An exploration within the complex worlds of senior and advanced nurse practitioners roles : a constructivist grounded theory study

Over the past 30 years, Senior and Advanced Nurse Practitioners (SNPs/ANPs) have been introduced into the healthcare arena across the world. The international literature reports such roles have created tensions within healthcare systems (Smith 2000; Tye & Ross 2000; Scholes & Vaughan 2002). However, over the past three decades the root causes of such tensions remain still to be addressed. The literature reports the consistent entrenched reluctance to collaboratively engage with SNP/ANP roles (Cummings et al. 2003; Reay et al. 2003; Davies 2006). This led to the aims of my Constructivist Grounded Theory (CGT) study, which were to discover why there continues to be tensions surrounding Senior and Advanced Nurse Practitioner roles in healthcare, in addition to attempting to generate a substantive theory to provide a foundation in which a hypothesis could be tested across a wider arena. Arising from these aims were three research questions which were explored in three phases. The first research question, posed in phase 1, was ‘where are tensions created by Senior and Advanced Practitioner roles from a service user and healthcare team perspective?' This led to in-depth interviews taking place with service users (n=12) and members of the healthcare team (n=18). Theoretical sampling consisted of medical staff (n=9), nursing staff (n=7) and Allied Health Professionals (n=2). Data were considered saturated when no new data could be identified and the main categories with focused codes were coherent. The second research question, posed in phase 2 of my study, was ‘where do tensions remain apparent in service and what meanings and actions are attributed to them?' The method of Grounded Theory Ethnography was employed, which gave priority to interactions rather than the setting. This method consisted of a 3 stepped approach, employing participative observation and individual interviews. In total, 13 periods of observation were undertaken, which equated to 64 hours of observation within different sites. The emergent categories from this phase built upon the categories from phase 1. In phase 3 the research question posed was ‘what are the interpretations of Senior and Advanced Nurse Practitioners on interactions with the healthcare team and service users?' Six focus groups and one paired interview enabled the development of the core category “Status Games”. This subsumed the main categories from each phase and incorporated common themes and patterns across all data. This core category was further verified with five individual interviews and no new properties emerged. This core category reflected the data across all phases effectively. Interpretative theorising incorporated advanced memos across all 3 phases of my study and enabled the development of a substantive theory. Social psychological game theory and underpinning script theory, which is part of the Transactional Analysis Paradigm, provided the theoretical lens to interpret what was grounded in the data. This led to the development of two new concepts, the first was status games which incorporated game analysis and highlighted ulterior transactions which have not been previously reported in the literature. The second was the professional script concept, which it is theorised underpins status games. This is also new and has not been conceptualised in the Transactional Analysis or healthcare literature. This theoretical framework illustrated that status games which fulfil professional script are being played out with awareness. It is proposed that by recognising these concepts, this will reduce tensions with SNP/ANP roles and lead to improved patient-centred care. As Vandra (2009) reports by recognising the processes and actions of communication it is possible to bring ulterior transactions into full awareness and prevent games, thus problems with communication. This led to the development of the substantive theory in this study which is: ‘The tensions generated by SNP/ANP roles stem from playing status games to fulfil professional script which requires to be recognised and acknowledged by the healthcare team in order to change the status quo and culture'. Whilst social psychological game and script theories can provide an underpinning understanding of social games and life scripts for individuals, the status game concept which emerged from my study expands our knowledge and provides a unique understanding surrounding the impact of professional script in healthcare organisations. It is hypothesised that this script has led to status games, which is central to the tensions surrounding SNP/ANP roles.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

An exploration within the complex worlds of senior and advanced nurse practitioners roles: a constructivist grounded theory study

Over the past 30 years, Senior and Advanced Nurse Practitioners (SNPs/ANPs) have been introduced into the healthcare arena across the world. The international literature reports such roles have created tensions within healthcare systems (Smith 2000; Tye & Ross 2000; Scholes & Vaughan 2002). However, over the past three decades the root causes of such tensions remain still to be addressed. The literature reports the consistent entrenched reluctance to collaboratively engage with SNP/ANP roles (Cummings et al. 2003; Reay et al. 2003; Davies 2006). This led to the aims of my Constructivist Grounded Theory (CGT) study, which were to discover why there continues to be tensions surrounding Senior and Advanced Nurse Practitioner roles in healthcare, in addition to attempting to generate a substantive theory to provide a foundation in which a hypothesis could be tested across a wider arena. Arising from these aims were three research questions which were explored in three phases. The first research question, posed in phase 1, was ‘where are tensions created by Senior and Advanced Practitioner roles from a service user and healthcare team perspective?’ This led to in-depth interviews taking place with service users (n=12) and members of the healthcare team (n=18). Theoretical sampling consisted of medical staff (n=9), nursing staff (n=7) and Allied Health Professionals (n=2). Data were considered saturated when no new data could be identified and the main categories with focused codes were coherent. The second research question, posed in phase 2 of my study, was ‘where do tensions remain apparent in service and what meanings and actions are attributed to them?’ The method of Grounded Theory Ethnography was employed, which gave priority to interactions rather than the setting. This method consisted of a 3 stepped approach, employing participative observation and individual interviews. In total, 13 periods of observation were undertaken, which equated to 64 hours of observation within different sites. The emergent categories from this phase built upon the categories from phase 1. In phase 3 the research question posed was ‘what are the interpretations of Senior and Advanced Nurse Practitioners on interactions with the healthcare team and service users?’ Six focus groups and one paired interview enabled the development of the core category “Status Games”. This subsumed the main categories from each phase and incorporated common themes and patterns across all data. This core category was further verified with five individual interviews and no new properties emerged. This core category reflected the data across all phases effectively. Interpretative theorising incorporated advanced memos across all 3 phases of my study and enabled the development of a substantive theory. Social psychological game theory and underpinning script theory, which is part of the Transactional Analysis Paradigm, provided the theoretical lens to interpret what was grounded in the data. This led to the development of two new concepts, the first was status games which incorporated game analysis and highlighted ulterior transactions which have not been previously reported in the literature. The second was the professional script concept, which it is theorised underpins status games. This is also new and has not been conceptualised in the Transactional Analysis or healthcare literature. This theoretical framework illustrated that status games which fulfil professional script are being played out with awareness. It is proposed that by recognising these concepts, this will reduce tensions with SNP/ANP roles and lead to improved patient-centred care. As Vandra (2009) reports by recognising the processes and actions of communication it is possible to bring ulterior transactions into full awareness and prevent games, thus problems with communication. This led to the development of the substantive theory in this study which is: ‘The tensions generated by SNP/ANP roles stem from playing status games to fulfil professional script which requires to be recognised and acknowledged by the healthcare team in order to change the status quo and culture’. Whilst social psychological game and script theories can provide an underpinning understanding of social games and life scripts for individuals, the status game concept which emerged from my study expands our knowledge and provides a unique understanding surrounding the impact of professional script in healthcare organisations. It is hypothesised that this script has led to status games, which is central to the tensions surrounding SNP/ANP roles

Learning from the evaluation of two large improvement programmes for emergency general surgery in the UK National Health Service.

PhD Theses MedicalBackground Robust evaluations of the effectiveness of Quality Improvement (QI) remain rare, and subsequently the evidence for the use of QI, and what may influence the success of such efforts, is weak. Methods EPOCH was a stepped-wedge, randomised trial of a QI programme, in 93 hospitals, designed to reduce mortality in patients requiring emergency abdominal surgery. CholeQuIC was a controlled evaluation of a 12-hospital project designed to reduce time to emergency laparoscopic cholecystectomy for patients with acute gallstone disease. Both studies had concurrent process evaluations. Results The EPOCH trial found no reduction in 90-day mortality associated with the improvement programme (16% mortality in both groups (Hazard ratio, QI vs usual care: 1.11 [0.96-1.28])). Hospital-level time-series analysis identified that only a small cohort of hospitals (14/93) improved half or more of the target care processes, suggesting a degree of implementation failure. Major influences included limited time and scarce resources to support clinicians leading improvement, including an onerous burden of data collection. CholeQuIC demonstrated that eight of 12 participating hospitals significantly reduced time to surgery when compared to national data from the same period (relative change in surgery ≤8 days, QI vs control group: 1.45 vs. 1.08 ([1.29-1.62]). Major influences include stakeholder 6 engagement, allocated time to lead plus effective project support and a willingness to test out new ideas. The QI methods used in both projects were similar, but the scale and complexity of the change required was less in CholeQuIC and more within the control of clinicians to improve. Conclusions Concurrent outcome and process evaluations are necessary to understand if and how Quality Improvement projects work. Choosing a problem amenable to clinician-led Quality Improvement, using QI multiple methods that focus on effective stakeholder engagement and protected time for clinicians to lead improvement are major influences on whether Quality Improvement is effective or not

Grounded theory analysis of hospital-based Chinese midwives’ professional identity construction

Background: The professional development of midwifery in China has been challenged by its marginalised professional status and the medical dominance within midwifery practice in the contemporary maternity care system. There has been growing confusion about, ‘Who the midwife is and what does the midwife do?’ within and outside the profession. The sense of identity crisis for the profession has become particularly salient when Chinese midwifery becomes a sub-branch of the nursing profession during the contemporary period. If, however, we consider the International Confederation of Midwives (ICM) Mission Statement (2008: 32) that midwives are the ‘most appropriate professionals for childbearing women in keeping childbirth normal’, then the focus on a greater understanding of midwives is needed. It is the aim of this research to facilitate this understanding by exploring how hospital-based Chinese midwives construct their professional identity in the contemporary maternity care system and the factors that significantly influence the process. Design and Method: A Constructivist Grounded Theory (CGT) study was conducted to achieve the research aim. A sample of 15 midwives and 5 women participants was recruited between October 2010 and May 2011 from a capital city in one province of China. The accounts from the participants in the form of in-depth individual interviews were digitally recorded and three work journals from midwife participants were also included to facilitate the exploration of the study subject. NVivo 8 was used to assist with data management for the analysis. Findings: Six principle categories were identified: ‘institutional position’; ‘organisational management’; ‘professional discourse’; ‘compromising strategies’; ‘engaging strategies’; and ‘hybrid identity’. The integration of the principle categories has developed the theoretical model ‘navigating the self in maternity care’, which suggests that professional identity construction in midwives is a dynamic process, involving a constant structural and attitudinal interplay between the external (‘obstetric nurse’) and internal (‘professional midwife’) definitions of the midwife. The model indicates that the midwives’ professional identity construction was contextualised in their ‘institutional position’ in the contemporary maternity care system. In everyday practice, midwives experienced identity dissonance in relation to two competing identities: the ‘obstetric nurse’, bound up to the ‘organisational management’ in hospital settings; and the ‘professional midwife’, associated with the ‘professional discourse’ in the midwifery profession. Two types of strategies were identified to reduce the identity dissonance – ‘compromising strategies’ and ‘engaging strategies’ – which resulted in a ‘hybrid identity’, as the construction of professional identity in individual midwives is navigating along an identity continuum with ‘obstetric nurse’ and ‘professional midwife’ at opposing ends. This thesis has expanded on the current theoretical knowledge of identity work by elaborating on the discursive practices professionals employ to legitimate their professional identity and the various strategies individuals use to negotiate their identities at work. It has also extended attention to the influence of institutional forces on professional identity construction. With specific regard to Chinese midwifery, this emerging theoretical model provides a number of possible implications for midwifery practice, education and policy which would facilitate the exploration of effective operational processes for midwives in China to develop professionally

Interventions to improve antibiotic prescribing practices for hospital inpatients

Background Antibiotic resistance is a major public health problem. Infections caused by multidrug-resistant bacteria are associated with prolonged hospital stay and death compared with infections caused by susceptible bacteria. Appropriate antibiotic use in hospitals should ensure effective treatment of patients with infection and reduce unnecessary prescriptions. We updated this systematic review to evaluate the impact of interventions to improve antibiotic prescribing to hospital inpatients. Objectives To estimate the effectiveness and safety of interventions to improve antibiotic prescribing to hospital inpatients and to investigate the effect of two intervention functions: restriction and enablement. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library), MEDLINE, and Embase. We searched for additional studies using the bibliographies of included articles and personal files. The last search from which records were evaluated and any studies identified incorporated into the review was January 2015. Selection criteria We included randomised controlled trials (RCTs) and non-randomised studies (NRS). We included three non-randomised study designs to measure behavioural and clinical outcomes and analyse variation in the effects: non- randomised trials (NRT), controlled before-after (CBA) studies and interrupted time series (ITS) studies. For this update we also included three additional NRS designs (case control, cohort, and qualitative studies) to identify unintended consequences. Interventions included any professional or structural interventions as defined by the Cochrane Effective Practice and Organisation of Care Group. We defined restriction as 'using rules to reduce the opportunity to engage in the target behaviour (or increase the target behaviour by reducing the opportunity to engage in competing behaviours)'. We defined enablement as 'increasing means/reducing barriers to increase capability or opportunity'. The main comparison was between intervention and no intervention. Data collection and analysis Two review authors extracted data and assessed study risk of bias. We performed meta-analysis and meta-regression of RCTs and meta-regression of ITS studies. We classified behaviour change functions for all interventions in the review, including those studies in the previously published versions. We analysed dichotomous data with a risk difference (RD). We assessed certainty of evidence with GRADE criteria. Main results This review includes 221 studies (58 RCTs, and 163 NRS). Most studies were from North America (96) or Europe (87). The remaining studies were from Asia (19), South America (8), Australia (8), and the East Asia (3). Although 62% of RCTs were at a high risk of bias, the results for the main review outcomes were similar when we restricted the analysis to studies at low risk of bias. More hospital inpatients were treated according to antibiotic prescribing policy with the intervention compared with no intervention based on 29 RCTs of predominantly enablement interventions (RD 15%, 95% confidence interval (CI) 14% to 16%; 23,394 participants; high-certainty evidence). This represents an increase from 43% to 58% .There were high levels of heterogeneity of effect size but the direction consistently favoured intervention. The duration of antibiotic treatment decreased by 1.95 days (95% CI 2.22 to 1.67; 14 RCTs; 3318 participants; high-certainty evidence) from 11.0 days. Information from non-randomised studies showed interventions to be associated with improvement in prescribing according to antibiotic policy in routine clinical practice, with 70% of interventions being hospital-wide compared with 31% for RCTs. The risk of death was similar between intervention and control groups (11% in both arms), indicating that antibiotic use can likely be reduced without adversely affecting mortality (RD 0%, 95% CI -1% to 0%; 28 RCTs; 15,827 participants; moderate-certainty evidence). Antibiotic stewardship interventions probably reduce length of stay by 1.12 days (95% CI 0.7 to 1.54 days; 15 RCTs; 3834 participants; moderate-certainty evidence). One RCT and six NRS raised concerns that restrictive interventions may lead to delay in treatment and negative professional culture because of breakdown in communication and trust between infection specialists and clinical teams (low-certainty evidence). Both enablement and restriction were independently associated with increased compliance with antibiotic policies, and enablement enhanced the effect of restrictive interventions (high-certainty evidence). Enabling interventions that included feedback were probably more effective than those that did not (moderate-certainty evidence). There was very low-certainty evidence about the effect of the interventions on reducing Clostridium difficile infections (median -48.6%, interquartile range -80.7% to -19.2%; 7 studies). This was also the case for resistant gram-negative bacteria (median -12.9%, interquartile range -35.3% to 25.2%; 11 studies) and resistant gram-positive bacteria (median -19.3%, interquartile range -50.1% to +23.1%; 9 studies). There was too much variance in microbial outcomes to reliably assess the effect of change in antibiotic use. Heterogeneity of intervention effect on prescribing outcomes We analysed effect modifiers in 29 RCTs and 91 ITS studies. Enablement and restriction were independently associated with a larger effect size (high-certainty evidence). Feedback was included in 4 (17%) of 23 RCTs and 20 (47%) of 43 ITS studies of enabling interventions and was associated with greater intervention effect. Enablement was included in 13 (45%) of 29 ITS studies with restrictive interventions and enhanced intervention effect. Authors' conclusions We found high-certainty evidence that interventions are effective in increasing compliance with antibiotic policy and reducing duration of antibiotic treatment. Lower use of antibiotics probably does not increase mortality and likely reduces length of stay. Additional trials comparing antibiotic stewardship with no intervention are unlikely to change our conclusions. Enablement consistently increased the effect of interventions, including those with a restrictive component. Although feedback further increased intervention effect, it was used in only a minority of enabling interventions. Interventions were successful in safely reducing unnecessary antibiotic use in hospitals, despite the fact that the majority did not use the most effective behaviour change techniques. Consequently, effective dissemination of our findings could have considerable health service and policy impact. Future research should instead focus on targeting treatment and assessing other measures of patient safety, assess different stewardship interventions, and explore the barriers and facilitators to implementation. More research is required on unintended consequences of restrictive interventions

Mask: Mirror: Membrane. The photograph as a mediating space in clinical and creative pain encounters

Pain is difficult to communicate and constrict into the verbal or numerical scales commonly used. This thesis explores how photographic images can expand pain dialogue in the consulting room to include aspects of experience frequently omitted using traditional measures. It draws on material generated by the face2 face project, a collaboration with facial pain specialist Professor Joanna Zakrzewska and clinicians and patients from University College London Hospitals. The project has many strands: art workshops for clinicians and patients to attend together; the co-creation of photographs with facial pain patients reflecting their experience at different points in their treatment journey; the creation of an image resource developed as an innovative communication tool for clinical use; and an artist’s film focusing on doctor-patient dialogue and the role of narrative. The thesis argues that photographs of pain placed between patient and clinician can trigger more negotiated dialogue in the consulting room. It presents the co- creation of ‘pain portraits’ with pain sufferers as part of a Fine Art practice, extending the boundaries of what is considered Fine Art by shifting the power- dynamics inherent within the act of portraiture. Through shared control of the lens and a negotiated aesthetic, pain sufferers retain control of how their pain is visualised, instead of being on the passive receiving end of a medical/photographic gaze. The thesis explores and questions the specificities of photography as a particularly apposite medium for this work. It validates and makes visib le the invisible subjective experience of pain, addressing its incommunicable nature. Semiotic and metaphoric analyses of the material reveal the possibility of a developing inter-subjective and trans -cultural iconography for pain. The thesis aims to demonstrate that not only is medicine capable of providing new material for the gallery space, but art is capable of bringing new knowledge into the consulting space