The researcher had a particular interest in the AP role. From a personal perspective the researcher had been involved with the development of APs since 2002 and employed in one of the first fourteen pilot sites engaged with “Delivering the
Workforce”. The researcher had first-hand experience of the emerging role, he had been a participant in the Benson and Smith research project in 2007. Over fourteen years the researcher had directly supported TAPs, been involved as an operational team manager and lectured on the foundation degree. Equally, the researcher on many occasions presented locally, regionally (North West) and nationally,
establishing a sound knowledge and understanding of the type of information stakeholders were requesting. The original concept of the research study was: ‘The training and development of APs: An action research project to develop a tool to evaluate the impact of the role in practice and inform service development within NHS and Non -NHS organisations.’ The hypothesis formulated by the action research team and utilisation of personal experience of the author, concluded
although there was a plethora of qualitative evidence evaluating the AP role, there was a lack of quantitative evidence available. Equally, a tool to collate evidence and measure impact was not apparent. The project aims in summary were to enhance the evidence base with more comprehensive data and therefore assist stakeholders make informed decisions about the development of their non-registered staff. As a member of the WBEF network, the author has a prime focus on the development and promotion of APs, particularly in the North West. Discussion and analysis will be conducted under the following headings.
The AP role
The literature supports the view that the AP role has gathered momentum since it’s conceptualisation in 2002. Benson and Smith (2007) had evaluated the role and concluded mixed results. They comment on the impact of the role however, report from a predominately qualitative paradigm. They convey confusion around the role, lack of trust, reluctance by registered staff to delegate and uncertainty of the
potential the role might have. Allen et al. (2012) had noted that ambiguity of the AP had influenced the effective integration of the role in critical care. Miller et al. (2015) subsequently echoed many of the concerns that Benson and Smith had raised. Lack of clarity and vision were still dominating concerns and lack of consistency in the deployment of AP nationally was still evident. The literature in almost every case had positive examples of how the AP role could be utilised but equally had the commonality that there were still barriers to optimising their use. Stewart-Lord et al (2011) examined the role specifically in radiography, where the AP role had been introduced as part of a national strategy, however they reported that despite a SoP being established for the role written by the SoR, there were still discrepancies in what the APs were doing. Confusion is a recurrent trend (Benson and Smith, 2007; Spilsbury et al, 2009; Stewart-Lord et al. 2011; Allen,2012; Miller, 2013; Miller et al. 2015).
The results from the market research questionnaire confirmed that participants viewed economic impact and effects on patients to be of great importance when introducing new roles into their service. These priorities needed to be addressed in the impact evaluation tool. Indeed, at stakeholder briefings this type of information was commonly requested. Wilson (2008) supports the notion that this needs to be taken into account. She developed a comprehensive tool kit focusing on the
implementation of the AP role in the East Midlands. This offers guidance around on what stakeholders can do. She suggests that managers need to “…identify all
benefits expected from developing and implementing the AP role and how these will be measured” (p.14). She continues by emphasising the importance of
“Assessments of outcomes in the workplace” (p.15), and reiterating this sentiment identifying that the impact of the AP role must evaluate their effectiveness in service. Skills for Health (2015) identify staff costs as the largest expenditure in the NHS, value for money is high on the agenda, concluding “Making better use of support workers can also make a significant contribution to saving money and helping improve patient care” (p.14). The impact evaluation tool developed offers one document that enables stakeholders to consider this and engage in cost benefit analysis of the role.
Stakeholders identified that the contribution to skills mix and effects the role would have on meeting national targets, were factors in their decisions around developing the AP role. Miller et al. (2015) supports this view by recognising the great
contribution the AP role has to service delivery. They acknowledge that APs are generally a stable workforce. Equally stakeholders also reported how engagement with other organisations who had developed APs would be extremely helpful. Miller et al. (2015) clearly identify that: “Several employers commented that they were keen to learn from the experience of others” (p. 98), which echoes these findings. Participants in the questionnaire highlighted that the sharing of job descriptions and competency frameworks would be beneficial in developing new roles. The impact evaluation tool developed in conjunction with the findings of the market research questionnaire, offers the opportunity for intelligence sharing amongst stakeholders. Results of the market research questionnaire indicated 40% of participants, always looked at skills analysis when recruiting to vacancies, and although 77.43%
indicating workforce planning did play a part when recruiting future staff, this still indicated that over a fifth did not. The researcher also acknowledges that workforce planning can mean different things to different people. A definition of what is
considered workforce planning may have been helpful in establishing how many had considered this as part of a formal process. Miller et al. (2015) also consider the use of workforce planning and highlight in their findings that this was lacking in many cases although seen as important to the successful implementation of the AP role.
The action research group did take the view that gathering market research intelligence was a vital part of this process. Justifiably, the areas that people
developing the roles deemed important would need to be reflected in the finalised impact evaluation tool. On reflection there are limitations to the use of the
questionnaire and the sample chosen, with a final response rate of 13.25%. As participants had to prioritise their responses, there could have been the potential for some aspects to be seen as all having importance, some of the scores were indeed close. The action research team where however, very keen to encourage
stakeholders to think about their priorities, as they realised that there was potential for the document to become too unwieldly. Also the population of the research questionnaire where from the North West and were familiar with the AP role being developed through commissioned foundation degrees, therefore funding may not have been highlighted as a major issue, as funding of the programme already existed for their particular trainees. Miller et al. (2015) highlight that funding is an issue for managers they had interviewed and highlight the availability of funding to be influential in the decision to develop the role. This was not evident in the findings of this particular study. The majority of respondents to the questionnaire did come from NHS trusts which is the trend nationally (Miller et al., 2015), however there is a recognition that the AP role can be utilised in many different settings and whilst PIVOs and non NHS are represented their contribution could have been investigated further.
Sustainability and expansion of the role
The market research questionnaire elicited responses from different roles and across different service areas. The AP role can be adapted to meet the needs of a variety of disciplines. The Royal College of Nursing (2010) reported the growth of APs across the country and acknowledged the experience of the North West, who had developed the greatest number with sustained interest. Miller (2013) concluded that there would be a likely rise in the number of APs nationally. Miller et al. (2014) identified that the AP role was being deployed in a number of settings with growing interest. Miller et al. (2015) project the increased demand for the AP role concluding the role can continue to be embedded in the future. Skills for Health (2016; 2016a) supports the development at utilisation of the support worker role including APs, they advocate that the use of band 4 roles can work with minimal supervision and continued development of the role will assist in meeting demographic change and service demand. The evidence strongly indicates that the AP role has great potential for the future. The impact evaluation tool will support the continued development of the role by producing more holistic evidence to inform managers in developing their bands 1-4.
It is recognised by the author that one of the limitations of the tool is that it can be time consuming and has the potential to become a lengthy document. The action research group concluded that there is need for such a tool and to be robust, this would have to be a process that takes time and consideration on behalf of the stakeholder and the WBEF conducting the follow up interview. Equally, the pilot highlighted that motivation of the stakeholder to generate meaningful data from that service area, is vital to ensure that the impact of the role can be evaluated
effectively. It is acknowledged that the area highlighted for piloting may not have been the most appropriate and so test the tool most thoroughly. As the tool is disseminated more widely and used more extensively, the action research group will continue to review its use and gain more depth of understanding of its effectiveness. It is anticipated that future developments will produce a shorted version of the tool that can be utilised solely to examine cost effectiveness and patient impact. Education and training
Participants in the market research questionnaire confirmed that their preferred model of training was through work based learning, they indicated that work based competencies were key in this. The involvement of employers is fundamental to work-based learning as Raelin (2008) discusses. Philips (2012) also discussed the relationship between learner, employer and HEI in her discussion on work-based learning. Participants confirmed they were less concerned whether the programme lead to a nationally recognised qualification or at what academic level it would be delivered at. This suggests that fitness for practice and meaningful competencies were of far greater importance.
When piloting the impact evaluation tool the stakeholder indicated that their staff had followed a foundation degree programme but that there had been a need for additional competencies to be achieved, which had resulted in their APs not being fit for practice. Miller et al. (2015) also commented that they too had found managers indicating that their APs were not fit for practice and that in some areas the
qualification had become too generic, resulting in some managers losing confidence in the programme. The impact evaluation tool asks managers to consider deficits of the role and invites them to action plan to address these potential problematic areas.
Employer feedback on the training programme was deemed important to the action research group. Therefore, the impact evaluation tool developed offers opportunity for stakeholders to comment on the training programme they had utilised in
developing the AP role. Equally it invites stakeholders to examine ROI both from an economic perspective and patient experience. Considering the work of Kirkpatrick and Kirkpatrick (2012) evaluation of training programmes must capture the opinions and observations of employers. With Philips (2003) also considering ROI being argued as critical in establishing the true worth of development programmes This information should be shared with programme provides to influence the curriculum content and design of their courses.
Impact evaluation
The impact evaluation tool is envisaged to provide a resource for stakeholders in their decision making process as was the aim of the study undertaken. It was deemed important that the tool offered a mixed method approach to impact
evaluation of the role in services. This approach is supported by Bamberger (2012) who advocates that mixed methods approach to impact evaluation produces the most reliable results. The literature surrounding impact evaluation identifies it as a process. Robust impact evaluation relies on establishing a counterfactual and measuring the end product with original vision. This will help identify programme or change theory and develop a hypothesis to measure against (OECD, nd; Rogers, 2012). Findings from piloting the impact evaluation tool helped identify areas that needed adjustment and whether the questions were appropriate to the intended use. Rogers (2012) highlights that asking the right questions is imperative to good impact evaluation. The action research group considered feedback from different sources when construction the finalised tool.
The impact evaluation tool reflects these positions in both content and design. However, it is limited in that its deployment is to examine a before and after comparison. The researcher is aware that a comprehensive study would provide a more robust evaluation, however rationalises that logistically this would be a difficult and time consuming process for all participants. Feedback from the service
manager who engaged in the pilot study indicated that she felt it could be very time consuming and therefore dissuade them from engaging in the process. The
researcher acknowledges that the finalised tool does have limitations in this respect. There is scope to look at conducting a more extensive impact evaluation with organisations willing to participate over a period of time, which would produce a more comprehensive appraisal of the impact new roles have had in that service. Currently, the finalised tool has been agreed by the management team of the WBEF network and is available for future use. Continuous evaluation by the action
research group will monitor the effectiveness of the tool and reflect on its usefulness within the practice area.
Summary
This chapter has discussed the findings of the research study and how the literature supports or compromised the results. It has examined the data extrapolated from a market research questionnaire and compared its findings with those of others researching in the field. The findings of each phase of the study has been evaluated in relation to current evidence. The development of an impact evaluation tool has been debated and how the tool will be used to add to the evidence base
surrounding the development of the AP role. A justification for a mixed method approach has been offered and the intention for the tool to be available for use by stakeholders. It has explored the research methodology and acknowledged any limitations that exist.