranted, is extensively examined within the literature with few definitive solutions emerging. Little is known about the perceived barriers that exacerbate this reluctance, or about factors that might enable and support nurses to fail students. To address this issue our study employed a non-experimental cohort study of nurses (n = 365) from two large teaching hospitals in the Republic of Ireland (ROI). Preceptors in this study clearly enjoyed their role with students, and received positive feedback from students. However, findings suggest that preceptors require more support from colleagues in providing comprehensive evidence in assessment. They also require additional training for providing negative feedback to students. A collaborative approach to competence assessment is recommended, whereby the professional burden can be borne by the team, and where students can engage in a holistic, reflective, learning experience that will ultimately improve their competence.

Dying in acute hospitals: voices of bereaved relatives.

BACKGROUND: Internationally there is an increasing concern about the quality of end-of-life care (EoLC) provided in acute hospitals. More people are cared for at end of life and die in acute hospitals than in any other healthcare setting. This paper reports the views of bereaved relatives on the experience of care they and the person that died received during their last admission in two university adult acute tertiary hospitals. METHODS: Relatives of patients who died were invited to participate in a post-bereavement postal survey. An adapted version of VOICES (Views of Informal Carers - Evaluation of Services) questionnaire was used. VOICES MaJam has 36 closed questions and four open-ended questions. Data were gathered in three waves and analysed using SPSS and NVivo. 356 respondents completed the survey (46% response rate). RESULTS: The majority of respondents (87%: n = 303) rated the quality of care as outstanding, excellent or good during the last admission to hospital. The quality of care by nurses, doctors and other staff was highly rated. Overall, care needs were well met; however, findings identified areas of care which could be improved, including communication and the provision of emotional and spiritual support. In addition, relatives strongly endorsed the provision of EoLC in single occupancy rooms, the availability of family rooms on acute hospital wards and the provision of bereavement support. CONCLUSIONS: This research provides a powerful snapshot in time into what works well and what could be improved in EoLC in acute hospitals. Findings are reported under several themes, including the overall quality of care, meeting care needs, communication, the hospital environment and support for relatives. Results indicate that improvements can be made that build on existing good practice that will enhance the experience of care for dying persons and their relatives. The study adds insights in relation to relative's priorities for EoLC in acute hospitals and can advance care providers', policy makers' and educationalists' priorities for service improvement.

Experiences and perceptions of emergency department nurses regarding people who present with mental health issues: a systematic review protocol.

OBJECTIVE: The objective of this review is to identify, appraise and synthesize available evidence related to the experiences and perceptions of emergency department (ED) nurses regarding people with any mental health issue who present at the ED. INTRODUCTION: The ED is often the first point of contact for patients with a mental health issue, due to a shortage of available mental health services. Nursing staff in the ED are involved in key clinical decision making and hands-on care for these patients, despite a lack of mental health specialist training. In order to improve patient outcomes in the ED setting, it is necessary to have a thorough understanding of how ED nurses' experiences with this population affect their clinical decision making. INCLUSION CRITERIA: This review will consider studies that include ED nurses, with or without mental health specialist training, working in urban and rural EDs in healthcare settings worldwide. Qualitative studies that explore the experiences and perceptions of ED nurses regarding people who present with mental health issues in the ED setting will be considered. Studies published in English will be considered, with no date limitations. METHODS: CINAHL complete, MEDLINE, PsycINFO, Embase, Scopus, Web of Science and Google Scholar will be searched, along with several sources of gray literature. Retrieval of full-text studies, assessment of methodological quality and data extraction will be performed independently by two reviewers. Findings will be pooled using meta-aggregation, and a ConQual Summary of Findings will be presented.

Youths with asthma and their experiences of self-management education: a qualitative systematic review protocol.

REVIEW QUESTION: What are the experiences of youths with asthma in self-management education?

A hospital recreation room quality improvement intervention.

PURPOSE: Patients with extended hospital admissions had no recreation facilities in the ward. They were often confined to spaces around their beds, using the ward corridor for rehabilitation. The purpose of this paper is to outline a quality improvement (QI) intervention-provision of a recreational space for long-stay patients. DESIGN/METHODOLOGY/APPROACH: An exploratory quantitative pre-, post-test design was utilised, and executed in three phases: patients, visitors and staff survey to explore recreation and comfort needs and preferences; store room refurbishment; and patient, visitor and staff satisfaction with the recreation room. FINDINGS: Overall, 77 questionnaires were completed (n=49 staff; n=28 patient/visitor). Almost two-thirds (64.7 per cent; n=11) of patients had a stay greater than six weeks. Insufficient private space and concerns about disturbing other patients were identified as barriers to taking part in activities. Consequently, a store room was refurbished as a recreation room (9.0 m × 6.0 m) and furnished in three distinct areas. Following refurbishment, over 90 per cent (n=24) of respondents agreed that there was a suitable space where patients could "go and chat" and spend time with family and visitors or speak to the healthcare team. PRACTICAL IMPLICATIONS: The physical environment in acute hospitals is seldom prioritised. Needs-based QI projects can improve patient hospital experiences. ORIGINALITY/VALUE: This case study highlights how nursing staff can be informed by patients' and families' needs and preferences, and initiate QI projects that improve patient hospital experiences.

Voices that matter: end-of-life care in two acute hospitals from the perspective of bereaved relatives.

BACKGROUND: End-of-life care (EoLC) is an experience that touches the lives of everyone. Dying in an acute hospital is a common occurrence in developed countries across the world. Previous studies have shown that there is wide variation in EoLC and at times is experienced as being of poor quality. Assessing and measuring the quality of care provided is a key component of all healthcare systems. This paper reports on the qualitative analysis of open-ended free text questions that were asked as part of a post-bereavement survey conducted in two adult acute hospitals in Ireland. METHODS: This was a quantitative descriptive post-bereavement postal survey, gathering data retrospectively from relatives or friends of patients who died, utilising an adapted version of the VOICES (Views of Informal Carers - Evaluation of Services) questionnaire. VOICES MaJam has 29 core questions, seven questions requesting personal demographic information and four open-ended questions gathering descriptive data about the care experience during the patient's last admission to hospital. A total of 356 valid questionnaires were returned. Qualitative data were managed, coded and analysed with NVivo 10, using a template analysis framework approach. RESULTS: Three quarters (75%: n = 268) responded to at least one of the open-ended questions. Several key themes emerged, indicating areas that require particular attention in EoLC. Two themes relate to how care needs are met and how the hospital environment has a critical influence on EoLC experiences. The remaining three themes relate more to the interpersonal context including whether patients are treated with dignity and respect, the psychological, emotional and spiritual needs of patients and their family members and communication. CONCLUSIONS: Acute hospitals need to ensure that patients and their relatives receive high quality EoLC. Seeking the views of bereaved relatives should be considered by all hospitals and healthcare settings to ascertain the quality of care at end of life. This study contributes to our understanding and knowledge of what good EoLC looks like and where care can be improved, thus enabling hospitals to direct and inform quality improvement.

The patients' perspective of international normalized ratio self-testing, remote communication of test results and confidence to move to self-management.

AIMS AND OBJECTIVES: To elicit the perceptions of patients, who self-tested their international normalized ratio and communicated their results via a text or phone messaging system, to determine their satisfaction with the education and support that they received and to establish their confidence to move to self-management. BACKGROUND: Self-testing of international normalized ratio has been shown to be reliable and is fast becoming common practice. As innovations are introduced to point of care testing, more research is needed to elicit patients' perceptions of the self-testing process. DESIGN: This three site study used a cross-sectional prospective descriptive survey. METHODS: Three hundred and thirty patients who were prescribed warfarin and using international normalized ratio self-testing were invited to take part in the study. The anonymous survey examined patient profile, patients' usage, issues, perceptions, confidence and satisfaction with using the self-testing system and their preparedness for self-management of warfarin dosage. RESULTS: The response rate was 57% (n = 178). Patients' confidence in self-testing was high (90%). Patients expressed a high level of satisfaction with the support received, but expressed the need for more information on support groups, side effects of warfarin, dietary information and how to dispose of needles. When asked if they felt confident to adjust their own warfarin levels 73% agreed. Chi-squared tests for independence revealed that none of the patient profile factors examined influenced this confidence. The patients cited the greatest advantages of the service were reduced burden, more autonomy, convenience and ease of use. The main disadvantages cited were cost and communication issues. CONCLUSION: Patients were satisfied with self-testing. The majority felt they were ready to move to self-management. RELEVANCE TO CLINICAL PRACTICE: The introduction of innovations to remote point of care testing, such as warfarin self-testing, needs to have support at least equal to that provided in a hospital setting.

Facilitators and barriers in expanding scope of practice: findings from a national survey of Irish nurses and midwives.

AIMS AND OBJECTIVES: The aim was to examine current scope of practice among nurses and midwives in Ireland. The objectives were to describe practitioners' self-reported facilitators and barriers to expanding scope of practice and to develop a scope of practice barriers scale. BACKGROUND: Regulatory authorities permit practice expansion, so long as it falls within accepted parameters of scope of practice. Enduring difficulties in relation to scope of practice include the difficulty of balancing practice restriction with practice expansion. DESIGN: A postal survey design was used to examine registered nurses' and midwives' current scope of practice, including their experiences of facilitators and barriers to expanding practice. METHODS: A stratified random sample of registered nurses and midwives in Ireland was surveyed using the Scope-QB, a 19-item self-report scope of practice barriers scale. RESULTS: Based on a sample of 1010 respondents, the self-reported perceived barriers to practice expansion included fear of legal consequences, time restrictions and lack of remuneration. Professional satisfaction, patients' needs, organisational support and having access to continuing professional education were perceived as facilitators of practice expansion. Older nurses and midwives as well as nurses and midwives holding more senior promotional grades, such as clinical nurse manager grades, perceived fewer barriers than their younger and more junior counterparts. CONCLUSIONS: Nurses and midwives continue to experience difficulties in relation to expanding their practice. Practitioners can operate to optimal scope of practice when practitioner-centred and workplace-based circumstances are optimal. The optimal circumstances for practice expansion exist when the facilitators of practice expansion outweigh the barriers. RELEVANCE TO CLINICAL PRACTICE: Given the critical role that nurses and midwives play in modern health services, it is important that they are empowered and enabled to expand their practice and to work to full scope of practice when patient needs and service requirements warrant it.

Scope of practice decision making: findings from a national survey of Irish nurses and midwives.

AIMS AND OBJECTIVES: The aim was to examine and describe aspects of the current scope of practice among nurses and midwives in Ireland. The objective was to describe practitioners' decision making associated with the scope of practice. BACKGROUND: Regulatory frameworks on the scope of practice describe the roles and activities an individual registrant is permitted to undertake in the course of professional practice. Research into the scope of practice has examined practitioners' perspectives on particular frameworks or their experiences of practice expansion, and suggests that frameworks are helpful in guiding practitioners; however, local circumstances and practitioner competence often determine scope of practice. DESIGN: A national postal survey of registered nurses and midwives was conducted to elicit self-reports of current scope of practice. METHODS: A stratified random sample of 2354 registered nurses and midwives in Ireland were surveyed using the Scope-Q, a 64-item self-report questionnaire. RESULTS: While over half of the respondents consulted others when making scope of practice decisions, the majority relied on their own professional judgement, acted only when they believed that they were competent to act, and recognised the limitations of their own competence. Although a small number of statistically significant associations were observed between respondents' age and self-reported scope of practice, respondents' current scope of practice was independent of either grade or gender. CONCLUSIONS: When making a decision about scope of practice, practitioners may consult other resources, including published frameworks, professional colleagues and line managers; however, most particularly, older, more experienced practitioners, rely on their own professional judgement when making scope of practice decisions. RELEVANCE TO CLINICAL PRACTICE: While published scope of practice frameworks guide practitioners on how they may act in circumstances of uncertainty, regulatory authorities should continue to emphasise individual accountability and self-reliance in everyday decision making, so that practitioners' actions are grounded in local circumstances and self-assessed practitioner competence.

'Am I covered?': an analysis of a national enquiry database on scope of practice.

AIM: Analysis of a national database of enquiries to a professional body pertaining to the scope of nursing and midwifery practice. BACKGROUND: Against a backdrop of healthcare reform is a demand for flexibility in nursing and midwifery roles with unprecedented redefinition of role boundaries and/or expansion. Guidance from professional regulatory bodies is being sought around issues of concern that are arising in practice. DESIGN: Qualitative thematic analysis. METHOD: The database of telephone enquiries (n = 9818) made by Registered Nurses and midwives to a national regulatory body (2001-2013) was subjected to a cleaning process and examined to detect those concerns that pertained to scope of practice. A total of 978 enquiries were subjected to thematic analysis. FINDINGS: Enquiries were concerned with three main areas: medication management, changing and evolving scope of practice and professional role boundaries. The context was service developments, staff shortages and uncertainty about role expansion and professional accountability. Other concerns related to expectations around responsibility and accountability for other support staff. CONCLUSION: Efforts by employers to maximize the skill mix of their staff and optimally deploy staff to meet service needs and/or address gaps in service represented the primary service context from which many enquiries arose. The greatest concern for nurses arises around medication management but innovation in healthcare delivery and the demands of service are also creating challenges for nurses and midwives. Maintaining and developing competence is a concern among nurses and midwives particularly in an environment of limited resources and where re-deployment is common.

Comparative analysis of nursing and midwifery regulatory and professional bodies' scope of practice and associated decision-making frameworks: a discussion paper.

AIMS: To review, discuss and compare nursing and midwifery regulatory and professional bodies' scope of practice and associated decision-making frameworks. BACKGROUND: Scope of practice in professional nursing and midwifery is an evolving process which needs to be responsive to clinical, service, societal, demographic and fiscal changes. Codes and frameworks offer a system of rules and principles by which the nursing and midwifery professions are expected to regulate members and demonstrate responsibility to society. DESIGN: Discussion paper. DATA SOURCES: Twelve scope of practice and associated decision-making frameworks (January 2000-March 2014). IMPLICATIONS FOR NURSING: Two main approaches to the regulation of the scope of practice and associated decision-making frameworks exist internationally. The first approach is policy and regulation driven and behaviour oriented. The second approach is based on notions of autonomous decision-making, professionalism and accountability. The two approaches are not mutually exclusive, but have similar elements with a different emphasis. Both approaches lack explicit recognition of the aesthetic aspects of care and patient choice, which is a fundamental principle of evidence-based practice. CONCLUSION: Nursing organizations, regulatory authorities and nurses should recognize that scope of practice and the associated responsibility for decision-making provides a very public statement about the status of nursing in a given jurisdiction.

Nurses', midwives' and key stakeholders' experiences and perceptions of a scope of nursing and midwifery practice framework.

AIM: This paper reports on the qualitative findings from a national review of a nursing and midwifery scope of practice framework. BACKGROUND: Scope of professional practice frameworks offers a system of rules and principles to regulate its members and demonstrate its responsibility to society. Key issues in reviewing the scope of practice include notions of specialist and advanced practice, accountability, autonomy, competence, supervision, continuing professional development and delegation. Evaluation of scope of practice frameworks has particular application value to nurses, midwives, regulatory bodies and healthcare employers across the globe. DESIGN: A mixed methods approach was used. This included a national survey of nurses and midwives and focus groups and interviews with key stakeholders. The qualitative data are reported in this paper. METHODS: Focus groups and interviews were conducted among a convenience purposive sample of key stakeholders, including nurses and midwives working in the widest range of services and settings in 2014. The participants contributed to thirteen focus groups and thirteen interviews. FINDINGS: Six global themes, as follows: Evolution of the nursing and midwifery professions and practice; Scope of practice: understanding and use; Expanding scope of practice; Professional competence; Practice setting and context; Reflections on the current framework. CONCLUSION: Practitioners understand the scope of professional practice and while some see it as empowering others see it as potentially restrictive. Nurses and midwives are generally willing to expand their scope of practice and see it as resulting in improved patient care, improvement in overall quality of standards and increased job satisfaction.