Senior and Advanced Senior and Advanced Practitioners as part of Practitioners as part of the multidisciplinary team the multidisciplinary team The Reality of PracticeThe Reality of Practice

Ms J Corcoran- Lead practitioner for professional & Role Ms J Corcoran- Lead practitioner for professional & Role

DevelopmentDevelopment

Aims of SessionAims of Session

To present the findings of a To present the findings of a qualitative study.qualitative study.

To provide a theoretical To provide a theoretical understanding on current understanding on current barriersbarriers

To highlight strategies to To highlight strategies to facilitate such roles within a facilitate such roles within a team context. team context.

Design & MethodDesign & Method

Charmaz (2006) constructive Grounded Charmaz (2006) constructive Grounded Theory (GT) approach was employed; Theory (GT) approach was employed;

Data collection was via in depth Data collection was via in depth interviews from 18 mulitprofessionals interviews from 18 mulitprofessionals who had worked with an SNP or ANP who had worked with an SNP or ANP within an acute care setting in Scotland. within an acute care setting in Scotland.

Data were analysed by constant Data were analysed by constant comparative analysis inherent with this comparative analysis inherent with this GT approach. GT approach.

Background Background

In the United Kingdom In the United Kingdom government policy has government policy has highlighted the need for NHS highlighted the need for NHS modernisation; central to this modernisation; central to this reform is multidisciplinary team reform is multidisciplinary team working (DOH 2000;SGHD 2007). working (DOH 2000;SGHD 2007).

These changes have also lead to These changes have also lead to an increase in SNP/ANP roles. an increase in SNP/ANP roles.

Research QuestionResearch Question

How do members of the How do members of the multiprofessional team perceive the multiprofessional team perceive the senior or advanced practitioner role? senior or advanced practitioner role?

This research was part of phase one of This research was part of phase one of a larger Grounded Theory study. a larger Grounded Theory study.

The purpose of the first phase was to The purpose of the first phase was to develop a theoretical understanding of develop a theoretical understanding of a wide range of stakeholders to inform a wide range of stakeholders to inform phase two of the overall study. phase two of the overall study.

Design & MethodDesign & Method

In-depth interviews following a In-depth interviews following a topic guide was employed for data topic guide was employed for data collection. collection.

Data collection took place in 2007, Data collection took place in 2007, exclusion criteria for this study exclusion criteria for this study was participants who did not have was participants who did not have an experience working with a an experience working with a senior or advanced practitioner.senior or advanced practitioner.

Sample Sample

The sampling strategy was inherent The sampling strategy was inherent within the constant comparative within the constant comparative method, data were analysed and a method, data were analysed and a number of themes emerged that number of themes emerged that informed the sampling strategy. informed the sampling strategy.

18 multidisciplinary team members 18 multidisciplinary team members participated in the study participated in the study

Results Results

Professional CulturesProfessional Cultures Doctor/Nurse practitioner gameDoctor/Nurse practitioner game Nurse/Nurse practitioner game Nurse/Nurse practitioner game

Professional CulturesProfessional Cultures

It has been widely reported that It has been widely reported that the underlying philosophical base the underlying philosophical base of professions within a health of professions within a health care team may limit true care team may limit true multiprofessional working.multiprofessional working.

(Firth -Cozens 1998; Finch 2000; Zwarenstein & Reeves 2000; (Firth -Cozens 1998; Finch 2000; Zwarenstein & Reeves 2000;

Kavanagh &Cowan 2004).Kavanagh &Cowan 2004).

Professional CulturesProfessional Cultures

Kavanagh & Cowan (2004) Kavanagh & Cowan (2004) propose that teams within the propose that teams within the NHS can be deeply hierarchical NHS can be deeply hierarchical with big differences in status and with big differences in status and rewards between team members. rewards between team members.

Professional Cultures Professional Cultures

Thomas (nurse) illuminates one of issues in relation to Thomas (nurse) illuminates one of issues in relation to communication and professional cultures when he statescommunication and professional cultures when he states

““I mean it’s all very hierarchical, and I think I mean it’s all very hierarchical, and I think we …are very aware of that because we we …are very aware of that because we are lower down in the hierarchy than are lower down in the hierarchy than them and that naturally breeds a them and that naturally breeds a resentment, you know, ‘Oh why should I resentment, you know, ‘Oh why should I clean up after them, they earn more than clean up after them, they earn more than me!’me!’

Professional Cultures Professional Cultures

All participants outlined that a barrier to these roles was due to All participants outlined that a barrier to these roles was due to differences in professional cultures. differences in professional cultures.

In words of George (Medic)In words of George (Medic)

““We are from different professional cultures We are from different professional cultures maybe that’s why it doesn’t work””.maybe that’s why it doesn’t work””.

Whilst Mickey (Medic) further elaborates,Whilst Mickey (Medic) further elaborates,

““I think for the junior doctors that’s much more I think for the junior doctors that’s much more difficult, there is still kind of ‘I’m a doctor difficult, there is still kind of ‘I’m a doctor you’re a nurse, you’re below me”.you’re a nurse, you’re below me”.

Professional Cultures Professional Cultures

All participants within this study All participants within this study highlighted that resistance to NP highlighted that resistance to NP roles came from both medical and roles came from both medical and nursing professions, In the words nursing professions, In the words of Fraser (Consultant Medic) of Fraser (Consultant Medic)

“It’s like some sort of doctor and nurse game and then you’ve got the nurse and nurse practitioner game”.

Doctor/Nurse practitioner Doctor/Nurse practitioner gamegame

All medics (n=8) highlighted that All medics (n=8) highlighted that there is a lot of resistance there is a lot of resistance towards NP’s as they are towards NP’s as they are undertaking roles that they would undertaking roles that they would never have been “never have been “allowed”allowed” to do to do previously. previously.

Doctor/Nurse practitioner Doctor/Nurse practitioner gamegame

Michael a junior surgeon outlined that there is still Michael a junior surgeon outlined that there is still resistance to these roles, when he statedresistance to these roles, when he stated

““There comes a point where, sort There comes a point where, sort of, a boundary may well have to of, a boundary may well have to be drawn where if somebody be drawn where if somebody would say you know essentially would say you know essentially this is the kind of thing that this is the kind of thing that medical school might prepare medical school might prepare you for, and not nursing school”.you for, and not nursing school”.

Doctor/Nurse practitioner Doctor/Nurse practitioner gamegame

Jayne (Junior Charge Nurse), Jayne (Junior Charge Nurse),

““Some of the medical staff Some of the medical staff focus on the negative focus on the negative component. Whether that be component. Whether that be that they’re threatened that they’re threatened because of their roles because of their roles changing or a general blurring changing or a general blurring of roles in departments”.of roles in departments”.

Nurse/Nurse Nurse/Nurse practitioner gamepractitioner game

All nursing and medical All nursing and medical participants (n=16) illuminated participants (n=16) illuminated the perception that nurse the perception that nurse practitioners are treated with practitioners are treated with hostility from other nurses. hostility from other nurses.

Nurse/Nurse Nurse/Nurse practitioner gamepractitioner game

Mark (Medic) illustrates medical participants’ views,Mark (Medic) illustrates medical participants’ views,

““The bigger issue that there is nurses The bigger issue that there is nurses not medics and I’ve had this where not medics and I’ve had this where … nurses have phoned up and said … nurses have phoned up and said ‘I need to speak to the doctor and ‘I need to speak to the doctor and refused to speak to the nurse refused to speak to the nurse practitioners. practitioners. … … but those are the but those are the people who make some nurse people who make some nurse practitioners lives miserablepractitioners lives miserable ‘you ‘you think you’re something special now’think you’re something special now’

Nurse/Nurse Nurse/Nurse practitioner gamepractitioner game

Nurse practitioners originate from the Nurse practitioners originate from the same profession as nurses therefore one same profession as nurses therefore one could debate if the resistance is generated could debate if the resistance is generated from a NP making decisions rather than a from a NP making decisions rather than a medic. medic.

In the words of George (Medic) In the words of George (Medic) The nurses say who’s this jumped up so The nurses say who’s this jumped up so

and so coming and telling me how to and so coming and telling me how to do my job”do my job”

Nurse/Nurse Nurse/Nurse practitioner gamepractitioner game

One could liken this to the doctor-nurse game, One could liken this to the doctor-nurse game, this links to the original work of Berne (1964).this links to the original work of Berne (1964).

In a social system individuals play games in all In a social system individuals play games in all

human relationships. human relationships.

Roles also become personal for individuals and Roles also become personal for individuals and these personal expectations shape or define the these personal expectations shape or define the role of a nurse. role of a nurse.

Debate that NP’s who are seen to be in Debate that NP’s who are seen to be in substitution roles, are viewed as an alternative substitution roles, are viewed as an alternative doctor rather than a nurse within this social game.doctor rather than a nurse within this social game.

Nurse/Nurse Nurse/Nurse practitioner gamepractitioner game

Louise (Nurse) illustrates,Louise (Nurse) illustrates,

““NursesNurses are hard on nurses…Other are hard on nurses…Other staff will do things for a doctor staff will do things for a doctor

but won’t help if it’s a nurse but won’t help if it’s a nurse practitioner…something in the practitioner…something in the

hierarchy of nursing.hierarchy of nursing. ””

Nurse/Nurse Nurse/Nurse practitioner gamepractitioner game

As Thomas (Nurse) states,As Thomas (Nurse) states,

““These roles were forced upon us”. These roles were forced upon us”.

Whilst Rosie (Medic) illustrates,Whilst Rosie (Medic) illustrates,

““You know the nurses in the ward don’t You know the nurses in the ward don’t seem to accept them, it’s like they’re seem to accept them, it’s like they’re deserting their kind, you know and deserting their kind, you know and going off to the dark side as suchgoing off to the dark side as such “ “

Current Barriers Current Barriers

It would appear that traditional It would appear that traditional professional boundaries within a professional boundaries within a multiprofessional team context multiprofessional team context are hindering the acceptance of are hindering the acceptance of NP roles within practice. NP roles within practice.

Hybrid role – increase level of Hybrid role – increase level of resistance resistance

Current BarriersCurrent Barriers

This has implications on the This has implications on the acceptance of such roles and thus the acceptance of such roles and thus the ongoing socialisation of working within ongoing socialisation of working within multiprofessional teams. multiprofessional teams.

Resistance is apparent from both Resistance is apparent from both nursing and medicine perspectives, nursing and medicine perspectives, fuelled by the lack of clarity fuelled by the lack of clarity surrounding varying NP roles within surrounding varying NP roles within the research site. the research site.

Current BarriersCurrent Barriers

Junior medical staff resistance Junior medical staff resistance appears to stem from a appears to stem from a professional belief system, professional belief system, encompassing the perceived encompassing the perceived reduction in training opportunities reduction in training opportunities due to the implementation of due to the implementation of such roles such roles

Current BarriersCurrent Barriers

NP roles raise identity issues for most NP roles raise identity issues for most nurses, with the undercurrent that nurses, with the undercurrent that such individuals within these roles are such individuals within these roles are deserting their profession and siding deserting their profession and siding with medicine. with medicine.

This appears to be threatening for This appears to be threatening for nurses as it challenges their nurses as it challenges their professional belief system surrounding professional belief system surrounding what it is to be a nurse. what it is to be a nurse.

Strategies to facilitate Strategies to facilitate such roles within a team such roles within a team context.context. Service led NHS Not professional Service led NHS Not professional

rigid NHS service. rigid NHS service. Clear outline of how such roles will Clear outline of how such roles will

work within a team. work within a team. Organisational planning with Organisational planning with

different members of teams input different members of teams input in planning.in planning.

Dual reporting structure .Dual reporting structure .

Any Questions Any Questions