The role of the assistant practitioner in the clinical setting: a focus group study

A qualitative focus group study design was chosen to explore the role and scope of the AP in the clinical setting from the perspectives of both APs and RNs. Focus groups were chosen, to allow participants the opportunity to explore their own and others’ perspectives collectively, with opportunity for shared discussion and debate. In addition, focus groups allowed the researchers to gather data from a variety of APs and RNs working across the two participating hospital Trusts within a relatively short time frame, something which would have been more difficult with one-to-one interviews, due to time pressures on healthcare staff. Six focus groups were conducted in total. Of these, three were carried out in each participating Trust; two for APs and one for RNs. Separate focus groups were undertaken for APs and RNs to allow the participants to speak freely without feeling inhibited in the presence of other group members, thus facilitating discussion.

The study was commissioned by the two participating NHS Trusts and took place between February and March 2017. It was undertaken as a means of evaluating the introduction of the AP role across the two Trusts. Ethical approval was sought and obtained from Oxford Brookes University Research Ethics Committee in October 2016 (FREC 2016/05). HRA approvals were obtained in December 2016 and permissions from the two local Research and Development departments were subsequently obtained in January 2017 (IRAS number 214408). Individual written consent was taken from participants before they undertook the focus group study.

APs and RNs working in the two Trusts were invited to participate in the focus groups. Convenience sampling was used to recruit participants to the study. Participants in community, mental health and acute settings were accessed through the researchers contacting AP line managers to seek their permission for their staff to be approached to participate. Once permission was granted line managers were provided with copies of the participant information leaflets via email, which detailed the study purpose and were asked to distribute it to any members of staff who were eligible to participate. Potential participants were asked to contact the researchers if they were interested in participating in the study. Following this, times and locations for the focus groups were scheduled that were convenient for the majority of participants who were hoping to attend. Focus groups were held on Trust premises across the region to accommodate the preferences and travel constraints of most participants.

The focus groups were held in meeting rooms at the two participating hospital Trusts and refreshments were provided. Each focus group lasted around one hour and was informed by a topic guide devised by the researchers that covered issues relating to the role and scope of the AP in the clinical setting (Table 1). Each focus group was moderated and facilitated by two researchers from the team.

The focus groups were recorded using a digital voice recorder before being transcribed by a local transcription service. All identifying participant details were anonymised during the transcription process and the focus group recordings were removed from the voice recorder once they had been uploaded for transcription. Copies of the digital recordings were stored on the university computers in line with local data protection policies. Data was analysed thematically and managed using the Framework method, with its matrix output providing a structured and systematic way for managing and analysing the qualitative data [24]. Transcripts were double-coded by two members of the research team (CH, HA). Following this a working analytical framework was established and elements of the constant comparative method were used, with the researchers iteratively moving back and forth between data collection and analysis [25]. This enabled the researchers to establish any similarities and differences in perspectives between APs and RNs, in relation to the role and scope of the AP in clinical practice. Transcript data were inserted into a Framework matrix to enable ordering and data synthesis of the data [24] and this enabled within and across case analysis of the data from the six focus groups. Once both researchers had analysed the dataset, they met to compare their findings and to talk through any emerging themes arising from the participants’ discussions. Following this, a further meeting was held with all members of the research team to discuss, explore and develop these emerging themes further. Through studying the focus group data in this level of detail, we were able to draw out relevant themes relating to participants’ views on the role and scope of the AP in the clinical setting. The findings will now be reported on.

Nineteen participants (APs, n = 12; RN, n = 7) attended the focus groups. A summary of participant characteristics is provided in Table 2. APs and RNs worked in a wide and diverse range of acute, community and mental health settings across the two Trusts including forensics, dialysis, acute vascular, endoscopy, breast, ambulatory care, gynaecology, cardiothoracic, orthopaedic and emergency assessment and district nursing.

The main themes to emerge from the dataset related to the fluctuating roles and responsibilities of the APs, key differences in the roles of RNs and APs, working relationships between RNs and APs, supervision of APs and redefining nursing pathways.

Participants revealed that the roles of APs, both across and within the two hospital Trusts, were multifaceted and covered a wide range of clinical tasks and responsibilities. These included, but were not limited to, undertaking ECGs, venepuncture, cannulation, pressure area care, wound dressings, administering injections and assisting with activities of daily living. In addition, some APs also took on extended roles which included admitting and assessing patients, overseeing bed management duties, making patient referrals, assisting with paperwork and providing specialist clinical advice to patients, for example through the provision of anticoagulation advice.

However, APs had varying levels of clinical responsibility that were not always consistent with that of peers in nearby units or departments. For example, in some clinical areas, such as the community, APs administered medications intravenously, catheterized patients or provided teaching sessions to HCAs, whereas in other areas this was deemed beyond their competency boundaries and requirements. One AP commented:

‘The role can be as diverse as the setting that you’re working in, depending on who you’re working with; how far they want you to... they want to take you with your competencies.’ (AP focus group 1).

Some APs described how some clinical roles such as skin care assessments, teaching roles, administering flu vaccinations and caring for sedated patients, that they had previously undertaken and gained competencies in, had been revoked, due to their current line manager deciding the roles were beyond the remit of a band 4 practitioner. Some RNs expressed their concern at this ‘de-skilling’ of the AP workforce, feeling it had the potential to leave APs feeling undervalued.

‘I think it’s important that they feel valid and then they don’t have skills taken away from them.’ (RN focus group 2).

However both RNs and APs commented that when RN staffing levels were low, APs were often counted back in the numbers and expected to take on these once relinquished roles and responsibilities. Participants commented that it contributed to AP role ambiguity, as other nursing colleagues couldn’t keep up with what APs could and couldn’t do. This selective use of their expertise led to participants feeling that APs were sometimes used and taken advantage of.

Participant 1: ‘If we’re short then they’ll be put in as a role…One day it’s good enough for them to do something…And then the next day it’s...When we’ve got enough, when we’ve got another trained on, oh, you can go back to doing that then. I mean, it’s just a bit...’

Participant 2: ‘Just to suit needs really.’ (RN focus group 3).

Most RNs felt that the inconsistency surrounding which roles APs were allowed to undertake within and across the hospital Trusts was due to local decision-making, often dependent on what individual managers felt to be within the scope of a band 4 role rather than national role descriptions. In addition, these RNs felt that many AP competencies had been designed to be setting specific, leading to the huge diversity between the skill sets of APs across different clinical areas. It was felt that this could make it more difficult for APs to transfer to other clinical areas. Both APs and RNs described a need for increased role clarity for APs at an organisational level, through the development of a range of core competencies, to increase the transferability of AP skills.

‘Doing the competency work right from the beginning and Trust wide I think is helpful rather than it being, kind of, each unit or each service…Then you end up with it being very different…The idea is that we’d have sort of core competencies and then there would be some specifics for the area. But they would be understood at a ward level and a service level and a Trust level which I think will hold much more power.’ (RN focus group 1).

Participants identified some key differences between RN and AP roles, the main one being that APs could not dispense medication, as they did not hold NMC registration. Yet, some RNs and APs suggested that there were few differences between their roles, apart from medication administration and discharging patients.

‘The nurses do the same as me. They can discharge the patients, though, from the ward and also they administer the drugs and look after the controlled drugs. But, other than that, most things I can do’. (AP focus group 2).

However, other responsibilities were identified that were considered to be largely, though not always, the domain of the RN. These included administering intravenous saline, performing palliative care, undertaking initial assessments, first visits, discharges, dispensing controlled drugs and administering certain injections, such as insulin. RNs were also identified as being the named nurse for their patients due to their professional registration and accountability. Whilst for most APs this came as a relief, RNs described feeling accountable for the actions of APs as their registration depended on them ensuring that APs worked in a professional and competent manner, despite the frequent overlap in their clinical roles and responsibilities. One RN commented:

‘Everything is so blurry and then at the end of it, it’s still accountable to the nurse.’ (RN focus group 3).

The blurring of boundaries between AP and RN roles had at times caused tensions, with one AP commenting that some RNs she had worked with had been unable to accept that she was able to take on some aspects of the RNs role, resulting in clarification at managerial level being sought. Other APs gave examples of doctors assuming that APs could dispense medications and of uncertainty and grey areas around what distinguished APs from both RNs and HCAs.

‘A little while back I had some issues in my department. Nurses not seeing that I could actually do certain parts of the role so we had to have some sort of clarification for what I can and can’t do so that all the staff know what they can ask me to do and what I can’t do.’ (AP focus group 2).

The majority of RNs spoke positively about how APs had integrated in to the clinical team, describing how they ‘get on with it’ are ‘highly skilled’ and ‘fit into the team well.’ APs also described strong working relationships with RNs and spoke of how they helped RNs to offload some of their clinical tasks that HCAs were unable to take on, such as cannulation, so RNs had more time to spend on other aspects of patient care. In this way RNs and APs felt they went some way to bridging the gap between RNs and HCAs.

‘APs just get on with it and fit in well with the team. And even though they may not be doing medication…They actually do have a list of what they need to do and they link in well with the nurses and say like delegating and kind of picking up things that aren’t done.’ (RN focus group 2).

The level of integration between APs and RNs was described as particularly high in the community, attributed to the planning and infrastructure that had been implemented by community leads to support their APs. Initiatives such as regular AP updates at band 6 meetings, regular group and individual AP supervision and AP competency planning were all viewed as key in helping APs to integrate fully into their community roles alongside RNs. Although APs and RNs acknowledged that RNs worked more autonomously than APs, some RNs commented that many APs were more experienced and used more initiative than some of their fellow nursing colleagues.

‘Both of the APs that we’ve got do take on more in the department and maybe I shouldn’t be saying it but sometimes they take on a bit more than some of our qualified nurses.’ (RN focus group 3).

Some APs felt that although they had developed good working relationships with RNs over time, they had experienced initial distrust and suspicion from RNs who felt that APs were trying to take over their roles. APs spoke of having to ‘prove themselves’ to RNs over time before any responsibility was relinquished to them. Though in most cases this had resulted in positive working relationships, a few APs spoke of how they felt some of their RN colleagues were unable to differentiate between the role of the AP and the HCA and were unable to comprehend what their role entailed.

‘It’s not just: hey presto, you’re autonomous, you know, you build up your... your colleagues get to know you... You have to prove yourself.’ (AP focus group 1).

Most participants acknowledged that APs made decisions in conjunction with, rather than independently of RNs. However, the level of independent working varied from role to role. Some APs described working very closely with RNs on a daily basis, whilst others described spending much of their time doing home visits independently as lone workers in the community. This led to infrequent supervision and as a result, APs working in this context often made clinical decisions. One AP spoke of how she worked semi-autonomously, with oversight but not direct supervision from, RN.

‘On a day to day basis, not very often we work alongside anybody, other than, when you discuss something in handover. I suppose that’s the only time when you talk about something you’ve encountered, or you talk about patients, that would be the only time.’ (AP focus group 1).

This often remote and relatively infrequent supervision from RNs meant that often APs were called to use their judgement to make decisions about patient care. One AP commented: ‘

‘The unit is very busy and although I have the support there, sometimes I have to use my skills to make the situation appropriate. But I can do things like using my initiative.’ (AP focus group 2).

Some RNs commented that understanding of the AP role across the two Trusts was limited as there had never been any formal acknowledgement as to what the role should look like at the outset. A few APs described feeling unsupported when they started in new roles due to none of their colleagues knowing what the purpose of an AP was, leading to ambiguity. Another AP spoke of how her colleagues didn’t know what to do with her when she started in her new role.

‘They didn’t really know what to do with me when I first came into the district nursing team. There wasn’t a specific role for me. So, it was quite confusing.’ (AP focus group 1).

RN participants described a need to clearly define competencies for all clinical staff bandings, as a means of clearly demarcating their different role expectations. They spoke of how the current banding system was unclear and ambiguous and had been detrimental to the development of the AP role when it was initially established. One RN commented that it was difficult to see how the AP role fitted into the existing nursing structure, largely as it was never budgeted for or considered in the staffing numbers when the role was developed, leading to APs being slotted in to vacant posts in an ad hoc and unstructured way. Some of the RNs were keen to learn from the unstructured and inconsistent way the AP role had been developed, by delineating clearly from the outset what the upcoming NA role should consist of, to enhance role clarity and purpose.

‘I think that there will be lessons that we’ve learned then that now we’ll need to do this properly…Because one you’ve got to develop it but then you’ve also got …To get people to understand what [the Nursing Associate role] is...And I don’t think you can do that without kind of reviewing all your roles and structures as to how they fit in. And... Just people understanding what that role is.’ (RN focus group 1).

This lack of role identity had led to some APs feeling that they had to fight to ‘prove their worth’ and demonstrate their level of expertise in their relevant clinical areas. This had added to feelings of uncertainty for some APs in terms of job security and career progression, with some expressing a lack of career development opportunities since becoming APs. As a result, some APs commented that they would consider undertaking the newly developed NA training, despite feeling it was very similar to their own AP training, as they felt that the NA role would be seen as more high profile. In addition, some were concerned that the NA role would result in a phasing out of the AP role, as it was regulated by the NMC, whereas the AP role was not. APs spoke of the importance of considering the differences between their role and that of NAs, as they were both band 4 roles within the discipline of nursing. Some also felt it was wrong to have the word ‘nurse’ in the NA title as it would lead to confusion about who is and is not qualified.

‘Having an [Nursing] Associate role …Does that…Make it difficult as to what is the NA role and what is the AP role and what is the difference? They are all the same banding, the same discipline and what’s the difference?’ (RN focus group 1).

Some APs reported feeling stuck as they didn’t know how to progress further in their roles. They described a sense of uncertainty as to whether the onus was on themselves or their managers to take responsibility for their role development, with the pro-active nature of individual APs recognised as a marker of successful development. Other APs and RNs spoke of developmental opportunities such as undertaking nurse training or apprenticeship pathways as vehicles for progression, as well as moving into non-clinical band 5 jobs such as administrative, finance and discharge planning roles.

‘They actually want people to be employed as apprentices, and then, move up the ladder that way…They feel that there’s going to be more bang... more opportunities for band 4s within the trust, within the NHS…Because, that’s what the government wants.’ (AP focus group 1).

This study sampled RNs and APs from across a wide variety of clinical settings, including acute, mental health and community trusts and therefore the findings can be applied to a range of clinical nursing areas. In addition the study gained the perspectives of both APs and RNs, which enabled the researchers to identify similarities and differences in the views and perspectives of RNs and APs; this strengthens the qualitative methods undertaken. However, due to the large geographical area the two NHS trusts spanned, we were unable to recruit as many participants to the study as planned, largely due to difficulties in participants travelling to the focus group locations due to time pressures. However, despite this the focus groups were able to generate and uncover a breadth and depth of rich experiences relating to this important topic.