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Role Transition and the Nurse Practitioner: An Investigation into the Experience of Professional Autonomy
Dr Andy MercerUniversity Department of Mental Health School of Health & Social CareBournemouth University
Project aims To explore nurse practitioners’ experiences of role
transition and professional autonomy, to gain a new understanding of how nurse practitioners experience their role, and new insight into the potential of the nurse practitioner role in the ever changing arena of health care delivery.
To addresses the concept of professional autonomy, the boundaries of professional practice, and how this links to the legal, ethical and epistemological foundations of nursing practice in general, and more specifically to the professional role of the nurse practitioner.
Initial considerations
Personal history Philosophy & health care Nursing ethics Patient/client autonomy UKCC-ENB-NMC
Focus & methodology
Qualitative study, considering human experience Link between nursing ethics, nursing philosophy
and method Phenomenology - hermeneutics
Consideration of research focus
Nurse practitionersProfessional autonomy
Role transition
Detailed discussion of methodology
Phenomenology (Husserl, Giorgi)Hermeneutics (Heidegger, Van Manen)
Narratives, interpretation (Ricoeur)
Paul Ricoeur (1913-2005)
“Who am I?” “How should I live?” People play an active role
in structuring their perceptions, therefore the meaning of perception needs to be interpreted in the context of the individual's situation.
Ricoeur's ethicsRicoeur believes that human life has an ethical aim, and that aim is self-esteem: “the interpretation of ourselves mediated by the ethical evaluation of our actions”. Self-esteem is itself “an evaluation process indirectly applied to ourselves as selves”
(The Narrative Path, 1999)
Ricoeur's ethics
Ricoeur emphasises the importance of the first person perspective and the notion of personal responsibility, but notes that we are “mutually vulnerable”, and so the fate (or self-esteem) of each of us is tied up with the fate of other(Oneself as Another, 1992)
Rosemarie Rizzo Parse
US nurse, studied phenomenology at Duquesne University
Best known for theory of 'human becoming'
Sees the key role of the nurse as helping people understand personal (human) experience, and achieve 'wholeness'
Linked nursing theory to research method
Research process NPs were approached by
Email/ phone and invited to participate
Information and consent managed as per ethical approval
Interviews typically lasted 45 – 60 minutes
Interviews were transcribed verbatim
WinMax used as aid to analysis
Method, Data Collection
Derived from Ricoeur
Narrative interviewsRecordings transcribed to
create texts
Data Analysis
Three phases:Naïve interpretation
Structural (descriptive) analysis
Hermeneutic interpretation
Sampling
Purposeful sample: accredited NPs Mix of UK & US registered, all with
experience of topic Diversity of clinical experience (Maximum variation sampling)
Methodology - detail
Three stage process, based on Ricoeur, borrowing from work carried out by Wiklund, Lindholm & Lindström (2003), and by Lindseth & Norberg (2004), among others
Naïve interpretation Descriptive structural analysis Hermeneutic Interpretation
Findings: naïve interpretation Initial impression was that participants discussed their
experience of autonomy with reference to: Inspiration Self promotion Regulation Frustration Optimism
“Nurse practitioners are comfortable in their role, and believe they are autonomous practitioners who offer a high standard of care to their patients. They do however feel some frustration in their day to day work within interprofessional teams because of their unequal relationship with medical colleagues, and the way in which care is organised and regulated, which together interfere with their ability to maximise their effectiveness”
Findings: Descriptive structural analysis
First theme: Role Transition NP' experiences of role transition Barriers to role transition Other disciplines’ misunderstanding of the NP role Motivation to move into a NP role
Second theme: Exercising autonomy The exercise of autonomy in practice Developing self-confidence within the NP role Experiencing frustration Legal Restrictions on practice
Findings: Descriptive structural analysis
Third theme: NP’s professional relationships A unique perspective Professional boundaries Controlling influences Professional Relationships
Fourth theme: NP-patient relationships Nurse practitioners’ attitudes to patients Experiencing ‘role satisfaction’ through patient care Patients’ misunderstanding of the NP role Reluctance to see the NP
Findings: Descriptive structural analysis
Fifth theme: Nurse practitioners’ skills Nurse practitioners’ use of nursing skills
Sixth theme: Reflections on the NP role Future prospects for nurse practitioners
Interpretation and discussion
1. Exercising autonomy
Feelings of pride, self-esteem Evidence of doubt regarding potential for autonomy Controlling influences, legal restrictions, and
prescribing Organisational structures Protocols, guidelines and clinical pathways External factors limiting the potential for autonomous
practice Feelings of inferiority, deference to others
Interpretation and discussion
2. Nurse practitioner skills
Promoting the nurse practitioner role Power and relationships Holistic care, better care Implementing care: knowledge and skills for practice Reflections on the effectiveness of the nurse practitioner
role Collaborative working - nurse practitioners’ relationship with
other disciplines Responses to being mistaken for a doctor
Interpretation and discussion
3. Role definition and role transition
Uncertainty about the future Optimism
Implications for practice nurse practitioners have confidence in their ability to offer
care to patients that is holistic, evidence based and effective
nurse practitioners need an assertive voice to promote their role and their success in providing holistic care to diverse patient groups.
ongoing uncertainty regarding statutory regulation of nurse practitioners, and continuing variation in their precise role definition have implications for maximising the potential evident in existing nurse practitioner roles.
/cont
Implications for practice (cont.)
the potential for nurse practitioners to work autonomously is dependent on their relationships with fellow professionals, particularly doctors
more effective planning within multi-disciplinary teams prior to the introduction of a nurse practitioner might help to enhance positive professional relationships.
nurse practitioners demonstrate evidence of ongoing uncertainty, or at least ongoing dissonance with regard to their position within the profession of nursing.
Conclusions
A more robust definition of the nurse practitioner role, enshrined in statutory regulation, might pave the way for a philosophical debate about the future of advanced practice roles.
To achieve maximal autonomy in practice settings, nurse practitioners may have to dissociate themselves further from the wider nursing profession, or at least to establish clarity in their role and regulation. This may provide the best opportunity for nurse practitioners to realise the external recognition that they appear to believe is vital to their further professional development.