Title: Advanced Practice Nurses: Promoting evidence based practice and capturing impact: lessons from two UK studies
1Advanced Practice Nurses Promoting evidence
based practice and capturing impact lessons from
two UK studies
- Ann McDonnell
- Sheffield Hallam University
- UK
2The 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
3Faculty 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
4- 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/
5Two studies
- Empowering frontline staff to deliver evidence
based care the contribution of nurses in APN
roles - Capturing the impact of nurse consultant roles
6Facilitating 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
7Definition 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
8Overview 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
9Case 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
10Sample
- 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
11Data 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
12Data 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
13Findings from the case studies
14Evidence-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
15Knowledge 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)
16Knowledge-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
17Knowledge-brokering
- Two aspects
- Managing knowledge
- Promoting uptake of knowledge
18Knowlege management
- generating knowledge
- accumulating knowledge
- synthesising knowledge
- translating knowledge
- disseminating knowledge
19Generating 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)
20Accumulating 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
21Synthesising knowledge
- Bringing together different types of knowledge to
present a composite picture to inform practice - Synthesising research evidence, professional
expertise and patient experience
22Translating 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
23Disseminating 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
24Promoting 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
25Factors 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
26Conclusion
- 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
27Capturing 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)
28Background
- 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).
29Overall 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
30Project 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
31Framework for capturing impact
Informed by the work of Schulz et al (2002)
Gerrish et al. (2007)
32Capturing 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
33References
- 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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