Senior and Advanced Practitioners as part of the multidisciplinary team The Reality of Practice Ms J Corcoran- Lead practitioner for professional & Role Development

Aims of Session To present the findings of a qualitative study. To present the findings of a qualitative study. To provide a theoretical understanding on current barriers To provide a theoretical understanding on current barriers To highlight strategies to facilitate such roles within a team context. To highlight strategies to facilitate such roles within a team context.

Design & Method Charmaz (2006) constructive Grounded Theory (GT) approach was employed; Charmaz (2006) constructive Grounded Theory (GT) approach was employed; Data collection was via in depth interviews from 18 mulitprofessionals who had worked with an SNP or ANP within an acute care setting in Scotland. Data collection was via in depth interviews from 18 mulitprofessionals who had worked with an SNP or ANP within an acute care setting in Scotland. Data were analysed by constant comparative analysis inherent with this GT approach. Data were analysed by constant comparative analysis inherent with this GT approach.

Background In the United Kingdom government policy has highlighted the need for NHS modernisation; central to this reform is multidisciplinary team working (DOH 2000;SGHD 2007). In the United Kingdom government policy has highlighted the need for NHS modernisation; central to this reform is multidisciplinary team working (DOH 2000;SGHD 2007). These changes have also lead to an increase in SNP/ANP roles. These changes have also lead to an increase in SNP/ANP roles.

Research Question How do members of the multiprofessional team perceive the senior or advanced practitioner role? How do members of the multiprofessional team perceive the senior or advanced practitioner role? This research was part of phase one of a larger Grounded Theory study. This research was part of phase one of a larger Grounded Theory study. The purpose of the first phase was to develop a theoretical understanding of a wide range of stakeholders to inform phase two of the overall study. The purpose of the first phase was to develop a theoretical understanding of a wide range of stakeholders to inform phase two of the overall study.

Design & Method In-depth interviews following a topic guide was employed for data collection. In-depth interviews following a topic guide was employed for data collection. Data collection took place in 2007, exclusion criteria for this study was participants who did not have an experience working with a senior or advanced practitioner. Data collection took place in 2007, exclusion criteria for this study was participants who did not have an experience working with a senior or advanced practitioner.

Sample The sampling strategy was inherent within the constant comparative method, data were analysed and a number of themes emerged that informed the sampling strategy. The sampling strategy was inherent within the constant comparative method, data were analysed and a number of themes emerged that informed the sampling strategy. 18 multidisciplinary team members participated in the study 18 multidisciplinary team members participated in the study

Results Professional Cultures Professional Cultures Doctor/Nurse practitioner game Doctor/Nurse practitioner game Nurse/Nurse practitioner game Nurse/Nurse practitioner game

Professional Cultures It has been widely reported that the underlying philosophical base of professions within a health care team may limit true multiprofessional working. It has been widely reported that the underlying philosophical base of professions within a health care team may limit true multiprofessional working. (Firth -Cozens 1998; Finch 2000; Zwarenstein & Reeves 2000; Kavanagh &Cowan 2004). (Firth -Cozens 1998; Finch 2000; Zwarenstein & Reeves 2000; Kavanagh &Cowan 2004).

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

Professional Cultures Thomas (nurse) illuminates one of issues in relation to communication and professional cultures when he states “I mean it’s all very hierarchical, and I think we …are very aware of that because we are lower down in the hierarchy than them and that naturally breeds a resentment, you know, ‘Oh why should I clean up after them, they earn more than me!’

Professional Cultures All participants outlined that a barrier to these roles was due to differences in professional cultures. In words of George (Medic) “We are from different professional cultures maybe that’s why it doesn’t work””. Whilst Mickey (Medic) further elaborates, “I think for the junior doctors that’s much more difficult, there is still kind of ‘I’m a doctor you’re a nurse, you’re below me”.

Professional Cultures All participants within this study highlighted that resistance to NP roles came from both medical and nursing professions, In the words of Fraser (Consultant Medic) All participants within this study highlighted that resistance to NP roles came from both medical and nursing professions, In the words 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 game All medics (n=8) highlighted that there is a lot of resistance towards NP’s as they are undertaking roles that they would never have been “allowed” to do previously.

Doctor/Nurse practitioner game Michael a junior surgeon outlined that there is still resistance to these roles, when he stated “There comes a point where, sort of, a boundary may well have to be drawn where if somebody would say you know essentially this is the kind of thing that medical school might prepare you for, and not nursing school”.

Doctor/Nurse practitioner game Jayne (Junior Charge Nurse), Jayne (Junior Charge Nurse), “Some of the medical staff focus on the negative component. Whether that be that they’re threatened because of their roles changing or a general blurring of roles in departments”.

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

Nurse/Nurse practitioner game Mark (Medic) illustrates medical participants’ views, Mark (Medic) illustrates medical participants’ views, “The bigger issue that there is nurses not medics and I’ve had this where … nurses have phoned up and said ‘I need to speak to the doctor and refused to speak to the nurse practitioners. … but those are the people who make some nurse practitioners lives miserable ‘you think you’re something special now’

Nurse/Nurse practitioner game Nurse practitioners originate from the same profession as nurses therefore one could debate if the resistance is generated from a NP making decisions rather than a medic. Nurse practitioners originate from the same profession as nurses therefore one could debate if the resistance is generated from a NP making decisions rather than a medic. In the words of George (Medic) The nurses say who’s this jumped up so and so coming and telling me how to do my job”

Nurse/Nurse practitioner game One could liken this to the doctor-nurse game, this links to the original work of Berne (1964). One could liken this to the doctor-nurse game, this links to the original work of Berne (1964). In a social system individuals play games in all human relationships. In a social system individuals play games in all human relationships. Roles also become personal for individuals and these personal expectations shape or define the role of a nurse. Roles also become personal for individuals and these personal expectations shape or define the role of a nurse. Debate that NP’s who are seen to be in substitution roles, are viewed as an alternative doctor rather than a nurse within this social game. Debate that NP’s who are seen to be in substitution roles, are viewed as an alternative doctor rather than a nurse within this social game.

Nurse/Nurse practitioner game Louise (Nurse) illustrates, “Nurses are hard on nurses…Other staff will do things for a doctor but won’t help if it’s a nurse practitioner…something in the hierarchy of nursing. ”

Nurse/Nurse practitioner game As Thomas (Nurse) states, “These roles were forced upon us”. Whilst Rosie (Medic) illustrates, “You know the nurses in the ward don’t seem to accept them, it’s like they’re deserting their kind, you know and going off to the dark side as such “

Current Barriers It would appear that traditional professional boundaries within a multiprofessional team context are hindering the acceptance of NP roles within practice. It would appear that traditional professional boundaries within a multiprofessional team context are hindering the acceptance of NP roles within practice. Hybrid role – increase level of resistance Hybrid role – increase level of resistance

Current Barriers This has implications on the acceptance of such roles and thus the ongoing socialisation of working within multiprofessional teams. This has implications on the acceptance of such roles and thus the ongoing socialisation of working within multiprofessional teams. Resistance is apparent from both nursing and medicine perspectives, fuelled by the lack of clarity surrounding varying NP roles within the research site. Resistance is apparent from both nursing and medicine perspectives, fuelled by the lack of clarity surrounding varying NP roles within the research site.

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

Current Barriers NP roles raise identity issues for most nurses, with the undercurrent that such individuals within these roles are deserting their profession and siding with medicine. NP roles raise identity issues for most nurses, with the undercurrent that such individuals within these roles are deserting their profession and siding with medicine. This appears to be threatening for nurses as it challenges their professional belief system surrounding what it is to be a nurse. This appears to be threatening for nurses as it challenges their professional belief system surrounding what it is to be a nurse.

Strategies to facilitate such roles within a team context. Service led NHS Not professional rigid NHS service. Service led NHS Not professional rigid NHS service. Clear outline of how such roles will work within a team. Clear outline of how such roles will work within a team. Organisational planning with different members of teams input in planning. Organisational planning with different members of teams input in planning. Dual reporting structure. Dual reporting structure.

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