Findings of the research are discussed with regards to the three phases of the study. It is appropriate to refer back to the overall aims and objectives of the project to rationalise the approach and finding
Aims: -
1. To provide managers with evidence based resources that can inform their decision making when contemplating the training and development of non- registered staff into the role of AP.
2. To develop a tool that will evaluate the impact of the AP role within a service area.
Objectives: -
1. To scope out the current literature in relation to impact evaluations of new roles within service areas.
2. Design an initial market research questionnaire to ascertain stakeholder’s priorities when considering the development and introduction of new roles within their service.
3. Utilise the findings of the initial survey to construct an impact evaluation tool to gather both qualitative and quantitative evidence of the impact of the role. 4. Assist managers to make informed decisions with regards to the future
training and development of their non-registered staff within their service area.
The initial stage was threefold: -
Firstly, to scope out current evidence and conduct market research to illicit the priorities of managers in relation to the design and content of the impact evaluation tool itself.
Secondly, conduct research to analyse the current evidence and formulate a picture of the main themes surrounding the AP role, equally establish what methods or tools if any, had been developed when collecting the data.
Finally, to test the initial hypothesis of the action research team that the majority of available evidence was qualitative in nature and lacked quantifiable data, which stakeholders were now demanding. This lack of evidence justified the need to develop an impact evaluation tool, that would enable the gathering of qualitative and quantitative data regarding the AP role, to illustrate the extent of patient, service and economic outcomes
Phase one part one: Secondary research and Scoping the AP role and evaluation methods. (Objective 1)
Gray, (2009) discusses the role of secondary research of both qualitative and quantitative evidence. He notes that in quantitative terms this might be the reference to official statistics or documents where as in qualitative terms this would concern itself with research done by others and often analysed by others. He advocates that the purpose of secondary research in both methods is “…to perform additional, in- depth analysis of a sub-set of the original data; or to apply a new perspective or conceptual focus to the data” (p.497). He proclaims secondary research does come under criticism, arguing that the context of the original research may be
compromised. Duffy (2009) contributes discussing the analysis of documentary evidence and acknowledges this as a valid contribution when evaluated with other forms of evidence. Clifford (1997) discusses how written text can be subject to content analysis and is a useful method to gain perspective of the current evidence base. The results of secondary research combined with the results of the
questionnaire would be incorporated into the content and design of the impact evaluation tool. Duffy (2009) identifies two approaches to scrutinising documents a ‘source-orientated approach’ and a ‘problem-orientated approach’ (p.123). The latter is deemed appropriate in this circumstance. Also the credentials of the documents need to be considered, including the authors and content. The sources for this particular analysis were subject to peer review and published in reputable journals, or carried out in connection to professionally established organisations. In relation
to the stated purpose for this phase of the research project, which was fundamentally a scoping exercise it is deemed an appropriate method. A content analysis approach was taken allowing the researcher to determine
themes that would influence the focus of the study and impact evaluation tool. In the first instance the approach of role evaluations was considered. An appraisal by the researcher of the vast majority of the research projects analysed in an extended literature review, provided a qualitative profile of the AP role. Ross, (2012) confirms that although not considered as scientific as quantitative methods, qualitative investigation should not be “less vigorous” (p.114) in its approach. However, when considering the evidence, a mixed method approach was often identified in the methodology. Questionnaires featured heavily in the research and more often than not this was followed up with semi-structured interviews. In some circumstances there had been some investigation into statistical analysis most regularly around the numbers of APs and organisations in which they were deployed. In most instances there was no evidence of direct impact of the role on patient throughputs or the economic benefits the role had brought about. Equally, there was no evidence of any specific tool developed for capturing the impact of the role in practice.
The validity and reliability of the literature analysed from this section was considered in relation to where it was published and by whom. The research papers were from reputable journals and professional bodies. The credentials of the authors provided reassurance to the vigour of the investigation. In depth interrogation of the literature enabled recurrent themes to be established which would also be reflected in the finalised impact evaluation tool. In the second instance the national distribution of APs was interrogated. It emerged that in most instances evaluation of the role had been conducted in NHS organisations and within the acute setting. However, there was acknowledgment that the role should be extended to community settings and the non NHS. This was taken into account when designing the impact evaluation tool, ensuring that its design could be adapted to a number of different settings. Equally, the evidence supported the view that the AP role had great potential and was likely to become more widespread across NHS and non NHS organisations. The evidence from several investigations in the literature review suggested:
1. Increased numbers of Assistant Practitioners in the future. 2. The extension of the AP role across different clinical settings. 3. The expansion of the AP role in response to new initiatives.
4. Future investment in the role in addressing increasing demographic challenges in service provision.
These observations reinforced the concept that developing an impact evaluation tool and offer opportunity to fully evaluate the impact of the AP role, was a worthwhile venture.
Barriers to the role were also highlighted in several of the studies as areas for concern. A thematic approach identified the following concerns:
1. Confusion surrounding the role: - lack of clarity in what the AP could and could not do and what tasks could be delegated appropriately to the post holders.
2. Lack of opportunity for the skills of the AP to be fully utilised: - instances whereby qualified APs were not allowed to carry out the skills and competencies they were trained to do.
3. Inconsistencies in the level of qualification and course content: - There was no singularly recognised qualification for the AP role. The title is not
protected and as such there is a wide variance in the level of training
received. Although the foundation degree was recognised as by far the most popular route for qualification and AP status there was no standardisation of content across these programmes.
4. Lack of registration and regulation: - This was envisaged as an obstacle to confidently delegating tasks by the registered professionals and gave rise to concerns with regards to accountability of the AP for their acts and
omissions
5. APs deemed not fit for practice: - There was evidence from some managers that the AP could not carry out the tasks the manager required on
completion of the programme leading in some instances to managers having little confidence in the role.
6. Limitations of the role and level of responsibility: - Managers reported that delegation to an AP was limited worrying it exceed their remit and scope of practice.
It was important that these concerns were incorporated into the design of the impact evaluation tool to identify whether they had been addressed in other services and if so, how? When constructing the impact evaluation tool, sections where therefore included as to the type of service and area of practice. An opportunity to consider
the tasks and responsibilities of the role, including the scope of practice,
competencies achieved, what training programme or qualification had been used to underpin the role development were included in the body of the impact evaluation tool. Equally, how well the role measured up to the original vision, along with anticipated benefits, were incorporated into the text of the tool.
Phase one part two: Developing an initial market research questionnaire to establish stakeholder’s priorities (Objective 2)
In conjunction with the secondary research of the literature an initial market research questionnaire was also constructed and launched. Ross (2012) confirms that surveys are a popular method of collecting data and the structured
questionnaire a preferred instrument to investigate opinion. It was agreed that survey monkey would be deployed to distribute the questionnaire. Survey monkey ensures that the questionnaire looks professional which Bowling (2009) highlights as being important. Survey monkey also permits participants to engage
anonymously protecting individual’s identity and assuring confidentiality, which is considered the basis of good practice (Bowling 2009). The results are automatically calculated for the researcher ensuring that data analysis is more straightforward. Choosing the right sample is considered fundamental to the success of a
questionnaire. A non-randomised sampling strategy described as purposive sampling was employed as it was deemed necessary for those selected to have similar characteristics, knowledge of the subject and have an insight into the issues of role development (Bowling 2009; Gray, 2009; Ross, 2012). The sample group would therefore be in one context from a homogenous group who all had an interest in the AP role, however, heterogeneous in that within the sample group there would be stakeholders from a number of different service areas, both clinical and non- clinical, different professional backgrounds, holding different posts and from NHS and non NHS organisations.
Determining the right questions to ask was an important factor in considering the validity of the questionnaire in ascertaining the information that was of most
significant importance to stakeholders, therefore the results in each section with the highest value could be incorporated into the impact evaluation tool. This also was factored into the design of the questionnaire and format. Stakeholders where presented with a range of statements that they were asked to rank in accordance with the most important and least important information they would require when considerations the implementation of new roles. This could be likened to a semantic
differential scale with numerical options representing the participant’s opinions around priority areas (Ross, 2012).
The questionnaire was piloted with three people prior to full distribution to ascertain whether if it was too complicated, targeted the right information and how long to complete. Ross (2012) indicates that this enhances the validity of the tool. Feedback confirmed that the questionnaire was use friendly, asked the right questions and that it took approximately ten minutes to complete. These three returns were removed from the final results. For efficacy and economy, it was agreed that the contacts already held by the WBEF network would be an
appropriate sample for this survey and would become the population for this survey. Population refers to any grouping that has been chosen for the purposes of the research (Ross, 2012). This would give the potential of accessing 292 participants. The campaign function of 10Fulcrm was utilised as this allows one e mail to be sent to multiple recipients at the same time.
Analyses of the questionnaire results
The questionnaire was initially distributed to 292 individuals on the 11th December 2015, (n=292), with a covering e mail which is considered important (Bowling, 2009) (see appendix 3). 28 e mails were subject to delivery failure from the original
distribution due to inaccurate details being recorded in the system. This meant a 9.52% reduction in the original population of the study. This resulted in 264 participants successfully receiving the e mail and questionnaire link (n=264). Response rate was low in the first instance and by the 22nd December 2015, 33 individuals had responded this represented a 12.5% participation rate. There had also been communication from a small number of individuals who had not been able to open the link or had reported that the questionnaire had not worked. The survey was resent on the 22nd December with a second accompanying e mail (see
appendix 5). A further 22 individuals responded. As responses are anonymous it was impossible to know if any of the individuals experiencing problems had now completed the questionnaire. This totalled 55 individuals who had responded, representing a 20.8% engagement (when n=264).
Question one requested consent from participants to use the data produced in relation to this dissertation,100% of participants agreed to this. Throughout the survey the results are calculated to two decimal points.
10 Fulcrm is a data management system utilised by the WBEF network. It contains contact data as
Question two asked the person to identify their role. This would enable the researcher to gain an understanding of the breadth and diversity of the sample group. The researcher was able to code the respondents into categories therefore identifying what positions were held by those participating. There were ten
categories identified. The greatest response rate was from first line managers, equally other managerial roles also featured heavily. It was thought that this was an appropriate group as they often were the individuals with decision making
responsibilities in relation to new staff. Significantly ten of the participants were categorised as ‘Specialist Practitioners’, these tended to be lead nurses or specialist practitioners. The researcher’s knowledge of the AP role acknowledged that there were significant numbers of APs in specialist services (see table 1).
Your Role (55 Respondents: n=55)
Role Number % Rate
Director of Services 2 3.36% Educational leads 6 10.90% Managers 19 34.54% Matrons 3 5.45% Practice Managers 3 5.45% Service managers 8 14.54% Specialist Practitioners 10 18.18% Practitioners 3 5.45% Other 1 1.82%
(Table 1 Roles of Respondents)
Question three related to the types of organisations employing the participants. This would assist the researcher in quantifying different types of organisations to
establish a broad range of responses. It was acknowledged that the impending impact evaluation tool would capture the interests of both NHS and non NHS organisations. The researcher coded this section into five distinct categories. The majority of respondents were from NHS Trusts; however, a quarter of respondents were from organisations outside the of NHS Trusts. This enabled consideration to be given to the needs of individuals across services, acknowledging that the trend for AP roles to be developed outside of the NHS (see table 2).
Organisation Type Number %Rate NHS Trust 41 74.54% GP Practices 3 5.54% PIVO 7 12.72% Social Services 3 5.54% Other 1 1.82%
(Table 2 Types of Organisations)
Question four related to the service areas that the participants practiced. This would allow the researcher to examine whether there was representation from the different bases to identify whether practitioners in different circumstances, who may have different priorities were represented in the survey. Once again this would offer intelligence with regards to developing the AP role across a divergence of services. The researcher coded this section into eight distinct categories. This data indicated that there was participation across many different settings. The development of the AP role in community is envisaged as a growth area for the new role (see table 3).
Service Area (55 Participants: n=55)
Area Number %Rate
Acute 15 27.27% Community 24 43.63% Primary Care 4 7.27% Integrated Care 5 9.09% Education 1 1.81% Secure Services 1 1.81% Other 5 9.09%
(Table 3 Service Area)
The results of questions two to four enabled the questionnaire to be placed into context. It had established the designation held by the participants and so their positions within organisations and as such, the influence they would have in developing staff within their organisation. The types of organisations and
environments, said individuals worked in, helped understand the needs of those organisations where APs might be developed. Therefore, input was provided from a divergence of roles, employment cultures and circumstances for service delivery.
Questions five to twelve would establish the priority individuals had given to a variety of statements which would be embodied into the structure and text of the impact evaluation tool. The statements receiving the highest responses would be represented in the tool itself enabling the researcher to concentrate on priority areas and eliminate areas that participants had indicated were less influential factors. Participants were asked to rank in order of importance for each statement dependant on the number of options available. The highest priorities have been summarised in the tables below and ‘n’ defined in relation to the number of
participants completing each question. The top two statements in each instance are identified (For full results see appendix 4).
Q5 When considering the financial benefits of the development of a new role, I want information on: - (45 participants: n=55 participation rate 81.81%)
Highest identified priority statements out of 5 options The impact on patient’s /service users.
Cost effectiveness (value for money).
Table 4 (Financial considerations of developing the AP role)
Q6 When considering the impact the new role might have on patient care, I want information on: - (38 participants: n=55 participation rate 69.09%)
Highest identified priority statements out of 6 options Patient / service user satisfaction.
Number of patient / service user interventions.
Table 5 (impact on patient care)
Q7 When considering the training/ education of the staff in the new role, I would want information on: - (38 participants: n=55 participation rate 69.09%)
Highest identified priority statements out of 4 options
What skills could be acquired/developed by the training /education provider.
If there is opportunity to develop the staff after their initial training/education programme was complete.
Table 6 (Training and education of the role)
important that:- (36 participants; n=55 participation rate 65.45%) Highest identified priority statements out of 5 options
It had work based competencies included in the programme. It was work based.
Table 7 (Type of training /education programme)
Q9 When considering the impact of the role on the functioning of the team/service, I would want information on: - (36 participants: n=55 participation rate 65.45%)
Highest identified priority statements out of 5 options The potential to maximise skills mix.
Where the role could support service development and overall performance.
Table 8 (Impact on teams/service)
Q10 When considering staffing the new role, I would want information on (36 participants n =55 participation rate 65.45%)
Highest identified priority statements out of 4 options
Growing your own? (Recognising talent in your own staff and developing them).
Examples of how similar roles had been successfully integrated in other organisations.
Table 9 (Staffing of the roles)
Q11 When considering developing the new role, I would find it useful to have: - (35 participants: n=55 participation rate 63.63%)
Highest identified priority statements out of 6 options
Competencies and competency frameworks used in other organisations for similar roles. Examples of job descriptions and person specifications from other organisations.
Table 10 (Useful resources on the AP role)
Q12 When considering developing the new role, I would want information on how: - (35 participants: n=55 participation rate 63.63%)
Highest identified priority statements out of 5 options
Fits in with national and local health and social care priorities. Offers career opportunities for my staff.
Table 11 (Compatibility with national priorities and workforce opportunities)
Questions thirteen to fifteen considered wider human resource issues in relation to