The Advanced Paediatric Practitioner role in NHS Scotland: an exploratory study Mandy Allen 2014
Background and Policy Drivers: Changing patterns of care and complex needs for children and their families, reflects the need for service redesign and role development (Scottish Government 2006a, Scottish Government 2007b) The Scottish Government s key priorities in child health centres on building capacity and capability - shortage of skilled senior and middle ranking paediatric medical staff Significant changes to the way the medical workforce is prepared + reduction in junior doctor s hours - innovative development opportunities - one reason for the recent impetus to implement advanced paediatric practice (APP) roles
Background and Policy Drivers: Policy drivers have led to a reduction additionally in nursing and AHP workforce (Scottish Government 2006a, Scottish Government 2007a, Scottish Government 2009, Department of Health 2008) therefore need to develop innovative ways of working The increase in service user involvement leading to higher expectations for better choice, accessibility and better quality services (Scottish Government 2006, Scottish Government 2007)
What is the need for the workforce? To provide adequate, efficient and cost-effective health care which meets the need of the patient (child) and their family Role meets evolving service need Governance of new roles working within existing professional guidelines (Matzoukas and Watkinson 2006).
Who is the Advanced paediatric nurse practitioner? The International Council of Nurses (2002), International Nurse Practitioner/Advanced Practice Nursing Network definition: "A registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. A Master's degree is recommended for entry level."
NMC Advanced practitioners: take a comprehensive patient history carry out physical examinations; use their expert knowledge and clinical judgement to identify the potential diagnosis; refer patients for investigations where appropriate; make a final diagnosis; decide on and carry out treatment, including the prescribing of medicines, or refer patients to an appropriate specialist; use their extensive practice experience to plan and provide skilled and competent care to meet patients health and social care needs, involving other members of the health care team as appropriate; ensure the provision of continuity of care including follow-up visits; assess and evaluate, with patients, the effectiveness of the treatment and care provided and make changes as needed; work independently, although often as part of a health care team; provide leadership; and make sure that each patient s treatment and care is based on best practice. (NMC 2005)
Challenges for Advanced paediatric nurse practitioner role? Have roles evolved to be replacement for doctors (Bryant-Lukosius et al 2004) danger of being medically driven (Manley 1997). Sparse evidence showing the value of some roles, alongside inconsistent implementation of roles accusations of reactive policy implementation (Wilkinson 2008). Limited evidence suggests that advanced practitioners offer a key contribution to improving and enabling children to achieve their full potential (Scottish Government 2008, Newhouse et al 2008) Little evidence describing the impact of nurse practitioners value in the health service (Wilkinson 2008).
Scope of study Aim: To explore the understanding of the Advanced Paediatric Practitioner role from the perspective of service users and service providers within NHS Scotland Objectives: Explore the understanding of the Advanced Paediatric Practitioner role as experienced by parents whose child has been cared for by an Advanced Paediatric Practitioner within NHS Scotland Gain understanding of the Advanced Paediatric Practitioner role by exploring the perspective of current Advanced Paediatric Practitioners working in NHS Scotland Analyse the perception of the Advanced Paediatric Practitioner from the perspective of other professional groups who work closely alongside Advanced Paediatric Practitioners within NHS Scotland
Methodology - Hermeneutic Phenomenology: Gadamer s (1989) philosophical hermeneutics - theoretical framework underpinning this study. Gadamer s hermeneutics - the art of understanding text. He includes any text, conversation, a piece of art or a play in his definition of text so this is not limited. A hermeneutic framework will allow for the understanding of the APP role to be developed from as wide a perspective as possible - advocating openness and prohibiting any focus. No claim to be objective or to bracket my presuppositions (as often used in phenomenology). Presupposition is allowed and acknowledged through reflection, and development of shared understanding of dialogue. Guided by Fleming et al (2003) 5 stages research process
Developing a shared understanding Understanding what we are consists of the traditions and history (our norms, attitudes + values) which shape our view of the world therefore what we describe cannot be done outwith this context. It is our understanding of the world that allows us to ask questions and receive answers entering into dialogue. In this dialogue questions asked are based on our previous understanding given by Sache (subject matter) open us up to the Spiel (play or game) of language that takes place between question and answer. Therefore Gadamer shows that dialogue reaches far beyond the consciously constructed conversation.
Method of study: Sample - Purposive (selected subjects have experience of the phenomena under study). Participants: APPs (8), their managers, senior medical staff /AHPs who work with APPs(8), and parents whose children have been looked after by an APP(8). Gatekeepers: 8 Health boards approached. Pre-understanding of topic pre recorded (Fleming et al 2003). Individual interviews with participants recorded and field notes taken alongside. Interviews - transcribed verbatim and analysed in sequence- development of themes, understanding of whole text 2 nd round dialogue/conversations organised to engage with development of shared understanding of the emerging themes.
Underpinning the rigour of study: Hermeneutics - recognition that biases and assumptions are embedded and are essential to the interpretive process (Gadamer 1989, Laverty 2003). The researcher engages in a process of self-reflection, giving thought to their experience and making this explicit in the writing. Reflexivity will inform this process, supported by Koch (2006) who suggests that the researcher s position is never fixed and should be an on-going process of self-critique and self-appraisal. Guba and Lincoln (1994) framework to support study rigour.
Conclusion Initial themes are emerging some of which identify similarity to the literature surrounding this role but is separate and unique due to the methodology / hermeneutical framework being used. No other study has explored these dimensions together so this will demonstrate a unique understanding on the advanced paediatric practitioner role from different perspectives utilising this theoretical framework and will add a unique contribution to the body of knowledge on this topic area.
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