Empowering front-line staff to deliver evidence-based care: the contribution of nurses in advanced practice roles

Transcription

1 Empowering front-line staff to deliver evidence-based care: the contribution of nurses in advanced practice roles Final report submitted to the Department of Health September 2007 By Professor Kate Gerrish 12 Dr Louise Guillaume 3 Dr Marilyn Kirshbaum 1 Dr Ann McDonnell 1 Professor Mike Nolan 3 Professor Susan Read 3 Dr Angela Tod 1 1 Sheffield Hallam University 2 Sheffield Teaching Hospitals NHS Foundation Trust 3 University of Sheffield

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3 TABLE OF CONTENTS LIST OF FIGURES AND TABLES... V ACKNOWLEDGEMENTS...VI EXECUTIVE SUMMARY... VII BACKGROUND...VII RESEARCH AIMS AND APPROACH...VII KEY FINDINGS FROM THE SURVEY OF APNS...VIII KEY FINDINGS FROM THE CASE STUDIES...IX Evidence-brokering as an approach to promoting evidence-based practice... ix The impact of APNs through promoting evidence-based practice... ix Factors influencing APNs ability to promote EBP... x KEY MESSAGES TO ARISE FROM THE STUDY...XI Educational implications for APNs... xi Educational implications for front-line staff... xi The APN s role in empowering front-line staff... xi Infrastructure required to support APNs promoting evidence-based practice... xi APN role development... xii CHAPTER 1: INTRODUCTION INTRODUCTION RESEARCH AIMS AND APPROACH STRUCTURE OF THE REPORT TERMS AND CONVENTIONS... 4 CHAPTER 2: THE POLICY CONTEXT FOR ADVANCED PRACTICE NURSING: IMPLICATIONS FOR PROMOTING EVIDENCE-BASED PRACTICE INTRODUCTION THE POLICY CONTEXT FOR THE DEVELOPMENT OF ADVANCED PRACTICE ROLES HEALTH SERVICE POLICY ISSUES AFFECTING NURSING ROLE DEVELOPMENT FROM 1990 ONWARD THE NURSING POLICY CONTEXT THREATS TO THE ADVANCEMENT OF THE APN ROLE IDENTIFICATION OF OUTCOMES AND LINKS TO EVIDENCE-BASED PRACTICE FROM RESEARCH-BASED TO EVIDENCE-BASED PRACTICE WHAT COUNTS AS KNOWLEDGE? USING KNOWLEDGE/EVIDENCE IN PRACTICE RELATIONSHIP-CENTRED CARE THE SENSES FRAMEWORK AND ENRICHED ENVIRONMENTS OF CARE APNS CONTRIBUTION TO PROMOTING EVIDENCE-BASED PRACTICE AMONG FRONT-LINE STAFF CONCEPTUAL FRAMEWORK AND SENSITISING CONCEPTS CHAPTER 3: THE RESEARCH METHODOLOGY OVERVIEW OF THE RESEARCH PROCESS SURVEY OF APNS Aims i

4 3.2.2 Design and piloting of the questionnaire Sampling strategy Research governance and ethical approval Administration of the questionnaire Data analysis CASE STUDIES Aims Sampling strategy Ethical and research governance approval Recruitment Data collection Data analysis PRESENTATION OF THE FINDINGS CHAPTER 4: SURVEY FINDINGS INTRODUCTION THE SAMPLE Biographical profile of APNs Role and responsibilities Qualifications and experience UNDERSTANDING OF EVIDENCE-BASED PRACTICE The nature of evidence-based practice Rationale for evidence-based practice Types of evidence Benefits of evidence-based practice Knowledge and skills SOURCES OF EVIDENCE USED IN PRACTICE WAYS OF WORKING WITH FRONT-LINE STAFF PERCEPTIONS OF IMPACT ON FRONT-LINE STAFF Impact on care delivery Impact on wider care environment KNOWLEDGE OF AND CONFIDENCE TO SUPPORT EVIDENCE-BASED PRACTICE SKILLS TO SUPPORT EVIDENCE-BASED PRACTICE BARRIERS TO PROMOTING EVIDENCE-BASED PRACTICE FACILITATORS TO PROMOTING EVIDENCE-BASED PRACTICE SUMMARY CHAPTER 5: THE BACKGROUND TO THE CASE STUDIES INTRODUCTION OVERVIEW OF CASE STUDY SAMPLE STAKEHOLDERS UNDERSTANDING OF EVIDENCE-BASED PRACTICE CHAPTER 6: EVIDENCE BROKERING AS AN APPROACH TO PROMOTING EVIDENCE-BASED PRACTICE INTRODUCTION ii

5 6.2 EVIDENCE-BROKERING Generating evidence Accumulating evidence Translating evidence Disseminating evidence Applying evidence to practice EVIDENCE-BROKERING IN RELATION TO APN ROLES SUMMARY CHAPTER 7: THE IMPACT OF APNS IN PROMOTING EVIDENCE-BASED PRACTICE AMONG FRONT-LINE STAFF INTRODUCTION ISSUES ASSOCIATED WITH DEMONSTRATING THE IMPACT OF APNS The importance placed on demonstrating APNs impact Challenges of measuring impact Approaches to measuring impact DIMENSIONS OF IMPACT APNS IMPACT ON THE PROFESSIONAL DEVELOPMENT OF FRONT-LINE STAFF Competence Empowerment of front-line staff Personal development and job fulfilment APNS IMPACT ON THE CARE PROVIDED BY FRONT-LINE STAFF APNS IMPACT ON PATIENTS AND FAMILY MEMBERS Patient experience and satisfaction Improvements in patient outcomes Family member / carer experience APNS IMPACT ON THE ORGANISATION AND DELIVERY OF SERVICES APNS IMPACT ON THE CARE ENVIRONMENT SUMMARY CHAPTER 8: FACTORS INFLUENCING THE PROMOTION OF EVIDENCE-BASED PRACTICE INTRODUCTION PERSONAL ATTRIBUTES OF THE APN Clinical credibility Leadership style Knowledge and skills in evidence-based practice APN S ROLE Focus of role and span of responsibility Workload of APNs RELATIONSHIPS WITH STAKEHOLDERS Managers Medical staff Front-line staff ORGANISATIONAL CONTEXT iii

6 8.5.1 Organisational culture Workload of front-line staff Resources Professional networks SUMMARY CHAPTER 9: CASE STUDY EXEMPLAR INTRODUCTION PROFILE OF THE ROLE EVIDENCE-BROKERING IMPACT FACILITATORS AND BARRIERS SUMMARY CHAPTER 10: DISCUSSION OF THE FINDINGS AND CONCLUSIONS INTRODUCTION METHODOLOGICAL ISSUES APPROACHES TO PROMOTING EVIDENCE-BASED PRACTICE IMPACT OF APNS FACILITATORS AND BARRIERS TO PROMOTING EVIDENCE-BASED PRACTICE EDUCATION IMPLICATIONS ARISING FROM THE STUDY CONCLUSION AND KEY MESSAGES TO ARISE FROM THE STUDY Educational implications for APNs Educational implications for front-line staff The APN role in empowering front-line staff Infrastructure required to support APNs promoting evidence-based practice APN role development REFERENCES APPENDIX 1: QUESTIONNAIRE APPENDIX 2: CHARACTERISTICS OF THE CASE STUDY SAMPLE APPENDIX 3: DIFFERENT WAYS OF WORKING ACCORDING TO ROLE iv

7 List of Figures and Tables Table 2.1: Conceptual frameworks characterising advanced nursing practice Table 2.2: Canadian Nurses Association Framework for Advanced Nursing Practice Table 2.3: Nurse sensitive outcomes of advance practice nurses Table 2.4: Barriers to using research (ranked as greatest barrier) Figure 2.1: Conceptual framework for APNs promoting evidence-based practice Table 3.1: Summary of data collection Table 4.1: Age profile of advanced practice nurses Figure 4.1: Role of respondents (n=855) Table 4.2: Span of responsibility according to role Figure 4.2: Academic qualification according to role Table 4.3: Sources of evidence Table 4.4: Importance of different sources of evidence Figure 4.3: Different ways of working with front-line staff Figure 4.4: Perceived impact on front-line staff Figure 4.5: Knowledge and confidence to support evidence-based practice Figure 4.6: Knowledge and confidence in evidence-based practice according to role (%) Figure 4.7: Skills in evidence-based practice Figure 4.8: Skills in evidence-based practice according to role (% competent or expert) Table 4.5: Barriers to promoting evidence-based practice among front-line staff Table 5.1: Characteristics of the case study sample Table 6.1: Evidence-brokering Figure 7.1: Dimensions of APN impact Table 7.1: Activities to enhance the continuity of care received by patients Table 7.2: The impact of APNs on the delivery and organisation of services Table 7.3: Summary of the impact of APNs Table 8.1: Factors influencing the APN s ability to promote evidence-based practice among front-line staff Table 10.1: An overview of the impact of APNs Table 10.2: APNs influence on enriching the care environment v

8 Acknowledgements We would like to thank the advanced practice nurses who participated in the research by completing questionnaires, by answering interview questions and by agreeing to be observed. We are also indebted to the many front-line staff, managers, patients and family members who agreed to be interviewed. We also wish to acknowledge the contribution that Dr Mark Limb made as a member of the project team during the first year of study. Finally, we would like to thank the Advisory Panel who provided us with support and feedback at important points in the project. The panel consisted of the following people: Gabrielle Atmarow Professor Rosamund Bryar Professor Charlotte Clarke Shirley Harrison Patty Hempshall Hazel Marshall-Cork Abigail Masterson Maureen Morgan Dr Caroline Shuldham Maxine Simmons Dr John Wilkinson Chief of Performance and Standards / Chief Nurse (interim), Rotherham NHS Foundation Trust Professor of Community Nursing, St Bartholomew s School of Nursing and Midwifery, City University, London Chairperson, Nursing, Midwifery and Allied Health Professions Research Unit, School of Health, Community and Education Studies, Northumbria University Patient representative Infection Control Clinical Nurse Specialist, Sheffield Teaching Hospitals NHS Trust Patient representative Director, Abi Masterson Consulting Ltd Nursing Officer, Policy and Planning, Primary Care Director of Nursing and Quality, Royal Brompton and Harefield NHS Trust Head of Education and Training, Chesterfield and North Derbyshire NHS Trust Policy Research Programme, Department of Health vi

9 Executive summary Background Empowering front-line staff to deliver evidence-based care: the contribution of nurses in advanced practice roles The need for front-line staff to be empowered to deliver a quality service is a core component of contemporary healthcare policy. Within the nursing professions this has been supported by the introduction of new advanced practice roles such as consultant nurse and modern matron, to augment the existing clinical nurse specialist, nurse practitioner and practice development nurse roles. Policy guidance on advanced practice roles identifies the need for nurses in such positions to base not only their own practice on research evidence, but also through clinical leadership to act as change agents in promoting evidence-based care amongst front-line staff. Despite widespread recognition of the need for nursing practice to be based on sound evidence, frontline staff experience considerable challenges to implementing evidence-based care at an individual and organisational level. In particular, front-line nurses have difficulty interpreting research findings and although willing to use research they often lack the skills to do so. A lack of organisational support in the form of unsupportive colleagues and restricted local access to information is also problematic (Nolan et al 1998, Bryar et al 2003). Research examining evidence-based practice identifies the role that opinion leaders such as advanced practice nurses 4 (APNs) can play in influencing the practice of front-line staff (Fitzgerald et al 2003). They act as conduits for disseminating evidence-based information (McCaughan et al 2002) and are a resource to front-line staff in clinical decision making (Thompson et al 2001). Milner et al (2005) propose that APNs act as knowledge brokers by creating links between different practice communities, in particular acting as intermediaries between the clinical and research communities in facilitating evidence-based practice. However, little is known about the approaches that APNs use to promote evidence-based practice and the impact of this activity on front-line staff, patients and the wider care environment. Research aims and approach This study was commissioned by the Department of Health, as part of its Policy Research Programme, to examine the contribution of advanced practice nurses (APNs) to promoting evidence-based practice among front-line staff. More specifically the study sought: To identify the various approaches used by APNs to promote evidence-based practice among front-line staff. To identify factors which facilitate or inhibit the promotion of evidence-based practice by APNs. To examine the impact of APNs in promoting evidence-based practice on staff and patient experiences in the context of an enriched care environment. To identify the educational implications for APNs and front-line staff to deliver evidencebased care. A multi-method research approach was used to examine the research aims. The study had two related stages. The first stage comprised a survey by postal questionnaire of 855 APNs who worked in hospital and primary care settings throughout seven strategic health authorities that existed in England 4 The term advanced practice nurse referred to nurses who demonstrated expert knowledge and skill while maintaining an element of clinical involvement. As there is considerable diversity in the job titles and role descriptions of nurses occupying such roles, the definition included, but was not restricted to, clinical nurse specialists, clinical educators, community matrons, modern matrons, nurse consultants, nurse practitioners, practice development nurses. vii

10 in The second stage involved 23 case studies of APNs and involved a range of other stakeholders, i.e. health care professionals, managers, patients and family members with whom the nurses had contact. Data were collected by means of interviews with the APNs and stakeholders and observation of the APNs practice. Key findings from the survey of APNs The survey provided a broad overview of factors influencing the contribution that APNs make to promoting evidence-based practice amongst front-line staff. APNs had a broad understanding of evidence-based practice. Research findings were the main form of evidence used in practice although evidence derived from professional experience and from interactions with patients was also seen as legitimate. Evidence-based practice was valued as a means of providing a rationale for care, promoting high quality care, ensuring consistent standards and improving patient outcomes. APNs drew upon different sources of evidence, including that gained experientially through caring for patients and interacting with other APNs and members of the multi-disciplinary team. APNs relied heavily on evidence which had already been processed in some way, for example synthesised into guidelines, transmitted through education programmes or judged by colleagues to be relevant. APNs were less likely to obtain evidence directly from reading journal articles or via the World-Wide Web. APNs used a range of approaches through which they promoted evidence-based practice among front-line staff. Over two thirds of APNs influenced the care provided by front-line staff through their involvement in direct patient care, by working alongside front-line staff and acting as a resource to solve clinical problems. Many APNs disseminated information to frontline staff through education and training and informally through encounters in the clinical setting. APNs felt that they had a positive impact on the care provided by front-line staff and on the broader care environment. Their direct impact on care delivery was mainly through taking action to prevent or to solve clinical problems. APNs often took corrective action to remedy shortfalls in the standard of care provided by front-line staff. They enhanced care delivery by providing opportunities for front-line staff to further develop their knowledge and skills beyond standard practice. APNs influenced the care environment by developing guidelines and care pathways, through service redesign and by contributing to a culture where front-line staff felt able to question care. APNs varied considerably in terms of the skills they possessed to support evidence-based practice. Nurse consultants perceived themselves to be the most knowledgeable, skilled and confident in supporting evidence-based practice and in generating evidence through research. APNs had a wide range of educational qualifications and were evenly divided between those with no academic qualification, those with a bachelor degree and those with a master s or higher degree. APNs with a master s degree were significantly more confident in their ability to support evidence-based practice and more likely to consider themselves to be competent or expert in this area. The heavy workload of APNs and front-line staff together with a lack of resources were perceived to be the greatest barriers to promoting evidence-based practice. viii

11 Key findings from the case studies The case studies built upon the survey findings to provide a more in-depth account of the APNs contribution to promoting evidence-based practice among front-line staff. The main findings in relation to the project aims are summarised below. Evidence-brokering as an approach to promoting evidence-based practice APNs assumed an active role in brokering different forms of evidence, making links between the source of the evidence (e.g. the research community or considered experts) and the practice community of front-line staff. Evidence-brokering involved five processes: Generating evidence APNs generated different types of evidence including empirical evidence from research, audit and service evaluation, professional expertise, and personal knowledge about patients. New knowledge was generated through blending different types of evidence. Accumulating evidence APNs accumulated evidence through actively searching it out, networking and acting as a conduit for organisational evidence. Translating evidence APNs engaged in a number of processes including evaluating, interpreting and distilling evidence to make it accessible and understandable to different audiences such as patients, front-line staff and managers. Disseminating evidence APNs used a range of formal and informal approaches to disseminating evidence to front-line staff, patients and family members. Applying evidence APNs utilised different types of evidence directly, persuasively or conceptually in their own practice and in promoting the use of evidence among front-line staff. The impact of APNs through promoting evidence-based practice The case studies identified how inherently difficult it is to demonstrate the impact that APNs exert through their evidence-based practice activity. Their roles were multi-faceted and complex. Many APNs were part of a wider multi-disciplinary team and worked in different clinical settings and in some cases across organisational boundaries. The more complex the role, the harder it was to be clear about an APN s individual impact. Despite these difficulties, the case studies identified the overall positive impact that APNs exerted on front-line staff, patients and family members within the context of an enriched care environment. Their impact on the care environment comprised the following dimensions: Care giving environment as experienced by front-line staff, patients and family members. Through direct involvement in care giving and developing and implementing evidence-based protocols and pathways APNs were able to enhance the quality of care provided by front-line staff. By means of anticipatory and responsive problem solving they ensured that care standards were maintained and took remedial action to address any shortfalls in the standard of care patients received. Although APNs impact on patients and family members was often indirect, and channelled through their influence on front-line staff, there were clear examples where APNs exerted a positive impact on the patient and family member s experiences of care. APNs influence on care giving served to increase patients confidence and ensure the timeliness, safety and continuity of care. Relationship-orientated environment as experienced by front-line staff, patients and family members. Both patients and front-line staff gave examples of how APNs adopted an holistic approach in which patients were seen as individuals within their family context. When a patient was referred to them for a specific problem, APNs took a broad view of the patient s needs rather than focus solely on the reason for referral. Through their evidence-brokering activities they were able to mediate and negotiate between individuals where there were differences of opinion or act as an advocate for patients. ix

12 Learning environment as experienced by front-line staff and, to a lesser extent, patients and family members. APNs contributed to an enriched learning environment through role modelling, teaching and facilitating the professional development of front-line staff. They empowered front-line staff by developing their competence, confidence and decision making ability. However, a note of caution was voiced about the potential disempowering effect of some APNs who acted as custodians of knowledge and through retaining responsibility for care served to deskill front-line staff. Workplace environment as experienced by front-line staff. Whereas the ward manager / team leader was most influential in determining the workplace environment experienced by frontline staff, APNs exerted an impact on the job fulfilment of front-line staff through providing opportunities for personal and professional development. Evidence-based environment as experienced by front-line staff and patients. Through their evidence-brokering role APNs were able to promote an environment where evidence was used by front-line staff to inform their practice and patients were enabled to make decisions based on appropriate evidence. In addition to their influence on the care environment, several APNs exerted an impact on the organisation and delivery of services. This included achieving a positive impact on length of hospital stay, admission rates, efficiency of service delivery, shifts in service delivery and changes in policy and practice. Factors influencing APNs ability to promote EBP Factors influencing the ability of APNs to promote evidence based practice related to the personal attributes of APNs, the nature of their role, the relationships they had with various stakeholders and the organisational context in which they worked. The personal attributes of APNs affected their ability to empower front-line staff. Being seen as clinically credible and street-wise, together with demonstrating a transformational leadership style, political acumen and effective interpersonal skills were important. Moreover, APNs who sought to complement rather than substitute for front-line staff when providing care were most effective. Conversely, those who acted as custodians of specialist knowledge and were reluctant to let go of patients who had been referred to them by front-line staff ran the risk of disempowering staff. Support from senior managers and senior doctors was valuable, especially for APNs with complex roles spanning one or more organisations. APNs valued the autonomy that senior nurse managers gave them to be creative in developing their role. Conversely, where the support for the role from senior managers was not so forthcoming, APNs encountered more obstacles. Medical champions were often instrumental in gaining the support of their fellow medical colleagues for evidence-based initiatives that APNs were seeking to take forward and they often acted as clinical mentors. APNs with clinical responsibilities that brought them into regular contact with front-line staff were more readily able to influence practice than those whose role spanned organisational boundaries. The multiple and sometimes conflicting role expectations of some APNs meant that it was difficult to juggle the various demands placed on them. The heavy workload of many front-line staff detracted from their ability to engage in evidence-based practice activities promoted by APNs. Strong organisational commitment towards evidence-based practice led to structures being put in place and resources being allocated to support evidence-based practice. Professional networks both within and external to the organisation were used by APNs as a means of accessing relevant evidence, sharing information on evidence-based initiatives and providing peer group support. Networks established by APNs to develop the knowledge and skills of front-line staff, such as link nurse schemes were also beneficial. x

13 Key messages to arise from the study Educational implications for APNs Educational preparation for APNs should be at master s level to enable them to develop proficiency in critical appraisal, analysis and evaluation to support advanced practice and the promotion of evidence-based practice. APNs need to be equipped with a broad repertoire of knowledge and skills to support their role in promoting evidence-based practice. They need to be able to critically appraise different types of evidence, develop skills to undertake audit, service evaluation and/or research, together with mastering skills in decision making, change management and information technology. In order to be effective evidence-brokers, APNs need to develop inter-personal and interprofessional skills in establishing effective relationships with patients, family members and other health care professionals / managers, transformational clinical leadership abilities and the political acumen to work in complex organisations and across professional and organisational boundaries. Educational implications for front-line staff Front-line staff should be supported to further develop their knowledge and skills in evidencebased practice and critical thinking. The core processes of evidence-brokering identified in this study could inform the development of a curriculum for the educational preparation of nurses and other health care practitioners, at both qualifying and post-qualifying levels. In recognising that many APNs devoted considerable time to remedying shortfalls in the standard of fundamental aspects of care provided by front-line staff, consideration should be given to further developing the clinical leadership abilities of senior front-line staff to enable APNs to use their specialist expertise more effectively. In recognising the impact of effective relationships on enriching the care environment, the educational preparation of nurses and other health care practitioners should include both the acquisition of technical knowledge and skills and the development of the capacity to enter into and sustain relationships with patients/family members and other health care professionals. The APN s role in empowering front-line staff APNs should be encouraged and enabled to develop front-line staff through a range of educational opportunities such as formal teaching, active role modelling, and other initiatives such as secondment opportunities and link nurse schemes. APNs need to be aware of how their actions can serve to empower or conversely disempower front-line staff. Clinical supervision and/or appraisal schemes could be used to enable APNs to reflect upon their impact on front-line staff. Link nurse schemes were a potentially valuable means of empowering front-line staff although some link nurses lacked the structural power to be able to influence change. Organisations should ensure that these nurses have the knowledge, skills and resources to enable them to carry out this aspect of their role effectively. Infrastructure required to support APNs promoting evidence-based practice APNs benefited from having access to specialist expertise and practical assistance in relation to audit, research and evaluation to assist them in assessing the impact of evidence-based initiatives they take forward. Organisations should ensure that such resources are available to support APNs in promoting evidence-based practice. Further progress needs to be made to bring information technology closer to the work environment. Ready access to the Internet, a well developed local Intranet and other xi

14 information resources to support evidence-based practice in clinical areas for APNs and frontline staff are required. APN role development Advanced practice roles need to be developed with realistic consideration of the extent and scope of the post. This study revealed how achievements can be compromised if the role is too broad in terms of geographical base as well as roles and responsibilities. APNs who benefited from the support of a local champion (senior managers or senior medical staff) were often highly effective in achieving organisational change. In establishing new APN roles consideration should be given to the professional partnerships, collaborations and support required. Maintaining a strong presence in clinical areas allowed for opportunistic as well as planned interventions to promote evidence-based practice. The responsibilities and workload of APNs should be designed to allow them to spend sufficient time in clinical settings interacting with, and thereby influencing, front-line staff. Further research is required to develop an evaluative framework for APN roles which captures the complexity of their role (including evidence-brokering), the clinical significance of their impact on patients / family members and the professional significance of their impact on frontline staff. Further research is needed to examine the impact of different APN roles in order to guide service redesign. Whereas some differences were observed between nurse consultants and other APNs these differences are somewhat tenuous and merit further exploration. xii

15 Chapter 1: Introduction 1.1 Introduction In 2004 the Department of Health, as part of its policy research programme, commissioned several research studies that focused on enhancing the quality of nursing care. The programme was in response to developments in nursing policy which sought to: improve access, service quality and the patient experience; drive up standards of care; empower front-line nurses; recruit and retain experienced nurses; make best use of nurses skills. (Source: DH Policy Research Programme Research Specification Nursing Quality) This report presents the findings from one of these studies which examined the contribution that nurses in advanced practice roles make to promoting evidence-based practice among front-line staff. Enhancing the quality of patient care by basing health care practice on the best available evidence is a core component of a number of contemporary policy directives underpinning the government s modernisation agenda for the NHS (DH 1997, 1998, 1999a, 2000, 2001a, 2006a). Significantly, the Standards for Better Health (DH 2006b) by which the performance of NHS organisations are judged, make explicit reference to the need for NHS trusts to be able to demonstrate that health care services are based on robust research evidence. The recent Sicily statement on evidence-based practice sums up the responsibilities of individuals and organisations in achieving this objective: All healthcare professionals need to understand the principles of evidence-based practice, recognise evidence-based practice in action, implement evidence-based policies, and have a critical attitude to their own practice and to evidence. Without these skills, professionals and organisations will find it difficult to provide best practice. (Dawes et al 2005) At a macro level, the government has invested in initiatives to make research evidence accessible to policy makers, managers and practitioners. The NHS Centre for Reviews and Dissemination, for example, has been instrumental in synthesising and disseminating research findings on important clinical topics, the Electronic Library for Health facilitates the dissemination of information and the National Institute for Health and Clinical Excellence (NICE) produces evidence-based guidelines on the clinical and cost-effectiveness of clinical interventions. At an organisational level, the implementation of clinical governance requires NHS trusts to seek to enhance the quality of care through promoting clinical effectiveness, audit, and evidence-based practice (DH 1998). However, a perusal of reports of visits made by the former Commission for Health Improvement and more recently by the Healthcare Commission indicates that NHS trusts are meeting these intentions with varying degrees of success. There remains a need to facilitate front-line staff to deliver high quality evidence-based care with the support of their managers in order to achieve these policy aspirations. 1

16 Public expectations of health care services are changing. Professionals are no longer seen as the sole repository of health-related knowledge. Patients are increasingly accessing information, for example via the internet, and this informs their preferences for health care. There is also growing recognition that the tacit knowledge that patients and family carers have acquired through managing their disease or disability can be harnessed to play a part in addressing the challenge of shifting the burden of disease (Donaldson 2003). Seeing patients and family carers as valuable sources of evidence in their own right underpins the expert patient initiative (DH 2001b). Such developments present new challenges for nurses to consider how their clinical expertise can be synthesised with research evidence and patient knowledge and preferences to provide evidence-based care. The government s modernisation agenda for the NHS emphasises the need to empower front-line staff to assume more responsibility for decisions concerning service delivery (DH 2001a). Within nursing this has included the introduction of new advanced practice roles in the form of consultant nurses, modern matrons and community matrons, to augment the existing clinical nurse specialist, nurse practitioner and practice development roles. There is considerable variability both within and between these different advanced practice roles (Shewan and Read 1999; Roberts-Davis and Read 2001; Daly and Carnwell 2003). Nevertheless, policy guidance on such roles, for example nurse consultants (NHSE 1999), nurse specialists in cancer and palliative care (NHSE 2001), modern matrons (DH 2003) and community matrons (DH 2004), identify the need for advanced practice nurses (APNs) to base, not only their own practice on research evidence, but also through clinical leadership to act as change agents in facilitating evidence-based care. Despite wide-spread recognition of the need for nursing practice to be based on sound evidence, frontline nurses experience considerable challenges to implementing research in practice at an individual and organisational level (Nolan et al 1998; Tod et al 2003; Gerrish and Clayton 2004). McCaughan et al s (2002) research examining barriers to using research information in clinical decision making by front-line nurses identifies that nurses may: encounter problems with interpreting and working with research products which are seen to be too complex: nurses may be willing to use research but feel limited in their ability to do so due to lack of skills; encounter a lack of organisational support in the form of unsupportive colleagues and restricted local access to information; perceive that research products lack clinical credibility and fail to provide sufficient clinical direction; lack the skills and motivation to utilise research directly, preferring instead to access researchbased information through a third party. Research has shown that front-line staff draw heavily on experiential learning in the workplace to inform their practice rather than formal sources of knowledge such as research reports. Such learning 2

17 is derived from involvement in patient care, interactions with more experienced nursing colleagues and medical staff, in addition to utilising evidence-based pathways and protocols (Estabrooks 1998; Gerrish and Clayton 2004). Moreover, nurses are more likely to value interpersonal contact and prefer to use communication with colleagues and patients rather than on-line sources of evidence (Estabrooks et al 2003). Recent studies examining research use by front-line staff identifies the role that opinion leaders can play in influencing the practice of others (Fitzgerald et al 2003) and act as conduits for disseminating evidence-based information (McCaughan et al 2002). It is recognised that APNs facilitate evidencebased practice (Davies et al 1999), act as a resource to front-line staff (Thompson et al 2001; Gerrish and Clayton 2004) and thereby promote an enriched care environment (Nolan et al 2002). It is essential, therefore, that APNs are skilled not only in basing their own practice on evidence but also in empowering front-line staff to deliver evidence-based care. Arguably, skills additional to those normally associated with research utilisation, such as clinical leadership, change management, IT competency, and protocol development are important. Whereas there is an expectation that APNs should promote evidence-based practice among front-line staff, recent studies examining the implementation of these innovative posts (e.g. Read et al 1999, 2001, 2004; Gibson and Bamford 2001; Guest et al 2001, 2004) have not considered this element of their role. 1.2 Research aims and approach The current study sought to address the gaps in knowledge identified above by examining the contribution of nurses in advanced practice roles to promoting evidence-based practice among frontline staff. More specifically the study sought: to identify the various approaches used by APNs to promote evidence-based practice among front-line staff; to examine the impact of APNs in promoting evidence-based practice on staff experiences, and patient experiences in the context of an enriched care environment; to identify factors which facilitate or inhibit the promotion of evidence-based practice by APNs; to identify the educational implications for nurses in advanced practice roles and front-line staff to deliver evidence-based care. In order to address the above aims, a postal survey of APNs in a broad range of hospital and primary care settings was undertaken. This was followed by 23 case studies of APNs who, on the basis of the survey findings, used innovative approaches to promoting evidence-based practice. Interviews and observation were used to elicit the opinions of stakeholders within the practice environment of APNs, including front-line nurses, patients/family carers, managers, and the multi-disciplinary team. 3

18 1.3 Structure of the report The report is divided into 10 chapters. Chapter 2 provides an overview of policies, issues and conceptual perspectives within the literature on advanced practice roles and draws out the implications for evidence-based practice. Chapter 3 describes the research methods employed for the survey and case studies. Chapter 4 presents the findings from a postal survey of 855 APNs working in hospital and primary care settings across seven Strategic Health Authorities (SHA) in England. Chapter 5 provides an overview of the 23 case studies undertaken and summarises how evidencebased practice was interpreted by research participants. Chapters 6-10 present the findings arising from the case studies: Chapter 6 examines how APNs act as evidence-brokers in facilitating links between evidence and practice in their interactions with front-line staff. Chapter 7 considers the different dimensions of the APNs impact including their impact on staff, patients and family members, care delivery and the organisation and delivery of services. Chapter 8 examines factors that facilitated or hindered APNs in promoting evidence-based practice among front-line staff. Chapter 9 presents a case study exemplar which illustrates the complexity of APN roles in promoting evidence-based practice and the influence of the context in which these nurses work. Chapter 10 provides a discussion of the key findings from the study in relation to the research aims. It concludes with a summary of the key messages to emerge from the project. 1.4 Terms and conventions For the purpose of this study, the term advanced practice nurses is used to describe nurses whose roles include an element of clinical involvement and in which they demonstrate expert knowledge and skill. It is recognised that there is considerable diversity in the job titles and role responsibilities of nurses occupying such roles, however the definition has included but not been restricted to, clinical nurse specialists, clinical educators, community matrons, modern matrons, nurse consultants, nurse practitioners and practice development nurses. We are mindful that since the study commenced in 2004, the Nursing and Midwifery Council (NMC) has been progressing work to clarify the components of advanced practice nursing with a view to establishing a register of advanced practice nurses. The NMC envisages advanced practice nurses as demonstrating advanced knowledge and skills in relation to the direct provision of patient care, and defines them as advanced nurse practitioners (NMC 2006). As the explanation above confirms, we have taken a broader and more inclusive view of advanced nursing practice within this study. 4

19 Chapter 2: The policy context for advanced practice nursing: implications for promoting evidence-based practice 2.1 Introduction The last three decades have seen a proliferation in the UK of new advanced practice nursing roles; this is a direct reflection of the expansion and extension of what is traditionally viewed as nursing. These new roles initially emerged subtly as individual nurses began to acquire expertise within specialist areas of clinical practice, but from the early 1990s onwards, such roles appeared more widely in a seeming explosion of nursing job titles that could be placed under the umbrella of advanced practice nursing. More recently advanced practice roles have become a significant component of the government s reforms of the NHS. At the commencement of this project, a review of the literature on the advanced practice nurse (APN) was undertaken to establish an up-to-date profile of the prominent issues and conceptual perspectives for the purpose of informing the study. This review has been augmented by a further exploration of the relevant UK policy areas. A parallel review of literature examining evidence-based practice and related concepts was also undertaken. The results of these reviews are now presented. 2.2 The policy context for the development of advanced practice roles To set discussion about role development in context we quote by permission from the report entitled Reduction of Junior Doctors Hours in Trent Region: the Nursing Contribution (Read and Graves, 1994). The concept of the extended role of the nurse originated at a time when a disease-oriented, task-based, medical model of practice was accepted by a majority of nurses working in hospitals. Work study of nurses in the 1950s labelled tasks as either basic or technical (Goddard 1953); successive statements issued jointly by the Royal College of Nursing (RCN) and the British Medical Association (BMA) outlined the duties and position of the nurse, and also referred to duties allocated to nurses which appear to be outside the generally accepted and current scope of nursing practice (RCN 1961, 1970, 1978). These were to be agreed between the professions and adequate safeguards regarding training and competence put in place. The Briggs Report (Briggs 1972) stated that nurses should be required to undertake only those duties for which they had been educated and trained. In 1977, the Chief Medical Officer and Chief Nursing Officer at the Department of Health and Social Security (DHSS) issued a circular (DHSS 1977) setting out the parameters within which extended role tasks might be assumed by nurses. In essence, the concept of the extended role of the nurse pictured a registered nurse, after 3 years training, as a standardised package recognised as competent to perform a specified list of tasks for which education and certification had been given. Any new duties of a technical nature, which had been previously, or were also currently performed by doctors, were viewed as extended roles and needed training, examining and certifying in the local area. Examples of the 5

20 tasks viewed as extensions included suturing, applying plaster of Paris, infiltration of local anaesthetic, electrocardiogram, defibrillation, venepuncture, immunisation, ear-syringing, and acting as firstassistant to a surgeon in the operating theatre. Because of developments in both the knowledge base of nursing, and the profession s growing sense of autonomy during the 1980s, the RCN suggested a new approach to professional accountability for extended roles in 1988 (RCN 1988). The Department of Health was not yet ready for such a revolution, and reaffirmed the old guidance in 1989 (DHSS 1989). The pressure for change was now increasing, however; in 1990 the Welsh National Board for Nursing, Midwifery and Health Visiting (WNB 1990) issued an influential discussion paper on the topic, which fuelled a debate in the profession. So it was not surprising that in June 1992 the Chief Nurses of the UK Health Departments (DH 1992) withdrew earlier guidance on the extended role and asked all nurses and managers to act in accordance with the simultaneously issued UKCC documents The Scope of Professional Practice (UKCC 1992a) and the new Code of Professional Conduct (UKCC 1992b). The Scope of Professional Practice (UKCC1992a) emphasised the attributes of knowledge, judgement and skill required by nurses, and said that in the context of changing developments in health care, nursing practice must be sensitive, relevant and responsive to patient need and have the capacity to adjust, where and when appropriate, to changing circumstances. Education must keep pace with such change, both in pre-registration and postregistration areas. There is no doubt that the 1992 guidance to nurses on their scope of practice encouraged many to consider new developments in their roles, and the introduction of Scope coincided with a number of other pressures for nurses to expand their practice, including discussions in the UKCC in the following years about specialist and advanced nursing practice (UKCC 1994, 1995, 1996, 1997a, 1997b, 1997c, 1999a). In 1995 the UKCC stated that: Specialist practitioners will exercise higher levels of judgement, discretion and clinical decision making. They will be able to monitor and improve standards through supervision of practice, clinical audit, provision of skilled professional leadership, and the development of practice through research, teaching and support of professional colleagues. (UKCC 1995) The Council differentiated between nurses practising within a given specialty who may not be functioning with the level of expertise described above and nursing specialist practitioners, who were properly prepared for a higher level of responsibility. Such specialist practitioners should be educated to first degree level, becoming experts in clinical practice for their specialty, care and programme management, clinical practice development and leadership. The UKCC (1995) document also referred to advanced nursing practice, differentiating it from specialist practice, but denying any hierarchical relationship between the two. The following year, the UKCC held several colloquia to consult with key stakeholders about the possibilities for regulating advanced practice, and produced a report on their deliberations as part of the PREP project (UKCC 1996). 6

21 Despite further work and a lengthy consultation process by the UKCC, including a pilot project for trialling mechanisms to regulate specialist and advanced practice, (UKCC 1999a), legislation on this subject was not achieved and the project lapsed when the NMC took over the functions of the UKCC, and was only in 2006 being revived. Linked with these discussions were attempts to define and differentiate between the various roles which were seen as advanced particularly those of clinical nurse specialists and nurse practitioners. (Read 1995, 1998a,b; Watson et al 1996; Roberts-Davis et al 1998; Read et al 1999, 2001; Roberts-Davis and Read 2001; Daly and Carnwell 2003). 2.3 Health service policy issues affecting nursing role development from 1990 onward From the early 1990s, the NHS witnessed massive transformation leading to fundamental changes in the delivery of healthcare. The NHS and Community Care Act of 1990 led to the introduction of internal markets and the creation of independent NHS trusts, which subsequently led to a reconfiguring of the workforce and fostered the creation of new roles for nurses and allied health professions. This occurred within a context of staff shortages and pressure for change from purchasers and patients and was reinforced by two key policy initiatives; the Patients Charter (DH 1991a) and proposals for reducing junior doctors working hours (DH 1991b). The Patients Charter gave patients much greater say in their care whilst the reduction in junior doctors hours (to 72 per week) affected the availability of junior doctors throughout the NHS. Trusts were allocated funding to meet these requirements and in many cases this was used to develop new nursing roles (Read and Graves 1994; Read 1995; Read et al 2001). More recently, the European Working Time Directive has stimulated a proliferation of hybrid roles to cover acute care at night or other times when junior doctors are scarce (Bernhaut and Mackay 2002; Jones 2003; Nielsen 2003). The move away from an internal market to a commissioning process was introduced within the White Paper The New NHS Modern, Dependable (DH 1997). This paper enunciated the Government s commitment to encouraging and extending nursing role developments. In 1998 A First Class Service (DH 1998) was published, which detailed the process of clinical governance as a means for maintaining excellent clinical standards within the NHS. This paper also highlighted the need for continuing professional development and lifelong learning as a means of achieving quality care. The importance of staff development was enforced still further within the NHS Human Resources Strategy Working Together (NHS Executive 1998). These were key features for preparing nurses to undertake new roles and helped to pave the way for nurses to continue to challenge traditional ways of working. The NHS Plan, published in 2000, was heralded as the biggest change to healthcare in England since 1948 (DH 2000). At the centre of the modernisation agenda were National Service Frameworks; these were blueprints for improving patient care in a number of areas including care of the elderly, coronary heart disease and cancer. In addition, Ten Key Roles for Nurses were developed as ways in which 7