The training and development of Assistant Practitioners(AP): An action research project to develop a tool to evaluate the impact of the AP role in practice and inform service development within NHS and Non -NHS organisations

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“A dissertation presented in the University of Bolton in partial

fulfilment of the requirements for the degree of M.Ed. (Professional

Development)”.

By David Andrew Morris

July 2016

Total word count excluding acknowledgments, appendices and bibliography (21,898)

Dissertation

The training and development of Assistant

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CHAPTER 1: Introduction to the Study

Impact and Evaluation of the AP Role in the National Health Service (NHS) and Non National Health Service Organisations

The training and development of Assistant Practitioners(AP): An action research project to develop a tool to evaluate the impact of the AP role in practice and inform service development within NHS and Non -NHS organisations.

Aims and Objectives 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 tool 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 (see appendix 1).

Rationale

The topic was highlighted as an area of investigation in the operational plan of the Work-based education facilitator (WBEF) network. The WBEF network is

commissioned by Health Education England -North West Office. Its primary function is the promotion, development and support of the Trainee Assistant Practitioner (TAP) and AP across the North West. Its wider remit is in relation to Bands 1-4 1_staff within the NHS and non NHS organisations. The Network is unique to the North

1_{Bands 1-4 refer to the grades of staff within the NHS who characteristically are non-registered}

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West; however, the introduction of the AP role is a national initiative which has been implemented with varying success across the United Kingdom.

Smith and Brown (2012) consider the introduction of assistant practitioners into the health and social care workforce stating, “The introduction in 2002 of the Assistant Practitioner role in health and social care aimed to provide a new type of worker who could provide direct health and social care under the direct supervision of a Registered Professional” (p.6). NHS Employers (2015) describe the role as non-occupationally specific and discuss how AP s work across a number of disciplines.

As Smith and Brown (2012) indicate, one of the primary functions of the AP role is the provision of patient care and there is a vast array of literature evaluating the AP role and the types of activities they are involved in. However, it could be argued that the vast majority of the evidence is anecdotal and falls short in measuring the impact of the role in terms of cost effectiveness, direct effect on patient throughput2_, the AP contribution in achieving local, national targets and its measure against the original workforce vision or generally accepted definition. Their impact in relation to cost benefits, service efficiencies and quantifiable effects on the patient experience is lacking. Spilsbury et al. (2009) indicated that the AP role had not been introduced in some Trusts because of the lack of evidence of the effectiveness. It was noted by the WBEF network that it would be useful to develop a tool that not only gathered qualitative information but also facts and figures in relation to the impact of the role, particularly regarding cost and patient outcomes.

Intended Methodology

An action research approach was agreed as fitting to facilitate the progress and conclusion of the project. This approach was identified as an appropriate method in line with several requests from managers that information centring on the impact of the role be made available as a resource. Cohen et al. (2013) advocates that action research is a robust method of problem solving and instigating change. The

development of an evaluation tool which measured the impact of the AP role, was identified as a priority for the network, thus providing appropriate resources to individuals with workforce planning and role design as part of their remit. Although the primary focus of the tool design would be to evaluate the role of the AP, the network considered a generic model might be useful. Working collaboratively with colleagues would refine research methods and shape the design of the final tool. Learning from previous inquiry, evaluating the knowledge gained and incorporating

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its findings as the research progressed, would inform the end product. Winter and Munn-Giddings (2002) acknowledge the role of action research as a process of continuous inquiry and development. The action research group primarily consisted of two permanent members and utilised input from others where appropriate.

An initial Political, Economic, Social and Technological (PEST) analysis was conducted to focus on the potential design of an initial market research

questionnaire which would precede the eventual impact evaluation tool. PEST analysis is often used in business to look at market potential (CIPD, 2015). Adapting this model would assist in determining what areas to consider in the initial design of the questionnaire to establish priority areas identified by stakeholders when

considering the development and introduction of new roles (see appendix 2).

A mixed method approach was utilised in the completion of the research study, which was carried out in three phases. Phase one would include desk top research assessing current evidence with regards to innovative roles within the NHS and non NHS sector and the evaluation of said roles. A scoping exercise would be

conducted to establish how new roles had been evaluated with particular reference to the AP role. This would also include identifying any potential tools that had already been written and tested. Concurrently, a questionnaire would be devised to establish the type of information considered most useful and so be explicit in the design of the final tool. Participants would be identified through the WBEF data base system and invitation to complete a questionnaire via survey monkey 3_{would be} disseminated to appropriate individuals. The issue of consent was addressed as participants were asked to affirm consent to take part in the study and for inclusion in this dissertation.

Phase one part two of the study analysed the results from the questionnaire. This informed the design of the impact evaluation tool. The tool will be used to collate both qualitative and quantitative evidence in service areas where the AP role is established.

Phase two of the study took the opportunity to pilot the tool by selecting a service area and using the tool to guide a member of the WBEF network through a semi-structured interview with an identified stakeholder. To ensure objectivity and avoid bias an impartial member of the team was asked to conduct the interview. Guidance

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notes were devised for both the interviewee and interviewer. A process map was also devised to ensure consistency in approach with the final impact evaluation tool.

Phase three of the research study was the finalised tool to be ready for use by the network.

Future use of the impact evaluation results would produce information sheets, support briefing sessions, whilst offering managers who have introduced the role, an opportunity to analyse its impact and efficacy. One aspect of an impact evaluation assessment is to consider the future growth or reproduction of an intervention (OECD, n.d.; Rogers, 2012).

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Chapter Two:

Literature Review

The literature review constituted a broad based approach. The study would initially involve a scoping exercise to establish whether there were examples of impact evaluation tools in existence. In the first instance phrases such as ‘Designing an impact evaluation tool for new roles’ produced poor or inappropriate results. Data bases with a health focus such as Cumulative Index to Nursing and Allied Health Literature (CINAHL), British Nursing Index (BNI) and Medline returned zero results when this phrase was entered. However, entering less specific criteria such as, ‘evaluating new roles’, ‘impact of the Assistant Practitioner role’, ‘Assistant Practitioners’, ‘developing support workers’ and ‘impact evaluation’ resulted in a range of research studies that could help establish the current evidence base in relation to the introduction of new roles in health and social care had been evaluated. and its impact measured.

The concept of impact evaluation as a process was also perused. Much of the literature examined was generated by commerce and charitable organisations. However, the principles of ‘change’ or ‘programme theory’ were transferable to evaluate the impact of the AP role in general. The impact evaluation process was adapted to directly influence the design of the impact evaluation tool, in gathering both qualitative and quantitative information. This would provide a fuller

understanding of how robust impact evaluation can be facilitated and effectiveness of any new roles assessed. A historical review of the NHS was briefly considered to appreciate the frequency of change in health and social care since its inauguration on the 5th_{July 1948 (NHS Choices, 2015). The introduction of new roles in both the} NHS and Social Services in response to changes such as demand, public

expectation, demographics, staff shortages, technology to name but a few influences have resulted in a dynamic ever evolving workforce.

The findings of the survey monkey questionnaire, elicited the priorities of

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alignment to national agendas were highly influential in their decision making process. Mindful of this, investigation into research on work based learning and initiatives such as ‘the talent for care’ HEE (2014), and ‘widening participation’ HEE (2014a), were also considered as appropriate components of the literature search.

Background

The NHS Plan 2002, acknowledged the pressures on the NHS and the need for a major shift in health care provision, identifying the need for nurses and other staff to extend their skill set. It advocated the need to utilise the skills of all grades of staff in the NHS, offer opportunities for career development and education and training. Many of the commitments stated in the NHS Plan are still prevalent. Many of the issues raised still challenge the provision of health and social care today. The plan commits to the joined up working between health and social care as opposed to working in silos. (DOH, 2002; Stewart- Lord et al., 2011) Many of the themes discussed in the NHS Plan are echoed in the governments ‘Five Year Forward View’, which commits to joined up integrated services between health, social care and the tertiary sector4_{. (NHS England, 2014) The NHS Plan advocated the} breaking down of professional boundaries and optimising the talents of the

workforce. It can be argued that this philosophy underpinned the creation of the AP role. (DOH, 2002)

The AP role was created in 2002 as part of a project entitled ‘Delivering the Workforce’. As in many areas of the country, the North West was experiencing significant challenges in maintain an effective health service workforce. Kilgannon and Mullens (2008), proclaim that “Vacancies were increasing and pressure was mounting for a more flexible and productive workforce” (p.523) Miller et.al. (2014) reiterate that staff shortages, lack of registered professionals and growing emphasis on skills mix, remain potent drivers for introducing the role. As part of delivering the workforce project, the role was initially introduced in Greater Manchester, followed by Cumbria and Lancashire and finally Cheshire and Merseyside.

Kilgannon and Mullens (2008) discuss the introduction of the AP role arguing that a strategic approach to developing the AP in Greater Manchester ensured

consistency in standards. Prior to the initiative, training and development of the support worker workforce was fragmented and inconsistent. The new role coincided with the launch of foundation degrees whose characteristics of employer

4_{Tertiary sector for the purposes of this study refers to the work of private, independent and}

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involvement, a combination of academic and work based learning, appealed as the preferred vehicle to develop the role that was envisaged. Miller (2013) noted there was a wide variance in the qualifications for APs, this was subsequently clarified by Miller et al. (2015), noting that although there are still many qualification routes to becoming an AP, currently the foundation degree is still the preferred option. They do however air caution and note that many Local Education and Training Boards (LETB) have diverted funding away from foundation degree qualifications, with many employers feeling that on completion staff still required ‘top up’ training from the organisation to be fit for purpose.

From the outset the intention was for the newly designed role to undertake extended skills and greater responsibility. Kilgannon and Mullens (2008) articulate: “It was also important to ensure that if the new role was to undertake some of the

responsibilities of a registered practitioner, and the education package was credible” (p.513). This fundamental concept is still a driving principle in the current

development of the role and plays a significant part in the evaluation data available. Wakefield et al. (2010) support such comments adding, “The rationale for

introducing the role was help sustain effective, efficient health care services across the NHS and free up registered nurses to take on new expanding roles” (p.17). Miller et.al. (2014) expand on this and indicate that: “Having simpler tasks

undertaken (under supervision) by Assistant Practitioners is one way in which the throughput of patients can be increased” (p12).

Reviewing the evidence

Since 2002 there have been numerous evaluations of the AP position across different disciplines and from a national perspective. One aspect of the literature review was to examine how the evaluations have been conducted, what methods were used, what tools have been developed to capture the information. The primary focus of the literature review concerns the AP role however; evaluations of other innovative roles have also been considered with regards to transferable

characteristics that might assist in the production of a generic impact evaluation tool with potential to be applied across numerous settings.

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stakeholders where the role has been developed, opportunity to evaluate objectively how influential the role has been in their service.

Benson and Smith (2007) from the University of Manchester carried out an

evaluation of the role of the AP across pilot sites in Greater Manchester, evaluating health and social care. Benson and Smith’s work can be seen as the first substantial evaluation of the AP role. The study reported some positive results from the project highlighting that some qualified APs were utilising their newly acquired skills. Comments on working across professional boundaries and greater patient satisfaction were also highlighted.

There were instances where the role had not been embraced or had caused confusion for both the registered and non-registered staff. Overall the report was positive given the expectations at that time. However, Benson and Smith noted that there was uncertainty surrounding the role from some quarters with some

professions unsure about the AP role itself and level of responsibility that might be delegated. Miller et al. (2015) highlight in some instances this is still the case, resulting in underutilisation of the role with professional attitudes sometimes hindering progress. Confusion over what an AP can and cannot do, remains. They argue “Where there is a lack of clarity concerning these roles it is unlikely that organisations will achieve the full benefits of these roles” (p.25). They state that this sometimes is a result of registered staff being reluctant to delegate more

straightforward tasks and procedures. Wakefield et al. (2009) add to the discourse noting the increasing number of patients with complex needs and pressures on registered staff concluding, “In response to the predicated crisis in professional workforce resources and freeing up registered practitioners to complete more complex caring work, a new type of health care worker was proposed: the AP” (p.227). However, Miller et al. (2015), argue that given the current economic climate, many registered staff have lacked the opportunity to develop themselves and this has compounded the difficulties in devolving more responsibility to APs.

Lack of clarity, confusion, misunderstanding of the AP role spurred Skills for Health in 2009 to formulate a definition of an AP. The definition was widely accepted and to a large extent still referred to. Coupled with the development of the AP core

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post holders in England. Equally, this would offer some degree of transferability and portability of the role. (Skills for Health, 2009) Consequently, APs were defined as:

-An Assistant Practitioner is a worker who competently delivers health and social care to and for people. They have a required level of knowledge and skill beyond that of the traditional healthcare assistant or support worker. The Assistant Practitioner would be able to deliver elements of health and social care and

undertake clinical work in domains that have previously only been within the remit of registered professionals. The Assistant Practitioner may transcend professional boundaries. They are accountable to themselves, their employer, and more importantly, the people they serve (Skills for Health, 2009a p.1).

Evaluation of the AP role

Benson and Smith (2007) favoured a mixed method of data collection the evidence was predominately qualitative in nature, with a reliance on interviews as the

preferred research method in the evaluation. Although the study provided a comprehensive overview of the ‘Delivering the Workforce’ initiative and thematic analysis of the results helps evaluate the positives and the negatives of the AP role, statistical information such as cost benefits, patient throughput, service efficiencies that can be directly attributed to the role was sparse.

Following Benson and Smiths work there has been a plethora of evaluations at regular intervals across the United Kingdom. Miller et al. (2015) commence their very comprehensive evaluation of the AP role in the NHS stating the following; “There is a growing recognition of the value of these posts. Stakeholders can clearly articulate the benefits of introducing the Assistant Practitioner role which includes improvements in quality, productivity and efficiency” (p.3). This sentiment is echoed in many other studies of the AP role. (Wilson, 2008; Allen et. al., 2012; Skills for Health,2016a) However, National Institute for Health and Care and Excellence (NICE) safe staffing levels have focused on registered staff and patient ratios (NICE, 2014). This has unnerved some managers regarding the utilisation of support roles, conversely managers have also indicated a preference for an AP in the clinical area as opposed to registered agency staff. (Miller et al. 2015)

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deployed, their impact on organisations, patient management and transfer of activities from the registered nurse (RN) to the health care support worker(HCSW) role. They noted the uneven distribution of APs nationally, with 84% of trusts based in the North West having APs in their organisations. The debate on differences between bands 3 and 4 caused confusion, this was compounded by the current tradition of extended roles for Bands 2 and 3, which in some Trusts led the DoN failing to see the value of the AP. Most of the Trusts confirmed that the APs had been developed from the existing workforce but they could see little opportunity for development within the role, other than accessing pre-registration courses. One DoN expressed that they could not understand why anyone would train to

foundation degree level and not want to become a qualified nurse. However, it was acknowledged that the AP role was becoming more prevalent, often in response to service demand. The Royal College of Nursing (RCN) concluded that the AP role was not a threat to that of the RN but rather a complimentary role. They advocated the use of APs but aired caution that they must not be introduced merely as a cost cutting exercise. (RCN 2009)

Wakefield et al. (2010) carried out an evaluation of the role by comparing and contrasting twenty-seven job descriptions across organisations, measuring against policy vision identified as working under supervision and reporting concerns to the registered staff. They confirmed a blurring of roles, with APs often working outside of policy and taking on responsibilities of the registered professional. Mackey and Nancarrow (2005) noted this as a cause of resentment, in their study of APs in occupational therapy in Australia.

Allen et al. (2012) discuss their experiences of the introduction of APs in critical care. Although the role was generally evaluated positively, with registered

professionals acknowledging the skills that some of the APs had, ambiguity around the role was identified as a concern. Respondents commented on the excellent standards of care demonstrated by APs. “…having the Assistant Practitioner on duty helped the registered staff to provide care in a more efficient way” (p.17). However, there was conflicting opinions by staff as to the level of responsibility the APs should undertake. Some senior staff felt the APs took on too much

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difference. Registration was highlighted as an issue and the lack of professional accountability, this is still a recurring theme in evaluating the effectiveness of the AP role. Miller et al. (2013) predicted the likely growth and expansion of the AP role. She calls for more extensive research into numbers of APs along with greater clarification of the roles. She identifies a lack of a national specification for the role and a wide variance in the level of qualifications that APs possess, in some instances holding no recognised qualification whatsoever.

Miller et al. (2014) embarked on a study of APs in Wales. They advocate that the role had brought benefits to the health service in Wales. Simpler funding

arrangements had enabled developments across acute and community services. They noted that the AP title was inconsistently used, with a variety of job roles that could be cross referenced to the level four descriptor 5_{of the careers framework for} the NHS (Skills for Health, 2010). They noted comments from a variety of

respondents that the APs had brought both cost efficiencies and increased capacity within the sector. Such claims lacked tangible evidence of this with no indication of exact figures in relation to cost efficiencies. Once again it was highlighted that there was a lack of consistency in implementation of the roles and a variance in the tasks and procedures the APs and equivalent level four practitioners undertook. This has led to many organisations developing local guidance and implementation toolkits, however, many organisations did not have this in place.

Miller et. al. (2015) unearthed a wide acceptance from those they interviewed, that APs can have a very significant impact in their work areas. They acknowledge currently most evidence of AP assimilation into the workforce has been in the acute setting, however recommend the role is extended and embraced more widely into community settings. The closer integration of health and social care with less complicated funding arrangements, gives rise to new opportunities for APs. Changes in technologies have resulted in more tasks and procedures becoming straightforward enabling increased opportunities for level four practitioner. APs carrying out more straightforward tasks result in greater patient throughput. Some posts have been introduced in response to national targets and strategies, others it appears were as a result of funding being available. Cost benefit analysis and

5_{Career Framework Level 4 People at level 4 require factual and theoretical knowledge in broad}

contexts within a field of work. Work is guided by standard operating procedures, protocols or systems of work, but the worker makes judgements, plans activities, contributes to service

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impact on capacity is only carried out in a small minority of departments, so hindering the true impact evaluation of the role to be robust.

Workforce planning verses evolution

Miller et al. (2015) identify the AP role as the way forward in addressing the recruitment crisis currently faced in the NHS. They discuss the successful

implementation of the AP role concluding there are more positive results if the AP role is introduced as part of workforce planning as opposed to evolution. In many circumstances the AP role is seen as a development opportunity for staff as opposed to establishing a clear vision of their impact on services. This can lead to the delegation of duties being at the discretion of individuals rather than an agreed vision of the AP’s scope of practice6_{(SoP). This can distort the true potential of the} role in clinical areas. They draw on an example from tissue viability reporting that the APs were not allowed to perform any of the skills they had learnt under the leadership of one specific individual. Once the individual had left they were allowed to practice in line with their skills set and competencies.

Perceived risk also played a significant role in restricting the APs SoP. In many organisations medicines administration has been a problematic area, with Trusts reluctant to delegate this procedure to non-registered staff. However, Miller et al. (2015) highlight a pilot study where APs were administering medication, reports indicated that APs were more cautious when administering medication, highlighting in the course of the pilot there had been zero medication errors by them. They confirmed that one occasion, the AP identified a medication error made by the registrant. Therefore, perception of risk and delegation of duties based on

personality, in contrast to objective decision making as part of a planned strategy, reinforces that the role is more successful introduced as part of workforce planning.

Miller et al. (2015) highlight radiography as an area where the AP role is part of a national strategy around workforce planning and considered to have a positive impact. Radiography as a profession have made great strides to shape and define the AP role within its discipline and acknowledge this level of practitioner as part of strategic view. The Society of Radiographers 7_{(SoR) have produced a SoP for APs} in this clinical area. This has help establish the role within radiographic services and offered guidance to the registered professional on delegation (SoR, 2012).

6_{Scope of practice refers to the procedures and tasks health care workers can undertake.} 7_{Society of Radiographers refers to the professional body and union which supports most}

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Stewart-Lord et al. (2011) discuss the introduction of the AP role in radiography and changes to the workforce programme in response to expectations of supply and demand within the profession. Evaluation of role design between 2001 and 2005 established the role of the radiographer taking on some of the responsibilities of the radiologist and so offering opportunities for APs to assimilate some of the

radiographer’s roles into their SoP. The profession developed a four tier approach embracing four levels of practitioners, level one APs, two practitioners, three advanced practitioners and four consultant radiographers. The extended use of the AP would provide the catalyst for the progression of the registered practitioner offering development opportunities within the profession, whilst also addressing the increasing expectation of public demand. Appropriate opportunities were identified within the diagnostic and therapeutic fields. Their study analyses the effectiveness of the workforce strategy and utilisation of the role. They established that despite professional guidance and documentation being available to guide the

implementation and use of the AP, in some areas and in some circumstances, it was still based on individual’s personal experience and perceptions of the role. They argued that there was still a need for more systematic approach to implementation of the AP.

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practice and without direct supervision” (p.198). In much of the literature from other disciplines the opposite appears to be true, with individuals regularly identifying the lack of opportunity to perform all their skills being the case (Miller et al. 2015).

The SoP developed by the SoR does show commitment from the profession in attempting to regulate APs and establish the role as part of a national strategy, however evidence would suggest it is not always being consistently applied. Therefore, it might be argued that the role of workforce planning is inconclusive (Stewart-Lord et al., 2011).

Registration and Regulation of the AP

Registration and lack of regulation is consistently highlighted as a barrier to the optimum use of APs (Wakefield et al., 2009; Steward-Lord et al., 2011; Allen et al., 2012; Allen and Wright, 2012; Miller et al., 2015). The Francis Report in 2013 recommended the registration of support staff but this was rejected by the then coalition government their response concluded “‘Regulation is no substitute for a culture of compassion, safe delegation and effective supervision. Putting people on a centrally held register does not guarantee public protection” (DoH, 2013, p.72). Currently there are no plans by government to register staff below band 58_despite 80% of HCSWs, including APs, who according to Unison (cited in Miller et al., 2015), believing they should be. Many professionals highlighted the lack of registration being an obstacle to confident delegation of duties and ultimate

accountability. Miller et al. (2015) discuss professional concerns over regulation and registration and stipulate: “…continuing concern regarding the non- registration of Assistant Practitioners is known to have impeded progress in some areas” (p.20). Conversely, Miller et al. equally argue their lack of registration can be seen as a positive, meaning APs can work across professional boundaries and not be restricted to one profession. Vaughn et al. (2014) contribute stating whilst most articles they had considered in their literature review had called for registration of APs, there was little evidence that this would support patient safety.

Some professionals remarked that educational programmes which did not lead to registration lacked credibility. Educational content and training programmes were not routinely standardised. The level of study and content varied considerably adding to a lack of confidence in the abilities of APs. From an employment perspective, transferability of the qualification was not as clear as it was for registered staff. As a result of Francis (2103) and Cavendish (2013) many

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employers have been apprehensive with regards to inadequate training of staff (Miller et al., 2015)

Skills for Health (2015) examined the broad range of roles that support staff were engaged in. They estimated that 2.1 million individuals were employed by the NHS mostly in professional roles. However, approximately 40% of that figure are in support roles, with around 17% providing direct patient care. They identify staffing as the largest major expenditure within the health service. Transference of duties is nothing new in health. The move to all graduate nursing has helped move this along with more and more work being delegated to the support staff. They identify “…with the correct governance and clarity of roles and responsibilities; as well as

recognition of competence, support workers and Assistant Practitioners can enhance quality and efficiency of care” (p.13). They consider the demographic profile of the country and project that by 2037 the United Kingdom will have a population of approximately 73,000,000. This will be combined with longer life expectancy and an increase of people living with long term conditions. This 30% of the population will account for 70% of the health service’s spending. They suggest given the small difference in wages between bands 3 and 5 (which is approximately £6,000) alternative thinking is often ignored locally. However, this differential on a national scale amounts to significant savings. “Making better use of support staff can also make a significant contribution to saving money and help improve patient care” (p.14).

Skills for Health advocated that with good planning and support the AP role can carry out many of the roles of their registered colleagues. They estimate that if 1% of work was transferred from registrants to APs and support workers this could result in £100,000,000 saving across the NHS. They champion the Band 4 role suggesting that most of these staff members can work with minimal supervision. Development of support staff can have a positive impact on both economics and quality. (Skills for Health, 2016)

A subsequent publication by Skills for Health investigate the possibilities of

optimising the use of support workers, examines the need to look outside of working in traditional cultures. They recognise the clear case for developing the support workforce. They suggest that work is needed to look at future workforce

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advocate the need for support workers to have parity of esteem in recognition of their contribution to health care. (Skills for Health, 2016a)

Powel et al. (2016) researched the impact APs in GP practices, discovering that the introduction of the role had reduced appointments for patients with the practice nurse from twenty minutes to ten.

The AP: Foundation Degrees and Work-based Learning

There is no single route or programme to develop the AP role. Levels of qualification underpinning the role varies considerably. The title of AP is not protected and as such staff can be defined as an AP holding any number of

qualifications or none. Apprenticeships, diplomas, national vocational qualifications and foundation degrees are some of the development programmes leading to the title of AP. Miller et al. (2015) report that Skills for Health indicated that the role should be underpinned by a level five qualification as indicated in the qualifications and credit framework, sitting just below bachelor’s degrees. (Accredited

Qualifications, 2012). There is the suggestion that as foundations degrees have in many instances become more generic, the AP is emerging unfit for practice. This in itself has led to a lack of confidence amongst some employers. Uncertainty around course content or qualification level has led to issues of transferability amongst employers. However, in juxtaposition bespoke foundation degrees, tailored

specifically to service needs can be limiting when compared with a generic model. Some Higher Education Institutes(HEI) have discontinued their foundation degree in health and social care completely, assessing them as economically unviable. To this extent organisation are considering the development of ‘professional diplomas’ as a viable, more practical alternative. Trailblazer apprenticeships9_{are also being hailed} as an appropriate method of developing APs. The literature indicates that there is great discussion surrounding development opportunities for the AP. (Miller et al., 2015)

Seagraves et al. (1996) carried out a study of work-based learning in small companies. Their research highlighted a great deal of anomalies surrounding this style of learning and structure of the programme. They identify that work-based learning has improved access opportunities to learning and improvements on performance and economic success.

9_{Trailblazer Apprenticeships are developed with employers working in that particular sector to}

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Defining work-based learning they conclude it as learning that improves an

individual’s ability to do their job. They acknowledge that the application of the term varies widely and is utilised to describe a host of different learning situations. Therefore, they conceptualise said term under three distinct headings:

a) learning for work

b) learning at work

c) learning through work (p.6)

The study highlights that in many instances the success of work-based learning initiatives have rested on the tenacity and enthusiasm of individuals who champion the cause within individual organisations. Many organisations however, appeared reluctant to change their working practices or reshuffle workloads to allow for successful progression and implementation. This was often compounded with inadequate or inappropriate mentorship. Perception of the programmes amongst some organisations envisaging a speedy way to qualify staff, were in most cases incorrect. They identify these as a major reason for attrition amongst the learners.

Boud et al. (2001) describe work-based learning as an approach to education that involves bringing together HEIs with employers to develop learning opportunities in the workplace. They discuss the wide variation in design, in some instances

indicating only minor differences to established programmes, whereas others they claim have “…developed new pedagogies of learning” (p.5). They identify six characteristics that they feel all work-based leaning programmes share; partnership working; earners are usually employed; infrastructure needs to be present in the workplace and the organisational needs form part of the curriculum; learner’s needs are established and reflected in the curriculum; a substantial element of the learning should be in the workplace; and academic standards maintained by the HEI.

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The programme embraced both academic standards and work-based competencies.

Harvey (2009) conducted a comprehensive review of a wide variety of research and maintained “Lack of understanding of foundation degrees amongst employers is a major challenge for institutions attempting to develop partnerships with employers” (p. 35). He maintains that employers would engage in programme design, if they could clearly see the benefits to their business. Mentorship is acknowledged as a cornerstone of work-based learning. however, difficulties around consistent

mentorship was a constant theme with some learners reporting very poor standards leading to problematic assessment of work based elements.

Wright et al. (2010) join the discourse examining the situation in Scotland identifying relationships with HEIs and stakeholders had changed with the expansion of work-based learning. They too note with the progression of the widening participation agenda, learner centred approach, flexibility in programme delivery and adapting to the demand for skills in the workplace, HEIs have extended their repertoire of work-based learning programmes. They acknowledge that work-work-based learning means different things to different people and that this results in confusion. Equally their research established that whilst the relationship between HEI and employer was important, it also had its difficulties, with different concepts of what actually

constitutes knowledge and learning. Accreditation of the courses where still HEI led with an agenda for academic bias. Philips (2012) considers her thoughts on work-based learning. She purports that they are attractive to employers as the learners are not excluded from the work place. She agrees with previous claims that there is a lack of clarity surrounding definition, but concludes that the usual model reflects a tripartite relationship between the student, employer and HEI. This leads to learning that can be directly applied to practice and personalised to the individual learner.

Work-based learning theory

Raelin (2008) discusses the concept of work based learning theory. His initial thoughts on traditional learning echoes much of the literature available he

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1. It views learning as acquired in the midst of action and dedicated to the task in hand.

2. It seeks knowledge creation and utilization as collective activities where learning becomes everyone’s job.

3. Its users demonstrate a learning to learn aptitude, which frees them to question underlying assumptions in practice. (p.2)

He discusses how work-based learning differs from conventional learning as it is engaged with real life experience. He advocates that the concept of metacognitivism is fundamental to the process whereby it is insufficient to merely look at what we learnt but views it in a much wider context, ensuring that we fully understand the ramifications of the learning, thus assisting us to analyse out current knowledge base and rethink what we know. In doing so provide a framework to develop and synthesise new knowledge.

Raelin relays that for many individuals the concept of work-based learning has become synonymous with vocational study, which in turn has become tantamount to saying that it is most suited for individuals who dislike classroom or academic study. He reiterates that this should not be the case “…work-based learning is not

antagonistic to theory it respects and uses theory” (p.69). He recognises that all too often practice and theory are developed devoid of each other’s contribution whereby theory is determined as the thinking and practice the action, with both parties holding somewhat derogatory ideas about the other. “Theory is often constructed as impractical or as ‘academic’ or ‘ivory towerish’. Meanwhile, practice is viewed by academics as banal and a theoretical” (p.64).

Raelin although reflecting on Kolb’s experiential learning model (1984), concludes that work-based learning is much more, it is multi-layered with practice well capable of producing theory. Raelin’s model of work-based learning initially incorporated two dimensions’ theory and practice and explicit and tacit knowledge. He suggests that theory offers a framework to challenge assumptions that when combined with action creates a model of learning. Practice is viewed as the process by which

practitioners develop their skills and experience. Raelin highlights that positivism, whereby knowledge is produced under scientific paradigms, is more credible due to its objectivity and unbiased nature. It was deduced therefore, that theory be

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in practice. Some schools of thought feel that this approach has produced a

framework even further removed from practice. He speculates that teaching became disjointed from learning, teaching imparting knowledge and learning being the storage, retrieval and recapitulation of the subject matter, leading to theory based teaching with little regard to context. Once again the learner has to make sense of this on their own out in the field. He argues that we now know that our

understanding is changes, we construct our knowledge and it is influenced by many factors, knowledge that is abstract is of limited use in the real world. He concludes “Theory makes sense only through practice, and practice makes sense only through reflection as enhanced by theory” (Raelin, 2008 p.67). Work based learning relies on a blend of both.

Raelin (2008) consequently explores the role of both explicit and tacit knowledge. Work-based learning is more than just the knowledge and procedures passed on from one individual to another. It also involves tacit knowledge not typically taught but gained through experience and constitutes deep-rooted understanding

expressed through contextualised action often difficult to put into words. He describes this as the difference between ‘knowing how’ and ‘knowing that’ (p.67) Raelin argues that tacit knowledge can be transferred by observation and modelling of others. He reiterates that conventional theory based learning can leave the practitioner ill prepared in the workplace, unable to think independently and problem solve. Tacit knowledge is what aids us in difficult situations or to engage in complex problem solving. This can be built on by the collective knowhow of the environment as a whole by the proximity of others and sharing of experiences. Theory may well be developed as a living experience than that which is preordained. Work based learning requires both explicit and tacit learning to have true impact. (Raelin, 2008; Philips, 2012) Therefore, by utilising theory and practice, coupled with explicit and tacit learning, Raelin advocates a conceptual model of work-based learning can be constructed. In addition, he also considers a third dimension that of learner activity, each individual learns at their own pace and from the people around them. (Raelin, 2008)

Impact Evaluation Process

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Wilson (2008) project managed and developed the East Midlands AP tool kit. She considered how the role might be measured and how the role must be identified in the business plan which should “…identify all the benefits expected from developing and implementing the AP role and how they will be measured” (p.14) She

recommended that outcomes in the workplace should look at value, costs and savings. They considered the impact of the role from a number of perspectives:

1. The service: Have strategic targets been met? Had the patient experience improved? What affect had there been on key performance indicators? 2. Care Team: Had it allowed practitioners to work differently? Had it affected

capacity within the team?

NHS Wirral (2011) developed a number of fact sheets. including evaluating a project or service. They identify three types of evaluation:

1. Formative: Carried out prior to the project commencing

2. Process: Begins at the start of the project can be used to look at delivery and implementation of the project and whether it delivered to the original plan?

3. Impact/Outcome: Did it meet its aims and objectives?

They cover a number of important issues; considering the purpose for evaluation and who is the audience posing the question “Is the main impetus one of

demonstrating the benefits of the service to other potential users? “(NHS Wirral 2011) A key aspect of the impact evaluation project the researcher was engaged in, was to provide tangible information that both the participant and others could use.

NHS Employers (2012) discussed their rationale for ‘evaluating an AP project’ and how this helps establish the effectiveness of the intervention. They believe that a project’s impact and success must be measured in relation to the original objectives to assess its validity. They employed a number of methods in their process,

including interviews, surveys, staged assessments and the use of feedback forms.

Stern, et al. (2012) discussed the design of impact evaluation tools and states, “Impact evaluation (IE) aims to demonstrate that development programmes lead to development results” (p.i). They consider three elements to be essential in IE design, the evaluation questions, appropriate design and method and programme attributes. Stern et al. advocates five different types of impact evaluation

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The Organisation for economic co-operation and development (OECD) claim that impact evaluation is an assessment of how interventions have affected outcomes, “… the proper analysis of impact evaluation requires a counterfactual of what those outcomes would have been in the absence of the intervention” (OECD, n.d., p.1). Counterfactual is not necessarily a before verses after, however this can be seen as a valid method of impact evaluation. Robust impact evaluation will highlight both successful and unsuccessful aspects, where there is potential for redesign by establishing which objectives have been met and what lessons can be learnt along the way. In turn this can influence decisions on whether future investment is worthwhile. OECD discuss the importance of base line assessments and how this will develop programme theory. They recommend a mixed method approach declaring “Good evaluations are almost invariably mixed method evaluations” (OECD, n.d., p.5). They conclude that impact evaluation surrounds specific interventions and set in a specific context.

Rogers (2012) considers impact evaluation and echoes OECDs perspective; “Impact evaluation investigates the changes brought about by an intervention” (p.2). She suggests that expected results are an important aspect of impact evaluation, whilst exploring unexpected results as part of the process. She discusses some common reasons why impact evaluations are conducted:

1. Decisions around continuing to fund the intervention. 2. Whether to continue or expand the intervention. 3. Whether to replicate the intervention in other areas. 4. Whether it can be successfully adapted to suit other areas. 5. Reassurance to stakeholders that it is a valid use of funds.

The rationale is readily transferred to the AP role and its impact on services.

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interventions role in producing them” (2012, p.9). Perrin (2012) discusses change theory identifying it as referred to as programme theory, result chain, programme logic model or attribution logic and the series of assumptions. He examines the link between inputs, activities, intermediate outcomes and the intended impact. There needs to be a logically constructed counterfactual, as in there is no other logical reason for the identified impact other than the intervention itself. Quality impact evaluation according to Rogers (2012), must be utilised, be accurate paying attention to both intended impacts and unintended impacts, positive and negative and have propriety, that is ethically sound recognising any potential harmful effects. Rogers highlights that impact evaluation can be influenced by the characteristics of participants and the environment. She claims impacts can take many years to fully emerge, on some occasions results are needed before enough time has elapsed to gain the true picture (2012).

Bamberger (2012) assesses the benefits of mixed methods and impact evaluation advocating this as the preferred model. He suggests that quantitative results give breadth of the impact whist qualitative inquiry adds depth to the evaluation. He claims that no single method on its own can fully explain the impact of an

intervention in the real world and that a mixed method is a truer reflection. He notes that whilst quantitative evaluation can provide information such as how many, how much, significant differences, qualitative evaluation can provide evidence on how the changes were experienced. He recommends that a multi-level, mixed method is the most robust.

Evaluating training Programmes for the AP role

Equally important in assessing the role of the AP in practice is evaluating the training programme itself. Work-based learning and in particular the foundation degree, has both academic aspects to evaluate and those in the work place. Seminal work by Kirkpatrick originally in 1959, defines his four levels of evaluation model. Now in its third edition, and written in collaboration with his son he discusses the four levels:

1. Reaction of the student 2. Learning

3. Behaviour 4. Results

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At the first level the programme is evaluated in relation to the learner’s experience of the programme. Did they enjoy it? Was it at a suitable pace? Could they see application of the training back in practice? The second level looks at the learning that took place as part of programme. This examines whether knowledge or capacity to learn has increased for participants. Did participants have more

understanding as a result of the programme than they did before? Did the students learn what was intended to be taught and experience what was intended in the programme? Level three concerns itself with the behaviours of the participants and their ability to interpret what they have learnt back in the workplace. Have they been able to apply their learning? Has it resulted in a change of behaviour and practice? Are the confident to pass on skills to others? The fourth level looks at the results of the training on the organisation itself. Has the programme delivered on the

expectations of the business? Are there measurable impacts within the

organisation? Does the performance of the participant live up to the expectations within the business case? (Kirkpatrick and Kirkpatrick, 2012).

Kirkpatrick emphasised that training needs to reflect the demands of the market place and that it is not enough for educator to only concern themselves with the first two levels of his model. He discusses the need for training to be practical,

interesting, enjoyable and relevant to the job in hand. He advocates that all four levels must be explored to truly evaluate how effective a training programme has been, claiming much of the learning is embedded through work once the training programme is over (Kirkpatrick and Kirkpatrick, 2010). Kirkpatrick and Kayser Kirkpatrick (2009) reflected on the model, suggesting that in many instances the model had been misinterpreted and viewed too simplistically, creating an inability in to understand the inter-relationship of the four levels.

A fifth level has been suggested by Phillips (2003) looking at return on investments (ROI), he argues that in many circumstances ROI is intrinsically linked to

accountability and justification for time and money spent on training and

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Kirkpatrick’s model can be applied in the most part to the development of the AP and training programme. For the vast majority of APs, the foundation degree qualification has proved to be the programme of choice. Students are requested to evaluate their experience of learning at an individual level through local evaluation procedures and the national student survey. Level two is evidenced in many evaluations of the foundation degree programme by the students who prudentially comment on the improvements they have seen in both their academic ability, learning capacity and confidence levels. (Bungay et al., 2015) Level three of the evaluation model can be measured by the students’ performance in practice. Foundation degrees are characterised by their work based learning content; students are expected to show competence in practice as well as academic rigour. Level four it might be argued is somewhat compromised with managers reporting that some APs lacked the desired skills in the workplace and that often the content of the foundation degree had been too generic. Investigation into the fifth level suggested by Philips reflects the spirit of this research investigation. The

development of an impact evaluation tool would consider return on investment as one of its primary domains.

Summary

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Chapter Three: Methodology

This dissertation discusses an action research approach, taken to develop an impact evaluation tool that would provide resources for stakeholders to make informed decisions supporting role development. The research is carried out in three phases, ultimately leading to the development of the tool itself. A mixed methodology was considered as the most appropriate way of conducting the research study. Triangulation of both quantitative and qualitative methods were employed within the study, to reap the benefits from both approaches. Research is considered within two broad paradigms, quantitative methods, aligned to a

positivist /post positivist tradition and qualitative methods aligned to a naturalistic tradition (Bowling, 1997; Bell,2006; Gray,2009; Ross, 2012). Silverman (2010) identifies that traditionally quantitative methods have dominated proclaiming, outside of the social sciences their prevalence still exists. Ross (2012) identifies that quantitative research is prevalent in health care and is “considered more scientific and trustworthy” (p.43). This has led to greater influence in shaping policy and interventions. Ross (2012) continues by examining the contribution of qualitative investigation in the field of health care, considering the impact and feelings that research may have on its participants. Ross considers the mixed method approach and argues that this is now defined by many as the third paradigm. She suggests, “There are very strong arguments for combining approaches in order to capitalize on the strengths and produce a more holistic view of the phenomena being

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Ethics

The need for ethical approval was considered throughout the process and sought. Ethical principle such as voluntary participation, informed consent, risk of harm and confidentiality was maintained (Trochim,2006). The health research authority decision tool was used in the first context, concluding that it was not designated as research in line with their principles (Health research authority, n.d.). Proposal for the research was made via the University and the researchers employing

organisation. It was deemed not necessary from both quarters. The employing organisation considered the study to constitute a service review and as such did not require ethical approval (see appendices 6,7). Information from the initial survey provided an anonymous return and participants agreed approval for use in this dissertation by providing an affirmative answer at the commencement of the study. Equally, on the pilot documentation the stakeholder is explicitly asked to sign to give permission for use of their information.

Why an action research approach?

Action research is considered a very flexible approach that can be adapted and applicable to many situations and for many different purposes. It is a very powerful approach that requires both action and reflection to improve practice and decision making (Cohen et al., 2013). Bell (2006) proclaims that it can be used in any context where specific knowledge is required for specific problems. Bowling (2009)

highlights action research as a means of developing knowledge whilst

simultaneously changing it, and identifies two distinct features of improvement and involvement, sentiment which is echoed by Gray (2009). Stringer (1996) proposes a simple three stage model of action research of looking, thinking and acting. Ross (2012) comments on the cyclical nature of action research and reports on the discourse that surrounds it. She suggests a five stage model: identifying the problem, fact finding, planning, action, evaluation. She argues that action research has gained popularity with in health care as it is able to respond more readily in an environment of rapid change. Bowling (2009) concludes, “Action research is a popular technique for attempting to achieve improvements by auditing processes and critically analysing events” (p.367). Bowling continues by suggesting that action research often uses many different methods and may often use evidence generated from both qualitative and quantitative methods, considering a variety of data

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1. Research subjects are themselves researchers or involved in a democratic partnership with researchers.

2. Research is seen as an agent of change.

3. Data are generated from the direct experience of research participants. (p.313)

This study can be argued is aligned itself, to many of the different models of action research. Cooperative inquiry model which focuses on research with people, as opposed to on people, underpins the approach of the project undertaken. Although cooperative inquiry is identified as a particular type of participatory research it acknowledges its overlap with action research in general. (Herron, 1996). This study is characterised by a small core group of two researchers with input from a variety of individuals when and where appropriate.

Identifying the problem

Initially, a problem was highlighted through employers concerning resources available to support them in developing their bands 1-4, in particular the role of the AP. Stakeholders were increasingly requesting more statistical evidence in relation to the impact of the AP role to compliment the qualitative data available. Although some evidence relating to cost effectiveness and direct effects on patient put through and experiences were available, it remained limited. The action research team believed that a possible solution to the problem was to create an information gathering tool that could evaluate the impact of new roles within organisations. The action research team consisted of two core members from the WBEF network with a mission to produce a more holistic impact evaluation tool that would yield both qualitative evidence and statistical data. Contributions from a number of sources culminated in the final design of the impact evaluation tool.

The search cycles

The research was carried out in phases utilising a variety of methods to produce the information gathering tool, otherwise referred to as an impact evaluation tool. With respect to this particular study the main focus was consideration of the AP role. The first aspect was to look at the problem at hand. The research team identified the projects objectives and considered how these would be addressed. A PEST analysis was carried out by the team to help identify the areas that might be

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also considering the training and qualifications that might underpin role development. The project was identified as having two objectives:

1. To develop a tool to determine the impact of a new role within a service area.

2. Conduct research to determine the impact of a new role with a service area – analysing results obtained from research.

Phase One of the research process

The first phase concentrated on two aspects. Initially desk top research was conducted in line with the literature review, to investigate what evaluations had already been conducted, methods used and what evaluation tools if any, had been developed for said evaluations and measuring consequent impacts. Secondly, running concurrently, a market research questionnaire via survey monkey. The questionnaire was designed in conjunction with the PEST analysis, to establish what were the highest priorities for stakeholders concerning the development and introduction of AP roles within their organisation. This took a predominately quantitative approach to gathering information but did include some qualitative aspects providing opportunity for stakeholder comment.

Desk top research, also referred to as secondary research was conducted to scope out the current situation with regards to the AP role and also ascertain what tools had been used to gather the evidence. Utilizing the research finding of others in the field would help identify areas that were successful and also problematic with the AP role. Equally it would inform the research project at an early stage what methods and resources might already exist and whether these could be adapted to meet the needs of the project. Gray (2009) acknowledges that whilst some scepticism must be deployed when using secondary sources, arguing some data cannot be

effectively replicated, this method can be efficient in both time and cost. It was considered by the research team that analysis of secondary data would in this instance help benchmark current knowledge and the findings would influence the direction of the design for the impact evaluation tool.

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importance to help establish which domains should be captured in the design of the impact evaluation tool whilst disregarding areas of least interest. This would

produce quantitative data identifying numerically which statements on the questionnaire where of highest importance. A final section offered free text for respondents to add comments they felt were significant to the topic.

Bell (2006) offers a reminder that attention needs to be paid to the design of the questionnaire and the questions asked. The design should match up to the

objectives, the researcher must avoid ambiguity, provide a tidy questionnaire (which receives a better response) and asks “…what do I really need to know” (p.140). She advocates “It requires discipline in the selection of question writing, in the design, piloting, distribution and return of the questionnaire” (p.136). Ross (2012) adds that to some extent a questionnaire needs to be targeted at participants who have some knowledge of the subject matter, seeing no advantage in targeting those who have no understanding of the topic. She discusses that unless participants are selected it can compromise the validity and reliability of the study, as respondents may well be just guessing rather than providing a considered response. Bowling (2009) states advantages of structured questionnaires to be useful in that they can remain anonymous, economical and have the potential to access a relatively large audience. Disadvantages may arise if participants are obliged to choose options that do not reflect their true opinion or may not understand the instruction or questions themselves. Equally response rates may prove disappointing. Ross (2012) echoes the concerns raised by Bowling, whilst supporting the advantages highlighted.

The researchers were aware of both arguments but as this would not be the sole way of data collection felt that for market research purposes, this would be a valid method. Participants were selected on the basis of their current interest in the AP role and their positions within organisations to influence workforce development. Gray (2009), offers a reminder that successful completion of questionnaires often relies on the participants having a vested interest in completing them and cautions that they should not be too lengthy. Piloting questionnaires is deemed good practice (Bell, 2006; Ross 2012), therefore a small pilot was conducted prior to full

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data was embedded within the questionnaire itself and returns remained anonymous maintaining confidentiality.

Phase Two Piloting the tool

Data produced from the results of the survey and combined with secondary research were reflected on by the action research team. The questionnaire

identified the priorities managers had indicated as the most pertinent in influencing their decisions around role development. This was used in the design and content of a draft impact evaluation tool. An appraisal of secondary research highlighted that the majority of evidence surrounding AP evaluation was indeed qualitative in nature with repeated use of questionnaires and semi-structured interviews as the dominate data collection tools. Research into impact evaluation processes and work based learning theory were also considered in the construction of the design of the impact evaluation tool (see appendix 8).

The tool offered opportunity for stakeholders to consider the impact from both a qualitative and quantitative perspective and produce data that had both anecdotal and statistical qualities. Its design aimed to focus the stakeholders experience of the role within the service area and consider whether the training and development programme underpinning the role had resulted in individuals fit for practice. Equally, it offered opportunity to consider the original vision for the role and assess the actual role against the original concept. This is seen as a fundamental principle of impact evaluation. Any deficits could be identified and an action plan established. A meeting was held with the WBEF who would conduct the follow up interview to go through the tool itself and also the guidance notes. A discussion also took place around the process map provided to help the identified WBEF choose the area they felt would be suitable for conducting the study with (see appendices 9,10).