Background The development of advanced practice roles in nursing has been influenced by a number of key national and international drivers including increasing demand for healthcare and rising costs. There is an implicit assumption that the goal is to improve patient outcomes and improve the patient experience in a cost effective and timely manner. Remodelling and re-engineering clinical teams has been advocated by the Department of Health (2008) as a way of achieving patient-focused services, and the contribution made by nurses to workforce reconfiguration in the context of the advanced practice role, is an essential part of this process.
A key imperative for the strategic development of the advanced practitioner role has been the implementation of the European Working Time Directive (European Parliament 2000). The adoption of a maximum 48 hour working week for junior doctors, and the reduction in working hours that has resulted, has had huge implications for the provision of patient care, traditionally carried out by this group of professionals.
Barnsley Hospital NHS Foundation Trust, made the decision to address these workforce development issues by appointing Advanced Nurse Practitioners (ANPs) to work in acute care areas (medicine, surgery and orthopaedic) to complement or replace the existing F1/F2 junior doctors. This project is designed to evaluate the impact of these roles in practice.
Aim The aim of this two year project (March 2011-March 2013) is to evaluate the Advanced Nurse Practitioner roles at Barnsley Hospital NHS Foundation Trust More specifically, the objectives are:
To identify the key stakeholders involved in the development and implementation of the ANP roles
To identify the various meanings of a 'successful ANP role' as defined by these stakeholders
To identify criteria to judge success based on the above
To evaluate the overall success of the ANP roles using the above criteria as a framework
To identify factors which have been influential in contributing to the success of these roles
To provide an account of the ANP roles and suggest factors which were most influential in the implementation roles
To explore the economics implications of the ANP roles
Evaluation approach Selecting the outcomes against which to judge the success of ANP roles is far from straightforward. There are a number of reasons for this:
The introduction of ANP roles is taking place in the context of a complex, dynamic clinical environment, where strategic and organisational priorities and the environment in which innovation takes place, are all subject to rapid change. In such a context, there are likely to be unanticipated consequences to new developments as well as those which are anticipated.
Different groups or 'stakeholders' will have all an interest in the innovation and these stakeholders are likely to have different ideas about what the outcome of an ANP role should be. For example a patient might value most the quality of communication throughout an episode of care and have little interest in reduction in lengths of stay, which might be an important outcome for a Business Manager.
Stakeholders are therefore likely to use different criteria to judge the success of ANP roles.
In order to address these issues, we propose to use a pluralistic model of evaluation developed by Smith and Cantley (1988) which begins with the premise that success is a pluralistic notion, not a unitary measure, and should be judged from the perspective of multiple stakeholders. This approach had been used successfully to evaluate complex interventions in healthcare settings including day hospital services (Smith and Cantley 1985), integrated community nursing teams (Gerrish 1999) and nursing development units (Gerrish 2001). Data Collection
Stage 1. A focused search of the literature on ANP role development In order to provide context to the study, a focused search of the literature will be undertaken in order to identify:
impetus for ANP role development in the UK
methods used in studies to evaluate ANP roles
criteria which have been used to judge the success of ANP roles
criteria which have been used to judge the economic impact of ANP roles
Stage 2. Collective case study of ANP role implementation A collective case study, comprising three individual case studies (Stake 1995) will be undertaken. Each case study will represent the clinical area within which the first cohort of ANP roles have been introduced i.e. medicine (n = 3 ANPs), surgery (n = 3 ANPs) and orthopaedics (n = 2 ANPs).
The case studies will allow for detailed insights into the outcomes of ANP roles that are meaningful to different stakeholders and the criteria that can be used to judge success. Using these criteria as a framework, the case studies will also investigate the extent to which ANP roles in each case study have achieved success from the perspective of a variety of stakeholders. The case studies will also include in-depth exploration of factors that have facilitated or hindered successful role implementation.
Data collection will take place in a number of stages.
Stage 2a Interviews with strategic stakeholders A purposive sample of cross-case stakeholders will be selected. This will include individuals who hold strategic posts within the hospital and have been closely involved with the development of the ANP posts.
Initial in-depth interviews with the strategic stakeholders will explore their perceptions of the impetus for the ANP role developments across the trust, what objectives they see as the most important for the roles and what criteria they would consider to be the most useful to judge the success of the posts. Their views on the extent to which these criteria have been met will also be sought.
Stage 2b Creation of success Framework Following these interviews, the criteria for success identified will be cross-referenced with the criteria for success identified through the literature review and preliminary framework outlining potential criteria for judging success will be developed and used to inform Stage 2c.
Stage 2c Individual case studies For each of the three individual case studies (medicine, surgery and orthopaedics), the following data collection strategies will be used:
Data collection for each case study will start with an in-depth interview with each of the ANPs. These interviews will explore their perceptions of the impetus for the ANP role developments in their division, what they see as their objectives and what criteria they would consider to be the most useful to judge the success of their posts. Their views on factors which have acted as facilitators or barriers to successful role implementation to date will also be sought.
ANP’s will also be asked to identify individuals who are able to provide insights into the development, implementation and impact of their posts. For each case study, this sample is likely to include matrons, members of the multi-professional team, ward managers, business managers, front-line nurses, consultant medical staff, specialist registrars, junior doctors (F2s), patients and family carers.
Stage 2d Cross-case analysis Following these interviews, cross-cutting themes will be identified as well as overarching criteria for success that are common to all case studies and indicators for success that are unique to individual case studies.
Stage 3 Development of success Framework The framework outlining potential criteria for judging success will be further developed.
Stage 4 Gathering evidence of success The next stage of data collection will focus on gathering relevant data which will provide evidence in relation to these criteria in the framework in order to evaluate the success of the roles. The pluralistic evaluation approach used in this study means that this stage of data collection cannot be explicitly outlined a priori, but emerges as a result of exploring stakeholder perspectives. However, it is likely that the following strategies will be used:
episodes of participant observation in the clinical setting
collection of routine data relevant to ANP roles e.g. numbers of complaints, number of Serious Untoward Incidents (SUIs), number of medication and prescribing errors, length of stay
collection of data to inform the assessment of cost offset
further one to one interviews with selected members of hospital staff
collection of documentary evidence e.g. business plans, job descriptions
a focus group discussion with the ANPs for each case study