Action research can make changes to clinical practice while involving the whole team. A nursing team used this method to develop a thoracic support nurse role
Loretta Bellman, PhD, BSc, CertEd, RNT, RCNT, RN, was senior nurse research and development, University College London Hospitals Foundation Trust at the time of writing and is now trustee, Foundation of Nursing Studies; Philomena Corrigan,MSc (behavioural biology and healthcare), MSc (cardiology),BA, CertEd, RNT, DipN, RN, is consultant nurse cardiac care, University College London Hospitals Foundation Trust and senior lecturer, London South Bank University.
Bellman L, Corrigan P (2010) Using action research to develop a thoracic support nurse role to enhance quality of care. Nursing Times; 106: 22, early online publication.
Aim The project aimed to develop a new nurse role to support thoracic patients with complex needs.
Method An action research approach enabled frontline staff, called co-researchers, to systematically explore the change and development process of the new role. The 60 participants were the co-researchers, patients, ward nurses, and the multidisciplinary team.
Results and discussion Thematic analysis revealed five key themes: it is the need to improve patient care; it brought research to life; a rollercoaster of emotions and experiences; process is as important as outcome; and we did it ourselves and learnt so much.
Conclusion Patients and staff recognised how the new role significantly improved the quality of thoracic nursing care. However, there were many challenges to address including role conflict and continuing funding for the role.
Keywords Action research, Role development, Innovation
- This article has been double-blind peer reviewed
- New role development in clinical settings is complex, requiring a collaborative approach to planning, implementing and evaluating the role over a realistic timeline.
- An action research methodology enabled shared ownership and systematic planning, implementation and evaluation by frontline staff.
- In a new nurse role a key challenge is to try to maintain a clear boundary between new responsibilities and “helping out” in the ward, particularly when short staffed.
- There may be initial resistance from colleagues when significant changes to traditional nursing practice are being introduced, and this needs to be managed.
- Advanced practice nurses, particularly consultant nurses, can engage with colleagues to undertake practice based research.
This research project evolved from frontline nurses’ concern that thoracic patients with complex needs were not receiving optimal care. Nurses increasingly need to use their expertise, creativity and skill in innovative ways to improve patient care. Maben and Griffiths (2008) argued that greater freedom, enhanced accountability and staff empowerment are needed to make change happen.
An increasing number of thoracic patients requiring surgery are being cared for at a specialist heart hospital, situated at University College London Hospitals Foundation Trust. Thoracic patients currently make up 40% of surgery cases at the trust and the numbers continue to rise. Of these thoracic patients, 55% have either a primary or secondary cancer diagnosis. One clinical nurse specialist (CNS) works across the trust to support care for these patients.
Those areas of care that staff specifically identified for improvement included:
- The need to spend sufficient time with patients and carers to ensure understanding of their complex care needs;
- The importance of facilitating timely referral to members of the multidisciplinary team;
- The need to streamline the discharge process.
We anticipated that the development of a thoracic support nurse role (TSN) would lead to improved patient care and a potential reduction in length of stay. A cost benefit analysis identified that it would be cost effective and clinically beneficial to establish a new nurse post (Kwaku, 2008). This could be considered a partial role redesign (Hyde et al, 2005) as existing ward nurses would take on the new role, which would be integral to their current role and undertaken on a full time basis.
Aim and objectives
The project aimed to develop a TSN role. The objectives were to:
- Explore the process of change with the TSN and colleagues;
- Highlight the drivers and barriers to developing the role;
- Explore problems in TSN role development;
- Evaluate the impact of the TSN role.
Role development in nursing has increased in recent years, particularly in terms of the consultant nurse (Manley, 2000) and clinical nurse specialist roles (Read, 2001). However, no literature was found on developing a ward based TSN role.
The literature supported our choice of action research as the methodology for the project. This is a contemporary research approach to enable collaborative change and innovation in practice.
A number of characteristics distinguish action research from other methodologies:
- It is a problem focused, context specific and future oriented approach;
- It is a change intervention aimed at improvement and involvement;
- Those involved are participants/co-researchers in the change process;
- It is a cyclical process in which research, action and evaluation are interlinked;
- Educative for all (Hart and Bond, 1995).
This method has government support for advancing practice in Wales (Balogh et al, 2007) and in Scotland for supporting evidence based practice (Sharp, 2005). In England, a Health Technology Assessment report (Waterman et al, 2001) demonstrated multiple uses of action research for:
- Role development;
- Contributing to innovation and improvements in healthcare;
- Developing practitioners’ knowledge and understanding;
- Involving users and NHS staff.
Seers (2007) called these multiple uses complex interventions and supported the use of action research in evaluating as well as developing them. A conceptual framework for nurse led change and development in clinical practice has been developed from an action research methodology (Bellman, 2003). The framework has provided a valuable supportive tool for facilitating role development in an NHS trust (Walsgrove and Fulbrook, 2005) and underpinned this project.
Table 1 provides an overview of the project.
Sixty people took part in the study:
- Action research facilitator: senior nurse research and development;
- Co-researchers: staff nurse/thoracic support nurse (TSNs n=3); consultant nurse cardiac care (n=1); ward sister (n=1); clinical nurse specialist (thoracic care) (n=1); and clinical practice facilitators (n=2);
- Total population of ward nurses (n=21);
- Divisional senior nurse manager (n=1); nurse consultant, cancer and supportive care (n=1); surgeons (n=4); physiotherapist (n=1); occupational therapist (n=1);
- Patients (n=22).
Carr and Kemmis (1986) said the first step in action research is central: forming a “communicative space” in a way that articulates an issue of concern and allows participants to voice different views. In this study the communicative space took the form of the co-researcher review meetings, which lasted 2-3 hours and took place every month over nine months.
The action research process usually requires participants to be seen as equals. In this study the action researcher/senior nurse research and development worked as a facilitator of change, consulting with the nurse co-researchers about the study design and supporting them in undertaking the project.
A commitment by the co-researchers to attending the audiotaped monthly review meetings in the hospital was fundamental to the study’s success. One benefit is that this can make the research process and outcomes more meaningful to practitioners, by rooting them in the reality of daily practice (Meyer, 2000). Another benefit is the ongoing learning of practice based research and development for all participants.
Box 1 outlines the activities that co-researcher participants were involved in as part of the learning process.
Box 1. Research activities
- Co-writing and submitting the internet research information system (IRES) form for ethical approval
- Designing patient and staff consent forms and participant information forms
- Developing a research project timeline
- Acquiring advanced literature search skills
- Developing a TSN daily activity sheet
- Creating an online survey tool
- Facilitating audiotaped focus groups
- Designing a staff questionnaire and patient survey tool
- Fundamental data analysis skills
- Presenting the study at an international nursing research conference
A thematic analysis enabled data coding, category identification and key themes to emerge. Five themes showed how the study objectives were addressed:
- It is the need to improve patient care;
- It brought research to life;
- A rollercoaster of emotions and experiences;
- Process is as important as outcome;
- We did it ourselves and learnt so much.
These themes represent all the analysed data. Some examples of each theme are given below, along with the categories from which they were derived.
It is the need to improve patient care
The categories which underpin this theme were: thinking about standards of care; practice wisdom; and ward culture.
The survey revealed that some staff recognised that pain management was an issue for thoracic patients, and that many of these, in particular palliative care patients, needed appropriate psychological care. Increased support for carers was identified and the need for greater collaboration within the multidisciplinary team.
The following quotes are examples of this theme from the review meetings, senior nurse interview and focus groups, that is, data analysis of the qualitative research methods as listed in Table 1.
Sister co-researcher (to the action research facilitator):You posed the question what do you want? What we want is that no matter where the patient is nursed in the hospital they should have the same standard of care.
Divisional senior nurse: I think it’s a means of trying to improve standards for the patient overall and I think all you’re doing is taking the person [staff nurse/TSN] away from the team and saying: “You don’t have general duties now, you can now actually spend time with the patients, supporting them, doing all the things that we don’t get a chance to do any more.”
TSN co-researcher: I was able to discuss the positive things coming from my role – being able to recognise where we are failing patients; not spending sufficient time with them to really understand their worries and concerns; not addressing their pain issues adequately…I was extremely surprised as I always thought we were good in dealing with thoracic patients’ post-operative pain.
Ward nurse (focus group 1): Across the ward it’s a busy environment and you don’t have much time to spend with a patient. In her role she now provides emotional support, social support, psychological support for patients, it’s very important and this is where she excels in her role.
Ward nurse (focus group 1): She’s available to refer patients to the community palliative care team and also order oxygen…we’re not always competent in doing that…she’s always accessible and does that on our behalf.
Ward nurse (focus group 2):Patients’ relatives don’t have a clue. She provides information for them and follow up to help them cope…She liaises with the OT, dietitian, physio and picks up any concerns earlier.
Ward nurse (focus group 2): The uniqueness of her role is the support that we, the staff, didn’t have before…
Ward nurse (focus group 2): We don’t have the specific knowledge for cancer patients that she now has…Pain relief has certainly improved for these patients…we all need to go to theatres to watch thoracic operations, learn how to break bad news, read chest X-rays, do a complex discharge…
Sister co-researcher: I’m going to the strategic board meeting tonight so it’s one thing I can feed back now – complex discharge, exactly how it should be.
TSN co-researcher: I was thinking how can you explain to patients what they’re going to go through, I didn’t know then but now I do.
It brought research to life
This theme encompasses the categories of: learning the research process; co-researcher engagement; seeking knowledge; project planning; problem solving; real world research challenges; challenging expectations; and initiating action research.
The following quotes are some of the many examples of this theme from analysis of the review meetings.
Clinical practice facilitator co-researcher: I think for me it’s brought research to life. In the past in level 3 study, doing my research module and research proposal, it just didn’t really mean anything. But if someone were to ask me now, I’d find it quite easy to explain to them what we’ve done, the process we’ve been through, how we’ve gathered data and so on.
Sister co-researcher: It’s being systematic that’s really the crux for me. We started to pilot this new post and if we hadn’t done it as action research with all of you involved, I don’t really know if it would ever have got off the ground. There were a few hurdles and I would have quite happily have said: “That’s it then, we tried, didn’t like it, move on.” But because everyone else was involved it gives you the impetus to do it, to keep going.
Consultant nurse co-researcher: I was excited…not just about the new role, we were killing several birds with one stone, and one of those birds was that that’s part of my role as a nurse consultant, to be involved with research.
A rollercoaster of emotions and experiences
The categories in this theme were: role conflict; role ambiguity; feeling disempowered; new role learning; and role impact, encompassing the experience reflections of the TSNs’ journey trying to move from dependent to independent practitioners.
The following quotes are examples of this theme from analysis of the review meetings and the TSN reflective journal.
TSN (reflective journal): I thought I’d feel empowered with knowledge and skills to transcend from a functional staff nurse to a competent thoracic support nurse but I currently feel disempowered.
TSN (at co-researcher meeting): I felt I had wasted a whole morning of my time because I wasn’t given clear directions.
TSN (reflective journal): It was challenging trying to pass a negative comment about how I saw the role developing without offending anyone.
These issues were reviewed at the co-researcher meetings. They reflected the need to build TSNs’ confidence in their new role. There was a tension between what the TSNs thought the emphasis of the role should be and what the CNS knew patients needed. This issue could be understood within the behaviour of the expert nurse (Benner, 1994):
Consultant nurse co-researcher to the TSN: You’re looking at complex issues and need direction but expert nurses often work intuitively and can find it difficult to articulate their practice.
Exploring the issue enabled personal growth and development:
TSN (reflective journal): I recognised I would have to take personal ownership of problems. I’m now developing negotiating skills.
TSN (co-researcher meeting): I’ve new insights into patient care and these are now being acknowledged. I’m doing something right. I’ve also been challenging my personal assumptions. I’m now identifying changes in nursing practice.
Process is as important as outcome
The categories for this theme encompassed: sharing knowledge; demonstrable interpersonal support; and positive feedback.
The following quotes are examples of this theme from analysis of the review meetings over time and the senior nurse interview.
CNS co-researcher(to TSN): Confidence in your role will evolve over time. I can empathise with you. But don’t bite your lip [pause]… in future start to talk about this, or ask me how I can help you from a thoracic perspective.
TSN co-researcher (to CNS): When you did that palliative care patient with me a couple of weeks ago, the things you were telling me that I wouldn’t have thought of…It only took 10 minutes but it was very good and now I can pass that on…and I’m going to do some teaching sessions now for staff.
CNS co-researcher: I can relax now…I’m truly confident she’s [TSN] got it! She knows what she’s doing, she’s now got the experience. You just have to mention something and it’s done already, so it’s fantastic.
Sister co-researcher: It has been really interesting as a ward sister with managing change. You might make little changes here and there but any big changes tend to come from up there and you’re the one that has to implement them. But this whole process has been from the bottom up which is quite rare in the NHS. However, it’s also been quite daunting really and, at times, quite a risk for me personally.
Divisional senior nurse: Definitely from my point of view developing this role is going forward with looking at a business case to get substantive funding for the post.
We did it ourselves and learnt so much
Categories reflecting this theme were: empowerment; project learning outcomes; and demonstrating enlightenment. The clinical practice facilitators monitored the processes involved in implementing the TSN role. They facilitated role clarification; enabled clinical support; helped to raise the profile of the TSN role and ensured quality control through supporting clinical governance requirements and encouraging shared learning in the workplace.
Sister co-researcher: I’m really proud of all of us for being creative. The way that nursing is going, we need to look at new ways of being a nurse and providing nursing care, and we’ve been allowed from the management side to work with this, from the chief nurse and the chief exec, they know about it, down to the shop floor being willing to embrace it and give it a go. And I think that’s been quite exciting that we’ve done that ourselves, it’s not somebody has told us to do it, we decided to do it and we did do it.
Consultant nurse co-researcher: … I can see the results of the work we’ve done and it just reinforced for me that an action research project if done right and facilitated well can work. Which is what I always thought but now I know.
The agreed timeline for the project was six months. However, a three month slippage was unavoidable due to clinical demands, staff shortages, meeting NHS targets, annual leave and sick leave. Three ward nurses consecutively, and at times to ensure overlap, concurrently developed the TSN role. Some role development was organic in that the TSNs were encouraged to identify new ways of working as well as being guided by the CNS. The TSNs were also given a high degree of autonomy rather than a more familiar prescriptive approach. Within the project these new challenges reflected significant personal role development and, at times, role conflict within the nursing team.
Hannes et al (2007) found nurses may demonstrate lack of motivation, fear of change, difficulties in managing change and innovation, and there may also be inadequate systems to enable personal and professional development. However, the TSNs valued clinical supervision as an ongoing system of support. Equally important is colleagues’ recognition of, and support for, their commitment to nurse led change and development.
The CNS carried out a questionnaire with 22 patients at their follow-up appointment in the outpatient department, to provide evidence of their support for the role. They considered three key areas of care as essential:
- Pain management in the ward;
- Managing pain on discharge home;
- Detailed information of follow-up care.
Examples of positive patient support to continue the role included:
“Yes, I do agree a thoracic support nurse would be good. It was nice for somebody to spend time talking to me about…the pain… how often to press the [patient controlled analgesia] button…and the breathing…” (patient 16).
Box 2 outlines the patient centred processes and outcomes that the TSNs achieved during the project. Evidence of the effectiveness of the TSN should have resulted in funding the role but currently there is a delay due to a financial shortfall in the trust.
Box 2. TSN processes and outcomes of care achieved
- Ensuring sufficient time is spent with patients and their carers
- Assessing patients’ holistic needs before and after thoracic surgery
- Providing bespoke information about surgery and hospital stay
- Providing health improvement information and advice
- Ensuring effective liaison on behalf of patients within the hospital or with the referring hospital
- Coordinating the complex discharge process
- Liaising with community teams to support aftercare following discharge
- Being available by telephone for information and support following discharge.
Action research methodology symbolises much of what modern research is about - analysing the world but also seeking to change it (Gray, 2009). The action research facilitator was both co-participant and co-learner. The nurse co-researchers endeavoured and succeeded in making research come alive in everyday practice for patient benefit, and patients and staff recognised how the new role significantly improved thoracic nursing care. However, there were many personal and professional challenges to address including TSN role conflict, and the trust wide demands on the CNS, reducing the support she could provide for the TSNs. In the future, a protected budget for change and innovation is required. A clinical and academic partnership approach of engagement and support will enhance facilitation of future practice based nursing research.
The project could not have been undertaken without the commitment and knowledge of the other co-researchers: Simone Browning, clinical practice facilitator; Juanita Clarke, TSN; Jayne Kahende-Mohohi, TSN; Ellie Higgins, former ward manager; Dorcas McAsey, CNS; Theresa Roomaney, clinical practice facilitator; Luzvinminda Sebastian, TSN; and clinical supervisor Kay Eaton, consultant nurse, cancer and supportive care.
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