Making the case for advanced practice roles in nursing
Mounting costs of healthcare, limited financial resources and an ageing population have led to more Advanced Practice Roles in nursing (APN), such as clinical nurse specialists and nurse consultants. The aim of research has been to generate robust evidence of the contribution of APN roles to healthcare. In order to do this it has developed an evaluation framework and this has subsequently been used to underpin the development of a practical toolkit. The kit gives practitioners the tools needed to demonstrate their impact on patients, staff and the organisations in which they work. In addition to these practitioners, beneficiaries include policymakers, professional organisations and the NHS.
The research
A study to examine the impact of APNs in promoting evidence-based practice among frontline staff was carried out between 2003 and 2007 led by Professor Kate Gerrish alongside Professors Angela Tod and Ann McDonnell. This was a mixed-method study comprising a national survey of 855 APNs followed by qualitative case studies of 23 APNs, transferred to the University in 2006. It was here that all data analysis for this study and all publications relating to the study were written.
A key output was a conceptual framework to evaluate the impact of APN roles based on the work of Schultz et al. (2002), who proposed that outcomes should be viewed in terms of their clinical rather than statistical significance. This framework was extended and a parallel framework developed for judging the professional significance of impact.
A follow-up study exploring approaches to measuring the impact of nurse consultants (NCs) highlighted challenges in measuring their impact. These included attributing impact to individuals working in teams, the complexity of capturing indirect impact, difficulties in gaining a patient perspective and a lack of practitioner expertise in measuring impact.
An extended framework and a toolkit were developed in response to these issues. The framework measured an APN’s impact not only by measuring their clinical significance but also by quantifying their quality of working life and competence as professionals and impact at an organisational level. The toolkit, built on the framework, is a practical resource for APNs. It offers a series of reflective activities and examples to help users improve how they consider impact. It also contains tools for capturing impact that can be adapted for individual use.
The impact
The framework has helped to develop advanced nursing roles by providing robust theoretical guidance for the assessment of impact in these roles. Its development as the basis for a practical toolkit to assist these practitioners in capturing and demonstrating their impact represents a unique resource.
Both the theoretical framework and the practical guidance were disseminated through a variety of activities designed to engage the clinical community. Details of the toolkit were sent to the Chief Nurse in every NHS Trust in England and Wales and a dissemination event attended by 53 UK Nurse Consultants and managers was held in 2012. The research findings have also been presented at national and international conferences and keynote presentations given to groups including the Consultant Nurse Association for England. It is also highlighted on, and available for download from, a number health sector organisations websites, and has been publicised by The Foundation for Nursing Studies.
The research team have been called on to support three organisations in the use of the toolkit to capture the impact of APNs and allied health professional consultants: The Consultant Nursing, Midwifery and Allied Health Professional Forum for Wales, Great Ormond Street Hospital NHS Foundation Trust, Newcastle upon Tyne Hospitals NHS Foundation Trust. The toolkit has been particularly useful in helping these organisations evaluate specific projects within their organisation. For example, it has provided support for evaluating a newly established Integrated Children's Centre and evaluating patient experience in Accident and Emergency.
The toolkit and framework have been used and adapted to a number of other practice settings. For example, in 2012, the Specialist Nurse Forum at South Tees NHS Foundation Trust developed a six-month project to capture the impact of all the Specialist Nurses and Advanced Nurse Practitioners using an adapted version of the toolkit. The chair of the Forum described the toolkit as 'completely inspirational' and articulated ‘what our jobs really were about’.
The framework was also used for capturing impact was also used in a scoping exercise of nursing, midwifery, pharmacy and Allied Health Professional consultants in a large NHS Foundation Trust. It allowed the organisation to have a clear vision of where the consultants fitted within the Corporate Framework.
At a practitioner level, nursing and midwifery consultants in England, Scotland and Wales were invited to complete an online survey to capture feedback on the toolkit between Feb and May 2013. Of the 41 responses received, respondents reported using the toolkit to reflect on their impact, to inform their annual appraisal and to capture impact in practice.