Identity Crisis Within the Role of the Emergency Nurse Practitioner? an Exploration of Autonomy and Identity

IDENTITY CRISIS WITHIN THE ROLE OF THE EMERGENCY NURSE PRACTITIONER? AN EXPLORATION OF AUTONOMY AND IDENTITY. SALLY MOYLE A thesis submitted in partial fulfilment of the requirements of the University of the West of England, Bristol for the degree of Professional Doctorate Education. Faculty of Arts Creative Industries and Education June 2017 1 UNIVERSITY OF THE WEST OF ENGLAND ABSTRACT FACULTY OF HEALTH AND APPLIED SCIENCE SALLY MOYLE Introduction: Whilst the Emergency Nurse Practitioner (ENP) role is now well established within urgent care settings in the UK, it has evolved in an ad hoc manner with a range of titles and scope of practice. Aims: The aims of this study were to: Explore the concept of professional identity within the role of the ENP. Identify what factors contribute (positively or negatively) to a sense of professional identity. Consider the implications for managers, organisations and educationalists of changing identities within emerging roles in health care. Methods: A qualitative approach was adopted to explore in depth attitudes and perceptions of professional identity amongst a group of ENPs from two different settings; a nurse-led unit and a multi professional Emergency Department. A case study methodology was chosen, and data was collected using focus groups (n= 13 band 7 ENPs) and two semi-structured interviews (n=2 Senior Managers). The data was analysed using thematic analysis. Findings: The study identified several key factors that influenced the ENPs’ sense of professional identity. These fit broadly into three categories: career structure; education; the role. Participants reported high levels of pride and self-confidence related to the delivery of high quality care and their clinical expertise, and gained job satisfaction from the autonomous nature of the role. Participants also reported feelings of uncertainty, and were less confident in other areas such as relationships with other nurses, the public perception of the role, education and career structure. 2 Discussion: Participants in this study described moving away from their traditional nursing practice and expressed that they felt different to other nurses, although they were clear that they were not a doctor substitute. This thesis applies the concept of the ‘third space’ to the findings of the study, and suggests that ENPs have adopted a hybrid role that is operating within a ‘third (or hybrid) space’, where new identity is formed. Conclusion: ENPs have a central role within the urgent care setting, and professional identity is an important facet of the role as it relates to autonomy and job satisfaction. This in turn impacts on organisational loyalty and retention. The creation of a standardised national framework for the development of the ACP is welcome. However, this initiative will require support from educationalists, employers and commissioners to develop all four pillars of advanced practice, thereby ensuring that the success of the role is fully maximised for both practitioner and employer. 3 Contents Abstract 2 Acknowledgments 11 1. Introduction to the thesis 14 1.1 Rationale for my study 15 1.2 Background and policy context 16 1.3 Historical context 19 1.4 Professional identity 20 1.4.1 Knowledge acquisition and identity 20 1.4.2 The role of the ENP and professional identity 22 1.5 Summary of research design 23 1.5.1 Aim of the study 23 1.5.2 Research methodology 24 1.5.3 Data collection methods 24 1.5.4 Data analysis 25 1.5.5 Structure of the thesis 25 1.6 Summary 26 2. Literature review 27 2.1 Introduction 27 2.2 The search strategy 27 2.3 Part 1: Advanced practice 28 2.3.1 Evolution of the ENP role 28 2.3.2 ENP scope of practice 30 2.3.3 Role title 32 2.3.4 The evolution of advanced practice 33 2.3.5 Advanced practice education 41 2.4 Part 2: Professional identity and professionalization of nursing 43 2.4.1 Professional identity in nursing 43 2.4.2 Self-concept, socialisation and professional identity 43 2.4.3 The professionalization of nursing 46 2.4.4 Professional identity within advanced practice roles 48 4 2.4.5 ‘Hybridity’, third space and professional identity 50 2.5 Part 3: Theoretical framework and social theory 52 2.5.1 The social context of learning 53 2.5.2 Communities of practice 53 2.5.3 Situated learning 54 2.5.4 Legitimate peripheral participation 54 2.6 Social Theory 59 2.6.1 Cultural capital 59 2.6.2 Habitus 61 2.6.3 Fields 63 2.7 Chapter summary 64 3. Research Methodology 67 3.1 Introduction 67 3.2 Research paradigm 68 3.3 Ontological assumptions 70 3.4 Epistemological assumptions 71 3.5 Qualitative research 73 3.5.1 Evaluation of qualitative approaches 74 3.6 Case study - Review of the literature and justification 75 3.6.1 Defining the case 76 3.6.2 Selecting the case 79 3.6.3 Issues of generalizability 80 3.7 Summary of chapter 82 4. Research methods 83 4.1 Introduction 83 4.2 Focus groups 83 4.2.1 Selection of participants 85 4.2.2 Advantages of using focus groups 88 4.2.3 Limitations of using focus groups 89 4.2.4 Size, location and running of the focus groups 90 4.3 Photography as a research tool 93 4.4 Interviews 95 4.4.1 Advantages of interviews 96 4.4.2 Limitations of interviews 96 5 4.4.3 Other issues to be considered when using interviews 97 4.5 Ethical considerations 99 4.5.1 Consent 100 4.5.2 Confidentiality 101 4.5.3 Anonymity 102 4.6 The pilot study 103 4.6.1 Lessons learnt from the pilot study 103 4.7 Data analysis 104 4.7.1 Generating themes and subthemes 104 4.7.2 Reliability 111 4.7.3 Generalisability and transferability 111 4.8 Reflexivity 112 4.9 Summary of chapter 115 5. Case findings 116 5.1 Introduction 116 5.2 Theme 1: The key to identity: the role 119 5.2.1 Sub-theme 1: role definition 120 5.2.2 Sub-theme 2: titles 124 5.2.3 Sub-theme 3: teamwork 125 5.3 Theme 2: Value for money: perceptions 127 5.3.1 Sub-theme 1: the general public 128 5.3.2 Sub-theme 2: senior managers and employers 129 5.3.3 Sub-theme 3: other health care professional 133 5.4 Theme 3: The missing chapter: education 135 5.4.1 Sub-theme 1: undergraduate education 135 5.4.2 Sub-theme 2: knowledge 137 5.4.3 Sub-theme 3: postgraduate education and training 139 5.5 Theme 4: The meandering river: career structure 141 5.5.1 Sub-theme 1: career pathways 141 5.5.2 Sub-theme 2: role expansion 143 5.6 Theme 5: The expert practitioner: leadership and expertise 146 5.6.1 Sub-theme 1: clinical leadership 146 5.6.2 Sub-theme 2: seeing the bigger picture 148 5.7 Summary of chapter 150 6 6. Discussion 151 6.1 Introduction 151 6.2 Summary of key findings 152 6.3 The role 155 6.3.1 Self-esteem 156 6.3.2 Transition 157 6.3.3 Socialisation 159 6.3.4 The ‘third space’ 159 6.3.5 Perceptions 162 6.3.6 Teamwork 165 6.3.7 Organisational loyalty 167 6.4 Education 169 6.4.1 Undergraduate nurse training 169 6.4.2 New knowledge 171 6.4.3 Communities of practice to support learning 173 6.4.4 National standards for advanced practice 174 6.5 Career structure 177 6.5.1 Role expansion 177 6.5.2 A mixed picture of leadership 180 6.5.3 Influencing others 181 6.6 Summary of chapter 183 7. Conclusion 185 7.1 Introduction 185 7.2 Reflection on doctoral journey 189 7.3 Reflection on methodological approach 189 7.4 Reflection on research methods 190 7.5 New knowledge 192 7.6 Recommendations for educationalists 193 7.7 Recommendations for NHS Trust managers and commissioners 193 7.8 Future research 194 7.9 Limitations of the study 195 7.10 Concluding remarks 196 8. Appendices 197 9. List of references 222 7 List of tables Table 1. Advantages and disadvantages of focus groups 90 Table 2. Strengths and limitations of interviews 97 Table 3. Outline of the research methods used 99 Table 4. Phase of thematic analysis 105 Table 5. Description of themes 108 Table 6. Summary of named themes and sub-themes 117 8 List of figures Figure 1A. Timeline of the evolution of advanced practice: education and drivers for change 39 Figure 1B. Advanced practice continuum in emergency care 40 Figure 2. Basic types of designs for case studies 78 Figure 3A . Thematic map of themes and sub-themes 106 Figure 3B . Final thematic map of themes and sub-themes 110 Figure 4. Photograph presented by ENP 3: ‘Keeping your registration or professional identity closely guarded’ 119 Figure 5. Photograph presented by ENP 2: ‘We are a bargain, an absolute bargain’ 127 Figure 6. Photograph presented by ENP 4: ‘I missed the introduction’ 135 Figure 7. Photograph presented by ENP 5: ‘Drifting around with no pathway’ 141 Figure 8. Photograph presented by ENP 9: ‘The wise old owl’ 146 Figure 9. A conceptual framework representing the interaction of the key themes 154 Figure 10. Interprofessional theoretical framework 173 Figure 11. A conceptual framework representing the interaction of the key themes and the ‘third space’ in which new identity is formed 187 9 Appendices Appendix 1.

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