Role Transition and the Nurse Practitioner: An Investigation into the Experience of Professional Autonomy Dr Andy Mercer University Department of Mental Health School of Health & Social Care Bournemouth University

Project aims To explore nurse practitioners’ experiences of role transition and professional autonomy, to gain a new understanding of how nurse practitioners experience their role, and new insight into the potential of the nurse practitioner role in the ever changing arena of health care delivery. To addresses the concept of professional autonomy, the boundaries of professional practice, and how this links to the legal, ethical and epistemological foundations of nursing practice in general, and more specifically to the professional role of the nurse practitioner.

Initial considerations Personal history Philosophy & health care Nursing ethics Patient/client autonomy UKCC-ENB-NMC

Focus & methodology Qualitative study, considering human experience Link between nursing ethics, nursing philosophy and method Phenomenology - hermeneutics Consideration of research focus Nurse practitioners Professional autonomy Role transition Detailed discussion of methodology Phenomenology (Husserl, Giorgi) Hermeneutics (Heidegger, Van Manen) Narratives, interpretation (Ricoeur)

Paul Ricoeur ( ) “Who am I?” “How should I live?” People play an active role in structuring their perceptions, therefore the meaning of perception needs to be interpreted in the context of the individual's situation.

Ricoeur's ethics Ricoeur believes that human life has an ethical aim, and that aim is self-esteem: “the interpretation of ourselves mediated by the ethical evaluation of our actions”. Self- esteem is itself “an evaluation process indirectly applied to ourselves as selves” (The Narrative Path, 1999)

Ricoeur's ethics Ricoeur emphasises the importance of the first person perspective and the notion of personal responsibility, but notes that we are “mutually vulnerable”, and so the fate (or self-esteem) of each of us is tied up with the fate of other (Oneself as Another, 1992)

Rosemarie Rizzo Parse US nurse, studied phenomenology at Duquesne University Best known for theory of 'human becoming' Sees the key role of the nurse as helping people understand personal (human) experience, and achieve 'wholeness' Linked nursing theory to research method

Research process NPs were approached by / phone and invited to participate Information and consent managed as per ethical approval Interviews typically lasted 45 – 60 minutes Interviews were transcribed verbatim WinMax used as aid to analysis Method, Data Collection Derived from Ricoeur Narrative interviews Recordings transcribed to create texts Data Analysis Three phases: Naïve interpretation Structural (descriptive) analysis Hermeneutic interpretation Sampling Purposeful sample: accredited NPs Mix of UK & US registered, all with experience of topic Diversity of clinical experience (Maximum variation sampling)

Methodology - detail Three stage process, based on Ricoeur, borrowing from work carried out by Wiklund, Lindholm & Lindström (2003), and by Lindseth & Norberg (2004), among others Naïve interpretation Descriptive structural analysis Hermeneutic Interpretation

Findings: naïve interpretation Initial impression was that participants discussed their experience of autonomy with reference to: InspirationSelf promotion RegulationFrustration Optimism “Nurse practitioners are comfortable in their role, and believe they are autonomous practitioners who offer a high standard of care to their patients. They do however feel some frustration in their day to day work within interprofessional teams because of their unequal relationship with medical colleagues, and the way in which care is organised and regulated, which together interfere with their ability to maximise their effectiveness”

Findings: Descriptive structural analysis First theme: Role Transition NP' experiences of role transition Barriers to role transition Other disciplines’ misunderstanding of the NP role Motivation to move into a NP role Second theme: Exercising autonomy The exercise of autonomy in practice Developing self-confidence within the NP role Experiencing frustration Legal Restrictions on practice

Findings: Descriptive structural analysis Third theme: NP’s professional relationships A unique perspective Professional boundaries Controlling influences Professional Relationships Fourth theme: NP-patient relationships Nurse practitioners’ attitudes to patients Experiencing ‘role satisfaction’ through patient care Patients’ misunderstanding of the NP role Reluctance to see the NP

Findings: Descriptive structural analysis Fifth theme: Nurse practitioners’ skills Nurse practitioners’ use of nursing skills Sixth theme: Reflections on the NP role Future prospects for nurse practitioners

Interpretation and discussion 1. Exercising autonomy Feelings of pride, self-esteem Evidence of doubt regarding potential for autonomy Controlling influences, legal restrictions, and prescribing Organisational structures Protocols, guidelines and clinical pathways External factors limiting the potential for autonomous practice Feelings of inferiority, deference to others

Interpretation and discussion 2. Nurse practitioner skills Promoting the nurse practitioner role Power and relationships Holistic care, better care Implementing care: knowledge and skills for practice Reflections on the effectiveness of the nurse practitioner role Collaborative working - nurse practitioners’ relationship with other disciplines Responses to being mistaken for a doctor

Interpretation and discussion 3. Role definition and role transition Uncertainty about the future Optimism

Implications for practice nurse practitioners have confidence in their ability to offer care to patients that is holistic, evidence based and effective nurse practitioners need an assertive voice to promote their role and their success in providing holistic care to diverse patient groups. ongoing uncertainty regarding statutory regulation of nurse practitioners, and continuing variation in their precise role definition have implications for maximising the potential evident in existing nurse practitioner roles. /cont

Implications for practice (cont.) the potential for nurse practitioners to work autonomously is dependent on their relationships with fellow professionals, particularly doctors more effective planning within multi-disciplinary teams prior to the introduction of a nurse practitioner might help to enhance positive professional relationships. nurse practitioners demonstrate evidence of ongoing uncertainty, or at least ongoing dissonance with regard to their position within the profession of nursing.

Conclusions A more robust definition of the nurse practitioner role, enshrined in statutory regulation, might pave the way for a philosophical debate about the future of advanced practice roles. To achieve maximal autonomy in practice settings, nurse practitioners may have to dissociate themselves further from the wider nursing profession, or at least to establish clarity in their role and regulation. This may provide the best opportunity for nurse practitioners to realise the external recognition that they appear to believe is vital to their further professional development.