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Evaluation of the impact of nurse consultant roles in the United Kingdom: a mixed method systematic literature review Kate Gerrish, Ann McDonnell, Fiona Kennedy
(funded by the Burdett Trust for Nursing)
Faculty of Health and Wellbeing
Introduction
• Nurse consultants (NC) introduced into the NHS in England in 2000 • Early work in UK showed some evidence of NC impact in developing services & providing leadership for frontline staff (Guest et al. 2004) • Previous reviews have been methodologically limited & growing interest prompts the need to assess current state of evidence
Framework for capturing impact
• Empowering frontline staff to deliver evidence based care: the contribution of nurses in APN roles (Gerrish et al 2007) • Framework of clinical & professional significance • Extended from work by Schultz et al (2002)
Clinical significance
• Symptomatology • Quality of life/Quality of patient experience • Social significance • Social validity
Professional significance
• Professional impact • Quality of working life • Professional social significance • Professional social validity
Aims of review
• To explore the impact of nurse consultants on patient and professional outcomes within adult healthcare settings • To identify the extent to which existing studies have used quantitative outcome measures or qualitative dimensions of impact • Further refine the proposed framework for capturing the impact of NC roles • Preliminary stage of larger study on impact of NC roles
Methods
• Broad search strategy • Databases: MEDLINE, PsycINFO, Pubmed, CINAHL, British Nursing Index, Cochrane Library, Scopus, Web of Knowledge • Grey literature & incremental searching plus contact with known experts • Quantitative and qualitative studies included • All citations double reviewed against a priori inclusion criteria
Methods cont.
• No minimum quality threshold • All included studies double reviewed using established tools/checklists • Quantitative studies were appraised using Thomas et al (2003) • Qualitative studies appraised using the CASP framework (2006) • Rees et al (2010) checklist was used for descriptive surveys
Methods cont.
• Data extraction on customised forms for each study design • Dimensions of impact mapped on to the proposed framework for assessing impact • Overarching synthesis: use of matrices to explore how the evidence from the qualitative studies added to, challenged or identified gaps in the evidence from the quantitative studies and vice versa
Total Citations = 2313
Database references n = 2132 Grey literature results n = 181 Title/abstracts screened (excl duplicates) n = 1440 Rejected at title/abstract stage n = 1305 Full papers n = 135 n = 177 excluded Rejected at full paper stage n = 102 Total papers n = 33 + 4 grey literature + 3 handsearching Rejected at data extraction n = 5:
35 included papers (36 primary studies)
Findings
• 36 primary studies - 12 quantitative with a comparison group, 9 descriptive surveys (no comparison) and 15 qualitative studies • Heterogeneity in terms of clinical setting, nature of clinical services and outcomes assessed • Overall, study quality was weak • In quantitative studies, study design compromised by lack of adequate comparators • In qualitative studies focus was often on processes rather than outcomes of care
Clinical significance
• Symptomatology – Qual - e.g. resolving patient problems/controlling symptoms – Quant - e.g. reduced anxiety • QoL/quality of patient experience – Qual - e.g. patient satisfaction with care – Quant - e.g. patient satisfied with explanation of tests • Social significance – Qual - e.g. reduced waiting times/seen quicker – Quant - e.g. reduced length of stay or A&E attendance • Social validity – Qual & Quant evidence of acceptance/preference of NC by patients
Professional significance
• Professional impact – Qual - e.g. helping others to develop their practice/expertise – Quant - very little evidence - e.g. increased accuracy of recordings/ observations • Quality of working life – Qual - e.g. enhanced team/staff morale – Quant - almost no evidence - only e.g. staff reported feeling supported • Professional social significance – Qual - e.g. implications for workload/remit of others – Quant - almost no evidence - only e.g. single item alluding to impact on medical colleagues roles • Professional social validity – Qual & Quant evidence of value of NC role to staff
Discussion - where to now?
• Although study quality is poor, evidence suggests a largely positive impact & review suggests range of areas that NCs potentially influence • Further robust research is required – Quantitative evidence on professional outcomes – Quantitative/qualitative involving patients • Proposed framework could help NC (APNs?) in practice assess their impact & guide future research
Watch this space…
• Development of toolkit/guidance to help NC capture evidence of their impact • including reflective activities, tips to address challenges, and possible tools for capturing evidence • Has been developed through in-depth case studies with several NCs in larger study exploring NC impact
References
• Full paper on this work is currently under review in JAN • Gerrish et al (2007). Empowering frontline staff to deliver evidence based care: the contribution of nurses in APN roles. http://www.shu.ac.uk/_assets/pdf/hsc EmpoweringFrontlineStaffReport.pdf
• Guest et al (2004) An evaluation of the impact of nurse, midwife and health visitor consultants. King’s College London, London.
• Schultz et al (2002) Dementia caregiver intervention research: in search of clinical significance. BMJ 42(5), 589.