Ann McDonnell Sheffield Hallam University UK

1. Advanced Practice Nurses: Promoting evidence based practice and capturing impact: lessons from two UK studies Ann McDonnell Sheffield Hallam University UK

2. The City of Sheffield • Britain’s 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

3. 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

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/

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

6. 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

7. 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

8. 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

9. 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

10. 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

11. Data collection – short case studies (n = 18)

12. Data collection – in depth case studies (n=5)

13. Findings from the case studies

14. 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

15. 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)

16. 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 it’s 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 … It’s about bridging that gap between the theoretical and the practical in developing policy which then directs practice. Director of Nursing

17. Knowledge-brokering Two aspects: • Managing knowledge • Promoting uptake of knowledge

18. Knowlege management • generating knowledge • accumulating knowledge • synthesising knowledge • translating knowledge • disseminating knowledge

19. Generating knowledge • Empirical evidence • Research • Organisational evidence – audit / service evaluation • Professional experience • It’s 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. They’ve taken so much from all of their patients, absorbed things that have been said to them and put it together (Patient)

20. 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

21. Synthesising knowledge • Bringing together different types of knowledge to present a composite picture to inform practice • Synthesising research evidence, professional expertise and patient experience

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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)

28. 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).

29. 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

30. 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

31. Physical/psychological wellbeing Quality of life & social wellbeing Patient behavioural change Patient experience of healthcare Clinical significance Organisational Professional significance significance Professional competence Quality of working life Organisational priorities / targets D evelopment of policy Workload distribution Generation of new knowledge Team working Framework for capturing impact Informed by the work of Schulz et al (2002) & Gerrish et al. (2007)

32. 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

33. 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), 2004–2014. 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.

34. Sheffield