Advanced Practice Nurses: Promoting evidence based practice and capturing impact: lessons from two UK studies

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Advanced Practice Nurses Promoting evidence
based practice and capturing impact lessons from
two UK studies

• Ann McDonnell
• Sheffield Hallam University
• UK

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The City of Sheffield

• Britains 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

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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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Two studies

• Empowering frontline staff to deliver evidence
  based care the contribution of nurses in APN
  roles
• Capturing the impact of nurse consultant roles

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Facilitating the link between evidence and
practice the process of knowledge-brokering
undertaken by advanced practice nurses (APNs)

• Research Team
• Sheffield Hallam University
• University of Sheffield
• Funded by Department of Health (England)
• Nursing Quality Initiative, Policy Research
  Programme

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Definition of APN

• 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
• clinical nurse specialists
• nurse consultants
• nurse practitioners
• practice development nurses

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Overview of project

• 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

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Case study methods - sampling

• Purposive sampling of survey respondents to
  achieve maximum variation in
• clinical speciality
• type of role
• type of organisation
• ways of working with front-line staff
• geographical location

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Sample

• 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

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Data collection short case studies (n 18)
Participant Data collection
APN In-depth interview
Frontline staff and managers (n 3 to 6) Semi-structured individual interview
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Data collection in depth case studies (n5)
Participant Data collection
APN In-depth interview Non-participant observation Follow up in-depth interview
Frontline staff and managers (n 10 to 24) Semi-structured individual interview
Patients and family members (n 0 to 11) Semi-structured individual interview
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Findings from the case studies
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Evidence-based practice

• A move away from custom and practice to a
  position of being able to justify actions on the
  basis of robust evidence.
• Described in terms of process and outcome.
• Evidence-based practice was a means of
• providing care which was based on the best
  evidence available
• achieving the best possible outcome for patients
• Types of evidence
• Research evidence
• Organisational evidence
• Expert knowledge derived from professional
  practice
• Information gleaned from interactions with
  patients

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Knowledge brokering

• 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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Knowledge-brokering

• 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 its about making it more
  accessible, helping them see the implications for
  practice, incorporating it into guidelines that
  they can use.
• Clinical nurse specialist
• They (APNs) need to be able to translate research
  knowledge for practical implementation Its
  about bridging that gap between the theoretical
  and the practical in developing policy which then
  directs practice.
• Director of Nursing

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Knowledge-brokering

• Two aspects
• Managing knowledge
• Promoting uptake of knowledge

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Knowlege management

• generating knowledge
• accumulating knowledge
• synthesising knowledge
• translating knowledge
• disseminating knowledge

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Generating knowledge

• Empirical evidence
• Research
• Organisational evidence audit / service
  evaluation
• Professional experience
• Its 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)
• 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. Theyve 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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Accumulating knowledge

• 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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Synthesising knowledge

• 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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Translating knowledge

• 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
• Interpreting evidence
• Presenting evidence in a way that is readily
  understandable to the audience
• 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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Disseminating knowledge

• Active versus passive dissemination
• Formal
• Education and training
• Networking e.g. link nurse schemes
• Multi-disciplinary team meetings
• Informal
• Impromptu encounters
• popping in
• Passing on information e.g. journal articles

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Promoting the uptake of knowledge

• Capacity building e.g. shadowing, link nurse
  schemes
• Clinical problem solving e.g. working with
  frontline staff to solve clinical problems and
  using this as an opportunity to promote
  evidence-based practice
• 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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Factors influencing APNs ability to broker
knowledge

• Personal attributes
• 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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Conclusion

• Educational implications for APNs
• Need to develop skills to become effective
  evidence-brokers
• Educational implications for frontline staff
• Need to develop knowledge and skills in
  evidence-based practice and critical thinking
• Infrastructure to support APNs in
  knowledge-brokering
• Practical assistance (e.g. clinical audit) and
  resources (e.g. IT need to be available
• Impact of APNs is hard to capture

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Capturing the impact of Nurse Consultant Posts -
a project to develop practical guidance

• Project Team Kate Gerrish, Ann McDonnell, Fiona
  Kennedy(funded by the Burdett Trust for Nursing)

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Background

• Nurse consultants (NC) introduced into the NHS in
  England in 2000
• 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
• Impact of these multi-faceted roles is inherently
  hard to capture (Guest et al. 2004).

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Overall Project Aims

• To identify a range of indicators to demonstrate
  the impact of nurse consultants on patient, staff
  and organisational outcomes
• To develop a toolkit/guidance to help nurse
  consultants to demonstrate their impact on
  patient, staff and organisational outcomes

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Project Overview

• 2 year project commenced May 2009
• 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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Framework for capturing impact
Informed by the work of Schulz et al (2002)
Gerrish et al. (2007)
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Capturing impact A Practical Toolkit for nurse
consultants

• 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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References

• 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.
• 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), 20042014.
• 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.

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• Sheffield