Transcript Factors that influence advanced practice nurses in the

Ann McDonnell
Sheffield Hallam University
UK
The City of Sheffield
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Britain’s 5th largest city
Population of 530,300
Home to two universities and over 45,000 students
England's greenest city: 150 woodlands, 50 public parks
One third of the city lies
within the Peak District National
Park
• A thriving cultural scene
Faculty of Health and Wellbeing
• Over 600 staff and over
7500 students
• We are one of the largest
education providers for
radiotherapy, nursing,
physiotherapy and sport
in the UK
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We are renowned for the quality of our
research and have one of the highest
levels of research generated income
from any new UK university
http://www.shu.ac.uk/research/hsc/
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Empowering frontline staff to deliver evidence
based care: the contribution of nurses in APN
roles
Capturing the impact of nurse consultant
roles
Research Team:
Sheffield Hallam University
University of Sheffield
Funded by Department of Health (England)
Nursing Quality Initiative, Policy Research Programme
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Any nurse working in the area of adult
nursing or public health whose role
involved an element of clinical practice in
which they demonstrated expert knowledge
and skill.
Included
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clinical nurse specialists
nurse consultants
nurse practitioners
practice development nurses
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A study examining the contribution of
advanced practice nurses (APNs) to
promoting evidence-based practice among
front-line staff
Survey by postal questionnaire of APNs
working in 7 SHAs in England (n = 855)
Case studies of 23 APNs
Purposive sampling of survey respondents to achieve
maximum variation in:
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clinical speciality
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type of role
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type of organisation
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ways of working with front-line staff
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geographical location
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Final sample of 23 APNs were our 'cases'
5 in-depth case studies and 18 short case
studies
e.g. TB nurse specialist, practice development
nurse, lead nurse for care homes, nurse
consultant in sexual health
Participant
Data collection
APN
In-depth interview
Frontline staff and
managers
(n = 3 to 6)
Semi-structured
individual interview
Participant
Data collection
APN
In-depth interview
Non-participant observation
Follow up in-depth
interview
Frontline staff and managers Semi-structured individual
interview
(n = 10 to 24)
Patients and family
members
(n = 0 to 11)
Semi-structured individual
interview
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A move away from ‘custom and practice’ to a position of being able
to justify actions on the basis of robust evidence.
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Described in terms of process and outcome.
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Types of evidence
◦ Evidence-based practice was a means of :
 providing care which was based on the best evidence available
 achieving the best possible outcome for patients
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Research evidence
Organisational evidence
Expert knowledge derived from professional practice
Information gleaned from interactions with patients
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The human forces behind knowledge
transfer that help build relationships and
networks for sharing existing research,
ideas and stimulating new work (CHSRF
2005)
APNs act as knowledge brokers by creating
links between different practice
communities, in particular acting as
intermediaries between the clinical and
research communities (Milner et al 2005)
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I see myself as a resource for front-line staff in terms of facilitating
evidence-based practice. I have the information, the evidence if
you like, I make it available to them and I help them apply it in
practice. Research can be difficult to understand and so it’s about
making it more accessible, helping them see the implications for
practice, incorporating it into guidelines that they can use.
Clinical nurse specialist
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They (APNs) need to be able to translate research knowledge for
practical implementation … It’s about bridging that gap between
the theoretical and the practical in developing policy which then
directs practice.
Director of Nursing
Two aspects:
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Managing knowledge
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Promoting uptake of knowledge
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generating knowledge
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accumulating knowledge
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synthesising knowledge
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translating knowledge
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disseminating knowledge
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Empirical evidence
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Professional experience
◦ Research
◦ Organisational evidence – audit / service evaluation
◦ It’s through the experience you gain, being in a situation over and
over again and having to deal with it. The amount of observation
and contact with patients in terms of seeing what you do and what
happens as a result of that. Providing care, evaluating what
happens, seeing the effect, reflecting on the outcome (NC
Palliative care)
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Personal knowledge about patients
◦ I wonder if any of the breast care nurses had breast cancer
because they seem so knowledgeable about how it really is.
They’ve taken so much from all of their patients, absorbed things
that have been said to them and put it together (Patient)
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They (APNs) are a great resource for information to help me
in my job. They have up-to-date knowledge, they will be
aware of things that I am not aware of as they are experts in
their own field.
District nurse
Repository of evidence
◦ Primary research findings
◦ Research products such as clinical guidelines
◦ Best practice when research was lacking
◦ Organisational information – how to make things happen
◦ Information relating to individual patients
Process of accumulating
◦ Active searching
◦ Networking
◦ Conduit for organisational evidence
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Bringing together different types of
knowledge to present a composite picture to
inform practice
Synthesising research evidence, professional
expertise and patient experience
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Interpreting the significance of evidence and expressing it in plainer
terms for different audiences – frontline staff, patients, managers
Evaluating evidence
◦ Research evidence not taken at face value but evaluated regarding
applicability in local settings
◦ Research may indicate that a drug works well for treating a particular
condition. But the trial will have been done in a controlled way, the sample
will have been selected to fulfil particular criteria and the real world is not
like that. Patients often have multiple pathologies which mean that the drug
may not be the most appropriate one for an individual patient. We need to
take account of the whole picture before acting on what appears to be robust
evidence. CNS
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Interpreting evidence
◦ Presenting evidence in a way that is readily understandable to the
audience
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Distilling evidence
◦ Drawing together different types and sources of evidence to present it in a
more concise format that is accessible to end users
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Active versus passive dissemination
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Formal
◦ Education and training
◦ Networking – e.g. link nurse schemes
◦ Multi-disciplinary team meetings
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Informal
◦ Impromptu encounters
◦ ‘popping in’
◦ Passing on information – e.g. journal articles
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Capacity building e.g. shadowing, link nurse schemes
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Clinical problem solving e.g. working with frontline staff to
solve clinical problems and using this as an opportunity to
promote evidence-based practice
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Facilitating change
◦ We can take (research into silver coated catheters) to the
trust board and say ‘look if we go with this we can reduce
UTIs (urinary tract infections) by this amount’ and argue
about balancing cost with effectiveness
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Personal attributes
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Clinically credible & street wise
Political acumen
Interpersonal skills
Transformational leadership style – compliment rather
than substitute for FLS
Support from senior manager and doctors
Characteristics of role
Organisational commitment
Professional networks – internal and external
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Educational implications for APNs
◦ Need to develop skills to become effective evidencebrokers
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Educational implications for frontline staff
◦ Need to develop knowledge and skills in evidence-based
practice and critical thinking
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Infrastructure to support APNs in knowledge-brokering
◦ Practical assistance (e.g. clinical audit) and resources
(e.g. IT need to be available
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Impact of APNs is hard to capture
Project Team: Kate Gerrish, Ann
McDonnell, Fiona Kennedy
(funded by the Burdett Trust for Nursing)
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Nurse consultants (NC) introduced into the NHS in
England in 2000
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Set up to achieve better outcomes for patients by
improving quality and services and to provide an
alternative career pathway for experienced practitioners
to remain in clinical practice rather than move into
education, management or research
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Impact of these multi-faceted roles is inherently hard to
capture (Guest et al. 2004).
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To identify a range of indicators to demonstrate the impact
of nurse consultants on patient, staff and organisational
outcomes
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To develop a toolkit/guidance to help nurse consultants to
demonstrate their impact on patient, staff and
organisational outcomes
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2 year project; commenced May 2009
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Stage 1 - Systematic literature review
Stage 2 - Mapping exercise of nurse consultants
Stage 3 - Case studies of nurse consultants
Stage 4 - Iterative specialist panel phase
Stage 5 - Composite toolkit/guidance
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Physical/psychological wellbeing
Quality of life & social wellbeing
Patient behavioural change
Patient experience of healthcare
Clinical
significance
Professional
significance
Professional competence
Quality of working life
Workload distribution
Team working
Organisational
significance
Organisational priorities / targets
Development of policy
Generation of new knowledge
Informed by the work of Schulz et al (2002) & Gerrish et al. (2007)
Key features:
 Evidence based - developed through a rigorous
research study
 A useful and practical framework is introduced
to help nurse consultants consider the impact
they might have from a number of different
perspectives
Activities and examples are provided to
consolidate learning
Available for free download from:
http://research.shu.ac.uk/hwb/ncimpact/index.html
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Gerrish K, McDonnell A, Nolan M, Guillaume L, Kirshbaum M, Tod
A.(2012) Factors influencing advanced practice nurses' ability to
promote evidence-based practice among frontline nurses. Worldviews
on Evidence-Based Nursing 9 (1), 30-39.
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Gerrish K, McDonnell A, Nolan M, Guillaume L, Kirshbaum M, Tod A.
(2011) The role of advanced practice nurses in knowledge brokering
as a means of promoting evidence-based practice among clinical
nurses. Journal of Advanced Nursing 67(9), 2004–2014.
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Kennedy F, McDonnell A, Gerrish K, Howarth A, Pollard C & Redman J
(2011). Evaluation of the impact of nurse consultant roles in the United
Kingdom: a mixed method systematic literature review. Journal of
Advanced Nursing.
Sheffield