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- PublicationThe Discursive Positioning of the Advanced Nurse Practitioner in the Irish Healthcare System(University College Dublin. School of Nursing, Midwifery and Health Systems, 2022)Background: The Irish health service, in common with health services across the world, faces the challenge of operating within economic constraints while responding to changing demographics that increase demand for health and social care services. Within this dynamic environment, nurses, especially Advanced Nurse Practitioners (ANP), are experiencing new challenges. Whilst nursing and medicine have established systems of disciplinary practices that produce nurses and doctors within historically-contingent role boundaries, these boundaries are becoming more fluid and porous. ANPs constantly negotiate these boundaries, offering the possibility of a new and potentially more liberating identity for them within the healthcare system. Uncertainty about the ANP identity results in the full potential of the ANP role not being realised and, consequently, ANPs are underutilised. This study aims to understand how ANPs are positioned within current nursing and health systems by making explicit the discourses that construct the ANP role and how they both enable and constrain it. Methods: The study is based on a critical discourse analysis (CDA) of healthcare professionals’ language-in-use. To gain an analytic purchase on participants’ language-in-use, James Paul Gee’s Tools of Inquiry and Building Task Frameworks were employed. In addition, Barry Oshry’s Organic Systems Framework (OSF) was applied to deepen the analysis and to help identify how the patterns of relationships and processes inherent in human systems manifest in language. Data were elicited from a literature review and document analysis as well as seven in-depth interviews and four focus groups involving twenty-nine participants including twelve ANPs, two staff nurses, eight nurse managers, one director of nursing and one nursing project officer, three medical doctors and two allied healthcare professionals. Findings: Language-in-use established that ANPs add value to the healthcare system from both a monetary and non-monetary perspective and highlighted the centrality of nursing to the ANP role. Language-in-use constructs an identity for ANPs as a medical substitute, an inferior role, yet an innovative addition to the system and a threat to existing structures. Language-in-use constructs tensions between independence and autonomy, on the one hand, and collaboration and control, on the other. Findings show that when hierarchical structures and professional self-interest dominate, systemic processes and relationships are impacted, resulting in a healthcare system that is out of balance. Whilst nursing research and professional scholarship are seen as central to the ANP role, discourses related to these elements were not prevalent in this study. Instead, ANPs are busied by the demands of the clinical aspect of the role, and the ANP role itself is based around the performance of tasks that are mastered by experience rather than erudition. Conclusions: This study alerts healthcare professionals to the ways in which discourses influence opinion and frame the ANP role. To meet the demands of an ever-changing, dynamic healthcare system, it is vital that ANPs are supported and allowed to ‘advance’. When Conversations and Discourses disparage the ANP role, they should be challenged. We need to move away from positioning ANPs as a marginal and contested presence in the health system and instead see their role as making an important and necessary contribution to it. ANPs need to clearly articulate their role, the value that it adds to the healthcare system and demonstrate how it aligns with and complements other healthcare professionals’ roles. ANPs need to become more visible and vocal, and more engaged in policy formulation. They should recognise and harness the tremendous strength and rich diversity that they collectively represent. This is key to maximising the ANPs potential and strengthening their distinctive contribution to the healthcare system.
- PublicationA Participatory Action Research Study to inform the Development and Implementation of Combined Type 2 Diabetes and Chronic Kidney Disease Care Provided in the Context of Advanced Practice Nursing(University College Dublin. School of Nursing, Midwifery and Health Systems, 2020)The rise in the incidence of type 2 diabetes with chronic kidney disease across the age spectrum has been highlighted as a major public health concern and is correlated with increased economic burden, patient suffering and mortality. Preventative care and early chronic kidney disease management strategies informed by best practice recommendations are associated with improved clinical outcomes, patient survival and reduced economic burden. However, opportunities to implement preventative and early management strategies are missed when the care for type 2 diabetes and chronic kidney disease are provided separately. Patients report an uncoordinated impersonal approach when type 2 diabetes and chronic kidney disease care is provided separately. Furthermore, facilitating a combined care strategy enhances care coordination, communication and quality. As current healthcare delivery strategies are failing to implement best practice early management strategies or achieve best practice targets, an alternative approach is required to meet the needs of care providers and patients. One such strategy was the development and implementation of combined type 2 diabetes and chronic kidney disease care, informed by best practice early management recommendations provided in the context of advanced practice nursing. Contemporary literary discourse indicates care provided in the context of advanced practice nursing is safe and effective, albeit there is no national and limited international evidence pertaining to the direct care contribution for patients with type 2 diabetes and chronic kidney disease. The main aim of this national and international unique study was to utilise co-created knowledge between health care professionals and patients to inform development and implementation of combined care provided in the context of advanced practice nursing. The outcomes of this study will inform development and implementation of future services for patients with type 2 diabetes and chronic kidney disease led by advanced nurse practitioners. A Participatory Action Research approach was utilised, as this nonlinear iterative process facilitates flexibility and responsiveness to challenges presented within the current healthcare environment.
- PublicationEvaluating the impact of context within implementation research(University College Dublin. School of Nursing, Midwifery and Health Systems, 2021)The uptake of evidence-based healthcare interventions is challenging with, on average, a 17-year time gap between the generation of evidence and the implementation of change in routine practice. One of the key challenges to successful implementation requiring consideration is context. However, despite its noted importance, context remains a poorly understood construct, with a lack of consensus regarding how it should be accounted for within research. Subsequently, this research addressed this gap by exploring the following research questions: How does context influence the implementation of a collective leadership team intervention? Does context contribute to variances in implementation success across settings? If so, how? A systematic review was conducted which highlighted that inconsistencies exist when defining, assessing, and analysing context. These findings supported the development of an operational definition of context and the creation of a practical approach for measuring the construct. Using a multiple case study design and a triangulation of qualitative research methods (involving observation and interview data), this practical method was applied to evaluate how context influences implementation within two multidisciplinary healthcare teams. Two overarching themes were generated from the data. The first revealed the bidirectional influence of context and implementation, highlighting how these concepts dynamically interact, respond, and mutually evolve. The second theme addressed the micropolitical concepts of power, authority, and influence as essential contextual determinants impacting implementation. This thesis contributes to the implementation science literature by 1) developing an operational definition of context to improve the coherency and consistency with which the term is used; 2) advancing a practical method that captures the dynamism of the concept and creates actionable, detailed findings; and 3) exposing the impact of team-level contextual factors on implementation success. This valuable knowledge will help researchers negotiate the everyday realities of healthcare, supporting the successful implementation of change in routine practice.