A study of ward-based advanced nurse practitioners found them to be linchpin members of the team, role models and pioneers
Susan Williamson is senior research fellow at the School of Health, University of Central Lancashire; Timothy Twelvetree is research fellow at the School of Nursing Midwifery and Social Work, University of Manchester; Jacqueline Thompson is advanced nurse practitioner at Central Manchester Foundation Trust; Kinta Beaver is professor of cancer nursing at the School of Health, University of Central Lancashire.
Williamson S et al (2012) The role and benefits of ward-based advanced nurse practitioners. Nursing Times; 109: online issue.
Background: ANPs are able to carry out patient consultations and physical examinations, arrive at a differential diagnosis and prescribe where appropriate. However, there is little research evidence describing what
ANPs actually do to fulfil their role and their impact on nursing practice and patient care.
Aim: To examine the role of ward-based ANPs and their impact on patient care and nursing practice.
Method: Five ANPs employed on acute medical wards caring for patients within different specialties were observed by a researcher over a one-week period. In-depth interviews were also conducted with the ANPs, a sample of 14 ward nurses and five patients, as well as informal interviews with medical and other staff during the observation periods.
Results: The ANPs were seen as linchpins, role models and pioneers, and were found to enhance communication and practice, and help with the patients’ journey.
Conclusion: Ward-based ANPs developed a pivotal role in achieving the nursing and medical practice necessary for providing holistic patient care. Their role can be defined as more than junior doctor substitutes.
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article in the ‘Files’ section of this page
5 key points
- There is little research on what advanced nurse practitioners actually do in acute medical wards
- ANPs can be a vital link between medical and nursing teams
- Their familiarity with the hospital and networking skills mean ANPs can be an information and communication resource for staff at all grades
- There is a risk that having an ANP on the ward could be deskilling, reducing the need for ward nurses to use their initiative and develop their own skills
- ANPs often have to meet competing demands and, in some cases, overcome the antagonism of colleagues
Changes to doctor/nurse skill mix combined with a focus on improving the quality of care while also reducing costs has altered healthcare delivery in the western world (Gardner et al, 2007; Bryant-Lukosius et al, 2004; Ball and Cox, 2003). In the UK, a reduction in junior doctors’ working hours and more structured supervision requirements for training has led to the development of more specialist and advanced nursing roles.
Nurses are equipped to take on many procedures and tasks traditionally associated with junior doctors (Cox, 2001; Dowling et al, 1995; NHS Executive, 1991). Additional training and education has enabled advanced nurse practitioners (ANPs) to carry out patient consultations and physical examinations, arrive at a differential diagnosis and prescribe where appropriate.
Despite studies identifying what the role of ANPs should be and what ANPs are able to do, there is little research describing what they actually do to fulfil their role and how this affects nursing practice and patient care (Lloyd-Jones, 2005; Bryant-Lukosius et al, 2004). This study aimed to examine these issues.
The study was carried out using observation and interviews.
A researcher observed five ANPs as they worked on acute medical wards in different specialties at a large teaching hospital in the North West of England. Each ANP was observed over a one-week period for between two and three hours each day on different shifts to ensure the researcher had a balanced view of the tasks each ANP carried out.
In-depth interviews were also conducted with the ANPs, a sample of 14 ward nurses and five patients. Informal interviews were carried out with medical and other staff during the observation periods.
The main concept that emerged from the analysis was that of the ANP as a linchpin (Fig 1).
Other themes included enhancing communication and practice, acting as a role model, facilitating the patients’ journey and as pioneers of the role.
ANP as a linchpin
ANPs were involved in most aspects of patient care. Despite initial scepticism, medical consultants described ANPs as “pivotal”, and a vital link between medical and nursing teams. ANPs shared responsibility for patients with junior doctors and, because they were ward based, provided a continuity that junior doctors could not.
Their specialist knowledge, technical skills and clinical judgement were respected and their continued presence on the ward enabled staff to gain a detailed understanding of each patient’s history and circumstances. All grades and types of staff used ANPs as an information and communication resource, asking them about patients’ condition, diagnosis and treatment.
Ward nurses considered ANPs to be more closely allied to the medical rather than nursing teams and felt that, although ANPs assisted with nursing work, they did not actually do any “hands-on” nursing. This view was not shared by ANPs who felt their role enabled them to spend more time practising nursing.
Enhancing communication and practice
ANPs were observed to be experienced and confident practitioners who used complex communication skills that inexperienced nurses and doctors had not developed. They frequently “translated” medical instructions for nurses, patients and allied health professionals, to ensure the significance of planned care was understood.
Nurses generally found ANPs less intimidating and more approachable than doctors when resolving care issues, and having an ANP available inspired confidence as nurses felt they always had back-up and support. The ANPs picked up on issues that needed to be addressed to prevent patient deterioration or delayed stay.
ANPs used their technical knowledge and skills to provide support and teaching, particularly to nurses and junior doctors when they first started on the wards and were unfamiliar with the organisation. The ANPs’ familiarity with the hospital and their networking skills brought advantages. ANPs reported that part of their role was to support and guide junior doctors to enable them to be more efficient while still familiarising themselves with the hospital systems.
Sometimes having an ANP on the ward could be deskilling, reducing the need for ward nurses to use their initiative and develop their own skills. ANPs reported that it was flattering when ward nurses assumed they would always have answers to their questions, but it reduced the need for them to use their own skills.
Helping with the patient’s journey
ANPs anticipated what would be needed for patients and improved the speed at which tests and investigations were carried out. They ensured referrals were acted upon to improve patient care and reduce length of patient stay; they also anticipated patient discharge and ensured that prescriptions were ordered, and appropriate services were in place.
The ANPs’ rapid response to patient deterioration was highly valued; patients who might otherwise have “triggered” on the early warning score (EWS) system were subject to prompt intervention by an ANP.
Pioneering the role
ANPs felt that their role had not been clearly defined and their educational qualifications had not prepared them sufficiently for the role, and placed a high value on the clinical teaching and support provided by consultant physicians.
However, the ANPs perceived that they were part of neither the medical nor the nursing team, yet had to meet competing demands and, in some cases, overcome the antagonism of colleagues. Many senior nurses expressed initial misgivings about working with an ANP as they expected some degree of role conflict. They were concerned that ward nurses would be deskilled as the ANPs undertook many of the extended roles that senior nurses had previously performed. Each ANP had to prove their value by identifying a niche and developing their role.
The findings from this study confirm that ANP roles are not clearly defined, yet clear role definitions are essential if the quality and value of care are to be improved
(NHS Institute, 2012; Department of Health, 2010).
This study found key roles and common tasks that positioned ANPs as linchpins in the wards on which they worked. Table 1 describes these roles and tasks to give an overview of role expectation that may be useful for healthcare educators and providers. However, it is acknowledged that providing such structured definitions of the role could conflict with the professional autonomy an ANP role brings.
It could be argued that role uncertainty and a lack of clarity of roles is an inevitable consequence of increasing specialisation in the nursing profession. The ANPs in this study felt that their master’s degrees had not adequately prepared them for their clinical role, with too little emphasis on practical skills. Other research has shown that the characteristics required for effective ANP working include confidence, adaptability, negotiating skills, political astuteness, motivation and creativity (Lloyd Jones, 2005). However, these were areas that the ANPs in this study had to learn on the job. A vicious circle is evident here: how can ANPs be prepared for a role that has not been clearly defined?
All grades of staff involved in patient care clearly respected and valued the clinical judgement of these ward-based ANPs. Their knowledge and skills enabled them to work across specialist boundaries in a similar way to junior doctors, yet they were perceived as more useful as a result of their continued presence, approachability and enhanced technical and communication skills.
The introduction of ANPs was viewed as a way to reduce work pressure on junior doctors and a question remains whether the NHS is willing to continue with this development. Acute sector medical and nursing budgets are separate and distinct. If the contributions of ANPs to reducing medical workload are not recognised within nursing budgets, support for these relatively high-grade positions may not continue.
Further work is needed to assess the impact of ward-based ANPs on response to EWS triggers, patient length of stay and the corresponding economic impact on patient care (NHS Institute, 2012; Clarke and Aiken, 2003).
Ward-based ANPs ensure high-quality holistic patient care and use their considerable nursing expertise, networks and insider knowledge of healthcare systems not only to assist with patient care but also to develop a pivotal role in enabling high-quality nursing and medical practice.
This study demonstrates that their nursing heritage, and their increased skills and knowledge, mean ward-based ANPs are more than junior doctor substitutes. NT
● This is a summary of an article originally published in the Journal of Advanced Nursing. Williamson S et al (2012) An ethnographic study exploring the role of ward-based advanced nurse practitioners in an acute medical setting. Journal of Advanced Nursing. DOI: 10.1111/j.1365-2648.2012.05970.
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