Summary of the impact

Advanced practice roles in nursing (APN roles) have been developed widely across a range of healthcare settings and organisational boundaries in response to government policy directives. A programme of research has been undertaken to generate robust evidence of the contribution of APN roles to healthcare. Research outputs include a theoretical framework to evaluate the impact of these roles. This framework has been used to underpin the development of a practical toolkit to assist practitioners to demonstrate their impact on patients, staff and the organisations in which they work. Beneficiaries include policymakers, professional organisations and NHS providers and individual practitioners.

Underpinning research

Mounting costs of healthcare, limited financial resources and an ageing population have led to major reconfigurations of the healthcare workforce and the development of advanced practice roles which cross traditional professional boundaries. These include advanced nursing practice roles such as clinical nurse specialists and nurse consultants. Research undertaken at Sheffield Hallam University (SHU) enables the impact of these new service developments to be captured in practice. Underpinning research has been developed through publications and awards dating back to 2006. The focus of the studies used as exemplars here (Grants 1 and 2) has been to demonstrate the contribution that nurses in advanced practice roles make to healthcare, develop a robust theoretical framework to capture APN impact, and to translate this into practical tools that APNs can use to capture their own impact in routine practice. This work is now expanding to include evaluations of the impact of advanced roles in a variety of organisational settings (Grants 3 and 4). A study to examine the impact of APNs in promoting evidence based practice among frontline staff (Grant 1) was carried out between 2003 and 30/09/2007 (transferred to SHU on 01/10/2006) and was led by Kate Gerrish (left for Sheffield University 2011, Professor). Angela Tod (2006 - present, Professor) was a co-applicant and Ann McDonnell (2006 - present, Professor) was a member of the research team. This was a mixed-method study comprising a national survey of 855 Advanced Practice Nurses followed by qualitative case studies of 23 APNs. Data analysis for this study was completed at SHU and all publications relating to the study were written following transfer to SHU (e.g. Ref 3).

A key output from the study, developed following the transfer of the study to SHU, was a conceptual framework to evaluate the impact of APN roles based on the work of Schultz et al (2002) who proposed that outcomes should be viewed in terms of their clinical rather than statistical significance. This framework was extended and a parallel framework developed for judging the professional significance of impact, i.e. impact on staff. This was followed by a study exploring approaches to measuring the impact of nurse consultants (NCs) on patient, professional and organisational outcomes. This research was funded through a grant awarded to Kate Gerrish and Ann McDonnell (Grant 2). The research team included Fiona Kennedy (2009 to present, Research Fellow) and Judy Redman (2006 - present, Senior Lecturer). This was a mixed-method study including a systematic review of existing evidence on the impact of NC roles (Ref 2) and a series of six NC case studies. The findings highlighted that capturing the impact of nurse consultants was influenced by a number of challenges. These included attributing impact to an individual who often worked as part of a team, the complexity of capturing indirect (as opposed to direct) impact, identifying suitable outcome measures and comparators, difficulties in gaining a patient perspective, limited time and resources, and a lack of expertise in measuring impact.

The study had two key outputs:

i. An extended framework for capturing impact based on three domains (Ref 1):
Clinical significance (symptomatology, quality of life and social wellbeing, clinical social significance, clinical social validity)
Professional significance (professional competence, quality of working life, professional social significance, professional social validity)
Organisational significance (organisational social significance, achievement of organisational priorities and targets, development of policy, generation of new knowledge).

ii. 'Capturing Impact. A practical toolkit for Nurse Consultants'. This toolkit is a practical, evidence based resource which draws on the above framework and the lessons learned on the practicalities of capturing impact from the research study (Source 1).

This guidance helps nurses in advanced roles first to characterise and define the full scope of their impact. The guidance then goes on to help them to capture their impact in practice. Through a series of reflective activities and worked examples, readers are guided on how to distinguish impact from process, how to identify impact using the framework, how to prioritise which areas of impact to capture, how to capture impact in practice, how to evaluate economic aspects of their roles and how to disseminate evidence of their impact. A series of tools for capturing impact is included which may be adapted for individual use.

References to the research

Peer reviewed publications:

Key grants:

Grant 1. 2003 - 30/09/2007. Empowering front-line staff to deliver evidence-based care: the contribution of nurses in advanced practice roles. Department of Health Policy Research Programme. £169,872. PI: Kate Gerrish. Co-applicant: Angela Tod.

Grant 2. 06/05/2009 - 31/05/2011. Approaches to measuring the impact of nurse consultants on patient, professional and organisational outcomes. Burdett Trust for Nursing. £149,824. Co- applicants Kate Gerrish and Ann McDonnell.

Grant 3. 01/03/2011 - 31/03/2013. An evaluation of the implementation of Advanced Nursing Practitioner (ANP) roles at Barnsley Hospital NHS Foundation Trust. Yorkshire and Humber Strategic Health Authority and Barnsley Hospital NHS Foundation Trust. £106,000. PI: Ann McDonnell

Grant 4. 01/09/2012 - ongoing. Exploring the impact of Lung Cancer Nurse Specialist nurses on access to anti-cancer treatment: an exploratory case study. General Nursing Council Trust and the Lung Cancer Forum for Nurses. £25,000. PIs: Ann McDonnell and Angela Tod

Details of the impact

This work makes a unique contribution to the development of advanced nursing roles by providing a robust theoretical framework to guide the assessment of the impact of these roles. The provision of a practical toolkit, based on this framework, to assist advanced practitioners to demonstrate their impact is a unique resource. All research outputs are downloadable from the project website (Source 1) (which has had 1874 hits) and include:

• the composite toolkit
• a series of reflective activities
• a series of tools and instruments to capture impact
• spreadsheets and coding sheets for use with some of the data collection instruments
• guidance on return on investment and capturing economic aspects of advanced roles Both the theoretical framework and the practical guidance were disseminated through a variety of activities designed to engage the clinical community. The Executive Summary for the NC study and a flyer describing the toolkit was sent to the Chief Nurse in every NHS Trust in England and Wales (May 2012). A dissemination event attended by 53 Nurse Consultants and their managers from across the UK was held: 'Capturing the Impact of Nurse Consultant Roles: tips, tools & techniques' (April 2012). The research findings have also been presented at national and international conferences and by invited keynote presentations to groups including: the Consultant Nurse Association for England (Mental Health and Learning Disabilities) (Sept 2012) and the Nursing, Midwifery and Allied Health Professions Consultant Network in Lanarkshire, Scotland (Dec 2012). A news item 'Because you're worth it' was published in the Nursing Standard in July 2013 (Source 2). The Nursing Standard has an average weekly circulation of >61,000. Beneficiaries of this research include policymakers, professional organisations and NHS providers and individual practitioners.

Impact on policymakers
McDonnell and Gerrish were approached by a senior official from the Workforce Directorate of the Department of Health in Sept 2012 with a request to develop a proposal to adapt the toolkit for use by Health Visitor Practice Teachers in order to demonstrate their impact on student, professional and organisational outcomes. A decision regarding the funding of this work by the DoH was still awaited on 31 July 2013.

Impact on professional organisations and NHS providers
The toolkit is highlighted on and is available for download from the websites of the following organisations:
The Knowledge Network Scotland
http://www.knowledge.scot.nhs.uk/media/CLT/ResourceUploads/4005511/AHPConsultantImpactN C%20Toolkit%20final.pdf
The Forum of Mental Health & Learning Disability Nurse Directors and Leads
http://www.mentalhealthforum.org.uk/index.php/consultant-nurse-association
Nottingham University Hospitals Research and Innovation extranet
http://nuhrise.org/2011/11/measuring-nurse-consultant-impact-on-patient-professional-and- organisational-outcomes/
Centre for Nurse and Midwife Led Research http://www.cnmr.org.uk/article.php?article=431

The toolkit is highlighted in 'SCAN' Senior Nurse/Midwife Current Awareness from Northern Ireland Practice and Education Council August 2012. The Foundation for Nursing Studies sent a news release detailing the toolkit and included a link to the project website to everyone on their mailing list (n > 6000), 16^th July 2012 (Source 3). Three organisations contacted the research team directly in 2012, following the dissemination event, to express an interest in working with us to support them to use the toolkit in practice to capture the impact of their nursing and allied health professional consultants:

• The Consultant Nursing, Midwifery and Allied Health Professional (CNMAHP) Forum for Wales (Source 4)
• Great Ormond Street Hospital NHS Foundation Trust (Source 5)
• Newcastle upon Tyne Hospitals NHS Foundation Trust (Source 1)

The research team conducted a workshop with all or the majority of the consultants in each organisation in Jan 2013, Feb 2013 and April 2013 respectively, following which the consultants used the toolkit in practice. The process finished with a further workshop on each site to reflect on the process and for users to provide feedback on what aspects of their work had benefited from the toolkit and any challenges they faced when using it. The roles within these three organisations covered a wide range of clinical specialties including paediatrics, critical care, gynaecology, stroke services, accident and emergency, frail older people and mental health. Examples of the impact the toolkit has had include: helping to evaluate a newly established Integrated Children's Centre, evaluating patient experience in Accident and Emergency in order to inform service development and assessing patient and parent satisfaction in order to improve a nurse-led adolescent Chronic Fatigue Service. The CNMAHP Forum for Wales also plan to use the framework as the basis for their annual report (Source 4). Reports are available on the project website (Source 1).

In 2012, at the suggestion of the Director of Nursing, the Specialist Nurse Forum at South Tees NHS Foundation Trust developed a six month project to capture the impact of all the Specialist Nurses and Advanced Nurse Practitioners working within the organisation using an adapted version of the toolkit 'Capturing Impact: A Practical Toolkit for Nurse Consultants'. The chair of the Forum described the toolkit as 'completely inspirational' and added `It allowed accurate, validated articulation of `what our jobs really were about', clarified thoughts and really focused attention to key areas efficiently and accurately.' A report detailing this project is available on the NC project website (Source 1).

The framework for capturing impact was also used in a scoping exercise of nursing, midwifery, pharmacy and Allied Health Professional consultants in a large NHS Foundation Trust. By using the framework to gather information on their activities and impact the consultants were able to communicate effectively with the senior managers and the Trust Board about their contribution to the organisation. This allowed the organisation to have a clear vision of where the consultants fitted within the Corporate Framework and allow informed decisions to be made about how to make best use of the skills of this diverse group (Source 6).

The toolkit is also a useful training resource and was used in the consultant midwife training programme in Hampshire and Isle of Wight Strategic Health Authority to guide completion of professional portfolios (Source 6).

The framework for capturing impact was used as the conceptual framework in research commissioned by the National Council for the Professional Development of Nursing and Midwifery (NCNM) in the Republic of Ireland to evaluate the role and outcomes of the Clinical Nurse/Midwife Specialist (CNS/CMS) and Advanced Nurse/Midwife Practitioner (ANP/AMP) roles in Ireland (Source 7). The toolkit has also been used as the basis of an evaluation of Nurse Consultant posts in a study funded by the Queen's Nursing Institute for Scotland, this being a partnership project between McMillan Rome Ltd, Edinburgh Napier University and the James Hutton Institute (Source 8).

Impact on individual practitioners
Nursing and midwifery consultants in England, Scotland and Wales were invited to complete an online survey to capture feedback on the toolkit between Feb and May 2013. 41 responses were received (Source 1). The ways in which the toolkit had been used included:

• helping individuals to reflect on their impact
• to inform the individual's annual appraisal
• to capture impact in practice

Other examples of impact on individuals include the following:

• a physiotherapist applying for a post as a Rehabilitation Consultant used the framework and the toolkit to formulate his presentation at the recruitment event. An email sent on 22nd March 2012 stated 'I have been offered the rehabilitation consultant post. I used the framework in the toolkit as the framework for my presentation, which went down very well (all referenced to yourselves). They seemed particularly pleased with the range of stakeholders and variety of potential impacts' (Source 9).
• A nurse consultant used the toolkit to build a case for the continuation of their post. An email sent on 7^th Dec, 2011 stated 'I would like to use (the toolkit) to evaluate my own role because my employer is reviewing the roles of all non ward based nurses and I need all the evidence I can prepare for the review'.

Sources to corroborate the impact

Source 1. Capturing the impact of Nurse Consultant posts. http://research.shu.ac.uk/hwb/ncimpact

Source 2. Nursing Standard (2013) Because you're worth it. Nursing Standard 27 (38) 61.
http://dx.doi.org/10.7748/ns2013.05.27.38.61.s54

Source 3. The Foundation for Nursing Studies http://www.fons.org/common-room/news.aspx

Source 4. Contact at The Consultant Nursing, Midwifery and Allied Health Professional Forum for Wales

Source 5. Contact at Great Ormond Street Hospital NHS Foundation Trust.

Source 6. Consultant midwife contact

Source 7. Begley C, Elliott N, Lalor J, Coyne I, Higgins A & Comiskey CM. (2013) Differences between clinical specialist and advanced practitioner clinical practice, leadership, and research roles, responsibilities, and perceived outcomes (the SCAPE study). Journal of Advanced Nursing 69(6), 1323-1337. doi:10.1111/j.1365-2648.2012.06124.x

Source 8. Contact at McMillan Rome Ltd.

Source 9. Consultant physiotherapist contact