amanda fox - qut · graduate certificate in health promotion . queensland university of technology...
TRANSCRIPT
Amanda Fox Registered Nurse
Bachelor of Nursing
Graduate Certificate in Health Promotion
Queensland University of Technology
Faculty of Health
School of Nursing
Institute of Health and Biomedical Innovation
Submitted in fulfilment of the requirements for the degree of Doctor of Philosophy
2016
Factors influencing sustainability of health service
innovation; emergency nurse practitioner service
ii
iii
Statement of Original Authorship
The work contained in this thesis has not previously been submitted to meet requirements for
an award at this or any other higher education institution. To the best of my knowledge and
belief, the thesis contains no material previously published or written by another person
except where due reference is made.
Signature:__ __________________________________
Date: _____14th January 2016_________________________________________________
QUT Verified Signature
iv
v
Abstract
Title: Factors influencing sustainability of health service innovation: emergency nurse
practitioner (ENP) service.
Background: The Australian health care system is under increasing pressure to provide the
population with access to efficient and cost-effective health care. This is occurring at the
same time as many in the ageing health care workforce are retiring. Many health service
innovations have been implemented in an attempt to meet the growing demand for efficient,
cost effective health care, however, the sustainability of many of these innovations has not
been evaluated. An emergency department nurse practitioner service is one of the most
frequently implemented service delivery models in Australian emergency departments. This
research has examined the factors influencing the sustainability of emergency department
nurse practitioner services.
Aim: The aim of the research was to explore the factors influencing sustainability of nurse
practitioner services using a theoretical framework for innovation sustainability, in the
context of emergency nurse practitioner services. The results of this research will inform
health policy development and guide future implementation and evaluation of health service
innovations.
Design and methods: This research used case study methodology with a single case
embedded design. The case was the emergency nurse practitioner service, and the embedded
units of analysis were emergency department staff, emergency nurse practitioners and
documents relating to nurse practitioner service from a variety of services. The data
collection methods included survey, individual interviews, document analysis and telephone
survey.
vi
vii
Results: Findings from this research show that the innovation of emergency nurse
practitioner services partially fulfils the factors of sustainability as described by the
theoretical framework. Emergency department staff members were confident that ENP
services were safe, effective and met patient needs but were not kept informed or included in
decision making processes. Emergency nurse practitioner (ENPs)service staff feel isolated,
have limited input into decisions and the service is poorly utilised. ENPs reported marginal
organisational support and the documents examined reinforced a lack of service reform
support at the organisational level.
Discussion: ENP services did not meet any of the sustainability factors entirely and there is
potential for an innovation in health services to be sustained under these circumstances in the
short term. Long term sustainability of an innovation may be challenged if the factors are not
engendered. Organizational structures and processes to support ENP service integration need
to be adopted if the service is to be sustained. The Sustainability of Innovation framework
operationalised in this research and the factors as expressed in the literature are supported in
the application, however, some shortfalls and need for adaptation have been identified.
Conclusion: The rapidly expanding emergency nurse practitioner service has been examined
using case study design to find that certain factors are threatening the sustainability of this
health service innovation. The lack of organizational support and processes that enhance
positive workplace culture, decision making, reduce isolation and underutilisation of ENP
service, if left unaddressed, will potentially threaten the future of ENP service.
viii
ix
ACKNOWLEDGEMENT
There are a number of people I would like to thank for their contribution to my studies.
Firstly, I would like to thank the staff from each of the study sites who participated in this
research, for without these staff, this research would not have been possible. I would also
like to express my appreciation to the EDPRAC study research team for allowing me to
analyse data collected during their study to inform one component of this study.
I would like to express my gratitude to my supervisory team for their ongoing commitment,
guidance and understanding along my PhD journey. To Professor Glenn Gardner who
inspired me with her passion for this topic and helped me keep sight of the bigger picture;
and to Dr Sonya Osborne who has provided critical and insightful feedback and whose’
attention to detail was invaluable.
I dedicate this thesis to my beautiful family whose love, support and encouragement as well
as sacrifice over the years has allowed me to complete these studies. My husband Andrew
whose belief in my ability to complete this process has never waned and for picking up the
slack when the days just weren’t long enough. To my boys who have been my inspiration to
keep going when the going got tough; Haydn with his ‘never say die’ determination, Harry
with his quiet approval and loving support and Mac with his infectious happy disposition. I
thank you for your support and dedication to me through this journey.
x
Table of Contents Statement of Original Authorship…………………………………………………………..iii
Abstract………………………………………………………………………………………..v
Acknowledgement……………………………………………………………………………ix
Table of Contents……………………………………………………………………………..x
List of Figures………………………………………………………………………………..xv
List of Tables…………………………………………………………………………….….xvi
List of Abbreviations……………………………………………………………………....xvii
List of Appendices…………………………………………………………………………xviii
CHAPTER 1 Introduction…………………………………………………………………..1
1.1 Background……………………………………..………………………….…1
1.2 Research problem………………………………………………………….…5
1.3 Research aim………..…………………………………………………….......6
1.4 Research question…………………………………………………………….6
1.5 Outline of this document…. …………………………………………………6
1.6 Conclusion……………………………………...……………………………..9
CHAPTER 2 Literature review…………………………………………………………….11
2.1 Introduction………………………………………………………..…….…..11
2.2 Health services research……………………………………….……............11
2.3 Health care workforce…………………………….………………………..21
2.4 Australian health care workforce reform…………………………………22
2.5 The nurse practitioner service……………………………………………..23
2.5.1 International nurse practitioner service…………………………………23
2.5.2 Australian nurse practitioner service……………………………………26
2.5.2.1 Nurse practitioner service implementation…………………...26
2.5.2.2 Emergency nurse practitioner service implementation……….29
2.5.2.3 Challenges to nurse practitioner service implementation…….30
xi
2.6 Nurse practitioner service provision…………………………………….. ...32
2.7 Nurse Practitioner Service outcomes………………………………………33
2.8 Sustainability of health service innovations………………………………..37
2.9 Summary..………………………………………………………...………….42
2.10 Conclusion……………………………………………………………………43
CHAPTER 3 Theoretical framework……………………………………………………...45
3.1 Introduction………………………………………………………………….45
3.2 Innovation diffusion…………………………………………………………45
3.3 Historical Development of Diffusion of Innovation theory ……………. ..46
3.4 Research in the current health care context…………………………….. ..48
3.5 A responsive framework to evaluate sustainability of health service
Innovation……………………………………………..…………………….52
3.5.1 Political factors…………………………………………………………52
3.5.2 Organizational factors………………………………………………….54
3.5.3 Financial factors………………………………………………………..55
3.5.4 Workforce factors………………………………………………………55
3.5.5 Innovation- specific factors……………………………………………..57
3.6 Sustainability of Innovation Framework………………………...………..58
3.7 Conclusion………………………………………………………...………....60
CHAPTER 4 Proof of concept study……………………………………………………....61
4.1 Introduction………………………………………………………………….61
4.2 Background…………………………………………………………………..61
4.3 Rationale ………………………………………………………………….....63
4.4 Purpose……………………………………………………...……………….63
4.5 Research approach……………………………………..…………………...64
4.6 Methodology………………………………………………………………...64
4.6.1 Setting………………………………………………………………….65
4.6.2 Participants and recruitment……………………………………………65
xii
4.6.3 Instrument………………………………………………………………66
4.6.4 Data collection………………………………………………………….67
4.6.5 Data analysis…………………………………………………………....67
4.7 Proof of concept study results……….……………………………………...68
4.7.1 Survey results…………………………………………………………...68
4.7.2 Process results…………………………………………………………..68
4.8 Discussion…………………………………………………………………....69
4.9 Study outcomes……….……………………………………………………...70
4.10 Conclusion…………………………………………………………………...71
CHAPTER 5 Research methodology and methods……………………………………....73
5.1 Introduction………………………………………………………………....73
5.2 Methodology………………………………………………………………...73
5.3 Research question and propositions………………………………………..76
5.4 Research design……………………………………………………………...77
5.5 Study setting………………………………………………………………....81
5.6 Research process………………………………………………………….....82
5.6.1 Embedded unit 1- Emergency department staff………………………...82
5.6.2 Embedded unit 2- Emergency nurse practitioners……………………...86
5.6.3 Embedded unit 3- Documents related to Nurse practitioner service..…..92
5.7 Data Analysis Plan…………………………………………………………..95
5.8 Ethics………………………………………………………………………....97
5.9 Conclusion…………………………………………………………………....98
CHAPTER 6 Results ……………………………………………………………………....99
6.1 Introduction………………………………………………………………....99
6.2 Embedded unit of Analysis 1- Emergency department staff..………….100
6.3 Embedded unit of Analysis 2- Emergency nurse practitioners..………..109
6.3.1 Emergency nurse practitioner telephone-survey results…….……...…109
6.3.2 Emergency nurse practitioner-interview results..…………………..….111
xiii
6.4 Embedded unit of Analysis 3- Documents related to nurse practitioner services……………………………………………………....……………...124
6.5 Conclusion……………………………………………………………....…..131
CHAPTER 7 Discussion………………………………………………………………..….133
7.1 Introduction………………………………………………..…………….…133
7.2 Emergency Department Staff……………………………………………..133
7.3 Emergency Nurse Practitioners…………………………………………...136
7.4 Documents related to NP services…………………………………………142
7.5 Conclusion…………………………………………………………………..144
CHAPTER 8 Case Study Analysis……………………...………………………………...145
8.1 Introduction………………………………………………………………...145
8.2 Convergence and pattern matching………………………………………145
8.3 Proposition 1- Meeting organizational factor indicators for sustainability………………………………………………………………..147
8.4 Proposition 2- Meeting workforce factor indicators for sustainability...……………………………………………………………...150
8.5 Proposition 3-Meeting innovation specific factor indicators for sustainability……………………..………………………………………....153
8.6 Proposition 4- Meeting political factor indicators for sustainability………………………………………………………………..156
8.7 Proposition 5- Meeting financial factor indicators for sustainability………………………………………………………….…….159
8.8 Sustainability of emergency nurse practitioner service…………..….…..161
8.9 Operationalising the Framework………………………...………….……162
8.10 Strengths and limitations of this study……………………………………164
8.11 Conclusion…………………………………………………………………..166
CHAPTER 9 Summary and recommendations…...……………………………………..167
9.1 Summary………………………………………...……………………….…167
9.2 Conclusion and recommendations- ENP service..………………..……....169
xiv
9.3 Conclusion and recommendations –
Sustainability of Innovation framework………………………………….172
9.4 Recommendations for further research………………………...………...175
9.5 Closing comments………………………..………………………………...176
Reference List……………………………………………………………………………....179
Appendices…………………………………………………………………………….……214
Publication from this research…………………………………………………………….236
xv
LIST OF FIGURES
Figure 3.1 Sustainability of Innovation framework…………………………………………..59
Figure 5.1 Embedded single-case design (multiple unit of analysis)………………………...79
Figure 5.2 Research operational framework………………………………………………....80
Figure 5.3 Research analysis plan………………………………...………………………….97
Figure 6.2 Participant perception of meeting local population needs………………………101
Figure 6.3 participant responses to staff education and training ……...……………………103
Figure 6.4 ENP service need theme responses by item……………………………………..104
Figure 6.5 Participant response to safety theme by item…………………………………....105
Figure 6.6 Participant responses to impact of ENP service theme by item ………………...106
Figure 6.7 Supportive professional relationships participant responses by item …………..107
Figure 6.8 ATS category of patients seen by ENPs in NSW, QLD and VIC..……………..110
Figure 8.1 Research findings converged to inform framework factors..……………………146
Figure 9.1 Sustainability of innovation framework with recommended alterations…..……174
xvi
LIST OF TABLES
Table 5.1 Example of the qualitative content analysis process…………………………92
Table 5.2 Example of summative content analysis matrix……………………………...94
Table 6.1 Themes and Sub-themes identified in interview transcripts………..………112
Table 6.2 Websites searched and numbers of documents retrieved…………………...124
Table 6.3 Summary of documents retrieved…………………………………………...126
Table 6.4 Summary of document analysis results……………………………………..127
xvii
LIST OF ABBREVIATIONS
AHPRA Australian Health Practitioners Regulation Agency
AMA Australian Medical Association
ATS Australasian Triage Scale
COAG Council of Australian Government
CPG Clinical Practice Guidelines
ENP Emergency Nurse Practitioner
KPI Key Performance Indicators
MBS Medicare Benefit Schedule
MDT Multidisciplinary Team
NP Nurse Practitioner
NPIAC Nurse Practitioner Implementation Advisory Committee
PBS Pharmaceutical Benefits Scheme
RAT Rapid Assessment Team
VNPP Victorian Nurse Practitioner Project
WHO World Health Organization
xviii
LIST OF APPENDICES
Appendix A Queensland Department of Health, Human research ethics approval
(HREC/11/QHC/45)
Appendix B Queensland University of Technology Human research ethics approval
(1200000717)
Appendix C Nurse Practitioner Service Patterns Questionnaire
Appendix D Queensland Department of Health, Human research ethics approval
(HREC/13/QPCH/204)
Appendix E Participant information sheet (Multidisciplinary Team)
Appendix F Multidisciplinary Team Questionnaire
Appendix G Staff reminder notice (Multidisciplinary team questionnaire)
Appendix H MDT questionnaire theme development
Appendix I Participant information sheet (Nurse Practitioner)
Appendix J Nurse Practitioner Consent form
Appendix K Queensland Department of Health, Human research ethics approval
HREC/11/QHC/45/AM03
Appendix L Individual interview prompt sheet
Appendix M Categorisation matrix
Appendix N Interview data analysis example
xix
xx
1
Chapter 1
Introduction 1.1 Background
Australia is facing burgeoning costs in health care with an increasingly aged population
living with chronic debilitating co-morbidities. Current life expectancy of Australians at
birth is approximately 93.6 years for women and 91.5 years for men (Australian Government,
2015). The National Health Survey, 2007-08 reported that more than 80% of people over the
age of 65 years stated they suffer from three or more long term illnesses (Australian
Government, 2012). The impact of these chronic illnesses is longer, more frequent and more
complex hospital admissions and increasing use of health care services. This, coupled with
expensive new diagnostic and therapy options, as well as costly pharmaceutical treatments,
has led to spiralling costs for healthcare. Health spending in Australia increased from $122.5
billion in 2009-10 to $130.3 billion in 2010-11, an increase of $7.8 billion (AIHW, 2012a). It
is estimated that by 2054-55 Australia could be spending up to 7.1% of the Gross Domestic
Product on healthcare if current policy does not change (Australian Government, 2015).
As patient demographics change so to do expectations of the healthcare system. Patients are
more educated, expect more convenient and better service and expect more information and
treatment options (Taylor and Hill, 2014). Consumers expect health services to be
comprehensive, continuous and personalised to respond to their specific needs (Taylor and
Hill, 2014). Continuing to provide quality healthcare services in the current climate and
management and planning for provision of healthcare service into the future is of major
concern for governments around the world.
It could be argued that health care systems are dynamic by nature and that continual change
has always been evident. Many countries have been making significant reforms to health
2
systems since the 1970s, with health care reform featuring strongly on the Australian political
agenda since the 1990s (Boxall and Buckmaster, 2009). Australian health care reform has
been driven by three goals: 1) access and equity, 2) preparing the health system to better meet
emerging challenges and 3) creating a system that is sustainable in the long term (National
Health and Hospital Reform Commission [NHHRC], 2009).
In 1991, the Australian Federal Government commissioned a working party to implement
healthcare reform strategies to improve patient focus and provide quality care outcomes in
the most efficient manner of delivery (NHHRC, 2009). In an attempt to align with policy
changes and expectations, a number of health care innovations were implemented. For the
purpose of this study a health service innovation is defined by Greenhalgh, Robert,
Macfarlane, Bate and Kyriadidou, (2004, p. 582), as “a novel set of behaviours, routines and
ways of working that are directed at improving health outcomes”.
In Australia, many health service innovations are being implemented at both a national and
state level as well as informally by staff in local health care settings attempting to improve
health care service. Health service innovations attempt to reduce inefficiencies, integrate and
coordinate care across sectors, increase emphasis on primary care and prevention, improve
access for rural and remote consumers, improve health outcomes for Indigenous people and
to provide a well-qualified and sustainable health workforce (NHHRC, 2009). In an attempt
to meet the goals proposed by the National Health and Hospitals Reform Commission, many
health care reform strategies have been implemented with varying degrees of success.
Strategies have been implemented at macro, meso and micro levels within healthcare settings.
Large healthcare organizations amalgamated departments and funding in an attempt to meet
output achievements and key performance indicators (Australian Health Care Reform
3
Agreement [AHCRA], 2008). Attempts have been made to improve continuity of care across
the health system; provide a well-trained, collaborative workforce, focus health services on
prevention and early detection, maintain a patient centred approach and ensure inter-sectoral
collaboration (AHCRA, 2008). Health service delivery reform innovations have consisted of
placing more emphasis on health promotion and prevention strategies and public health
activities, with more funding being allocated to these primary health care programs (Boxall
and Buckmaster, 2009). There is widespread acceptance that increased emphasis on primary
health care can prevent or reduce hospital admissions and prevent further morbidity and
disability by investing in prevention and population health (Department of Health and
Ageing, 2009).
By the early 2000s, the focus of government funding had changed from acute tertiary care to
illness prevention strategies (AIHW, 2008). Health Department policies focussed on
preventing diseases, improving Indigenous health, and promoting healthy lifestyles, early
intervention for chronic illnesses and improving access to health care (NHHRC, 2009). As a
result, many small scale initiatives have been commenced at local level in an effort to meet
the perceived needs of individual groups. Examples of this include community based rural
health programs (Buykx, Humphreys, Tham et al, 2012) and mental health services. The
level of success of health care reform initiatives has varied across organizations and programs
as do the reporting measures of success which makes comparison and research difficult.
Effective implementation and long term sustainability of these and other service innovations
are dependent on the system’s ability to maintain a robust healthcare workforce (Buykx et al,
2012).
4
Australia is facing a health workforce crisis. With population growth and ageing of the ‘baby
boomer’ generation, there are increased demands on healthcare services at a time when there
is simultaneous ageing and retirement of the health workforce (Schofield, Page, Lyle and
Walker, 2006). A projected shortfall of approximately 85,000 nurses in Australia is predicted
by 2025 (Health Workforce Australia, 2014). It is suggested that a more flexible workforce,
extension of current health workforce roles and a shift of skill mix could safely and
effectively meet service gaps and improve patient outcomes (Duckett, 2005). Health service
planners under increased pressure to meet consumer demand have implemented a number of
workforce innovation models in an attempt to retain staff and improve service delivery
(Gardner and Gardner, 2005). The concept of flexible workforce has recently gained
momentum due to the introduction of the Expanded Scopes of Practice (ESOP) program by
Health Workforce Australia in 2012 (Health Workforce Australia [HWA], 2012a). A team
approach to meeting the health care needs of the population through expanding roles of the
health workforce and scope of practice is seen as one response to this problem.
Nurses, in particular, have embraced the opportunity for professional role enhancement. The
nursing profession has developed various advanced practice roles to help fill gaps in
healthcare (Gardner and Gardner, 2005). Along with refinement of roles has come a
multitude of titles and scope of practice for nurses such as clinical nurse specialist, advanced
practice nurse, clinical nurse consultant, clinical initiative nurse and many others (Cashin,
Waters, O’Connell et al, 2007; Chang, Gardner, Duffield & Ramis, 2011). These various
roles and titles may all loosely fall under the umbrella of advanced practice nursing, and
these, along with varied health service delivery models, have rapidly expanded. One of these
roles is the nurse practitioner.
5
In Australia, the nurse practitioner role is a relatively new, advanced clinical nursing role that
incorporates the assessment and management of patients, including direct referral, ordering of
diagnostic investigations and prescribing of medications in a collaborative or autonomous
context (Australian Nursing and Midwifery Council [ANMC], 2006). Australian nurse
practitioner services began in New South Wales in 2000 and have subsequently extended to
all states and most areas of healthcare. In 2009, the Australian Federal Government provided
nearly $60 million to expand the role of nurse practitioners within the Australian healthcare
system (Roxon, 2009). This significant outlay of resources for the implementation of nurse
practitioner service reinforces the need for greater understanding and review of this service.
Nurse practitioner services have been shown to improve consumer access to treatment with
cost-effective care to target at-risk populations in all settings including metropolitan, rural
and remote communities (Australian Nursing Federation [ANF], 2011). Whilst there is
evidence supporting the effectiveness and safety of nurse practitioner service (Jennings,
Clifford, Fox et al, 2015; Jennings, O’Reilly, Lee et al, 2008), there is a lack of evidence on
the long term sustainability of this rapidly expanding workforce innovation. Additionally,
there are limited research frameworks for, the examination of sustainability of any health
service innovation.
1.2 Research problem
Nurse practitioner services are expanding rapidly across Australian healthcare services.
Legislative changes and research findings related to the safety and quality of nurse
practitioner service support the use of these services as enduring healthcare reform
innovations. The Second National Census of Nurse Practitioners (Middleton, Gardner,
Gardner and Della, 2011) identified that nurse practitioner services are rapidly increasing as a
6
way of meeting rising healthcare needs in many contexts, and the most rapid uptake has been
with nurse practitioner service in hospital emergency departments. Despite large investments
in resources, both human and fiscal, to implement nurse practitioner services, the
sustainability of this health service innovation is yet to be investigated or established.
1.3 Research aim
The aim of this research was to explore factors associated with sustainability of emergency
nurse practitioner service.
1.4 Research question
How do the factors proposed by the Sustainability of Innovation theoretical framework
influence sustainability of the emergency nurse practitioner service?
1.5 Outline of this document
Chapter 1 Introduction
Chapter One outlines a brief account of the Australian healthcare context and health care
reform goals and initiatives. The development of nurse practitioner services to meet the
population’s increasing health care needs has been introduced followed by the research
problem, purpose and outline of the thesis.
Chapter 2 Literature Review
The literature review explores in more depth the current research related to healthcare reform
and the implementation, development and evaluation of nurse practitioner service. In
7
particular the emergency nurse practitioner service and the current research in the field of
sustainability related to health services will be presented. The evidence has been analysed
and critiqued to identify the quality of research and identify the gaps. Finally, the importance
of this research study in relation to the lack of empirical studies available and the future
healthcare reform initiatives within Australia are highlighted.
Chapter 3 Theoretical Framework
Chapter Three contains discussion of the theoretical underpinnings for this study, namely,
Diffusion of Innovation. Examination of Diffusion of Innovation theory, as it has been
related to health service organizations, and the use of this theory to inform the development
of the theoretical sustainability of innovation framework that is utilised in this research.
Finally, the rationale and justification underpinning the framework is presented and the utility
for the purpose of researching emergency department nurse practitioner service is examined.
Chapter 4 Proof of concept study
Chapter Four is a report of a proof of concept study that was conducted with Queensland
emergency nurse practitioners. The aim of this study was to identify issues that impact
sustainability specifically related to the ‘innovation’, that is, the emergency nurse practitioner
service. In this chapter, the purpose, aim, methodology, design, analysis and results of this
small scale study are presented. A discussion of the findings related to the research process,
insights gained on the research topic and direction for the implementation of an in-depth and
thorough examination of the complex phenomena of health service innovation is articulated.
8
Chapter 5 Research methodology and methods
The research methodology chapter presents the design for this study. The decision to use
case study methodology is justified and the applicability of the design to the research
question is rationalised. A thorough description of the operational definitions, sampling, data
collection methods, instruments and data analysis methods for the comprehensive
examination of emergency nurse practitioner service is presented in this chapter.
Chapter 6 Results
The results of this study are presented in chapter six according to the units of analysis that
were used for this study. Firstly, emergency department multidisciplinary team member
survey data results will be presented followed by the data collected from individual
interviews and results from telephone surveys conducted with emergency nurse practitioners.
Finally, the results of analysis of documents that relate to the implementation or governance
of nurse practitioner service will be presented.
Chapter 7 Discussion
Chapter Seven presents a discussion of the interpretation of results obtained through the data
collection sources. The study findings were considered in relation to the existing literature
and research of sustainability and emergency nurse practitioner service. More specifically,
new knowledge that emerged from this research has been examined in relation to the body of
knowledge that currently exists in this field.
9
Chapter 8 Case Study Analysis
This chapter will present converged, interpreted results from the multiple data collection
sources in order to compare the empirical findings from the research to the propositions that
have been developed for this study and presented in chapter five. Pattern matching
techniques will enable the development of new knowledge about the factors influencing
sustainability of health service innovation, emergency nurse practitioner service.
Chapter 9 Recommendations and conclusion
Chapter Nine will draw study conclusions and make recommendations based on the findings
and discussion points presented in earlier chapters. The study limitations are considered and
future research opportunities that this research has highlighted will be suggested.
1.6 Conclusion
Meaningful healthcare reform is necessary if Australia is to continue providing a universal
health care system (Martin, 2013). Service innovations are being implemented rapidly in an
attempt to meet consumer demands for high quality, cost-effective and safe health care
(Australian Government, 2013). The health care reform innovation of emergency nurse
practitioner service is rapidly being adopted throughout Australian hospitals to meet the
increasing pressure for service in this area of health care (O’Connell and Gardner, 2012).
However, despite large amounts of resources being expended to implement emergency nurse
practitioner service, there is a lack of evidence regarding the sustainability of this health
service innovation. Nurse practitioner services are growing most rapidly in hospital
emergency departments (Middleton et al, 2011) and, therefore, these areas provide an
10
appropriate platform to investigate the factors influencing sustainability of emergency nurse
practitioner service innovation. This chapter has provided an outline and the context of the
case study research that has been completed surrounding the sustainability of innovations.
11
Chapter 2 Literature review
2.1 Introduction
Chapter One has provided an introductory account of the Australian health care system,
health care reform and provided some background of nurse practitioner service development.
The research problem has been defined and the aim articulated. Chapter Two will present a
review of the research related to health care reform in Australia and advanced nursing roles,
including research related to nurse practitioner service and in particular emergency nurse
practitioner service. The research that has been published relating to sustainability of health
services and specifically nurse practitioner service sustainability will be examined. The
literature review chapter will identify the research gaps and how this relates to and has
informed the current research project. Finally, the purpose of this research study is
explained.
2.2 Health service research
Australia’s health care policy makers often use international comparisons to assess the
relative performance of the country’s health care system and to guide future directions.
Typically, comparisons are made in areas such as, health outcomes and quality of care, health
financing and spending and service delivery (Van Der Weyden, 2002). Australia has been
held in high regard internationally with the World Health Organization’s (WHO) overall
Health System Attainment Index placing Australia 12th out of 191 member nations in 1997
(Murray, Lauer, Tandon and Frenk, 2000). The overall health index is measured by the level,
distribution and equality of population health, health system responsiveness and fairness of
financial contribution by households to health care (WHO, 2000). These comparisons often
drive research and evaluation and as a result some health care reform issues receive very little
12
formal evaluation whilst others receive substantial examination. Focus in more recent times
has been related to Australia’s healthcare financial control and expenditure; access, continuity
and efficiency initiatives, and the health care workforce (Research Australia, 2011).
Australian government focus on health care reform in the early 1990s sparked an examination
of health care service provision and a number of inefficiencies in relation to service provision
were identified. Many health service innovations have been implemented over the years in
an attempt to rectify the identified service gaps and provide cost effective care to the
population with varying levels of effectiveness. Some of these health service innovations and
the outcomes of these have been explained below.
One area in particular identified to be impacting upon health care service was the division of
responsibilities between the state and federal governments. A combination of federal and
state financial responsibility for health care was contributing to a lack of multi-disciplinary
care planning and coordination across sectors (Anderson, 2004). In 1994, The Council of
Australian Governments (COAG) attempted to coordinate the organization, funding and
management of community and health services for patients requiring a mix of both chronic
and acute services, this led to nine mainstream and four Indigenous Coordinated Care Trials
across Australia (Esterman and Ben-Tovim, 2002). The aim of the Coordinated Care Trials
was to pool funds from federal and state sources into a common budget in an attempt to offer
better service delivery, improved health outcomes and greater efficiency (Hall and Viney,
2008).
The first round of Coordinated Care Trials was implemented in six states and territories from
July 1997 until December 1999 (Commonwealth Department of Health and Aged Care
13
[CDHA], 2001). The Government at the time invested $54.5 million over four years to
involve general practitioners in this program (Marcus, 1999). Research into effectiveness of
the coordinated care trials failed to demonstrate improved health or well-being of participants
and only three out of nine projects realised a reduction in admission to hospital (Anderson,
2004). Many Indigenous trials showed enhanced service access, infrastructure development
and improved individual and community empowerment (Esterman and Ben-Tovim, 2002). A
second round of trials were warranted to allow sufficient time for a true measure of outcomes,
and a further $33.5 Million was invested over a further four year period (Marcus, 1999).
These subsequent trials were instigated on a larger scale over longer time periods and used
outcome measures more specific to the target patient groups (Anderson, 2004). Evaluation
demonstrated equivocal results in terms of health outcomes, costs and financial viability to
previous health service delivery methods (CDHA, 2001). Whilst the original goal of
reducing hospital admissions did not come to fruition, often patients utilising hospital
services did so more efficiently. The costs saved through more efficient delivery of care was
spent in the coordination of the care.
Further initiatives have since been implemented in an attempt to improve the coordination
and efficiency of service provision within the Australian health care system. In 2011, COAG
initiated the National Health Reform Agreement with the aim of providing nationally
consistent and integrated community care to people aged 65 years and over and for
Indigenous Australians aged 50 years and over (COAG, 2011). The Commonwealth
Government provided funding of $3.4 million for this initiative (COAG, 2011). In 2012, the
Australian Government introduced the Living Longer, Living Better aged care reform
package at a cost of $3.7 billion over five years (Australian Government, 2013). The aim of
14
this reform was to support the aged to have more choice and control over their health care as
well as have easier access to services that support people to remain in their own home longer.
A further initiative is the 2010-2020 National Disability Strategy which aims to provide a
national approach for improving quality of life for people living with a disability and their
carers (COAG, 2011). The Australian Government has committed $1.8 million to this
initiative (Australian Government, 2008). Whilst these initiatives are in varying stages of
implementation and evaluation, the full extent of the impact on health outcomes or financial
implications for the health service will not be evident for some time.
There is rising pressure on health care planners to manage budgets in more efficient ways. In
this climate of increased accountability, spending on technological advances in virtually
every Western country has become subjected to comparative effectiveness research of one
form or another (Mushlin and Ghomrawi, 2010). A manufacturer is required to demonstrate
clear evidence of a products superior effectiveness, safety and cost effectiveness before it is
adopted at an increased cost. A large scale, robust cohort study conducted in 2010 by
Lindenauer and colleagues found patients hospitalised for acute exacerbation of chronic
obstructive pulmonary disease who were prescribed low-dose oral steroids, experienced
comparable outcomes to patients prescribed more expensive high-dose intravenous therapy.
Therefore, future patients were able to receive oral steroids at a reduced health care cost but
with equal outcomes (Lindenauer, Pekow, Lahti et al, 2010). This approach to decisions
regarding treatment options achieves positive clinical outcomes and cost effectiveness whilst
also encouraging manufacturers to produce only effective products.
Improved scientific knowledge, understanding and technology has accounted for many
changes to treatments and health care options. However, along with increased choice and
15
improved treatment has come increased costs and therefore government expenditure. Under
the Pharmaceutical Benefits Scheme (PBS) the government subsidises the cost of PBS
approved medications to provide timely, reliable and affordable access to medications for
Australians (Department of Health and Ageing, 2012). In recent years, pharmaceutical
manufacturers seeking to have products listed on the Australian PBS have become subject to
comparative effectiveness research before the drug qualifies to be listed (DoHA, 2012). In
2007, the government introduced market competition for pharmaceuticals which drove down
the cost of medications that were no longer under patent (Medicines Australia, 2011). The
result of this initiative is predicted to deliver a reduction of greater than $6 billion in
expenditure on pharmaceuticals by 2017-18 (Centre for Strategic Economic Studies, 2009).
The Medicare Benefit Schedule (MBS) subsidises the cost of health care to allow equitable
access to affordable, high quality health care provided by approved healthcare practitioners
and treatment in public hospitals (DoHA, 2012). A similar assessment process to the cost
effectiveness strategy being utilised with pharmaceuticals is now being employed to establish
evidence-based health care provided under the MBS. This will consist of an assessment of
new and existing procedures on the MBS subsidies list for safety, benefit and cost
effectiveness (Hall and Viney, 2008). Research to evaluate the outcomes of this relatively
new strategy has not yet been reported.
Additional to technological advances, a major contributor to health care spending, are costs
associated with length of hospital stays and service provision. In the early 2000s, hospital
funding faced a shift away from funding based on service delivery to funding based on output
achievements (Wynne, 2003). Casemix is a system used to measure and justify variations in
16
length of hospital stay and costs associated with various patient hospital admissions
(Australian Department of Health, 2013). This measurement process changed the focus of
health care and resulted in a decreased average length of hospital stay, more same-day
treatments and day-surgery procedures and more non-acute care provided in patient’s homes
or community settings (Hall and Viney, 2008). However, Casemix has its critics. Nurses
have reported that Casemix fails to recognise the importance of education and emotional
support and ignores the complexities of health care (Wynne, 2003); not to mention the
potential hidden costs as patients rebound with unplanned readmissions to hospital or
incomplete treatment that leads to further ongoing costs. In Queensland, other health costing
systems such as diagnostic related groupings (DRGs) and activity based funding (ABF) are
also being implemented in an attempt to quantify and standardise costs for health services.
These systems are under continual assessment and evolve in response to recommendations
and evaluation however, it is clear that focus is on health service expenditure.
Close review of health services recognised that use of acute hospital beds was very costly for
the health care system, thus a focus on public health and primary health care emerged. Some
argued that preventive health measures that reduce the incidence of disease and disability
represent a sound financial investment in the health of all Australians (Podger and Hagan,
1999). In the late 1990s, the trend was to reduce acute care hospital beds and increase
funding for population health promotion (Duckett, 2002). This included funding for tobacco
regulation, for communicable disease prevention strategies, to boost childhood immunisation
rates, to counter excess alcohol consumption and the use of illicit drugs, and for medical
research (Australian Government, 2011). Podger and Hagan (1999) argued that population
health initiatives are as cost-effective as other health care initiatives and deserve equal share
of the health care dollar. Research into the effectiveness and sustainability of health
17
promotion and community based health care programs have been conducted and tend to focus
on individual program sustainability following removal of formal funding and frequently uses
case study methods (Pluye, Potvin, Denis and Pelletier, 2004; Fuller, Harvey and Misan,
2004). This research has informed the development and ongoing delivery of many
community based programs however, results are often limited to the community setting many
of which were conducted in either rural settings or developing countries.
Research has repeatedly identified two areas of concern in Australia’s health care system,
namely the health status of Aboriginal and Torres Strait Islander peoples and access to
services for communities in rural and remote areas of Australia (Duckett, 2008). In an effort
to improve Indigenous health outcomes and access to services, programs specifically
focusing on improving access or delivery of Aboriginal health care have been initiated as part
of health care reform (Productivity Commission, 2005). Primary health care initiatives may
improve access to health care for indigenous and rural and remote communities. A series of
outreach programs aimed at providing access to specialist care for people in the top end of
Australia’s Northern Territory were introduced (Gruen, Weeramanthri & Bailie, 2002).
Evaluation of this primary health care initiative found that providing specialist care in a
regional centre can be a more equitable means of service delivery than within a hospital
setting, however only some of the programs had been sustained. In this case, the programs’
sustainability was dependent upon adequate and appropriate staff, funding, resources and
management of the program in a manner that responds to the needs of the local communities
(Gruen et al, 2002). Due to the nature of the innovation, participant numbers (particularly
patients) in this research were small, despite this the research did utilise multiple data
collection sources and methods.
18
On a larger scale in 2008, the National Indigenous Reform Agreement was implemented to
close the gap on Indigenous disadvantage (COAG, 2008). The program aimed to reduce the
disparity in Indigenous health outcomes, support early childhood development, improved
housing, schooling and remote services. The Australian Government committed $1.6 billion
over four years to the National Partnership Agreement on Closing the Gap in Indigenous
Health Outcomes (Australian Government, 2008). This large national program is planned to
continue over a twenty five year timeframe and at the first formal extensive evaluation in
2014, the initiative had been operational for five years. The main purpose of the program
was to reduce disparity, improve schooling, housing and remote health services to Aboriginal
and Torres strait Islander people and this is yet to come to fruition, however, results found
that the Close the Health Gap program has effectively strengthened foundations of trust,
partnerships, and information sharing, on which future improvements can be built (Victorian
Department of Health, 2014).
Further coordination of health care services was attempted by the introduction of Medicare
Locals in 2011, in an effort to improve coordination of care and progression for patients
through the health care system (Australian Government Department of Health [VGDH],
2011). The independent review of this innovation in 2014 (Horvath, 2014) recommended
extensive changes to the program, identifying that the name was confusing and a lack of clear
purpose or vision. Despite large fiscal, human and infrastructural resources being spent on
this innovation the program required broad changes to improve the chances that it would be
sustained. The number of Medicare Locals has since been reduced and restructured with less
staff, a change of function and name to Primary Health Networks (Australian Government,
Department of Health, 2015). Primary Health Networks were launched on July 1, 2015
however, there has been further controversy with Primary Health Care Limited, a private
19
company, suing the government in the Federal Court over use of the name (Aston, 2015).
Costs associated with implementation of health service innovation can be extensive and
understanding sustainability of these innovations is becoming more important to health
service managers.
Access to efficient health care is impeded by not only distance to facilities but also by the
current system of information management and this has led to the introduction of E-health
initiatives. Patients suffering chronic illnesses are likely to be regularly utilising the health
care system in fragmented occurrences, repeatedly having to describe their treatment and
medical history to health care professionals (National E-Health strategy, AHMC, 2008).
Information such as a patient’s health history, test results and treatment exist in separate
discrete areas, preventing effective sharing and utilisation of this information (AHMC, 2008).
Research found that safe storage, retrieval and linkage of health care records would facilitate
tele-health and tele-medicine that could lead to enormous gains in terms of improved patient
care, workforce efficiency and reduced duplication (Productivity Commission, 2005). The
gradual normalisation of electronic devices amongst society has paved the way for the
introduction of electronic health records.
In 2008, Australian Health Ministers commissioned the development of a strategic plan to
guide the national coordination and collaboration of E-Health (AHMC, 2008). The estimated
expenditure on E-Health by state, territory and commonwealth governments over the past ten
years is greater than five billion dollars (AHMC, 2008). In July 2012, the Australian
Government committed a further $233.7 million over three years to see E-Health move from
the developmental stage to operational (Jolly, 2013) The E-Health strategy identified the
perceived benefits of the initiative would be improved efficiency and reduced duplication
20
(Jolly, 2013). However, a systematic overview completed by Black, Car, Pagliari et al,
(2011) to explore the impact of E-Health on quality and safety of health care found that
despite support from policymakers, there was a lack of empirical evidence to support
improved patient outcomes or cost-effectiveness. There is also concern regarding knowledge
and understanding of the systems that are being used and the security of the patient
information that is being stored (Banna, 2010; Williams, 2011).
One goal of the introduction of E-Health is to ensure effective use of the available health care
workforce by preventing duplication and improving multidisciplinary communication. A
subjective evaluation of attitudes to E-health innovation conducted by Banna, Hasan and
Meloche in 2010, reported that patients believe that interactive technologies make more work
for healthcare workers. Despite improved availability of computers the knowledge, skills,
and experience of computer users is not always sufficient to gain the most from the system
(AHMC, 2008). Other concerns surrounding the move to online availability of health
information includes the ability of the user to effectively appraise the information available.
An integrative review by Mills, Chamberlain-Salaun, Henry et al (2013) into the experiences
of acute care nurses with e-health initiatives report nurses have mixed opinion surrounding
the introduction of E-health initiative, yet are positive in relation to the outcomes associated
with the implementation of E-health, such as clear documentation and improved
completeness of information. E-health is a relatively new field and ongoing expansion is
expected in the future, however, factors that influence the sustainability of these innovations
is yet to be examined.
21
2.3 Health care workforce
In the current climate, meeting the challenge of ensuring an adequate supply of an
appropriately trained health workforce is a key intention of the Governments’ reform and
planning. In recent years research and commentary has suggested that flexibility in health
care delivery processes and the health care workforce is needed in order to adequately meet
future demands on health services (HWA, 2012). Traditionally workforce planning has been
based on projections of demand and supply with little emphasis on innovative approaches to
increasing flexibility and productivity (Hall, 2005). Australia’s Health Workforce
Productivity Commission Research Report 2005, found that workforce shortages, inflexibility
and inefficiencies in workplace arrangements are largely contributing to poor health
outcomes for particular groups (Productivity Commission, 2005).
At a time when our health workforce is ageing, there continues to be unequal distribution of
health care professionals in all states and territories and in all health professions, with the
exception of nursing (Productivity Commission, 2005). A descriptive exploratory survey
completed by Searle (2007) in rural areas recognised that traditional roles have served well in
the past; however, changing population demographics has resulted in reduced numbers of
health care professionals and that shifting professional boundaries and roles were found to
improve collaboration, efficiency and quality of care (Searle, 2007). This study was
conducted in just one regional hospital with only 14 beds and therefore the results should be
considered with caution and the relevance to metropolitan setting is unknown.
Questions were raised regarding the health care workforce and the most efficient use of most
categories of health professionals. Australia was not alone with workforce issues being
raised in headlines internationally (Duckett, 2005). The over-specialisation of health
22
workforce roles has been questioned with some believing that this has led to inefficiency and
inflexibility (Duckett, 2005; Searle, 2007; HWA, 2012). Duckett (2005) has argued that
workforce flexibility and health workforce planning are necessary for future management of
healthcare needs. Support for policy and legislation change allows health care professionals
to expand their scope of practice and blurring professional boundaries is inevitable (Duckett,
2000). Informally the blurring of professional boundaries and scope of practice is seen in the
workplace in an effort to meet population health needs.
2.4 Australian health care workforce reform
Australia’s workforce is ageing and retiring thus placing further pressure on the health
workforce. This, coupled with the increased number of people living with chronic disease and
the development and use of advanced treatment options (Sibthorpe, Glasgow and Wells,
2005a), has led to healthcare system and health care workforce reform in an attempt to
control spiralling costs (Schofield and Beard, 2005). Changes to health care service
provision have been made to meet the overarching health care reform principles of:
continuity of care across the health system, provide a well-trained workforce, focus on
prevention and early detection, improve patient centred health planning and enhance inter-
sectoral collaboration (NHHRC, 2009). In particular, Health Workforce Australia’s
Expanded Scopes of Practice Program which aimed to improve productivity and
effectiveness of healthcare services by funding 26 projects across health and ambulance
serves (HWA, 2012a). Another health workforce service innovation initiated to meet these
increasing needs and demands of the healthcare consumer is that of the nurse practitioner
service.
23
2.5 The nurse practitioner service.
2.5.1 International nurse practitioner service
Nurse practitioners have been introduced to meet the health care delivery needs of the
population and globally nurse practitioners have been providing efficient health care services
to patients for many years. The first country to introduce a nurse practitioner role was the
United States of America. Nurse practitioners have been working in the healthcare industry
in the United States since the 1960s, initially in disadvantaged areas providing primary health
care to meet a short fall in physicians (Dunn, 1997; Keating, Thompson and Lee, 2010). The
potential of this new service to provide safe, effective and accessible healthcare to
communities with previously limited access, quickly became evident (Brown and Grimes,
1995) and the nurse practitioner role was quickly adopted across the United States in a
variety of settings (Sherwood, Brown, Fay and Wardell, 1997). According to the American
Association of Nurse Practitioners (2015), in 2013, there were more than 205,000 licensed
nurse practitioners within the United States and the number continues to increase. The
United States have state based practice and licensure for nurse practitioners rather than a
national approach. State based credentialing has resulted in varying roles, levels of autonomy
and education and is a barrier to utilisation of nurse practitioners to their full practice
authority (American Association of Nurse Practitioner [AANP], 2013). In addition, a
literature review completed by Clarin (2007) identified confusion surrounding nomenclature
and a lack of knowledge by health care professionals surrounding scope of practice of nurse
practitioners as an ongoing barrier to successful collaboration. These issues are not isolated
to the United States and continue to prevent full utilisation of this health care service.
24
Nurse practitioners have also been providing healthcare in Canada for more than 50 years. In
the late 1960s both nursing and medical organizations were supportive of the introduction of
nurse practitioner service in an effort to meet physician shortages predominantly in rural and
remote areas (Canadian Nurses Association [CAN], 2005). Despite research indicating safe,
cost-effective care with high levels of patient satisfaction (Spitzer, 1978; Horrocks, Anderson
and Salisbury, 2002), the lack of continued support from professional bodies meant that once
a surplus of physicians was found, the nurse practitioner role failed to be fully implemented
and sustained (CNA, 2005). There has since been a re-emergence of nurse practitioner roles
into health care services. In an effort to gain consistency in the role and scope across Canada,
the Canadian Nurse practitioner Initiative was implemented between 2004 and 2006 (CNA,
2011). The goal was to establish the legislation, educational requirements and to define and
promote the nurse practitioner role (CNA, 2011). The Collaborative Integration Plan for the
role of Nurse Practitioners in Canada was developed through this initiative and is currently
being implemented, 2011-2015. In November of 2011, there were over 3000 nurse
practitioners in Canada improving access to primary healthcare and nurse practitioners are
valued and trusted members of the healthcare team (CNA, 2011). The foundations for on-
going nurse practitioner service in Canada’s healthcare workforce have been reinforced by
this initiative.
The United Kingdom has also experienced workforce reform driven by the expanded and
changing needs of the population. In the 1980s, the potential for a more highly skilled
nursing workforce was identified and, in response to doctor shortages, a need to contain costs
of health service delivery and improve access to healthcare, nurse practitioner services were
implemented (Horrocks et al, 2002). A lack of consensus relating to role description has
proven problematic with the nurse practitioner and clinical nurse specialist roles overlapping
25
(Reveley, 2001). Factors such as lack of legal title protection and variability in training and
educational requirements, has hindered the advancement of this important segment of the
nursing profession in the United Kingdom (Morgan, 2010).
A report from the UK Prime Minister’s Commission on ‘The Future of Nursing and
Midwifery’ recommended that the Nursing and Midwifery Council (NMC) consider how to
reduce and standardise the proliferation of roles and job titles in nursing (Royal College of
Nursing, 2010). The Royal College of Nursing (RCN) recommended that common standards
and systems should be developed and formal records of patient outcomes and practice
competencies should be established within advanced nursing practice to benefit patient safety
(RCN, 2010). The Nursing and Midwifery Council identified that the project group should
seek to learn lessons from other countries, such as Australia and the USA, who have already
regulated advanced practice nursing (RCN, 2010). This recommendation by the NMC
recognises Australia a world leader in advanced nursing practice and specifically nurse
practitioner competencies.
Nurse practitioner service first came to fruition in New Zealand in 1998, when a ministerial
taskforce on nursing supported the development of the nurse practitioner role. The taskforce
recommended the formalisation and validation of specific competencies linked to nurse
practitioner title (Ministerial Taskforce on Nursing, 1998). The impetus for the development
of the nurse practitioner role was the untapped potential of the nursing workforce (Gardner,
Dunn, Carryer and Gardner, 2006). The development of the role in New Zealand has ensured
that educational requirements and authorisation processes are in place with employment
structures slowly evolving, the main focus being population health (Carryer, Gardner, Dunn
and Gardner, 2007b).
26
Registration as a nurse is mutually recognised between New Zealand and Australia due to the
Trans-Tasman Mutual Recognition Act of 1997. A formal commitment by the Australian
Nursing Council (ANC) and New Zealand Nursing Council (NZNC) to collaborate for the
development of the nurse practitioner role was agreed under a Memorandum of Cooperation
in 2002 (Gardner, Carryer, Dunn and Gardner, 2004). The anticipated benefits of this
agreement were mutual recognition and shared evidenced based authorisation and education
of nurse practitioners helping to provide credibility and confidence in the standards of service
and care provided (Gardner et al, 2004). The extent to which these benefits have come to
fruition is uncertain and research informing these areas, discussed below, demonstrates that
inconsistencies in nurse practitioner practice continue. The experiences of implementing
nurse practitioner services, and the barriers and challenges faced in countries around the
world has informed and helped shape the implementation of nurse practitioner service within
Australia.
2.5.2 Australian nurse practitioner service
2.5.2.1 Nurse practitioner service implementation
In the early 1990s, New South Wales introduced the first pilot nurse practitioner program into
the health care workforce (Driscoll, Worrall-Carter, O’Reilly and Stewart, 2005). In 1993, a
Steering Committee was established to manage and examine ten nurse practitioner pilot
projects in terms of feasibility, safety, effectiveness, quality and cost (Gardner et al, 2004).
The findings of the reports were favourable and saw amendments made to the Nurses Act
1991 to allow for authorised practice of nurse practitioners in NSW (Gardner et al, 2004).
Six broad areas of practice for nurse practitioners were recognised by the Nurses Registration
Board: mental health, high dependency, maternal and child health, rehabilitation,
medical/surgical and community health (Gardner et al, 2004).
27
The first nurse practitioner role was authorised in 2000, in a rural and remote healthcare
setting, and justified by the need to meet doctor shortages and, some argue, in an effort to
retain experienced nursing staff at the bedside (Taylor, 2007; Harris and Chaboyer, 2002).
Nurses had reported that they were leaving the profession due to an inadequate clinical career
structure and the NSW Department of Health saw the nurse practitioner service as a way of
addressing both issues (NSW Department of Health, 2000; Wand and White, 2007). Attrition
of highly educated nursing staff due to job dissatisfaction was beginning to be of concern for
future health care service provision.
The introduction of nurse practitioner service sparked a barrage of opposition by the medical
fraternity. The Australian Medical Association (AMA) responded to the introduction by
lobbying for restrictions to be placed on nurse practitioner service. The NSW Department of
Health (1995) replied to the AMA lobbying by geographically restricting nurse practitioners
to practice only in rural and remote areas and these roles were implemented within a doctor
substitution model (Driscoll et al, 2005). Substitution in healthcare is the replacement of one
service with another (Calpin-Davies and Akehurst, 1999), in this case doctors would be
replaced with nurses but only until a medical officer could be found. This type of workforce
territorialism and concern by medical practitioners about their position in the health care
system has compounded the barriers faced by workforce reform initiatives.
Following the introduction of the NSW pilot projects other states followed suit implementing
nurse practitioner service initiatives and the number of nurse practitioner services has since
been increasing. Due to the initial authorisation of nurse practitioners at state level,
inconsistencies in relation to entry level educational qualifications, scope of practice and
28
level of independent practice have arose (Driscoll et al, 2005). With lack of uniformity in
relation to implementation procedures, fragmentation occurred, bringing with it a number of
barriers to the progression of nurse practitioner service (Gardner, Gardner, Middleton, and
Della, 2009). State based introduction of varying nurse practitioner service models allowed
for individual services to meet local needs but reinforced inconsistencies.
Pilot projects and trials of nurse practitioner service also began in Victoria. The Victorian
Department of Human Services (VDHS) funded the introduction of eleven nurse practitioner
models including emergency department nurse practitioner service during Phase One of the
Victorian Nurse Practitioner Project in 1999 (VDHS, 2000). An external review of these
nurse practitioner models was conducted by the University of Melbourne twelve months
following implementation (Driscoll, et al, 2000). The final report was published in early
2000, outlining a framework for the implementation of nurse practitioner service across
Victoria (Driscoll et al, 2000). The second phase of the project funded a further eighteen
nurse practitioner service models in 2001 and ‘Nurse Practitioner’ became a protected title in
Victoria (Gardner, et al, 2004). The role was clarified by the development of nurse
practitioner competency standards following research that was commission by the Australian
Nursing and Midwifery Council in 2004 (Gardner, et al, 2004). This research report was
instrumental in articulating the knowledge and expertise of nurses in this role and laid the
foundations for nationally recognised competency standards and educational benchmarks
(Nursing and Midwifery Board of Australia [NMBA], 2010).
29
2.5.2.2 Emergency nurse practitioner service implementation
Nurse practitioner services continued to expand in both number and areas of specialty. In
response to service gaps within emergency departments: increased waiting times,
overcrowding and decreased patient satisfaction, nurse practitioners within the specialty of
emergency were introduced in some departments (Christofis, 2001; Jennings et al, 2008). In
January 2015, a total of 301 nurse practitioners were endorsed in Queensland (NMBA, 2014)
with 73 of these registered in the emergency medical services practice scope (Queensland
Health, 2015). The second national census of the status of Australian nurse practitioners
which consisted of a self-administered questionnaire was completed by 293 participants; a
response rate of 76.3% (Middleton et al, 2011). Use of the same instrument that was used in
the first national census allowed for effective comparison and discussion of changes to the
service over time. The survey revealed that emergency nurse practitioners were the largest
clinical specialty, comprising 30% of the total nurse practitioner respondents (Middleton et
al, 2011). Despite generic competency standards for nurse practitioner service, emergency
nurse practitioner services are implemented to meet local needs and variations and flexibility
in scope of practice must be retained in response to varying health care environments (Lowe,
2010). These variations, whilst necessary, limit generalisability and comparative research.
While nurse practitioner services in general were expanding and demonstrating the ability to
meet health service gaps, many barriers to service implementation were hindering continued
development of this new health service. It has been widely recognised that both patients and
other healthcare workers experience confusion surrounding the nomenclature relating to
nursing roles and services (O’Keefe and Gardner, 2004; Cashin et al, 2007). This problem
was addressed to some extent in 2008, when all jurisdictions in Australia had Nurse
30
Practitioner title protected by legislation and this was expected to help reduce confusion and
aid in public trust (Gardner et al, 2009; Wand and White, 2007). However, a study by
Allnutt, Allnutt, McCaster et al (2010) that examined the clients’ understanding of the role of
nurse practitioners, found that patients still have difficulty understanding nurse practitioner
service roles and scope of practice. This study used a self-administered survey supplied
directly to the client by the Nurse Practitioner following a consenting process (Allnutt et al,
2010). The research procedure undertaken, data collection instrument and analysis methods
used in this research was clearly outlined for replication however, the main concern with this
research was the potential selection bias. The results suggest that despite very high levels of
satisfaction with nurse practitioner service, ambiguity surrounding the service may lead to
service under-utilisation (Allnutt et al, 2010).
2.5.2.3 Challenges to nurse practitioner service implementation
The issue of the scope of practice of nurse practitioner service is controversial. The very
nature of nurse practitioner service is intentionally broad, dynamic and flexible to meet the
needs of individual health care sectors and the role varies depending upon the identified gaps
in service provision (Cashin et al, 2007; Lowe, 2010; Driscol et al, 2005). A review by the
Productivity Commission completed in 2005 identified that implementation of nurse
practitioner service in Australia had been a slow process due to resistance from parts of the
medical profession. This is evidenced by an Australian Medical Association (AMA) position
statement implying a lack of support for nurse practitioner service (AMA, 2005). The AMA
warned of fragmented patient care, potential unsafe prescribing, increased risks of inadvertent
patient outcomes, service duplication and increased costs (VDHS, 2000). Research
examining nurse practitioner services indicate these warnings are unfounded.
31
In 2005, Gardner and Gardner (2005) completed an observational analytical study into four
models’ of nurse practitioner service. The aim was to investigate the feasibility of the nurse
practitioner role and scope of practice in delivering local health services in the ACT and to
provide information related to the educational and legislative requirements for this service
(Gardner and Gardner, 2005). This research reinforced that nurse practitioners are able to
serve the needs of a wide range of consumers such as people from non-English speaking
backgrounds, sex industry workers, patient with mental health disorders and the aged in both
acute and primary care settings (Gardner and Gardner, 2005). It was recognised that the role
of the nurse practitioner had broad potential to reduce inequities between distribution of
health care services in both metropolitan and rural/remote areas (Gardner and Gardner, 2005),
however, lack of a standard scope of practice at this time left the nurse practitioner and the
role vulnerable.
In an effort to standardise the role of the nurse practitioner in Victoria and in other states, the
Nurse Practitioner Implementation Advisory Committee (NPIAC) recommended that nurse
practitioners work under Clinical Practice Guidelines (CPG) (DHS, 2004). These CPGs were
developed to guide nurse practitioners with a framework for the assessment, management and
referral process for specified patient groups and had been widely adopted amongst nurse
practitioner services (Carryer et al, 2007b). This framework proved to be both beneficial to
service development and overly restrictive to the full utilisation of the nurse practitioner
service (Carryer et al, 2007b). While this remains a concern for nurse practitioner service,
recent preliminary research by O’Connell and Gardner (2012) suggests the development of an
Australian framework that will inform specific competencies for the specialty of emergency
nurse practitioners.
32
In the first national census of Australian nurse practitioners Gardner, A. et al (2009),
surveyed 202 nurse practitioners in an effort to profile nurse practitioner service. The
findings suggest nurse practitioner numbers were rapidly increasing; however there was
under-utilisation of highly skilled and experienced members of the health workforce due to
the dissonance between state and federal legislation (Gardner, Gardner, Middleton and Della,
2009). Despite the role of the authorised nurse practitioner having a legal framework for
prescribing, referral and ordering diagnostic tests at the state level; a small scale research
project by Keating, Thompson and Lee in 2010 recognised barriers to progression of nurse
practitioners. Lack of MBS also prevents nurse practitioners from referring patients to
specialists and admitting or discharging patients from hospital (Driscoll et al, 2005).
Legislative changes surrounding the registration of nurse practitioners, prescribing rights,
referral and use of diagnostic processes was recommended (Gardner and Gardner, 2005;
Gardner et al, 2009). In 2010, legislation was introduced to allow eligible nurse practitioners
to access Medicare provider numbers and Pharmaceutical benefit scheme prescriber rights for
a list of specified items (DHA, 2012).
2.6. Nurse practitioner service provision
Nurse practitioner services improve consumer access to treatment with cost-effective care to
target at-risk populations in all settings including metropolitan, rural and remote communities
(ANF, 2011). In 2010, the national registration body, Australian Health Practitioners
Regulation Agency (AHPRA) became operational. With this, the Nursing and Midwifery
Board of Australia (NMBA) adopted the Australian Nursing and Midwifery Council’s
(ANMC) National Competency Standards for Nurse Practitioners (ANMC, 2006). Revised
Nurse Practitioner standards were adopted in 2014. Currently, in order to apply for
authorisation as a Nurse Practitioner, applicants are required to demonstrate:
33
• general registration as a registered nurse with no restrictions on practice;
• the equivalent of three years’ full-time experience in an advanced practice nursing
role, within the past six years from the date of the application completion.
• successful completion of a Master’s degree approved by the NMBA or education
equivalence
• compliance with the NMBA’s National Nurse Practitioner Competency Standards for
the Nurse Practitioner and
• compliance with the NMBA’s continuing professional development registration
standard. (NMBA, 2014)
2.7 Nurse practitioner service outcomes
Nurse practitioner services help to meet the goals of health care reform by improving
continuity of care across the health system, prevention and early detection of disease,
improving inter-discipline collaboration and access to health care for Australians. Early
research, both nationally and internationally sought to compare nurse practitioner service
with services provided by medical officers in the areas of cost, quality and patient satisfaction
(Brown and Grimes, 1995, Jenkins and Torrisi, 1995). Despite the argument presented by
the AMA, that nurse practitioner services will lead to unsafe prescribing, increased risks of
inadvertent patient outcomes, service duplication and increased cost, many studies have
found that nurse practitioner services deliver high quality, safe and cost effective patient care
(Jennings, et al, 2015; Jennings et al, 2008; Wilson and Shifaza, 2008; Carter and Chochinov,
2007).
34
Nurse practitioners have demonstrated effective management of common acute illnesses and
injuries as well as providing health promotion initiatives and education for stable chronic
disease management (Gardner and Gardner, 2005). Positive patient outcomes were reported
in relation to waiting times and satisfaction (Jennings et al, 2008; Driscoll et al, 2005).
Allnutt and colleagues (2010), completed a survey with 129 nurse practitioner clients from
Western Australia and New South Wales. The aim of the research was to evaluate the
clients’ understanding of the role of NPs as well as satisfaction with quality of care, education
provided and the knowledge and skill of the NP (Allnutt et al, 2010). Results suggest that
patients have an overwhelmingly positive report in relation to satisfaction and confidence in
the care provided by the nurse practitioner service however; are unsure of the role of an NP
(Allnutt et al, 2010). This research was conducted within a limited setting and across only
two states by a self-administered survey and therefore results should be considered with
caution.
An examination by Lowe published in 2010 explored the scope of emergency nurse
practitioner practice in a large metropolitan emergency and trauma centre in Melbourne. This
single site research questioned the use of clinical practice guidelines and identifies the
limitations and restrictions they place on the role of the emergency nurse practitioner (Lowe,
2010). Clinical practice guidelines (CPGs), protocols, standards and practice policies, as they
have variously been titled, were also criticised in work by Carryer and colleagues (2007b)
who state that CPGs can either support practice or be designed to control nurse practitioner
practice. Under a model that uses restrictive clinical practice guidelines, highly educated and
skilled emergency department nurses with years of experience attend patients with minor
injuries or illnesses and it must be questioned if this is the most efficient use of these highly
trained personnel (Carryer et al, 2007b).
35
This was reiterated by Gardner and colleagues (2010) who claim that specific protocols
defining nurse practitioner practice diminishes the effectiveness of nurse practitioner service.
Lowe’s (2010) research reported that emergency department nurse practitioners were mostly
treating patients with minor illnesses and injuries. When nurse practitioners care daily for
patients with minor concerns, maintenance of expert knowledge and skills to treat acute
patients attending emergency departments is questionable. Issues surrounding job
satisfaction may arise from the nurse practitioner workforce as their skills remain under-
utilised.
Carryer, Gardner, Dunn and Gardner (2007a) assert the unique nature of the role and posit
that the nurse practitioner role is strongly embedded in nursing philosophy. According to the
International Council for Nurses there are four responsibilities fundamental to nursing: to
promote health, to prevent illness, to restore health and to alleviate suffering (ICN, 2006). It
is believed that inherent in nursing is respect for human rights; cultural safety, the right to life
and choice, to dignity and to be treated with respect and that nurses provide care to the
individual, the family and the community (ICN, 2006). This is the unique nature of nursing
practice that Wand and Fisher (2006) assert supports nurses as professionals in their own
right.
Research into mental health nurse practitioner service in emergency departments by Wand
and Fisher in 2006, reports that the service is not a case of nurses being substitute doctors but
rather, nurses being acknowledged as specialists within their own right to better meet the
needs of patients. The three areas of focus in this research were therapeutic techniques,
prescribing and care coordination and patient referral (Wand and Fisher, 2006). Wand and
Fisher (2006), report that nurse practitioner services have been successful and effective in
36
regards to access, availability, acceptance, satisfaction, cost and clinical outcomes. This
success is reliant upon good consultation processes and evaluation, and partnerships across
the disciplines (Wand and Fisher, 2006). This is reinforced in a study by Nicholls, Gaynor,
Shafiei et al, (2011) who explored the effectiveness of mental health nurse practitioner
service in the emergency department and found that mental health nurse practitioners enhance
clinical outcomes for clients through improved assessment and management skills of nurse
practitioners. Wilson and Shifaza (2008) also evaluated the effectiveness and acceptability of
nurse practitioners in an adult emergency department and found that the majority of patients
were satisfied with the treatment they received.
The results of the second national census of the status of Australian nurse practitioners
completed in 2009, highlighted ongoing barriers to service implementation (Middleton, et al,
2011). At the time, there were 408 nurse practitioners authorised to practice within Australia
with 64.3% representation in emergency departments. The survey found that the
recommendations from the first census had largely not been incorporated into practice and
unacceptable barriers constraining the practice of nurse practitioner service were still evident
(Middleton, et al, 2011). The second census recommended that both professional and political
support is required for these services to ensure efficacy and sustainability of the role
(Middleton, et al, 2011).
Nurse practitioner service research has demonstrated positive patient outcomes, efficient care
delivery and high levels of patient satisfaction, suggesting there are grounds to continue this
delivery model. The innovation of emergency nurse practitioner service is recognised in the
second national census as a rapidly increasing service delivery model to meet rising
healthcare needs (Middleton et al, 2011). Despite large investments of resources, both
37
human and fiscal, to implement nurse practitioner services, it is yet to be demonstrated as a
sustainable healthcare reform innovation.
2.8 Sustainability of health service innovations
In order to examine sustainability within a health care context, it is first important to identify
an operational definition of sustainability. The definition of sustainability has been a
controversial and much debated topic throughout the literature. In 2009, Hanson, Salmoni
and Volpe, completed a multi-case study into program sustainability that devoted one
component to defining the meaning of sustainability as recognised by stakeholders’ differing
points of view. The results highlighted the diversity of responses and contexts and the impact
this may have on sustainability of a program (Hanson, et al, 2009). A literature review
conducted by Buchanan, Fitzgerald, Ketley et al in 2005 on sustaining organizational change
also acknowledged the ambiguity surrounding sustainability and suggested that researching
change may be more interesting than studying sustainability. A desire to sustain some
methods may prevent development or exploration to find better ways of doing things
(Buchanan et al, 2005).
In the public health domain, sustainability of healthcare programs has been described in terms
of financial self-sufficiency of the program (Olsen, 1998) whilst in the context of health
service delivery, Greenhalgh and colleagues, (2004, p. 582), define sustainability as ‘making
an innovation routine until it reaches obsolescence’ and routinisation refers to sustainability
within organizations (Pluye et al, 2004). Despite the numerous definitions and applications it
has been well documented that the sustainability of healthcare innovation is both highly
38
valued and sought by health care planners in the current climate (Hanson, Salmoni and
Volpe, 2009).
The literature on sustainability in health care research has predominantly reported studies that
have examined the sustainability of individual health care programs. These are usually health
promotion (Pluye et al, 2004), public health or primary health care innovations (Sarriot,
Winch, Ryan, et al, 2004) that are pilots and have been allocated short-term funding. As
many programs are introduced as pilot programs, research has often surrounded evaluating
patient outcomes as a result of these programs in an effort to justify ongoing program funding
(Fuller, Harvey and Misan, 2004; Tham et al, 2010; Ament, Gillissen, Moser et al, 2014).
The need for sustainability strategies to be considered concurrent with implementation
strategies in order to achieve long term routinisation has become evident (Pluye et al, 2004;
Evashwick and Ory, 2003; Forster, Newton, McLachlan and Willis, 2011) as has the
importance of the quality of the innovation (Murray Cram and Nieboer, 2013). Focus group
research conducted by Nordqvist, Timpka and Lindqvist (2009) into the factors that promote
sustainability of community based programs in Sweden found that collaboration, networking
and enabling the community all influenced program sustainability. Limitations to this
research design include group coercion and censorship during the focus groups, particularly
in this study as the participants were politicians and administrators who work together on a
daily basis.
Research surrounding sustainability of health service delivery has had increased attention in
recent times. A literature review into the sustainability of new programs by Wiltsey Stirman,
Kimberley, Cook et al (2012) recognised that research into sustainability often did not
present a working definition, most were retrospective and relied heavily on self-reports. The
39
research identified that very few studies employed rigorous evaluation methods were based
on a conceptual framework and recommended that further study into sustainability should
consider changes to the innovation over time (Wiltsey Stirman, et al, 2012). Development of
a solid research paradigm is dependent upon the ability to replicate and compare results of
research conducted within the field (Fox, Gardner and Osborne, 2015). Therefore without a
clearly articulated conceptual framework research results are diluted in their ability to inform
practice.
The United Kingdom Department of Health commissioned a systematic review into diffusion
of innovation in service organizations in 2004 (Greenhalgh et al, 2004). The review was an
extensive examination of innovations in health service delivery, consisting of 213 empirical
and 282 non-empirical studies (Greenhalgh et al, 2004). Although the aim of the systematic
review was to identify how innovations in health service delivery could best be implemented
and sustained, the authors acknowledged a near absence of research into the sustainability of
healthcare services (Greenhalgh et al, 2004). Greenhalgh and colleagues provided a
conceptual model of the determinants of diffusion, dissemination and implementation of
innovations in service organizations (Greenhalgh et al, 2004). This research has been the
impetus and has provided the foundations for further research in the area of health service
sustainability.
In 2005, the Australian Primary Health Care Research Institute (APHCRI) commissioned an
examination of the sustainability of five primary health care initiatives in operation at the
time. Five research teams were funded and Sibthorpe, Glasgow and Wells (2005a)
coordinated and reported the research efforts (Sibthorpe, Glasgow and Wells, 2005b). The
40
conceptual framework of Greenhalgh and colleagues (2004) informed the data collection
utilising six domains that were identified to impact upon sustainability: political, institutional,
financial, economic, client and workforce sustainability. The research findings were
congruent with the findings of Greenhalgh et al (2004) and highlighted three major themes in
relation to service delivery sustainability. The importance of relationships, networking and
champions, the effect of political, financial and societal forces and, the motivation and
capacity of agents within the system all strongly impact on the sustainability of an innovation
(Sibthorpe et al, 2005b. p S77).
The field of health service delivery is complex and research into the sustainability of this
concept is challenging. In rural health care service delivery the barriers for sustainable
services rests not only in funding but also workforce restraints (Humphreys, Wakerman and
Wells, 2006). A six year longitudinal study into a rural primary health care service has
described how effectively managing changes in workforce supply, linkages with external
organizations and infrastructure has impacted positively upon the sustainability of this service
(Buykx, Humphreys, Tham et al, 2012). Research by Forster, Newton, McLachlan and
Willis (2011) explored the implementation and sustainability of models of care in midwifery
and acknowledge that complex health service provision must take into consideration the
organizational context to sustain and normalise changes to practice and service delivery.
Forster et als’ (2011) research effectively emphasised the importance of using a theory to
evaluate a health services and recognised that ongoing changes to the context in which a
model of care is implemented may impact upon service model sustainability.
41
Current research specifically into sustainability of nurse practitioner service is minimal.
Some studies that utilise the term sustainability do not measure this as an outcome but report
sustainability as an unknown outcome or as part of future recommendations for further
research. In 2010, Considine and Fielding published a discussion paper outlining the
sustainability of programs initiated as part of the Victorian Nurse Practitioner Project
(VNPP). The aim of this paper was to discuss the sustainability of programs in terms of the
six domains identified by Sibthorpe and colleagues in 2005 (Sibthorpe et al, 2005).
Considine and Fielding (2010) concluded that many of the descriptors of sustainability
presented by Sibthorpe and colleagues were applicable to nurse practitioners in Victoria and
future research should focus on effectiveness of teams rather than individuals.
Research specifically surrounding emergency nurse practitioner service has focused on
examining the safety, efficiency or patient satisfaction with the service rather than
sustainability. Only one study has been published specifically examining the sustainability of
emergency nurse practitioner service. Keating, Thompson and Lee (2010), conducted a study
on the Victorian emergency nurse practitioner service. The aim was to explore the perceived
barriers to progression and sustainability of the nurse practitioner role in Victoria by survey
(Keating et al, 2010). A survey of 37 nurse practitioners across 17 emergency departments
reported that the lack of prescriber numbers and Medicare provider numbers (MBS) at the
commonwealth level restricted the ability of nurse practitioners to work autonomously
(Keating et al, 2010). This research study received a good response rate (77%) however, the
method chosen did not allow for in-depth understanding of the barriers or the impact of these
on nurse practitioner service which limit the understanding and application of the results. The
survey instrument was developed following a review of the current literature but lacks
theoretical linking or framework. The survey asked respondents to rate the perceived barriers
42
of ‘lack of ongoing funding’ and ‘lack of support or understanding’ on a five point Likert
scale to sustainability of the nurse practitioner service in their workplace. This research did
not include all stakeholders and therefore the results may have missed important points of
view regarding the barriers that are impacting progression of nurse practitioners.
It is naive to expect that a service providing good quality outcomes will automatically be
sustained. Despite evidence to suggest initiatives are delivering better quality outcomes,
some of these are not being sustained and routinised (Forster, et al, 2011). Bundaberg and
Gladstone Hospitals have previously implemented emergency nurse practitioner services
however, in the past two years these services have ceased to exist (Australian College of
Nurse Practitioners, 2012). The cause for this was unknown but recently these two hospitals
have again employed nurse practitioners in the emergency department and this demonstrates
the vulnerability and yet resilience of this health care service innovation.
2.9 Summary
Australia continues to implement health care reform innovations in an attempt to meet
growing population expectations and demand. Expenditure on health service innovation is
continuing to rapidly increase with little thought to the ongoing sustainability of these
services. The implementation, removal and re-structuring of services in the ad hoc manner as
has occurred in recent years is costly and knowledge and understanding of factors that
influence innovation sustainability could guide innovation longevity. Evidence suggests that
barriers and limitations facing emergency nurse practitioner service may be impacting upon
the full utilisation and sustainability of this service. Research examining the factors that are
influencing sustainability of emergency nurse practitioner service as a health service
43
workforce reform innovation are required to support best utilisation of valuable health care
resources. The purpose of this research was to examine the health service innovation of
emergency nurse practitioner service and explain the factors influencing sustainability of this
service. The results of this research will help to guide implementation of innovative services
and policy development related to nurse practitioner service.
2.10 Conclusion
Nurse practitioner services are just one of a multitude of health service innovations being
implemented as part of the health care reform initiatives. The research indicates this service
offers highly effective health care that is helping to meet population growing health care
needs. Despite large amount of fiscal and human resources being provided to implement
services, sustainability of this level of health care delivery is yet to be examined and the
factors influencing sustainability are not understood. Health service innovations require
ongoing research to ensure that resources are being utilised for the best possible outcome
This chapter has presented a discussion of Australia’s healthcare reform impetus and
innovations and has reported on policy changes and innovations put in place by authorities in
an attempt to respond to population healthcare needs. Improving access and efficiency in the
health care system and strategies to ensure better outcomes has also been discussed. Health
care workforce concerns and service delivery reform along with the implementation of nurse
practitioner service was explained and the published research currently available relating to
nurse practitioner service and implementation and barriers to implementation were
considered. Finally, research relating to sustainability of health care service innovation has
been presented with the lack of research into sustainability of nurse practitioner service has
44
been identified and in conclusion the research problem and aims of this study have been
made explicit. In the following chapter the theoretical framework that has guided this study
will be explained in detail.
45
Chapter 3
Theoretical Framework 3.1 Introduction
A thorough review of the current published literature and research relating to health care
reform innovations and service provision, in particular nurse practitioner service, has
identified gaps in the current knowledge. The review identified that nurse practitioner
services are effectively meeting health care needs of the community with high levels of
patient satisfaction and that these services are rapidly expanding. Also highlighted was
research evaluating sustainability of health workforce reform innovations and how important
this information is to ensure optimum utilisation of scarce resources. In this chapter the
historical development of innovation diffusion along with contemporary relevant theories that
have previously been used to research sustainability of programs will be explored. The
influence that these relevant theories have had on the development and justification for the
use of the Sustainability of Innovation framework to guide research into the factors that
influence sustainability of emergency nurse practitioner service is outlined.
3.2 Innovation diffusion
The introduction of an innovation or new process does not automatically equate to acceptance
or continuation of that innovation and is often, among other things, dependent upon the
people involved to maintain the momentum of implementation. Valente (1996) claims that
impersonal measures such as media and advertising may enhance awareness of an innovation
however it is through social networks and interpersonal influence that diffusion takes place.
Diffusion is defined by Rogers (2004) as a process through which an innovation spreads
among members of a social group. This spread is considered to be on a continuum, from
46
passive diffusion to active dissemination where a planned, formalised process is employed to
persuade target groups to adopt an innovation (Greenhalgh et al, 2004). Regardless of where
the innovation sits on the continuum, spread of the innovation is essential to continuation of
any innovation and understanding this process is imperative to research in this field. In order
to identify a theoretical framework suitable to guide research into health service
sustainability, the current science and theoretical frameworks used previously in similar
research were examined.
3.3 Historical development of diffusion of innovation theory
Diffusion of Innovation research can be traced back to a study completed in 1943, known as
the Iowa Hybrid Seed Corn Study (Ryan and Gross, 1943). Bryce Ryan, a Doctor of
sociology at Harvard and Neal Gross, a rural sociology graduate at Iowa State University,
completed the study to examine the sociological factors that influence a farmer’s decision to
adopt a new form of seed (Rogers, 2004). Since this time the concept of diffusion itself has
spread and developed across many other fields of research.
The methodology used by Ryan and Gross in their study has become the most commonly
adopted research method for most diffusion investigators (Rogers, 2004). A basic framework
for the diffusion model was developed and a paradigm of diffusion research has been
established over time (Rogers, 2004). Diffusion of Innovation is described as a process
through which an innovation spreads via certain communication channels, over time, among
members of a social system (Ryan and Gross, 1943; Rogers, 2004). Early diffusion studies
were discipline specific; however, similarities were identified across various disciplines in
relation to the rate of innovation adoption (Rogers, 2004). The Diffusion Process was seen to
47
contain consistent elements across all diffusion research studies regardless of discipline
(Rogers, 2003). This process was identified and generalised by Rogers in his first book in
1962. Three clusters of influence in relation to the rate of spread of an innovation were
documented; the innovation, characteristics of individuals and contextual factors (Rogers,
2004). The uptake of Rogers’ Diffusion of Innovation theory is evidenced by more than
5,000 publication citations and by the varied disciplines such as anthropology, political
science, marketing and public health that have applied Rogers’ theory (Rogers, 2004).
Over time the theory has undergone review, reorganization and refinement to present a
modernised conceptual framework useful for determining the spread of innovations in the
health care industry (Rogers, 1995; Greenhalgh et al, 2004). Rogers’ theory of diffusion was
an important concept however, diffusion does not equate to sustainability. Components of
Rogers’ theory have been adapted by other researchers such as Shediac-Rizkallah and Bone,
May’s Normalisation Process Theory, Sibthorpe and colleagues and finally the Dynamic
Sustainability Framework. These frameworks and concepts have been considered during the
development of a theoretical framework to evaluate sustainability in a contemporary complex
health care environment.
The influence of the diffusion of innovation theory is undeniable however, in the complex
changing environment of health care and more recently the changing concept of sustainability
from a static to a dynamic state has required adaptation of the theory. Subsequent theories
and frameworks have been developed modelled on the original work of Rogers, using the
common core elements of the innovation, the organization and the environment (Shediac-
Rizkallah and Bone, 1998; May, 2006). Shediac-Rizkallah and Bone’s (1998) framework for
conceptualising program sustainability has informed research examining sustainability of
48
many community based health promotion programs (Evashwick and Ory, 2003; Pluye,
Potvin, Denis et al, 2005; Pluye et al, 2004; Sarriott, Winch, Ryan et al, 2004; Scheirer,
2005).
The framework identifies three major groups of factors that impact upon program
sustainability: project design and implementation process, organizational factors and, broader
community factors (Shediac-Rizkallah and Bone, 1998). This framework has formed the
basis for several additional models that have emerged in the field of community-based
program planning and implementation for sustainability (Mancini and Marek, 2004;
Johnston, Hays, Center and Daley, 2004). The Shediac-Rizkallah and Bone model and
variations to this model have been specifically developed for health care programs within the
community context, sometimes in developing countries or on pilot projects and may fail to
address concepts that impact upon sustainability of an innovation within an acute care setting.
Whilst this framework recognises the importance of the innovation itself to sustainability,
closer examination of other factors that influence complex health care environments in an
acute hospital setting and acknowledges the dynamic nature of sustainability is required.
3.4 Research in the current health care context
Today’s health care exists in environments of constant change, using modern innovative
technology, inclusive of many stakeholders and interactions with patients of higher acuity
and expectations than ever before. In 2002, the United Kingdom Department of Health
commissioned Greenhalgh, Robert, MacFarlane, Bate and Kyriakidou to identify factors that
influence effective diffusion and sustainability of innovations within service organizations
(Greenhalgh et al, 2004). As a result, Greenhalgh and colleagues (2004) conducted a
systematic review and meta-narrative to conceptualise a model considering the determinants
49
of diffusion, dissemination and implementation of innovations in health service delivery and
organizations. Greenhalgh et al (2004) defined sustainability as “making an innovation
routine until it reaches obsolescence”. Sustainability was considered to be achieved when not
only new ways of working and outcomes were implemented, but when attitudes and
processes behind these actions were altered to support the innovation (Greenhalgh et al,
2004).
Greenhalgh and colleagues found that health service organizations consisted of a more
complex network of interactions and influences (Greenhalgh et al, 2004). These
interpersonal relations were much more influential that previously identified by Rogers.
Greenhalgh and colleagues’ developed a conceptual framework that was expanded to meet
the needs of evaluating complex service organizations (Greenhalgh et al, 2004). Elements
identified by Greenhalgh and colleagues (2004) specifically associated with sustainability of
an innovation are:
• Staff involvement and commitment - Early involvement of all staff, in particular, top
management to support and advocate the innovation as well as champions at ground
level.
• Human resources - The motivation, capacity and competence of individual
practitioners as well as the provision of education and training
• Organizational structure - Processes that support departmental (ground level up)
decision making and communication in the organization
• Organizational networks – communication within the organization and inter-
organizational networking.
50
Greenhalgh and colleague’s (2004) conceptual model for considering the determinants of
diffusion, dissemination and implementation of innovations is highly complex and has
formed the basis for further model development and use within specific fields of study,
particularly sustainability of primary health care innovations (Bush, Lord and Borrott, 2009;
Sibthorpe et al, 2005a). Research specifically examining sustainability of health service
innovation in an acute care setting has been minimal and that which has been completed lacks
a clear theoretical framework.
Health service reform initiatives of the early 2000s saw many primary health care innovations
implemented in an attempt to reduce acute hospital bed usage. In 2003, the Australian
Government, Department of Health and Ageing, funded the establishment of the Australian
Primary Health Care Research Institute (APHCRI) to provide leadership nationally for the
improvement of the effectiveness of primary health care innovations (Sibthorpe et al, 2005a).
The APHCRI research advisory team identified a lack of information relating to the
sustainability of existing health care innovations (Sibthorpe et al, 2005a). The work of
Greenhalgh and colleagues greatly influenced the comprehensive review of sustainability of
primary health care innovations that was completed by research teams and reported by
Sibthorpe and colleagues in 2005. Sibthorpe and colleagues (2005a) reported six domains
that were considered to either facilitate or inhibit sustainability of health service innovations.
These domains were political, institutional, financial, economic, client/patient and workforce
(Sibthorpe et al, 2005b).
In 2010, Considine and Fielding, utilised these domains identified by Sibthorpe et al (2005b),
to complete a discussion paper of the sustainability of health workforce innovations,
specifically the Victorian Nurse Practitioner Project (VNPP). The aim was to examine the
51
sustainability of nurse practitioner roles and ascertain the planning required for this ongoing
health care reform innovation (Considine and Fielding, 2010). The domains considered by
Considine and Fielding (2010) were institutional, political, client and workforce however the
financial and economic domains were combined for the purposes of the discussion.
Sibthorpe and colleagues’ domains for sustainability in primary health care were
recommended by Considine and Fielding as appropriate measures for assessing sustainability
of the VNPP. Considine and Fielding (2010) identify that there are commonalities in barriers
and facilitators of sustainability of innovations in health services and that each domain is
itself dynamic and complex. This discussion paper is not reporting upon research and
therefore can only inform, from an educated perspective, the influence of certain factors on
sustainability of primary health care innovation. Completion of robust research informed by
a theoretical framework is required to expand the body of knowledge in this field.
Recently, some academics have questioned the traditional concept of sustainability of health
innovations. In 2013, Chambers, Glasgow and Stange, presented a challenge to the terms of
sustainability and proposed a Dynamic Sustainability Framework. This framework
challenges the convention that sustainability is about the repetition of a program as it was
implemented and instead recognises the need for ongoing change, adaptation and evolution of
the innovation to maintain the desired impact within the context. This dynamic adaptation of
the innovation is referred to by Chambers and colleagues (2013) as program drift and is
considered an essential component to rather than contradictory to sustainability of an
innovation. Concepts and framework addressed in this article come at a time when
sustainability of health service innovations is high on the health care policy agenda, however,
this framework whilst in theory is credible and comes from highly qualified experts in the
field is yet to be operationally tested. Critical review of the research and current knowledge
52
and use of conceptual or theoretical frameworks surrounding sustainability of health service
innovation has informed the development of a theoretical framework.
3.5 A responsive framework to evaluate sustainability of health service
innovation
At the commencement of this study, theoretical frameworks to examine sustainability were
largely limited to those previously used to explore programs in developing and third world
countries or community based health programs. These programs differ in context to the
complex acute health care setting in many ways and the frameworks lacked capacity to
explore in-depth all the components that the literature reported influence sustainability of
innovations. The work of experts in the field of diffusion and sustainability of health service
innovations have provided the grounding for the development of the framework specifically
designed to evaluate sustainability of health service innovations in this study.
The operational definition of innovation sustainability that is used for this research is: an
innovation that continues to meet the purpose for which it has been introduced and provide
positive outcomes. The model consists of five factors of influence for sustainability:
political, organizational, financial, workforce and innovation specific factors. Below is an
outline of how these factors have been informed by the literature and the development of
indicators that will be examined by the research.
3.5.1 Political factors
Health care reform is recognised as inherently political in nature and the sustainability of
workforce innovation is dependent upon political support and funding (Weiland, 2008). For
the purpose of this study political factors influencing sustainability are considered to be the
53
innovation alignment with government and local policy, links to regional health plans, visions
and goals and involvement of local and national champions. Greenhalgh et al (2004) identify
that a strong political focus or “push” for one particular policy will strongly influence the
sustainability of an innovation related to this policy. Innovations that are well linked to
regional health planning and national policy directions are more likely to be routinised
(Greenhalgh et al, 2004; Sibthorpe et al, 2005b; Chambers et al, 2013). Threats to political
sustainability are identified as innovations that have poor acceptance by policy makers and
stakeholders as well as innovations that are outside the mainstream or focus on marginalised
groups (Sibthorpe, et al, 2005b).
Political sustainability is thought to be enhanced with high level management support and
when a positive attitude toward an innovation is displayed by these leaders (Greenhalgh et al,
2004). Including ground level staff in decision making and encouraging early and
widespread involvement of staff across all levels has demonstrated improved sustainability of
an innovation (Greenhalgh et al, 2004; May, 2006; Chambers et al, 2013). Local and
national champion involvement and advocacy of the innovation will also impact upon
sustainability (Shediac-Rizkallah & Bone, 1998; Sibthorpe et al, 2005b).
The indicators for political factors to be examined by this research are:
• Government and local policy alignment
• Links with regional health plans, goals and visions
• Local and national champion involvement
• Staff involvement in the implementation and decision making process.
54
3.5.2 Organizational factors
Organizational factors impact heavily upon an innovations ability to be sustained within that
organization. Sibthorpe et al, (2005b) considered this area to be bi-dimensional, occurring
both within organizations and between organizations. An organizational structure that
allows for flexibility and adaptation of the innovation to suit the local context will be more
successful (Greenhalgh et al, 2004; Chambers et al, 2013). It is recognised that the context
within which the innovation is implemented, will also change over time and the innovation
needs to be flexible enough to adapt to meet the new context requirements (Chambers et al,
2013). The agreed operational governance within an organization of who is responsible for
what skills, knowledge and attributes relating to the new innovation is identified as essential
(May and Finch, 2009).
Effective communication within and across departmental boundaries in an organization will
enhance sustainability of an innovation whilst, lack of meetings and teamwork has led to a
lack of support for innovation and poor sustainability (Sibthorpe et al, 2005b). Greenhalgh et
al (2004) posit that the more complex an innovation the more inter-organizational networking
is required for ongoing routinisation. The largest threat between organizations is considered
to be incomplete or absent partnerships and differing cultures and processes (Sibthorpe et al,
2005b). Ongoing stakeholder involvement can only lead to improved sustainability.
The indicators for organizational factors to be examined by this research are:
• Interdepartmental and intradepartmental communications
• Adaptation an appropriateness of the innovation to local context
• Dissemination of information to all staff and staff understanding of the innovation
• Existence of networking opportunities with external organizations.
55
3.5.3 Financial factors
Financial factors influencing sustainability are the provision of funding and budgetary
planning for ongoing resources, human and consumable as well as a demonstrated cost-
effectiveness of the innovation. An innovation that has a dedicated, ongoing and adequate
budget sufficient to meet needs is more likely to be routinised by the organization
(Greenhalgh et al, 2004). Innovations introduced as trials or projects often are not sustained
long term, due to the temporary funding associated with trials (Considine and Fielding,
2010). Funding mechanisms of innovations that are ambiguous or lead to income
disadvantage of either the provider or customer, seriously threaten the sustainability of an
innovation (Sibthorpe et al, 2005). Lack of research evaluating the financial value and cost
effectiveness of innovations often leave innovations vulnerable (Sibthorpe et al, 2005b).
3.5.4 Workforce factors
Successful sustainability of an innovation can be related to the motivation, capacity and
competence of individual staff members within an organization. Greenhalgh et al (2004)
found that when staff and role changes are minimal and clearly articulated, training is timely
with use of high quality training resources, sustainability of an innovation is enhanced.
Innovations consistent with values and needs of staff are more readily adopted (Sibthorpe et
The indicators for financial factors to be examined by this research are:
• Funding sources identified and secure
• budgetary planning for continuation of the innovation
• Evaluation strategies to examine cost effectiveness are in place
56
al, 2005). This is reiterated by May and Finch (2009) who found that a shared understanding
a new workplace model and employee perception of the value of an innovation strongly
impact upon the routinisation. Three distinct areas pertaining to workforce sustainability can
be identified as staffing, capability and motivation.
Staffing – Lack of continuity or simply not having enough staff to adequately implement an
innovation is a threat to sustainability (Sibthorpe et al, 2005b). Single staff member service
models found ability to meet demands proved difficult and annual leave, maternity leave and
staff attrition made innovations vulnerable particularly where succession planning was not
initiated (Considine and Fielding, 2010).
Capability – The capability of staff to implement the innovation will impact upon
sustainability. Occupational flexibility, responsiveness and increased workforce capacity is
identified as essential to a successful health workforce (Carryer, et al, 2007a). Acquisition of
skills and knowledge applicable to the innovation facilitates sustainability whilst a lack of
confidence in individual skill is seen as a major threat to the innovation (Considine and
Fielding, 2010; Forster, 2011). Capability, however, is considered a more accurate
description of the attributes required of staff to sustain an innovation. Carryer et al, (2007a)
posit that capability of staff is in contrast to direct, control and prescription of duties and
consists of an ability to use knowledge, experience and judgement and apply this to an
individual situation (Carryer, et al, 2007a).
Motivation- Workforce motivation and commitment to service improvement along with staff
perception of the value of an innovation will impact upon innovation sustainability (Sibthorpe
57
et al, 2005b). Providing staff with regular feedback around the quality and outcomes that
have resulted from the innovation, if positive is seen to enhance routinisation and conversely
reduce the chance of innovation routinisation (Greenhalgh et al, 2004). Staff are motivated to
continue an innovation that they perceive to be worthwhile.
3.5.5 Innovation- specific factors
The nature and type of the innovation will play a role in sustainability of that innovation.
Important features of an innovation are fluidity and adaptability to respond to changes in
funding and service requirements based on local decision making and need (Greenhalgh et al,
2004; Sibthorpe et al, 2005b). The impact and outcome as a result of the innovation as well as
the measured quality and safety of the innovation can be directly linked to the effectiveness
of the innovation. Patient satisfaction level is an obvious support or inhibitor to
sustainability of any health service innovation. Sibthorpe et al’s (2005b) framework of
sustainability refers to patient sustainability as access for clients to a health care program with
small out of pocket expenses for the individual. Further, the measure of sustainability must
include patient satisfaction with the health service that is being provided.
The indicators for workforce factors that will be examined in this research are:
• Staff recruitment, succession and leave planning
• Education and training provisions, processes and capability
• Staff perception of innovation need
• Staff perception of innovation safety and quality
58
3.6 Sustainability of Innovation Framework.
Each of the five factors with indicators as described above have been identified through
research and current literature to influence the sustainability of an innovation. These five
factors are not considered to work in isolation and are anticipated to influence each other in
some way once operationalised. They have been diagrammatically represented below as
figure 3.1 the Sustainability of Innovation framework. This framework will be utilised in the
research to evaluate the factors that influence sustainability of nurse practitioner service in
the context of the emergency department.
The indicators for innovation- specific factors that will be examined by this research are:
• Supports for the innovation in place
• Barriers to the innovation effectively managed
• Quality and safety of the innovation
• Patient satisfaction with the innovation
59
Figure 3.1 Sustainability of innovation framework
*Due to extensive research that has been completed in safety and quality of this innovation and patient satisfaction, these two indicators will be assumptions and not addressed in the research study.
Organis-ational factors
workforce factors
innovation specific factors
Financial factors
Political factors
• Staff recruitment processes, succession and leave planning
• Education and training provisions, processes and capability
• Staff perception of innovation need
• Staff perception of innovation safety and quality
• Supports for the innovation in place • Barriers to the innovation effectively
managed • Safety and quality of innovation * • Patient satisfaction with innovation *
• Funding sources identified and secure
• budgetary planning for continuation of the innovation
• Evaluation strategies to examine cost effectiveness are in place
• Government and local policy alignment • Links with regional health plans, goals
and visions • Local and national champion
involvement • Staff involvement in implementation
and decision making process.
• Interdepartmental and intradepartmental communications
• Adaptation of the innovation to local context • Dissemination of information to all staff and
staff understanding of the innovation • External networking opportunities
60
3.7 Conclusion
An examination of the history and importance of diffusion in relation to rate of adoption of an
innovation has been explained. The theory of Diffusion of Innovation and the long history
and proven track record as an appropriate measure to examine the adoption process by
individuals of new services has been explored. The adaptation of this theory by Greenhalgh
and colleagues in 2004 to develop a conceptual framework to examine the diffusion of health
service innovations has been influential in the health service research and this too was
explained in detail. Analysis of the concepts of the dynamic sustainability framework and the
applicability of these frameworks along with the domains reported by Sibthorpe and
colleagues to the research context has been presented.
These concepts have underpinned the development of a framework applicable to research that
examines factors influencing sustainability of innovation - emergency nurse practitioner
service. This framework is yet to be tested however, the process whereby the theoretical
framework guides this research design will be discussed in following chapters. It is
acknowledged that multiple sources of data will be required to effectively analyse all the
framework factors in relation to health service innovation sustainability. Application of the
framework and research design was trialled by conducting a pilot ‘proof of concept’ study.
The purpose, methods and results of this study are presented in the following chapter.
61
Chapter 4
Proof of concept study 4.1 Introduction Review of the literature related to sustainability of health service innovation and the
development of a theoretical framework to guide the research, revealed a reasonable body of
health service innovation research. There was scant evidence to suggest application of a
theoretical or conceptual framework to guide the research, therefore providing little guidance
for the research process. The proposed Sustainability of Innovation theoretical framework
and application is yet to be operationalised. The purpose of conducting this scoping study
was to collect data to gain insight in to the use of the frame work for a larger study. The
background driving the research, the methodology, methods, analysis processes and results of
this study will be presented. Recommendations for the research process prior to
commencement of a larger, main study are also recognised.
4.2 Background
In recent years, emergency departments have experienced overcrowding, increased patient
waiting times, decreased patient satisfaction and an increase in the number of patients who
did not wait for treatment (Jennings et al, 2008). Nurse practitioner services have been
implemented in emergency departments across Australia in an attempt to meet these service
gaps and to improve key performance indicators (Lowe, 2010). The second national census
of nurse practitioners completed in 2009 showed a 75% increase in nurse practitioner
numbers for the previous two year period, with the most significant growth in emergency
nurse practitioner service (Middleton, et al, 2011).
62
Nurse practitioner service capability is enhanced through limited prescribing rights and in
many cases, Medicare provider numbers; and they are able to refer patients to other health
professionals (NMBA, 2010). These extended skills and scope have been utilised to date to
improve patient outcomes in the emergency department. The utility of nurse practitioner
service has been supported by research which has shown reduced patient waiting time,
improved patient satisfaction and quality of care that is equivalent to junior doctors (Carter
and Chochinov, 2007). The research indicates positive outcomes however, the extent to
which these extended capabilities are being utilised is uncertain.
The emergency nurse practitioner as a health service innovation has been rapidly adopted
throughout Australia, often in an attempt to improve emergency department service
performance indicators. To this end, emergency nurse practitioner scope of practice is often
focused on reducing wait time and ‘did not wait’ rates through timely attention to patients
with minor injury and illnesses (Jennings et al, 2008; Considine, Martin, Smit and Winter,
2006). These presentations are categorised as level 4 and 5 in the Australasian Triage Scale
(ATS). The ATS ranges from 1-5 and is a method of prioritising patients as they attend the
emergency department to ensure patients are treated in order of clinical urgency (Australasian
College for Emergency Medicine, 2005).
Despite the rapid adoption of this service innovation and demonstrated positive impact on
emergency service key performance areas, there is only one published paper by Keating,
Thompson and Lee (2010) on research into the sustainability of emergency nurse practitioner
service however, publication of this research did not provide a theoretical or conceptual
framework that guided the study.
63
4.3 Rationale
Often the main goal articulated by researchers for conducting a small scale study is related to
the testing of a design or instrument for use in a larger venture. Research by Roberts and
Taylor (1997) report that trialling the research process and data collector’s full understanding
of the research protocol (Baird, 2000) are often cited as the purpose of a pilot study. There
are other advantages of conducting a small scale study. Gardner, Gardner, MacLellan and
Osborne (2003) acknowledge that publishing results of small scale research can inform the
paradigm and build credibility of the researcher. It may also prevent the replication of
research or processes that are flawed and can alert others to hazards that can be avoided
(Read and George, 1994).
Gardner et al, (2003) argue that whilst many report on the statistical or theoretical limitations
highlighted by a small scale study the important knowledge provided by a small study is the
modifications and adjustments made prior to conducting the main study and that researchers
need to remain receptive to small study findings and adjust appropriately. This proof of
concept study was conducted in order to trial the feasibility of the research process. It was
important to trial the research process as it related to the theoretical framework that had been
proposed for the main study.
4.4 Purpose
The purpose of this study was to test the concept that it was possible to examine innovation-
specific factors that influence sustainability of emergency nurse practitioner service via
telephone survey and, to test data collection methods, the utility of the data collection tool
and the research process for use in a larger study.
64
4.5 Research Approach
This proof of concept study was a descriptive study using a survey conducted with
emergency nurse practitioners. The survey data was collected from Queensland participants
of a large national study being conducted at the time titled: A prospective evaluation of the
impact of the nurse practitioner role on emergency department service and outcomes, (ED-
PRAC study), by Gardner, Gardner, Middleton, Considine, Hurst, Della and FitzGerald
(ARC Linkage grant ID: LP110211389). One discrete section of the survey data was utilised
in this proof of concept study. Ethics approval was granted for the small scale study using a
discrete section of data from one data collection source from the Queensland Department of
Health, Human Research Ethics Committee, approval number HREC/11/QHC/45 (see
Appendix A) and the Queensland University of Technology Human Research Ethics
Committee, HREC number: 1200000717 (see Appendix B).
4.6 Methodology
A telephone survey method was used to collect data from Queensland emergency nurse
practitioners. Survey interviews may be used for multi-method studies collecting both
quantitative and qualitative data (Hesse-Biber and Leavy, 2006). Combining methods may
assist when researching highly complex problems that contain several layers of understanding
(Hesse-Biber and Leavy, 2006). According to Yin (2014), survey methodology is
appropriate when the research aims to explore a what, where, why or how focused questions.
The emergency department with numerous patients of varying complexity and a multitude of
staff responsible for a variety of aspects of a patients care is considered a highly complex
environment and the exploratory nature of this proof of concept pilot study rendered survey
methodology as appropriate.
65
The characteristics of a survey interview allows for collection of quantitative data with
questions such as “how often?” or “how many?” and can also elicit the experience of the
participant by collection of qualitative data by asking “to what extent?” (Hesse-Biber and
Leavy, 2006; Patton 2002). Advantages of this method are that using a structured survey
ensures comprehensiveness and systematic data collection, with the benefit of a researcher
who can clarify and contextualise information (Patton, 2002).
4.6.1 Setting
The sites chosen for this study were Queensland emergency departments that met the
following inclusion criteria:
• provide 24 hour emergency department service,
• medical and nursing staff available 24 hours a day, and,
• use an emergency nurse practitioner service delivery model.
4.6.2 Participants and recruitment
The participants for the study were nurse practitioners employed in participating Queensland
emergency departments from metropolitan, regional, and rural hospitals. There were a total of
38 emergency nurse practitioners in Queensland that met the inclusion criteria. The ED-
PRAC study team granted access to 50% of the total Queensland participants for this proof of
concept study (19 participants). Following informed consent gained from each of the sites,
telephone contact was made with the emergency nurse practitioners by the researcher to
complete a discrete section of the survey instrument. A total of 16 (84%) emergency nurse
practitioners agreed to participate in the study.
66
4.6.3 Instrument
This study collected data from a discrete section of the questionnaire titled ‘Nurse
Practitioner Service Patterns’ (Appendix C) which consisted of three items. The first two
items were asked in order to gain information related to service patterns and the third item
consisted of five questions about the parameters of practice and limitations to practice using a
five-point Likert scale. The questionnaire used for this proof of concept study was developed
and validated during the ED-PRAC study.
Terms used in the survey are defined below:
Triage: The process of assessing a patient on arrival to the emergency department to
determine the urgency for medical care based on the patient’s presenting condition. Triage
staff may apply an ATS category (ACEM, 2005).
Resuscitation: Triage ATS category 1, Resuscitation: the patient must be seen immediately.
Patients in this category are critically ill and require immediate attention (DoHA, 2008).
Fast Track: is an ambulatory care system recently implemented in emergency departments in
an effort to reduce patient waiting times. Patients with minor illness or injury (ATS category
4 & 5) are streamed from triage into Fast Track for treatment by dedicated staff (Cooke,
Wilson and Pearson, 2002; ACEM, 2005).
Rapid Assessment Team: The RAT consists of a designated emergency physician and nurses
who assess and coordinate the care of category 4 & 5 patients to reduce waiting times and
length of stay in the emergency department (Winter, Jenkins and Stergiou, 2006)
PBS number: The Pharmaceutical Benefits Scheme (PBS) is a subsidy program run by the
Australian Government to provide all Australians with access to affordable medications. If
67
the prescriber of the medication has a PBS number the medicine will be subsidised and the
recipient will pay a lower price (National Prescribing Services [NPS], 2013).
Medicare provider number: The Medicare system is a program run by the Australian
Government to provide all Australians with access to affordable healthcare. If the provider of
health care has a Medicare provider number the cost of treatment will be subsidised or free to
the recipient (Medicare Australia, 2013).
4.6.4 Data collection
Telephone calls were made by the researcher to the emergency nurse practitioners over a one
month period in January, 2013. The questions from the survey were asked and responses
were recorded directly onto the hard copy questionnaire. The accuracy and context of the
extra information was clarified with the participant at time of collection. This data was then
transcribed into an electronic data base.
4.6.5 Data analysis
Initially, data cleaning processes were followed to identify invalid responses and duplication.
These were identified using visual checks due to the small amount of data from the sixteen
participants. Descriptive statistics of frequency were used for individual items and mean
results were used to summarise the quantitative data using the Statistics Package for the
Social Sciences (SPSS) Version 21. During the survey process the researcher made note of
inconsistencies, misunderstandings and process problems related to the data collection tool
and or the collection process. This information was collated to evaluate the instrument and
data collection process.
68
4.7 Proof of concept study results
4.7.1 Survey results
The majority of participants, (75%, n=12) reported that their service was limited to
Australasian Triage Scale (ATS) Categories 3, 4 or 5. When asked how much time they
spent in resuscitation, seven (44%) participants reported spending no time in this area. Most
of the participants, 15 (94%), reported spending most or all of their time in the Fast Track
area. More than half of the participants, nine (56%) did not have a Medicare provider
number and of these, all nine (100%) found this limited their practice. Of the 16 emergency
nurse practitioners surveyed, 13 (81%) found that refusal of their referrals were somewhat or
extremely limiting to their practice and 13 (81%) reported that they were somewhat or
extremely limited in their role by the scope of practice of the emergency nurse practitioner
service in their department. On average the participants reported they had < 8% of their time
available for non-clinical activities.
4.7.2 Process results
The data collection method of telephone survey was an appropriate and efficient method of
collecting data from all sites including diverse and remote area participating sites. Most
(n=16, 84%) emergency nurse practitioners contacted from the participating sites agreed to
participate in the study. The value of the interview approach in contrast to a self-
administered questionnaire was reinforced in this study, by the clarification of information
that took place at time of data collection. Varying perceptions of terms used in the questions
were able to be clarified, for example when asked, “Do you cover all ATS categories (1-5)?”
often the initial response was yes, however on further questioning it became clear that the
69
nurse practitioner would be ‘an extra set of hands’ to treat the category 1 and 2 patients rather
than being the primary practitioner caring for the patient. Additionally, when asked “to what
extent are you limited by your scope of practice?” some participants replied that their practice
was not limited because they had found alternate processes to manage and ‘work around’
these situations.
The survey was an efficient method of collecting data from rural and regional areas and it did
gain a very good response rate however, the method did not capture the level of information
that could provide insights into the clinicians’ experience. This suggests that in-depth
interviews with emergency nurse practitioners should be included in the larger study.
4.8 Discussion
This descriptive study indicated that innovation-specific factors, such as barriers and
limitations to practice, may be influencing emergency nurse practitioner services. The
emergency nurse practitioners surveyed spent most of their time in Fast Track areas, thereby
under-utilising the scope and capacity of emergency nurse practitioners. Nurse practitioners
in this area are senior clinicians who, prior to endorsement, were leaders and clinical experts
across the whole range of ATS categories and are now limited to lower acuity patients. This
is supported in the literature by research conducted by Lowe (2010). The majority of nurse
practitioners surveyed have had their referrals refused by other health care professionals and
report that they are limited by their scope of practice. A further barrier may exist with
insufficient time away from clinical activities to meet research and educational requirements
of the role or extend clinical knowledge. The methodology and participant numbers in this
study does not provide data to inform an in-depth understanding of these concerns.
70
The results of the proof of concept study suggested that it was appropriate to use the
telephone survey as part of a future study into sustainability of this innovation. Emergency
nurse practitioner service may be experiencing significant barriers and limitations to practice
that impact upon sustainability of the service. Survey alone however, was insufficient to
collect meaningful data to examine this complex issue and a methodology capable of
exploring these concepts is required. The scope of this study was to examine just one factor
of the Sustainability of Innovation Framework, utilising one data source, results indicate that
more data collection sources are required to sufficiently inform the factors of sustainability in
a meaningful way.
In this small study the data was collected by only one researcher, therefore minimising
variation and inaccuracies that may present when utilising multiple data collectors. Accuracy
of the data collected by survey method is dependent upon consistency between data collectors
with processes and understanding of terms used in the survey instrument. Emergency nurse
practitioner service sustainability is a problem that requires in-depth analysis and a thorough
examination which goes beyond the boundaries of the methodology used in this project. The
information gained from completing this study has informed the process taking and decision
to continue to use survey as a data collection instrument for the subsequent research study.
4.9 Study outcomes
The purpose of this proof of concept study was to test the concept of the research for one part
of a larger research study into the innovation specific factors of sustainability. The findings
indicated that it was appropriate to use survey methods to gain information about factors that
may be influencing sustainability however, additional use of other methods that would
71
provide more meaningful data related to evaluating complex health care innovations would
be required. Utilising many data sources will support in-depth understanding of the factors
influencing sustainability individually and how these factors are intertwined and impact on
innovations. Secondly, it was identified that data collection processes and methods would
need to be standardised in order to maximise accuracy of data collected in future studies.
Sustainability of the health service innovation ‘emergency nurse practitioner service’ may be
influenced by innovation-specific factors for sustainability. From this small study there were
indications that emergency nurse practitioner services were not utilised to full potential and
were experiencing barriers and limitations to their daily practice. This study confirmed a
thorough, in-depth methodology should be employed to examine and understand this
phenomenon and that survey and the questionnaire used in this study would be appropriate
for examining the innovation factors for the larger study.
4.10 Conclusion
This chapter has outlined the purpose, methodology and methods taken to conduct a small
proof of concept study. Conducting this scoping study helped gain insight into the use of the
frame work and the research process prior to commencing a larger main study. Results
suggest that survey method is appropriate to identify innovation specific factors influencing
emergency nurse practitioner services. Limitations have been recognised and the results have
informed the prospect of examining factors that influence sustainability of emergency nurse
practitioner service have been presented. The recommendations for alterations to be
implemented in the final research project have been explained. The following chapter will
72
discuss the methodology chosen for the main research project and outline the data collection
and analysis methods.
73
Chapter 5 Research methodology and methods
5.1 Introduction
Research examining sustainability of health service innovations has been minimal,
particularly in the complex environment of the emergency department. In previous chapters
the history of diffusion research and Greenhalgh and colleagues’ Diffusion of Innovation in
Health Service Model was explained and the significance of these seminal works to current
research and knowledge surrounding the field of innovation sustainability has been
articulated. A proof of concept study was conducted and reported outlining the findings that
impact upon the main study. This chapter explains the research methodology, data collection
methods, instruments and analysis techniques used in this research study designed to
comprehensively examine factors influencing sustainability of emergency nurse practitioner
service.
5.2 Methodology
This research study used case study methodology. Case study methodology is appropriate
when examining a complex multifaceted service such as the emergency nurse practitioner
service. Using a case study methodological approach enables development of knowledge and
information relating to complex and dynamic health care environments (Yin, 2014). The
complex changing nature of the acute health care environment requires a methodology that is
capable of in-depth investigation with flexible data collection methods and sources in order to
gain greater understanding of this phenomenon (Anthony and Jack, 2009). In the past, case
study methodology has been considered useful only in exploratory stages of research and the
findings have been criticised by some as not generalisable (Abercrombie, Hill and Turner,
74
1984). Case study research methodology allows for replication of the research to refine
understanding and increase confidence for a particular theory (Stake, 1995) and therefore can
make significant contributions to the body of knowledge. Furthermore, case study
methodology is recognised as a valuable empirical process for hypothesis generation and
testing (Bowling, 1997; Flyvbjerg, 2006). Yin (2014) asserts that case study research is
necessary, and compares favourably to other research methodologies in the health paradigm
due to the ability to contribute to the aggregate knowledge in a field of research (Flyvbjerg,
2006).
Case study methodology focuses on the circumstances, dynamics and complexity of a case
(Bowling, 2009) in a specific socio/cultural and/or political setting (Simons, 2009).
According to Yin (2014, p24.) case study methodology is applicable to “investigations of
contemporary phenomena within real life context”. This definition allows for clear
differentiation between case study research and other research methodology such as
experimental design which removes the phenomenon from the context; for example removing
cells from the human body to observe under a microscope, or survey research where limited
contextualising is possible and historical research that does not study contemporary
phenomenon (Yin, 2014). The term ‘case study’ methodology could be confused with a ‘case
report’ which describes a single interesting patient in terms of an illness / treatment
progression or ‘a case study’ which may be designed for educational purposes (Kirch, 2008;
Yin, 2014). This research uses the term case study research methodology as explained by
Yin (2014).
75
Case study methodology allows for the use of both qualitative and quantitative data through
multiple data sources and collection methods. This is considered a strength of case study
research as it brings together differing approaches to knowledge development and acquisition
to provide a thorough examination of the phenomenon (Yin, 2014). The data analysis
process allows the researcher to bring together all the data and draw conclusions that have
considered multiple perspectives (Mills, Durepos and Wiebe, 2010).
Yin (2014) reports that case study research is useful when the boundaries between
phenomenon and context are not clearly defined and Stake (1995) identified that the
phenomena of cases are often fluid and elusive. Such may be the case within the emergency
department where service needs are continually changing. The case may be an individual, a
program, a system, a process, a community or an organization (Yin, 2014). The definition of
the case is central to the formulation of research questions and identification of units of
analysis which enable development of a case picture (Bergen and While, 2000). These
relational elements of case study methodology are illustrated in research by Bergen and
While (2000) who found case study methodology effective and credible to study management
practices of community nurses, where the focus (or case) was the case management practices
rather than an individual practitioner. This research study, too, is examining the emergency
nurse practitioner service rather than the individual nurse practitioner which has often been
the focus of previous research in this field.
Using case study methods, identification of the case impacts upon the choice of research
design. Yin (2014) asserts that a clearly stated operational definition of the case is essential
to ensure that the case remains the main focus of data collection and analysis.
76
• The case for this research was factors influencing sustainability of health service
innovation – the emergency nurse practitioner service.
• The research context was hospital emergency departments.
Case study methods have gained recognition for use in nursing research with research by
Baxter and Rideout (2006), Bray and Goodyear-Smith (2007) and Anthony and Jack (2009).
Case study methods are a viable option for three approaches to inquiry: descriptive,
exploratory and explanatory research. The descriptive case study seeks to answer ‘who’ or
‘where’ questions in relation to the phenomenon whilst exploratory case study looks to
address questions relating to the ‘what’ of a phenomenon (Yin, 20014). Exploratory case
study methods are preferred when the research questions are concerned with operational links
rather than frequencies or incidence (Yin, 2014). The final type of inquiry, the explanatory
case study, seeks to find a causal link and explain ‘why’ or ‘how’ the phenomenon occurs in
real life context (Yin, 2014). The answering of ‘how’ and ‘why’ questions in a contemporary
phenomenon, where the researcher has little control of events is most suited to case study
methods (Yin, 2014). This research could be considered explanatory as the aim was to
identify links between factors of the theoretical framework and identify how and why certain
indicators influence sustainability of nurse practitioner service in emergency departments.
5.3 Research question and propositions
A blueprint that comprises a research question and propositions provides an essential guide
for case study research. The research question posed for this study is: How do the factors
proposed by the Sustainability of Innovation theoretical framework influence sustainability of
the emergency nurse practitioner service? To inform this research question propositions
have been developed. A proposition is a declarative statement that expresses an opinion or
77
argument (Avan and White, 2001), and in case study research represent key issues taken from
the literature or a theory and provide strong guidance for data collection and analysis
strategies (Yin, 2014). The propositions that have been developed for this study directly
reflect the Sustainability of Innovation framework and include:
The emergency nurse practitioner service innovation meets the indicators for:
• Political factors for sustainability
• Organizational factors for sustainability
• Financial factors for sustainability
• Workforce factors for sustainability
• Innovation specific factors for sustainability
5.4 Research design
This study used a single-case design to operationalise a framework developed to explore the
factors that influence sustainability of the emergency nurse practitioner service. A single-
case design is appropriate where a clear set of propositions have been specified by a theory
and the single-case meets all the conditions required for testing, confirming, challenging or
extending the theory (Yin, 2014). A single-case design is appropriate when the phenomenon
to be studied represents a unique situation or is representative of other cases, as is the case of
emergency nurse practitioner service. The single-case design can significantly contribute to
the development of knowledge and theory related to the case by helping to provide
operational definitions, characteristics of variables and other key outcomes that can be used
to inform future research (Yin, 2014).
78
An example of a single-case study design is research conducted by Adams (2010) who
examined the constructs of transformational leadership. Adams (2010) studied the leadership
of Florence Wald (1917- 2008), a world renowned nurse who successfully steered change for
care of the dying and was the driving force behind hospice care in the United States. This
study involved structured interviews with key stakeholders and document analysis to provide
deeper insight into meaningful changes to nursing leadership and health care delivery in
palliative care that could be directly attributed to Florence Wald’s leadership activity
(Adams, 2010).
Single-case design studies may be holistic or embedded. A holistic single-case design
recognises only one unit to be analysed and an embedded design accommodates more than
one unit of analysis that will provide data for the study (Yin, 20014). Yin (2014) proposes
that using multiple units of analysis may reduce unexpected problems related to the research
question by looking at the phenomena from multiple perspectives. The embedded unit design
aims to avoid the pitfalls of a broad abstract approach of the holistic design by examining the
case in operational detail from many perspectives (Yin, 2014). The embedded units of
analysis within this single-case design have allowed for closer examination of specific factors
identified in the sustainability of innovation theoretical framework and therefore answer the
research questions more thoroughly.
Using the theoretical framework as a guide, it was found to accurately explore factors that
influence sustainability in the emergency nurse practitioner service it would be necessary to
collect data across multiple data sources and stakeholders. Therefore three embedded units of
analysis from multiple services were identified: emergency department staff, emergency
nurse practitioners and documents relating to nurse practitioner service. The application of
79
the embedded single-case design to the case is illustrated below (Figure 5.1). The advantage
of this study design is that it allows for confirmation, challenge or extension of the
formulated theory, in this case by examining the empirical results with the expected
propositions derived from the current literature.
Figure 5.1 Embedded single-case design (multiple unit of analysis)
The emergency nurse practitioner service is a contemporary phenomenon within a real life
context that is complex and multifaceted in nature. Nurse practitioner services are a
controversial health service innovation that is contextualised in a political, social and
economic environment that lends itself to case study research. The case study methodology
allows for multiple types of data collection methods, sources of data and multiple types of
analysis to provide a rich explanation of the factors influencing sustainability.
Due to the timelines and limited funding associated with a PhD it was not feasible to
examine each of the theoretical factors across every embedded unit of analysis in this
Context (hospital emergency departments)
Case: Factors influencing sustainability of health service innovation – nurse practitioner services
Embedded unit of analysis 1 Emergency Department
Staff
Embedded unit of analysis 2 Emergency
Nurse Practitioners
Embedded unit of analysis 3 Documents
Related to Nurse Practitioner
Services
80
research therefore, methods were directed towards gaining data from a specific unit of
analysis, using a specific data collection source to inform specific theoretical framework
factors. The relationship between the embedded units of analysis, data collection sources
and the theoretical framework is demonstrated in Figure 5.2 and represents the
operational framework for the research.
Embedded Unit of Analysis Data collection source Theoretical Framework
Factors
Figure 5.2 Research operational framework
Embedded Unit of Analysis 1.
Emergency Department Staff
Embedded Unit of Analysis 3.
Nurse practitioner service Documents
Embedded Unit of Analysis 2.
Emergency Nurse
Interviews
Document analysis
Telephone Survey
Questionnaire
Political
Organizational
Financial
Workforce
Innovation specific
81
5.5 Study setting
The research involved two study settings. Firstly, one setting comprised hospitals in
Queensland, New South Wales and Victoria that operate an emergency nurse practitioner
service model. These hospitals were public hospitals with emergency service departments
that met the following inclusion criteria:
• provide 24 hour emergency department service,
• medical and nursing staff available 24 hours a day, and,
• use an emergency nurse practitioner service delivery model.
The second study setting included three Brisbane metropolitan hospital sites. Hospital A was
a 304 bed public teaching hospital located within 50kms of Brisbane central business district
(CBD). This hospital had 56,568 emergency presentations in 2013 (National Health
Performance Authority [NHPA], 2014). Hospital A is service Level 5 emergency department
which provides comprehensive trauma care and stabilisation of all trauma patients until
discharge, admission or transfer (Queensland Government, 2011b). Hospital A employed
1,174 full time equivalent health care staff including four full time equivalent nurse
practitioner positions in the emergency department at the time of data collection.
Hospital B was a 158 bed public teaching hospital located within 50kms of Brisbane, CBD.
This hospital had 52,628 emergency presentations in 2013 (NHPA, 2014). Hospital B is a 24
hour, seven days a week, adult and paediatric emergency health service, Level 4 Emergency
Centre. A Level 4 emergency department provides a 24-hour service, which includes triage
by qualified emergency staff and advanced care for all presentations including trauma care to
medium and minor level trauma patients and is capable of stabilising trauma patients until
82
transfer (Queensland Government, 2011a). Hospital B employed 552 full time equivalent
health care staff including four full time equivalent nurse practitioner positions in the
emergency department at the time of data collection.
Hospital C was a 341 bed public teaching hospital located within 50kms of Brisbane CBD.
This hospital recorded 50,447 emergency presentations in 2013 (NHPA, 2014). Hospital C
has an emergency department service Level 4 and the hospital employed 1,115 full time
equivalent health care staff including three full time equivalent nurse practitioner positions in
the emergency department at the time of data collection.
5.6 Research process
This study identified three embedded units of analysis relative to the study of ENP services:
emergency department staff, emergency nurse practitioners and nurse practitioner documents.
Each embedded unit of analysis was assessed using different data collection methods as
demonstrated in Figure 5.2. The sampling, multiple data sources, data collection methods
and instruments as well as the analysis methods used for each of the embedded units of
analysis have been individually presented below.
5.6.1 Embedded unit 1 - Emergency department staff
Method
The emergency department staff members (multidisciplinary team) of each of the Brisbane
hospital study sites were surveyed using a multidisciplinary team questionnaire. The purpose
of the survey was to identify the multidisciplinary team (MDT) attitude and views on the
83
emergency nurse practitioner service specifically in relation to Organizational and Workforce
factors within their workplace.
Survey is one of the most frequently used methods of data collection in health research
(Bowling, 2009). The survey method consists of data collection from a sample of a
population of interest either by face to face interview or by completion of a written
questionnaire (Bowling, 2009). The advantages associated with questionnaires are that the
completed document is stable and questions are standardised across participants (Yin, 2014)
Questionnaire results can be repeatedly reviewed by the researcher to ensure accurate data
analysis, and are relatively cost effective and unobtrusive compared to interview methods
(Yin, 2014).
Population and sample
The population consisted of all staff working full or part time in the hospital emergency
department registered with the Australian Health Practitioners Regulation Agency (AHPRA).
This included, nursing staff working in director or management positions, registered and
enrolled nurses, medical practitioners, radiographers, physiotherapists and pharmacists
working in an emergency department with a nurse practitioner service model in place. Nurse
practitioners were not included in this sample. A total of 382 emergency department staff
members across the three sites were eligible; 159 medical staff, 203 nursing staff and 20
allied health staff.
Recruitment
Following ethics approval, contact was made with the emergency department nurse unit
manager from each hospital site and they were briefed about the study. A face to face
84
meeting was organized to discuss the purpose and aims of the study as well as the data
collection processes. After discussions and recommendations regarding the most appropriate
time and place to conduct the interviews and survey within each department, times were
scheduled to meet with as many staff as possible. A presentation at two of the sites during
the regular staff meeting was conducted to provide the purpose, significance and aims of the
study verbally and staff were given time to ask questions. The third site did not hold regular
staff meetings and therefore ad hoc discussions with staff were completed. Multidisciplinary
staff members were then supplied with a study package containing copies of the ethics
approval details, participant information, a letter of instruction for completion and submission
of the questionnaire; and the questionnaire (Appendix D-F). Staff not available at the
presentation received their study package either by hand from the researcher or receptionist
working in the area, or via the internal mail system at their workplace. Consent was implied
by return of the completed questionnaire to the reply box.
Data Collection and instrument
Following distribution of the study package, a secure return box was provided within each
work unit at a place agreeable to the nurse unit manager. To allow questionnaire responses to
remain confidential after submission staff members were asked to return the questionnaire to
this secure location. The timeframe allocated for return of the questionnaire was four weeks
from the date of distribution of the study package. A reminder announcement was placed on
staff notice boards (Appendix G) and, email reminders and announcements were made by the
nurse unit manager at nurse staff meetings and by the receptionist at medical staff meetings in
an effort to improve response rate.
85
An instrument was first developed in 2009 by Drennan, Naughton, Allen and colleagues to
complete an independent evaluation of the nurse and midwife prescribing initiative in Dublin.
This instrument was adapted by Gardner, Gardner, Middleton and Della (2009) to conduct a
state-wide audit of Queensland nurse practitioners and the ‘Evaluating the Nurse Practitioner
Role- Multi-disciplinary team questionnaire’ was published in the Australian Nurse
Practitioner study, the Nurse Practitioner Research Toolkit (Gardner et al, 2009). This
questionnaire has been used in previous research to examine nurse practitioner services
(Gardner, Gardner and O’Connell, 2013) and the original instrument consisted of 32 items
each with a five point Likert response scale. This instrument was adapted for this research
with permission of the authors (see appendix F).
Minor alterations to the instrument included removal of four questions that were highly
specific to a particular action being examined, for example, ‘The nurse practitioner uses an
organized and systematic approach to history taking.’ On 15 occasions the word ‘service’
was added to the question to ensure that responses were relevant to the service rather than an
individual nurse practitioner. The words ‘in my unit’ or ‘in emergency’ were added to direct
the focus of the question to the context. Two items relating to staffing levels and
communication in the workplace were added to gain information about the MDT opinion on
these areas. The questionnaire (Appendix F) consisted of 30 items each with a five point
Likert response scale: 5= strongly agree, 4= agree, 3= no opinion, 2= disagree and 1=
strongly disagree.
Data analysis methods
The data collected from the MDT questionnaires informed the Workforce and Organizational
factors of the theoretical framework. Following collection, data were subjected to cleaning to
86
identify outliers, extreme values, invalid responses, unfeasible interactions and duplication.
Data from 10% of participants were randomly selected and checked for correct data entry
against the original questionnaire responses. Data was entered into the Statistics Package for
the Social Sciences (SPSS) Version 21 and analysed. Descriptive statistics were used to
summarise characteristics of the sample and frequency distributions were examined to
determine distribution of data. Data were also grouped and analysed with like factors
according to the theoretical framework and descriptive statistics were collated.
Six themes were identified from the 30 items that directly reflected the indicators for the
factors in the theoretical framework. These themes were informed by the indicators of each
factor as identified by literature and research published in the sustainability paradigm. The
themes comprised: six items that related to local population need and context, three items
relating to education and training, three items relating to the perceived need for ENP services,
five items relevant to perceived safety and three items relating to quality of the service.
Finally, three items relating to supportive professional relationships were identified and
grouped (Appendix H). There were four items on the questionnaire that related to
demographic data added to identify the participant’s professional profile and level of
involvement with the nurse practitioner service.
5.6.2 Embedded unit 2- Emergency nurse practitioners
Population and sample
The second embedded unit of analysis, emergency nurse practitioners (ENPs) consists of two
separate sample groups that informed this research. For sample group 1, this research used
87
secondary analysis of data collected as part of a large national cohort study being conducted
by Gardner, Gardner, Middleton, Considine, Hurst, Della and FitzGerald called EDPRAC
(ARC Linkage Grant ID:LP 110211389). Group 1 sample consisted of a population that
included endorsed nurse practitioner staff employed in the emergency department in
Queensland, New South Wales and Victoria and meeting the inclusion criteria. These sites
were identified through the Australian Hospital Directory to have 24 hour emergency
department services with, 24 hour medical and nursing cover and have an emergency nurse
practitioner service delivery model.
Sample group 2 consisted of all endorsed nurse practitioner staff employed in the emergency
departments of the three participating metropolitan hospitals. At the time of this research
there were five emergency nurse practitioners available at Hospital A, five at Hospital B and
two at Hospital C, a total of twelve nurse practitioners. Each of these sample groups, the
research method, recruitment, instrument and analysis techniques are addressed below.
Nurse practitioner group 1- Survey
Method
The national EDPRAC study aimed to evaluate the team structure within Australian
emergency departments and the role and influence on service safety and quality of patient
care, by the nurse practitioner within that team (Gardner, et al, 2013). The purpose of
analysing the data from the telephone survey for this study was to identify Innovation-
specific factors influencing sustainability of the service as outlined by indicators of the
88
theoretical framework specifically; supports, limitations and barriers to emergency nurse
practitioner service.
Recruitment
Recruitment to this group was completed by the researchers conducting the EDPRAC study.
The researchers sought consent from emergency nurse practitioners following the provision
of a study package to Nursing or Medical Directors of participating hospitals which contained
a letter of introduction to participants explaining the purpose of the research, participant
information and a consent form. Ethics approval to complete secondary analysis for this
study on the data collected was granted by the Human Resource Ethics Committee
(HREC/11/QHC/45/AM03) (Appendix K).
Data collection and instrument
Following consent to participate, emergency nurse practitioners were telephoned by the
EDPRAC researchers and surveyed using the ‘Nurse Practitioner Service Pattern Scale’
(Appendix C). A total of 114 emergency nurse practitioners were surveyed via telephone.
The survey instrument consisted of three items, the first item required a yes/ no response
followed by one item containing five-point Likert scale responses; none of the time, some of
the time, often, most of the time and all of the time. The third item consisted of three yes/no
responses followed by four five point Likert scale responses; from 1 = not limiting at all to 5=
extremely limiting, followed by one open ended question.
Data analysis method
Hard copy data from the telephone survey were made available to the researcher who
conducted data cleaning to identify outliers, extreme values, invalid responses, unfeasible
interactions and duplication. Data from 10% of participants were randomly selected and
89
checked for correct data entry against the original questionnaire responses. Data was entered
into the Statistics Package for the Social Sciences (SPSS) Version 21 and analysed.
Descriptive statistics of frequency and mean were used to summarise characteristics of the
sample and frequency distributions were examined to determine distribution of data.
Nurse practitioner Group 2- Interview
Method
Individual interviews were conducted with emergency nurse practitioners from the three
hospital sites. The purpose of the interviews was to explore nurse practitioners’ perceptions
relating to Organizational and Workforce factors influencing the sustainability of their
service. Qualitative interviewing can be a very effective line of inquiry when the interest to
be studied is surrounding the human experience of a certain situation (Brinkmann, 2013).
Some posit that interviews are a simplistic research technique, easy to master due to the fact
that everyone is capable of asking questions and recording the response however, this process
and the human relationship in the qualitative research interview is complex and if not
understood can lead to problems in validity of the responses (Brickmann, 2013).
Semi-structured interviews where prompts were used to keep the conversation on a particular
topic area but also allowed for opportunity in the conversation to capture other potential
knowledge were used. Qualitative interviews can be conducted with a purpose or research
goal in mind and to gain the interviewees perspective of a concept in their lived experience
with the goal to interpret the meaning of that experience (Brickmann, 2013), such as the
experience of the nurse practitioner in the emergency department. Many styles or interview
techniques are identified in the literature. The style chosen by the researcher for this study
90
was a receptive interview technique. This technique is said to use relatively open ended
prompts that empower the interviewee to have a large amount of control over the way these
questions are answered (Wengraff, 2001). The prompts used in this research have been
written to guide the response to be related particular topics as guided by the theoretical
framework and the propositions. The choice to use individual interviews was made based on
the fact that the researcher can gain an individual’s perspective that may be controversial or
sensitive in nature (Brickmann, 2013).
Recruitment
The nurse unit manager at each hospital site introduced the researcher to one of the
emergency nurse practitioners. At these introductions the study purpose, aims and data
collection process was discussed. Written information regarding the study purpose and aims
along with information about the management of responses and data was provided and
consent to participate was sought from individual participants (Appendix I & J). A mutually
convenient appointment time for in-depth semi-structured, individual interviews was
arranged.
Data collection
Interviews were conducted at each of the three sites at a suitable time for each nurse
practitioner from that site to attend and took place in a separate room away from other unit
activities and staff in an attempt to record genuine responses in confidence. The interview,
with participant consent, was audio recorded and began with a discussion of the purpose of
the interview and an outline of the course of proceedings. The interviews were guided by the
topic guide prompt (Appendix L). The aim was to promote an in-depth, focused discussion
on the key components of the communication and decision making processes, safety, quality
and workforce management of the emergency nurse practitioner service. The validity of the
91
topic guide was clarified by an experienced leader in the field of emergency nurse
practitioner service and two senior research academics experienced in individual interviews,
prior to use.
Data analysis methods
Interviews with the emergency nurse practitioners were audio record and then transcribed
into narrative text for analysis. Interview data were analysed using qualitative content
analysis methods drawing upon the approach from Graneheim and Lundman (2004).
Initially, interview text was sorted into eight content areas according the Organizational and
Workforce factors of the theoretical framework. For example, the first prompt question was
an organizational indictor about communication; ‘tell me about communication within the
department’; therefore all interview data that pertained to communication was aggregated
together and considered as one unit.
Following sorting of data qualitative content analysis was used – this consists of a thorough
reading of the interview data and identification of meaning units. The meaning unit is then
condensed into a description close to the original text, known as a condensed meaning unit.
According to Graneheim and Lundman (2004) condensing meaning refers to a process of
shortening but still preserving the core meaning and context. The condensed meaning units
were then abstracted to identify sub-themes which represent the manifest content of the
interview. The process of abstraction is when condensed text has been grouped together,
described and interpreted on a higher logical level to create a sub-theme (Graneheim and
Lundman, 2004). Reflection on, and review of sub-themes in relation to current literature
assisted the development of meaningful themes which are the end point of qualitative content
analysis and the expression of latent content of text considered in context (Graneheim and
92
Lundman, 2004). The themes that emerged from the interview data were then considered in
relation to the results from other data collection methods and the propositions for the
research. An example of the qualitative content analysis process is illustrated below in table
5.1.
Table 5.1 Example of the qualitative content analysis process.
5.6.3 Embedded Unit 3 – Nurse practitioner service documents
Methods
Review of relevant documents play an explicit role in case study research due to the value of
information available (Yin, 2014). Documents can be used to portray the context and to
contribute to the analysis of issues (Simons, 2009). The benefits of document review include
the unobtrusive nature of collection, the precision and stability of information available (Yin,
2014), the non-reactivity with the investigator and low costs involved with collection
(Bowling, 2009). It was important to review the documentation in relation to sustainability of
the innovation of emergency nurse practitioner service. The purpose of the document analysis
in this study was to evaluate the alignment between government and regulatory documents
related to the emergency nurse practitioner (ENP) services and data obtained from the other
embedded units of analysis.
Meaning unit Condensed meaning unit Sub-theme Theme
If they want the service to be sustainable long term then they need to implement a strategy to provide us with education and provide us with support P.1
A strategy for education provision and support needed
Disorganized education
Marginal Integration
From a NP specific education (the organization provides) nothing that I am aware of. P.9
No specific NP education provided by organization
You need to learn a whole new set of patient presentations that you have never even looked at before because they were of no real significance to you. P. 10
Need to learn a whole new set of skills and patient presentations
Role/ capability
misalignment
93
Sample and data collection
The document analysis focused specifically upon the Political and Financial factors
influencing sustainability as outlined in the theoretical framework and in the research
operational framework. Documents chosen for review in this study were the most recent
version of any government or regulatory document that aimed to guide the implementation,
development or governance of nurse practitioner service. Documents referring to nurse
practitioner service were obtained from May-June 2014 from publically accessible websites
via the internet using search terms: nurse practitioner, implementation and governance. Staff
at each of the research sites were approached regarding collection of documents relating to
the implementation, development or governance of nurse practitioner service however, all
three sites indicated the use Queensland Health regulatory documents at the local level and
that these were all accessible online. A summary of the documents retrieved is presented in
chapter 6, table 6.3.
Document analysis method
The documents were analysed using summative content analysis methods as explained by Elo
and Kyngas (2007) to examine Political and Financial factors influencing sustainability of
emergency nurse practitioner service. This research method can be successfully used to
analyse data in various forms, such as the written text, verbal, printed or electronic media
(Elo and Kyngas, 2007). There are three methods suitable to analyse the content of
documents. Firstly, qualitative or traditional content analysis that consists of coding data into
categories that are directly derived from the data and identifying themes or patterns (Hsieh
and Shannon, 2005). Alternatively, quantitative, deductive approach involves initially
identifying keywords or variables of interest and examining the frequency of these topics in
the content (Elo and Kyngas, 2007), and finally, summative content analysis which combines
94
the use of both methods. Initially, the presence of particular words or content are identified
in the document and further interpretation of the underlying meaning or the context within
which the content is presented and together these are considered summative content analysis
(Hsieh and Shannon, 2005; Elo and Kyngas, 2007).
In order to complete the summative analysis for this research a categorisation matrix was
developed using the theoretical framework indicators and propositions (Appendix M). The
matrix identifies the characteristic, key theme and term that is being sought in the document
and allows for frequency calculation as well as recording of the context in which the term
was discussed in the document. This matrix was used to abstract the content in the collected
documents and identify the context of its use. Summative content analysis techniques were
used to analyse the content of the documents in the context of emergency nurse practitioner
service. An example of the summative content analysis matrix is provided in table 5.2.
Table 5.2 Example of summative content analysis matrix.
Name of Document: Date of Document: Number:
Purpose of Document: Author:
Characteristics: Key theme Terms looked for
Theme discussed in document:
Evidence based:
Achievement mechanism discussed:
Context:
National, state and local policy alignment with the innovation
There are links between policy (National, State or local) and emergency nurse practitioner service
Australia Queensland local (research site specific) policy Nurse practitioner nurse practitioner service
95
5.7 Data Analysis Plan
The three embedded units of analysis in this single-case design were emergency department
staff, emergency nurse practitioners and documents related to nurse practitioner service. The
data collected from each of these embedded units were analysed according to convention for
the respective data type and guided by specific factors that have been identified in the
Sustainability of Innovation framework. This method does however attract the potential to
report on the embedded units rather than focussing on the original case question and applying
the data at this level (Yin, 2014). In order to allow high level analysis of this complex health
service innovation, the final step taken in the data analysis process was to use converging
lines of inquiry, by drawing together results from all data sources to examine the evidence
against the propositions.
The analysis of data from each collection method was integrated to provide a thorough
understanding of the research question and propositions. Yin (2014, p143) reports the
advantage of this method is to develop ‘converging lines of inquiry’ and therefore more
accurate conclusions which adds to the construct validity of this case study methodology.
The convergences of multiple sources of evidence informing the case study; in this case the
survey, individual interviews, document analysis and the telephone survey.
Finally, the findings from the multiple data collection methods were reconciled through
pattern matching. This is an analytic technique designed to compare the identified empirical
pattern with a predicted pattern (Almutairi, Gardner and McCarthy, 2013; Yin, 2014). The
predicted pattern is recognised by theory generated in previous literature or research, or from
96
the researcher’s experience and knowledge of the field, and presented as propositions (Yin,
2014). Propositions developed for this study can be viewed in section 5.3.
The propositions are the predicted pattern of outcome based on the factors of the theoretical
framework and as explained by the indictors (Almutairi, et al, 2013). If the results are as
predicted or fail to show patterns as predicted, conclusions can be drawn about the
propositions (Yin, 2014). The matching of these patterns is considered to demonstrate
internal validity of the case study research whilst reliability and external validity is
demonstrated by the ability for this research to be replicated to examine sustainability of
another innovation (Almutairi et al, 2013; Yin, 2014). Ultimately the outcome of this pattern
matching analytical approach will provided new knowledge about the utility of the
Sustainability of Innovation framework for evaluating emergency nurse practitioner service
sustainability and results to inform the factors influencing sustainability of emergency nurse
practitioner service.
In order to clarify the data analysis process that has taken place during this research a
diagram representing the analysis plan has been provided below in figure 5.3.
97
Case E
Unit of anlaysis Data source
Analysis
Aggregate results
Figure 5.3 Research analysis plan
5.8 Ethics
Ethics approval was granted from the Queensland Government Human Research and Ethics
Committee (HREC/13/QPCH/204) (see Appendix D), and from the University Human Ethics
Committee of Queensland University of Technology (1200000717) (see Appendix B). Ethics
approval was granted for secondary analysis of EDPRAC survey data from the Queensland
Government Human Research Ethics Committee (HREC/11/QHC/45/AM03) (see Appendix
A).
Emergency Department staff
Emergency Nurse practitioners
Emergency Nurse practitioner Documents
MDT questionnaire
Telephone survey
Interviews Document analysis
Quantitative descriptive
statistics
Quantitative descriptive
statistics
Qualitative Content analysis
Summative Content analysis
Converged results compared to propositions using pattern matching technique
Factors influencing sustainability of emergency nurse practitioner services
98
Participants were provided with written and verbal information regarding the study and
confidentiality was maintained throughout the study. Primary and secondary data were de-
identified and stored in a password protected computer file. Hard copy data was stored in a
locked cupboard in a QUT secure location, accessible only by the researcher. Data will be
retained for a minimum of seven years as per Queensland University of Technology Policy
and then destroyed.
5.9 Conclusion
The research methodology chosen for research into factors influencing sustainability of
innovation: emergency nurse practitioner service was case-study methodology. The
justification and applicability of this research design to the study are evident and the
philosophical perspective of case study research appropriate for this study context. This
research has used a single-case study with embedded units of analysis and the rationale for
this decision is clear along with the advantages to mixed methods of data collection. The
three embedded units of analysis as well as the data collection methods of survey, individual
interview, document analysis and the telephone interviews has been presented. The
development of data collection instruments and analysis techniques was explored and finally
the ethical considerations for this study discussed. The following chapter will present the
results of the research study according to embedded unit of analysis.
99
Chapter 6
Results 6.1 Introduction
Emergency nurse practitioner services are a rapidly expanding health service innovation.
Whilst understanding the sustainability of these innovations is essential, research to date has
provided minimal knowledge in this area. Case study methodology has enabled an in depth
examination of the complex innovation of nurse practitioner service in the dynamic context
of the emergency department. The single case design has allowed for exploration of
emergency nurse practitioner service considering three embedded units of analysis:
emergency department staff, emergency nurse practitioners and documents relating to the
nurse practitioner service. Mixed methods were utilised to collect both qualitative and
quantitative data and analysis of the results have informed the research question and
propositions. This chapter reports the findings from this research that has provided new
knowledge according to the embedded unit of analysis. The results will be presented in three
distinct sections: section one- emergency department staff questionnaires, section two-
emergency nurse practitioners survey and interviews and section three- documents relating to
emergency nurse practitioner service.
100
Section 1.
6.2 Embedded unit of Analysis 1- Emergency department staff
The purpose of the multidisciplinary team questionnaire was to gain information about
factors influencing sustainability of emergency nurse practitioner service in key areas of the
theoretical framework. According to the research operational framework, presented in figure
5.2 (p. 80), the emergency department staff questionnaire would examine organizational and
workforce factors. Following analysis of the data it became apparent that the questionnaire
results also informed some of the political indicators for sustainability.
Sample Characteristics
The emergency department staff sample consisted of nursing staff (excluding nurse
practitioners), medical officers and allied health team members across the three research sites,
hereafter referred to as the multidisciplinary team (MDT). Of the 382 questionnaires
distributed, 161 were completed and returned for an overall response rate of 42%.
Approximately 56% (n=90) were nursing staff, 29% (n=47) were medical officers, 12%
(n=19) were allied health professionals and 3% (n= 5) of respondents did not state their
professional role.
Following analysis of the questionnaire data, six themes were derived by grouping like items
in the MDT questionnaire relevant to the theoretical framework as explained in chapter 5 and
shown in appendix H.
101
Local needs met
The results of the MDT questionnaire showed that the emergency nurse practitioner services
were meeting the needs of the local population. The majority of the emergency department
multidisciplinary team members were positive that ENP services had been implemented with
consideration of the local population needs. Five like items were grouped in the ‘meeting
local population needs’ theme and the total mean score was 4.14 (SD 0.79). The five item
results are illustrated below in figure 6.1.
Figure 6.1 Participant responses to ENP service meets local population needs.
The highest ranked item was the response to ‘NP services meet the needs of patients within
my department’ with a total of 89% (n=143) agreeing or strongly agreeing, 8% (n=13) having
0
10
20
30
40
50
60
Strongly agree Agree no opinion disagree stronglydisagree
Perc
enta
ge o
f res
pons
es
Participant perception of meeting local needs
Meeting local population needs
Introduction of NPsuccessful in QLD
NP services meetneeds of EDpatients
ENP services areeasy for patients toaccess
NP services resultin improved EDhealth services
NP services reducedelays in EDpatient care
102
no opinion and 3% (n= 5) disagreeing. The ENP service is easy for patients to access
according to 76% (n=122) of respondents who agreed or strongly agreed. The introduction of
ENP services reduced delays in patient care within the unit according to 75% (n=120) who
agreed or strongly agreed with this statement, 17% (n=27) had no opinion and 9% (n=14)
disagreed or strongly disagreed.
Understanding the innovation
The MDT questionnaire results also highlighted staff understanding of the service innovation.
Multidisciplinary staff members self-reported they knew about emergency nurse practitioner
service with more than 85% (n=137) of the multidisciplinary team agreeing or strongly
agreeing that they ‘fully understood the emergency nurse practitioner service’. However,
many were uncertain about some aspects of the scope of practice of ENP services with results
to items relating to ENP service scope of practice revealing varied results, approximately
58% (n=94) agreed or strongly agreed, 24% (n= 39) reported no opinion, and 17% (n= 28)
disagreed or strongly disagreed. A substantial number (29%, n= 46) of respondents indicated
‘no opinion’ to questions such as ‘Nurse practitioners receive adequate training for their role’
and 24% (n= 39) respondents had no opinion of ‘The nurse practitioner service can refer
patients directly to medical specialists.’ These results indicate a lack of understanding around
education and scope of practice of ENP service.
Staff numbers and planning
Respondents were divided in their thoughts about the number of, and succession planning for,
ongoing staff within ENP services of the emergency department in which they work. The
multidisciplinary team response to the item, ‘the ENP service has enough staff to cover the
requirements of the emergency department’ found that only 36% (n=58) of staff agreed or
strongly agreed, 33% (n= 53) had no opinion and 31% (n= 50) disagreed or strongly
103
disagreed. Most (65%, n=104) multidisciplinary team members were unsure if ENP service
workforce planning was in place to meet the needs of the emergency department with 14%
(n=23) agreeing or strongly agreeing and 21% (n=34) disagreeing or strongly disagreeing.
Staff education and training
Most respondents to the MDT questionnaire believed that ENPs are adequately trained and had
adequate knowledge for their position with an overall education and training theme mean score
of 3.93 (SD 0.9). Three like items were grouped to form the ‘Education and Training’ theme
and responses are illustrated in figure 6.2 below.
Figure 6.2 participant responses to staff education and training theme items
0
5
10
15
20
25
30
35
40
45
50
Stronglyagree
agree no opinion disagree stronglydisagree
per
cent
age
of re
spon
ses
Participant responses to education and training
Education and Training
I am worried that ENP staff donot have knowledge to prescribe(Reversed result)
ENPs are adequately educatedand prepared for their role
ENPs receive adequate trainingfor their role
104
The highest scoring item was ‘Nurse practitioners are adequately educated and prepared for
their role’, with 75% (n=120) agreeing or strongly agreeing with this statement. Additionally,
66% (n= 106) agreed or strongly agreed that ENPs receive adequate training, 29% (n=46) of
respondents had no opinion and 6% (n=9) disagreed that ENPs are adequately trained. Only a
few respondents (9%, n= 15) worried that ENP service staff did not have the knowledge to
prescribe medications accurately, with 75% (n=120) agreeing or strongly agreeing that ENP
services do have the knowledge to prescribe accurately and 16% (n=26) having no opinion on
this.
Perceived ENP service need
Overall, the multidisciplinary team felt that there was a need for the emergency department
nurse practitioner service with a theme mean of 3.94 ( SD 1). Three like items formed the
ENP service need theme and responses are illustrated in figure 6.3 below.
Figure 6.3 ENP service need theme responses by item.
0
5
10
15
20
25
30
35
40
45
Stronglyagree
Agree no opinion disagree stronglydisagree
Perc
enta
ge o
f res
pons
e
Participant response to ENP service need
ENP service need
ENP service prescribing isnecessary
There is need for more ENPservices in QLD
ENP services are not necessary,patients can received all theirtreatment from a doctor(Reversed result)
105
Many (67%, n=109) agreed or strongly agreed that there was a need for more ENP services in
Queensland with 24% (39) having no opinion and 8% (n=13) disagreeing or strongly
disagreeing. Only 12% (n= 19) agreed or strongly agreed that all services could be provided
by the medical practitioner and that ENP service was not necessary. A further 15% (n=24)
had no opinion and 71% (n= 118) disagreed or strongly disagreed. It was agreed or strongly
agreed by 73% (n=117) of respondents that nurse practitioner prescribing was necessary, with
19% (n= 31) not having an opinion and 8% (n=13) disagreeing or strongly disagreeing.
Perceived ENP service safety and Quality
Overwhelmingly, the respondents felt that ENP service offers a safe service for patients with
a theme mean score of 4.14 (SD 0.84). The five like items that formed the ENP services are
safe theme are illustrated in figure 6.4 below.
Figure 6.4 Participant responses to ENP services are safe theme by item.
0
10
20
30
40
50
60
Stronglyagree
agree no opinion disagree stronglydisagree
Perc
enta
ge o
f of R
espo
nses
Participant response to ENP services are safe
ENP services are safe
ENP prescribing increases therisk of incorrect treatment(Reversed result)ENP services offer safe care
I trust the ENP service todiagnose correctly
I fear that ENPs will make anincorrect diagnosis (Reversedresult)The ENP service is safe
106
ENP services are considered to offer safe care by 90% (n=145) who agreed or strongly
agreed with this item. A large majority (82%, n=131) of multidisciplinary team staff agreed
or strongly agreed that they trusted the ENP service to diagnose correctly, 14% (n=22)
reported no opinion and 4% (n=7) disagreed with this statement. Very few (7%, n= 12)
respondents were concerned that ENP prescribing increased the risk of incorrect treatment
with a further 22% (n=35) having no opinion and 71% (n=114) disagreeing or strongly
disagreeing.
The perception that MDT members have of the quality and impact of ENP service on patients
was recognised by a four like items which is illustrated in figure 6.5 below.
Figure 6.5 Participant responses to impact of ENP service theme by item
0
10
20
30
40
50
60
Stronglyagree
agree no opinion disagree stronglydisagree
perc
enta
ge o
f res
pons
es
Participant responses to impact and quality of ENP services
Impact and quality of ENP services
ENP services are good for patients
The ENP service in my work area hasa positive impact on patient care
Introduction of ENP services hasreduced delays in patient treatment
ENP services has reduced the needfor patients to return to their doctoras frequently as previously
107
The highest ranked item ‘Nurse practitioner service in my work area has a positive impact on
patient care’ identified that the majority (n=149, 93%) agreed or strongly agreed, followed by
‘ENP services are good for patients’ with 92% (n=148) respondents agreeing or strongly
agreeing with this statement, 6% (n=10) having no opinion and just 2% (n=3) disagreeing.
The obvious outlier is item 25 ‘The ENP service has reduced the need for patients to return to
their doctor as frequently as previously’ with the majority (48%, n= 77) of respondents
having no opinion.
Supportive professional relationships
The MDT questionnaire results have reported on supportive professional relationships and
ENP services. Multidisciplinary team members generally consider that ENP services have
support of their colleagues with a theme mean score of 3.92 (SD 0.74). The three like item
theme relating to ‘supportive professional relationships’ is illustrated in figure 6.6
Figure 6.6 Supportive professional relationships participant responses by item
MDT members believe that ENPs had good access to medical colleagues with 91% (n=146)
of respondents agreeing or strongly agreeing with this statement. The respondents also agree
or strongly agree 84% (n=135) of the time that ENP staff were supported by doctors in their
0
10
20
30
40
50
60
70
80
Stronglyagree
Agree No opinion Disagree Stronglydisagree
Perc
enta
ge o
f res
pons
es
Participant responses to supportive professional relationships
Supportive professional relationships
ENP service has good acess to medicalcolleagues for consultation andsupport
The introduction of ENP services hashad a positive impact on inter-professional relationships
108
role, with 13% (n=21) having no opinion and 3% (n= 5) disagreeing or strongly disagreeing
with this statement. However, overall about 59% (n= 94) agreed or strongly agreed that the
introduction of ENP services has had a positive impact on inter-professional relationships,
with 32% (n= 52) having no opinion and 9% (n=15) disagreeing or strongly disagreeing.
Involvement in decision making
The MDT members showed greatest variation in responses to staff involvement in decision
making. In relation to being consulted about ENP service issues that would impact upon their
own work, the majority (36%, n=58) disagreed or strongly disagreed, 33% (n=53) had no
opinion and only 31% (n=50) agreed or strongly agreed. Additionally, only 29% (n= 46) of
respondents agreed or strongly agreed that they were kept informed of changes to ENP
services that impacted upon their work, with 25% (n=40) having no opinion and 46% (n= 75)
reporting that they were not kept informed of changes.
6.2.1 Summary of multidisciplinary team survey results
The results of the survey indicate that the emergency department multidisciplinary team agree
that NP services were highly needed and were meeting patient needs within their emergency
department. There was some poor understanding of the education provided to ENPs and
scope of practice of ENP service staff. Emergency department staff members were divided in
their thoughts about ENP service staff numbers, and succession planning but most emergency
department staff believed that ENPs were adequately trained and had adequate knowledge for
their role. Overwhelmingly, emergency department staff felt that ENP service offers safe
patient services and that ENP staff had support of their colleagues. The greatest variation in
responses was surrounding staff involvement in decision making and being kept informed of
changes to ENP services that impacted upon their work.
109
Section 2.
6.3 Embedded unit of analysis 2- Emergency nurse practitioners
This second embedded unit of analysis consists of two sample groups, firstly the emergency
nurse practitioner telephone survey respondents and secondly, one-on-one emergency nurse
practitioner interviewees. The two groups informed different factors that influence
sustainability of innovation. The results gained from each of these two groups are presented
separately below.
6.3.1 Emergency nurse practitioner telephone survey results
Sample Characteristics
Participants in the emergency nurse practitioner telephone survey consisted of ENPs working
in emergency departments in participating hospitals in Queensland, New South Wales and
Victoria. These hospitals all provided 24 hour medical and nursing care and report
Emergency Department Activity Data to the Australian Institute of health and Welfare
(AIHW). The original data was collected by the EDPRAC study researchers and at the time
of data collection there were 114 ENPs employed in 53 hospital emergency departments
across the states of Queensland, New South Wales and Victoria and all ENPs took part in the
survey. The telephone survey results informed two indicators of the innovation-specific
factors influencing sustainability of the emergency nurse practitioner service. According to
the theoretical framework the indicators were, characteristics of the innovation and support
and barriers to the service innovation and are discussed below.
110
Characteristics of the service innovation
Approximately 31% (n= 35) of ENPs reported that they managed patients who had been
allocated to an Australasian Triage Scale (ATS) category of 1-5, 29% (n=33) of ENPs
managed ATS categories 2-5, 34% (n=39) managed ATS categories 3-5 and 6% (n=7) only
managed ATS categories 4 or 5. Figure 6.7 below shows the distribution of work by ENPs
across the ATS categories of patients presenting to emergency departments according to
state.
Figure 6.7 ATS category of patients seen by ENPs in NSW, QLD and VIC
The ATS categories of patients cared for by the ENP service varied between the three states.
In Queensland where the total number of ENPs was 40, around 55% (n=22) attended to
patients categorised ATS 3-5 with a further 10% (n= 4) attending to ATS categories 4 and 5
only.
0
10
20
30
40
50
60
70
ATS 1-5 ATS 2-5 ATS 3-5 ATS 4 & 5
Perc
enta
ge o
f EN
Ps
ATS Category of patients seen by ENPs
ATS Category patients seen by ENPs by state
NSW
QLD
Vic
111
Limitations to scope
Across the three states, 67% (n=76) of ENPs spent some time working in the resuscitation
areas with 33% (n=38) spending no time at all in resuscitation areas of the emergency
department. Approximately 88% (n= 100) of ENPs reported spending most or all of their
time in fast track areas with low acuity patients and 11% (n=12) were often or most of the
time working in rapid assessment teams.
Approximately 64% (n=73) of ENPs reported having a Pharmaceutical Benefits Scheme
(PBS) prescriber number. Of the 41 ENPs who did not have a PBS number, 36(88%)
reported that not having a PBS number was limiting to their daily practice. Medicare Benefit
Schedule (MBS) provider numbers were held by only16% (n=18) of ENPs, and 86% (n=83)
of those who did not hold Medicare provider numbers reported that it limited their daily
practice. Just over half (51%, n=58) of the ENPs reported that their practice was limited by
their scope of practice and 97% (n= 110) reported that they did not have the authority to sign
work cover forms. A further 3% (n= 4) reported that the work cover forms were not
applicable to their work environment. Of those ENPs working in applicable areas, 80%
(n=87) reported the inability to sign work cover forms limited their daily work practice.
6.3.2 Emergency nurse practitioner- Interview results
The purpose of conducting ENP interviews was to collect data to inform the organizational
and workforce factors according to the theoretical framework as explained in the research
operational framework (figure 5.2). Data from the interviews was transcribed and analysed
using qualitative content analysis techniques as described by Graneheim and Lundman,
(2004) and explained in chapter 5, three themes emerged that informed indicators for
sustainability. An example of the process undertaken has been included in appendix N and
112
table 6.1 below provides the themes and subthemes identified. Reporting of the results will
focus on the themes that emerged with the subthemes subsumed in the content.
Table 6.1 Themes and sub-themes identified following analysis of interview transcripts
Sample characteristics
Emergency nurse practitioners (n=12) from the three Queensland hospital sites were
interviewed, n = 12. Demographic data collected during the one-on-one interviews revealed
the mean age was ranged between 40-59 years (75%, n = 9) with an average of 19.5 (SD 7.8)
years of experience working as a registered nurse. On average, they had been working with
their current employer for 5.7 (SD 6.7) years and averaged 3.3 (SD 2.05) years working as an
emergency nurse practitioner.
Theme Sub-theme
Marginal integration Inconsistent information sharing
Limited networking and poor group cohesion
Minimal staff and succession planning
Role/ capability misalignment
Disorganized education
Working to capacity rather than capability
Sluggish service change
ENP services not understood
Overly restrictive service scope
Standing up to scrutiny Staff attributes ensure safety
Extensive audit and reviews
Meeting key performance indicators and targets
113
Marginal integration
Analysis of data collected from interviews with emergency nurse practitioners identified
‘marginal integration’ as an emerging theme. ENP services have received little support at the
organizational level for integration of this innovation. Marginal integration of ENP services
was evident due to a number of areas where organizational management or processes were
lacking. This was supported with sub-themes reported by ENPs: inconsistent information
sharing, limited networking and group cohesion, minimal staffing and succession planning,
role/ capability misalignment and disorganized education for ENP service staff.
ENP services were isolated by a lack of communication both within and between departments
as well as limited staff involvement in decision making in relation to ENP services. ENPs
reported a lack of group cohesion or sense of belonging to a professional group or team and
identified that communication was at times, challenging. ENPs recognised that clear
communication with colleagues was necessary for optimal service delivery and essential
communications were conducted to ensure patient safety however, communication in relation
to changes in processes, departmental plans, goals and strategies were lacking and strained.
A complete absence of workplace staff meetings was reported and sometimes ENPs did not
attend general nursing meetings. This was either because they were not invited or they had
been told the discussions weren’t relevant to them; thereby further enhancing a sense of not
belonging to the team and compounding the poor dissemination of information. Participant 8
explains the disjointed communication and poor information sharing:
‘…Sometimes (communication is) a bit haphazard or a bit patchy, sometimes information is not disseminated well and sometimes we are the last to find out,… and not well relayed to us…(Participant 8)’
114
Interdisciplinary communication varied based on individuals and professional groups with
some communication described as excellent with one professional group and limited with
another. Participant 2 and 9 made the following statements about communication.
‘…we have good communication between the group of us (ENPs)…(Participant 2)’
‘…In the actual department we have very little communication with the NUM and from the top end there is very little communication…(Participant 9)’
Further to this, ENPs reported they did not fit in either camp; nursing or medical. They felt
that the nursing hierarchy struggled to find emergency nurse practitioners a place in the
nursing ladder and that this impacted upon relations between colleagues. ENPs stated that
nursing staff believed that ENPs have lost their nursing focus and that the role sits more
appropriately in medicine despite the rhetoric surrounding the nursing philosophy.
‘…ENPs don’t really fit under either umbrella and I am not sure that there is an answer to that because the whole place is running under a medical model…(Participant 10)’
Participant 10 reported that the medical model dominates service delivery within the
emergency department context. ENPs reported that they were out on their own and that
nursing colleagues had not nurtured the development of the role and in fact were hostile to
service integration. Participant 7 explained a lack of support, leadership and nurturing by
senior staff for ENP services:
‘…They haven’t nurtured my role, they talk about the million dollar nurse practitioners. That has come from nursing hierarchy…that can’t be good (Participant 7)’
Networking opportunities for emergency nurse practitioners were dependent upon the
Australian College of Nurse Practitioners, which was quoted as the main provider of
information about conferences and educational opportunities. Emergency nurse practitioners
115
perceived limited networking opportunities in the workplace or with other emergency
departments; this was problematic for development and support of staff working in ENP
services. Participant 5 and 8 recognised that ENP interaction was limited and that the group
lacked cohesion:
‘…there is not much networking really, the only time is at college conferences and I try to catch up with them then and talk about what they are doing...(Participant 5)’
‘….we aren’t a very cohesive group. I think we need to be a much stronger group because we have those forces working against us and it would be better if we were more united. (Participant 8)’
Isolation and minimal support within the workplace as well as limited networking with
colleagues from other departments are compounding the sense of separation experienced by
ENP staff. These attitudes and a lack of organizational support processes have led to
marginal integration of this service innovation.
Working at capacity rather than capability
The second theme to emerge following analysis of the interview data was ‘working at
capacity rather than capability’. Emergency nurse practitioner service scope of practice and
capability was misunderstood and consequently skills and knowledge of the staff in ENP
services was under-utilised. This theme was characterised by sub-themes of: sluggish service
change, ENP service role not understood and restricted service scope.
ENPs stated that services were reviewed and were effective in meeting population needs
within the scope of practice determined by the organization. The ENP service scope of
practice was recognised as limiting however, service staff were kept busy meeting the needs
of the set population and it was thought that services were at capacity.
116
‘I think there’s enough scope there for us to kind of do things within our scope, we see enough patients basically; there is very little down time with the patients that fall within the scope of the ENP criteria. There is more than enough work for us to get through in a day.’ (Participant 1)
Implementing change of practice scope was not always easy and often decisions were based
on individuals rather than ENP services as a whole. ENPs reported that decision making
around practice changes required negotiation and whilst a collaborative approach initiated
change ENPs had little say or influence over the final decision that was made by medical
executive. ENPs stated that often the outcomes were a compromise on the original
proposition. Participant 6 and 12 describes a process that takes place further up the
management line:
‘…It’s a collaborative approach. All the ENPs that are onsite at the time are involved and most of the discussion goes from that and then that information is collated and discussed further up with management…(Participant 6)’
‘…It’s taken to the consultant and they take it to the DOEM to discuss whether that’s a workable thing, I think all of the consultants talk about it with the DOEM to see if that would be ok. Not really sure but NPs are not in on that conversation...(Participant 12)’
Emergency nurse practitioners reported not being involved in decision making about changes
to the service at all as explained by participant 8 and participant 9.
…I have been here a while now and I have never been asked to make any decisions or helped to make any decisions at all…(Participant 8)’
‘I can genuinely say that I have never made any decisions about the ENP service at all.’ (Participant 9).
Decision making power over changes to practice remained with the Director of Emergency
Medicine (DOEM) and specific processes for change existed in individual workplaces. As
expressed by participant 2:
117
‘Obviously we need to work within a scope of practice but we do continually look at the population, the service we are giving and identify gaps in that service. Then as a group (ENP group) look at how we can meet the department needs in general, seeing if we could improve timeliness and service in other areas...(Participant 2)’
Whilst participant 8 recognised the restraints:
‘…we can’t go forward with anything too formal unless our medical director is involved because clinically he and his consultants have to be happy too so there is a definite medical influence about what we can do…(Participant 8)’
Unfortunately, those who make the decisions about ENP service scope of practice were
reported to have limited understanding of the role itself. Overwhelmingly ENPs expressed
concern over barriers to service provision that stems from a lack of understanding which
prevented ENP staff working to their full capability. ENP role, scope of practice and level of
education and training were all considered to be areas of confusion for patients and staff
working in the emergency department. In particular, ENPs reported that senior management
did not understand the scope of practice of the service or the level of responsibility taken by
ENPs. Participant 3 and 7 have recognised the lack of staff understanding of the ENP
service role:
‘…most nursing and medical staff struggle with what the ENP role entails (Participant 3)’
‘…nurses think we are just doing dressings and fixing bones, nurses don’t understand our role fully or the level of responsibility (Participant 7)’
It was acknowledged by ENPs that it was detrimental to services to have poor organizational
and staff understanding and it was necessary to raise awareness of ENP services amongst
their colleagues and patients. Participant 8 stated that the role and service had been poorly
explained and requires the profile to be raised:
118
‘…There has been a lack of articulation by the ENPs regarding the role, or about how the organization perceives what we do. …the best way to raise our profile is we need to sell it better on the floor (Participant 8)’
ENPs were also concerned about personal deskilling as a result of restraints placed on the
scope of practice of emergency nurse practitioners. Reports of ENPs feeling ‘out of depth’
taking part in nursing cares that were once daily routine. Participant 7 expressed concern
about deskilling and participant 8 recognised the altered patient population they are
supporting:
‘…All the skills we’ve got we lose those skills, we’ve all openly said we would feel a little bit uncomfortable walking into resus tomorrow with all the new equipment…(Participant 7)’
‘…We have actually deskilled ourselves and increased our knowledge in a lower acuity type of patient but not in a true emergency patient anymore which is why we all started doing the job in the first place…(Participant 8)’
Whilst ENP staff were required to be highly skilled Registered Nurses with extensive
experience in the emergency department to become an ENP, from the day they start ENP
work they began to lose these skills. It was perceived that the service was being prevented
from utilising their full scope of practice by members of the medical profession. Participant 6
and 7 explain the limitations to their scope of practice:
‘…We’ve often tossed up with the medical officers about us expanding into other things. In fact (medical officers name stated) said to a couple of us the other day why aren’t you seeing chest pains or abdo pains. There is a block there from the DOEM, he doesn’t want us to see these things…(Participant 6)’
‘…We used to be the ones leading resuses and it just it feels like blockage from one person ( DOEM) saying no you can’t do that…(Participant 7)’
Concerns were raised over a lack of ENP service staff to ensure the provision of an effective
service. ENPs discussed the impact insufficient ENP staff to cover leave requirements for
annual leave, conference and unplanned leave placed upon service provision and staff
119
development. Services were often left depleted or at times non-existent or ENP staff went
without breaks or educational requirements to cover service needs. Participant 10, 5 and 2
reported that they find this situation to be unacceptable and highly stressful.
‘…if someone (an ENP staff) is off sick they don’t fill that space which is a bit unfortunate as the service is left short, there is no one to step up and fill it…(Participant 10)’
‘…that was killing us (not having enough staff to cover leave), no sick leave no nothing. The evening shifts were just demoralising, you run flat out and never get through the work…(Participant 5)’
‘…I think we were getting quite exhausted and there was no slack to do education, no down time, just push, push, push…(Participant 2)’
Poor planning for both ENP service staffing in general and for ENP candidate succession
planning within emergency departments was recognised. Inconsistent training of ENP
candidates was due to unreliable funding for candidature positions. In contrast, nurse
practitioner candidates were being trained in some organizations with no future plans to
employ more ENPs into the service once candidates complete their training. Some ENPs
were working part time in ENP roles and concurrently working in other nursing positions.
The reason for this is unclear but may be related to the fear of deskilling, job satisfaction or
role security concerns.
Training and education in preparation for commencing the role of ENP was seen to be poorly
aligned to the final role and scope of practice as it was being operationalised. ENPs spent
most of their time with low acuity patients in fast track areas rather than with the acutely ill
patients they had years of experience nursing. Participant 8 and 10 highlighted some of the
challenges that face ENP staff regarding education:
‘…When I was an emergency nurse I rarely looked into ears or throats, but since becoming an ENP I have to look at them and know what they look like. All that background training and with the focus of the service now I think it is probably a
120
waste of all those years of training in ED. I think more training in primary care…. would help…(Participant 8)’
‘…you need to learn a whole new set of patient presentations that you have never even looked at before because they were of no real significance to you…(Participant 10)’
Despite this identified gap in the knowledge for ENP services, t ongoing education and
training relevant to the ENP clinical role was self-identified, managed and in most cases self-
funded. This consisted of pursuing specific conferences individually, self-initiating
subscription to journals and development of internal educational sessions on particular points
of interest or concern. Participant 9 and 5 reported that ongoing education is insufficient:
‘…you have to sort it out yourself basically, if you think you are lacking a bit of experience you might initiate a day in fracture clinic…I don’t think that is great (Participant 9)’
‘…there is some great education offered at the conferences, but of course we can’t all go, we have to still cover the service…I went last year so I won’t go this year (Participant 5).’
Healthcare organizations did not provide any nursing education sessions specifically for
ENPs or NPs in general. ENPs report that the level of education provided at sessions for
registered nurses did not meet their scope of practice needs and therefore most sought
education from medical staff colleagues during collaboration on patient treatment episodes.
Teaching junior staff, both medical and nursing was viewed as an expectation of the role.
ENPs provided a lot of education but did not receive a lot in return. Participant 8 and 2 report
receiving quality education from their medical colleagues:
‘I get the best learning and feedback when I am actually talking about the patient with the consultant on the floor…(Participant 8)’
‘…I started to go to the junior doctor training because I saw the topics given were presented by consultants. I loved them, they were good quality…(Participant 2)’
121
ENPs often reported putting immediate patient care needs ahead of attendance at meetings or
educational sessions. Participant 5 describes the inherent nature of nurses to stay and attend
to patient care rather than attend professional education. Participant 1 explains the impact of
staffing levels on education.
‘…I think the biggest problem is when it is busy ENPs are not keen to leave the floor anyway. Most don’t, they’ll stay and put the patient first. I think it’s the nature of the nurse in us (Participant 5).
‘… we don’t enjoy the same level of education time that the doctors get… that’s a problem across all of nursing.(Participant 1).’
The ENP service appears to be working to capacity but not to capability in terms of a
restrictive scope of practice, limited staffing numbers, misalignment between the role and
capability of ENP staff and the initial and ongoing education provided.
Standing up to scrutiny
The final theme that emerged from the interviews with ENPs was ‘standing up to scrutiny’.
ENP services were regularly audited and were meeting expectations. This theme was
characterised by: staff attributes ensure safety, extensive audit and review and meeting key
performance indicators and targets.
ENPs reported that personal attributes of individual staff as well as the attributes considered
common to nursing staff in general contributed to the safety and quality of ENP services.
These ethical and behavioural characteristics were said to ensure a trust and expectation of
the level of service provided by ENPs. Participant 1 and 5 recognise the attributes that
support a safe service:
122
‘…I work with ENPs who are of the highest ethical calibre, that are acutely aware of what they know and don’t know and if there is something they don’t know they don’t do it. They will seek out the correct information or consult where required…(Participant 1)’
‘…The expectations of providing quality care to patients- it’s part of our conduct and standard of service that we provide to clients…(Participant 5)’
Anecdotally and via formal survey processes patients were happy with the service they
received from ENP services. Patients were considered to be the ENP service’s best
supporters and the motivation behind ENPs to deliver high standard nursing care. Participant
4 and 6 explain:
‘Patients are our best advocate and that is why I come to work basically (Participant 4).’
‘The feedback we are getting from consumers has been excellent, we did a patient and staff satisfaction survey a while ago and we are just repeating that. (Participant 6)’
Extensive auditing of the service by both peers and self-audits reported ENP services were
safe and high quality. Key performance indicators and National Emergency Access Targets
(NEAT) amongst other measures were in place to evaluate ENP services. The NEAT is a
national target that has been implemented in an attempt to improve timely access to
emergency and elective services, with the goal that 90 per cent of all patients presenting to a
public hospital emergency department will either be admitted to hospital, referred to another
hospital or be discharged, within four hours (AIHW, 2013).
‘…We do a lot of peer auditing, chart, x-ray and prescribing audits and they find that ENPs prescribe very safely. The senior doctors do chart audits, the comments were that the NPs have got the best documentation…(Participant 6)’
‘…ENPs essentially are being evaluated more than any other health professional and it’s monthly. All our notes by peer review but also a medical review by the DOEM…(Participant 5)’
‘…The ENP was brought in to reduce waiting time for lower acuity patients and reduce the ‘did not waits’, after the service was introduced they reviewed the lower
123
acuity patients wait time and the ‘did not waits’ and they were reduced quite dramatically…(Participant 9)’
ENPs were contributing to emergency departments meeting the desired NEAT targets but
they also perceived they were meeting patient expectations and that patients were satisfied
with ENP services. In addition to the formal evaluation strategies employed, ENPs reported
other quality measures of ENP services. Relationships and trust between ENPs and medical
staff has developed over time through ENPs proving their worth. Once this relationship has
been developed there appears to be more acceptance of that particular person in that
particular role. Mutual professional benefits have been found along with a respect for each
profession that has developed over time. Participant 3 and 4 recognised that relationship
development was influencing ENP service delivery:
‘…we have a good standing with the doctors here. It comes down to relationships and trust with individual staff members and as a group. A tried and tested proven recipe…(Participant 3)’
‘We have gained a reputation now and once you do that and you can maintain that it does seep out….even the ones who didn’t really like the role when it started have been converted and those are the most steadfast in supporting and appreciative of the role. (Participant 4)
ENP services have been standing up to scrutiny that has been bestowed upon the service.
This new service innovation has endured extensive auditing and review and has proven
ability to assist the department to meet key performance indicators and targets. Individual
attributes of the staff employed in this role are thought to impact upon the quality of the
service that is provided.
124
Section 3.
6.4 Embedded unit of analysis 3 – Documents related to Nurse
practitioner service
Documents relevant to implementation and governance of nurse practitioner service were
analysed using summative content analysis techniques. This analysis was guided by an
analysis matrix developed in relation to the theoretical framework and propositions
specifically related to financial and political factors for sustainability.
Sample characteristics
Any documents that were published with the intent to direct the governance or regulation of
nurse practitioner service in Queensland were subject to analysis using summative content
analysis techniques (Elo and Kyngas, 2007) using an analysis matrix (see appendix M).
From May – June 2014, documents were sought from the three individual hospital sites and
those publically available via the internet by searching professional bodies and government
sites as illustrated in Table 6.2.
Table 6.2 Websites searched and numbers of documents retrieved.
Site Searched Number of documents returned from each website according to terms searched
Nurse practitioner implementation
Nurse practitioner governance
Queensland Health http://www.health.qld.gov.au/
1,575 1,808
Nursing and Midwifery Board of Australia http://www.nursingmidwiferyboard.gov.au/
93 49
Australian College of Nurse Practitioners http://acnp.org.au/
389 389
Australian Health Practitioner Regulating Agency https://www.ahpra.gov.au/
254 145
125
The retrieved documents were then manually searched and the following documents were
excluded; duplicates, news announcements, fact sheets outlining information that was
available in other documents, documents that referred to nurse practitioners within the
context of reporting another service or purely as a person’s role, documents that formed a
component of, or appendix to, a larger document, and old versions of updated documents. A
total of ten documents remained.
Unfortunately no business plans relating to the implementation of ENP services were able to
be retrieved. The nurse unit manager from each site acknowledged that business plans
relating to emergency nurse practitioner service implementation would have been submitted
to initiate their current service however, none of the research sites were able to recover any
business plans relating to the ENP service in their workplace. Each business plan had been
associated with the nurse unit manager in the position at the time of implementation of the
service and as the person in that role had changed, the document was unable to be retrieved.
All (n=10) documents originated from government departments with five published by
Queensland Health, three by the Nursing and Midwifery Board of Australia, one by the
National Health Department and one by the Queensland Government Health Protection Unit.
Two documents were emergency nurse practitioner Health Management Protocols and the
remaining eight documents were generic and related to nurse practitioner service in any
specialty area rather than specifically in emergency nurse practitioner service. All documents
were dated and identified the author or governing body responsible for publishing the
document.
126
Predominantly information contained in the documents was supported by evidence that was
cited to have informed and justified the information within. A clear purpose of each of the
documents was evident however no documents related to the implementation of ENP services
specific to local sites were available. Staff at all three sites were approached and asked for
any documentation relating to the implementation or governance of the emergency nurse
practitioner service and all three indicated the use of Queensland Health regulatory
documents at the local level and that these were available online. Table 6.3 provides a
summary of the documents examined.
Table 6.3 Summary of documents retrieved
No. Document Name Author written 01 Queensland Nurse Practitioner
implementation guide Queensland Health: Office of the Chief Nursing Officer
2008
02 Emergency Nurse Practitioner Health management Protocol- Management of acute episodic presentations in the adult population
Queensland Department of Health (site specific)
2008
03 Emergency Nurse Practitioner Health management Protocol- Management of acute presentations in the adult population
Queensland Department of Health (site specific)
2009
04 National Health (collaborative arrangements for nurse practitioners) determination 2010
Nicola Roxon, Minister for Health and Ageing
2010
05 Clinical Governance for Nurse Practitioners in Queensland
Queensland Health: Office of the Chief Nursing Officer
2011
06 Position Statement Scope of Practice of Nurse practitioners
Nursing and Midwifery Board of Australia
2013
07 Nurse practitioner standards for practice
Nursing and Midwifery Board of Australia
2013
08 Guidelines for endorsement as a nurse practitioner
Nursing and Midwifery Board of Australia
2014
09 Health (Drugs and Poisons) Regulation 1996 Drug Therapy Protocol – Nurse Practitioners
Health Protection Unit- Medicines Regulation and Quality Fortitude Valley
2014
10 Drug Therapy Protocol for Nurse Practitioners in Queensland – information sheet
Queensland Department of Health 2014
127
These documents were analysed using content analysis technique against the predetermined
categorisation matrix as explained in chapter 5 (see Appendix M). This analysis matrix was
derived directly from the indicators of political factors of innovation sustainability: local,
state and national policy alignment, linkage to strategic goals, national and local champions
and staff involvement in decision making processes. The results of the content analysis has
been tabulated and illustrated in table 6.4 below. The indicators for financial factors of
innovation sustainability were: funding sources, budgetary planning and cost effectiveness
evaluation. Further general information collected from each of the documents included: the
name and date of document development, the purpose of the document, and the explicit
evidence base supporting the information. Summative content analysis of the documents
revealed the following findings.
Table 6.4. Summary of document analysis results according to the matrix.
Factor Characteristic
Theme identified in document
Supported by evidence
Achievement mechanism discussed
Context specified
National, state and local policy alignment with the innovation
|||| ||||
|||| |||
|||| |||
|||| |||
Linkage of innovation to regional health goals
||||
||||
||||
|||
Local champion/supportive professional relationships
||||
|
|||
||||
Staff involvement in decision making
||| | ||| ||
Funding || - | |
Budgetary planning for continuation
- - - -
Evaluation of cost effectiveness
| - - |
128
Links to health policy and regional goals
There was strong documented evidence of links between National, State and Local
government policy and nurse practitioner service implementation with this being discussed in
all of the ten documents reviewed. Linkage is clearly articulated between legislation,
regulation and governance of nurse practitioner service and the implementation of these
services. It has been expressed in the documents that nurse practitioner service should be
closely aligned to regional and local health service goals with strategies for how to achieve
this also presented. The Queensland Nurse Practitioners Implementation Guide (Queensland
Government, 2008) recommends that a District Nurse Practitioner Steering Committee would
develop the terms of reference. Whilst the Clinical Governance for Nurse Practitioners in
Queensland – A Guide (Queensland Government, 2011a) states that local business planning
and key performance indicators should be considered when developing evaluation strategies.
Development of evaluation processes at a local level ensures that nurse practitioner services
are evaluated against local goals. Only one account of local evaluation strategies was able to
be found and this indicated that ENP services were closely evaluated against national targets
and key performance indicators. Comparisons of the recommendations at state level with the
occurrence at local sites was prevented due to lack of clearly documented goals and
evaluation strategies available for review.
National and local champions
Supportive relationships were overtly discussed in half of the documents analysed. These
were specifically in relation to collaborative practice and mentorship. The documents
presented legislation and processes that should be in place to maintain safe patient care
practices. Relationships with other health care professionals relative to nurse practitioner
129
scope of practice, referrals and requesting diagnostics or prescribing was explicit with
processes to implement this also being presented.
The Queensland Nurse Practitioner Implementation Guide (Queensland Government, 2008)
and Clinical Governance for Nurse Practitioners in Queensland – A Guide (Queensland
Government, 2011) conveyed in one sentence, the need for support by clinical and executive
champions of nurse practitioner service.
‘For a health service to incorporate a nurse practitioner role into a service delivery model, there must be consideration for key health service planning principles, supported by clinical and executive champions.’
Operationalising this leadership and support for implementation was not presented nor any
further reference to service integration. The need for all staff to understand nurse practitioner
service and for nurse practitioners to develop trust with colleagues through evaluation of the
service is implied but methods for doing this are also not clearly documented. This was also
the case with staff involvement in decision making about nurse practitioner service.
Including staff in decision making processes concerning the implementation of nurse
practitioner services was mentioned broadly however, the inclusivity of this group or
recommended approach was not provided. The absence of recommended consultation with
nursing staff in relation to any decisions about nurse practitioner service was noted.
Funding sources poorly documented
Ongoing funding or budgetary planning for the provision of ENP services was not addressed
in detail in any of the documents reviewed. Documents that did briefly mention funding did
so in relation to the initial nurse practitioner service implementation.
130
‘…the service team to demonstrate justification of the proposed nurse practitioner service model and to seek funding support of demonstrate funding availability’ (Queensland Nurse Practitioner implementation guide, 2008).
The onus to achieve this funding was placed on the health service wishing to implement the
service model. Clinical Governance for Nurse Practitioners in Queensland- A Guide
(Queensland Government, 2011a) states that
‘…employment as a nurse practitioner candidate is dependent upon the organization having funding’, and further, ‘appointment to a nurse practitioner position is decided by the employer and is subject to planning and funding by individual health services.’
The Queensland Nurse Practitioner Implementation Guide (Queensland Government, 2008)
advised the steps to take to implement a nurse practitioner service. Step four in this process
requires the development of a business case for the introduction of a nurse practitioner
position. This involves seeking funding support and demonstrating funding availability as an
essential step in establishing a nurse practitioner position, however, where funding should
come from or how health services go about securing funds or plans for future services was
not discussed. Ongoing demonstration of budgetary planning was also not considered. As
individual business plans for implementation of emergency nurse practitioner service from
the research sites were not available or documented evaluations of implementation were
available for analysis, how this process actually occurs in practice is unknown.
Cost effectiveness not directly measured
Evaluation of cost effectiveness of ENP services was not overtly highlighted in any of the
documents analysed. The importance of evaluation of nurse practitioner service in terms of
clinical safety and accuracy audits was clearly expressed and the expectation that nurse
131
practitioner service would help the department to meet key performance indicators was well
documented. Clinical Governance for Nurse Practitioners in Queensland – A Guide
(Queensland Government, 2011a) posits that the organization implementing an ENP service
achieves cost benefits through the application of best practice. Interdisciplinary reviews of
nurse practitioner service were recommended to include periodic case reviews for the
appropriate use of diagnostics and treatments, therefore inadvertently evaluating cost
effectiveness of treatment by ENP services. Additionally, no cost effectiveness evaluation
reports specifically relating to ENP services in this study were available. A review of the
literature recognises minimal research had been completed to measure the cost effectiveness
of ENP services (Jennings et al, 2015) and health economics research into ENP services
would provide valuable insights.
6.5 Conclusion
This research has provided extensive, rich and informative data surrounding the health
service innovation of emergency nurse practitioner service. Results that were provided by
embedded units of analysis: emergency department staff, emergency nurse practitioners and
documents relating to nurse practitioner service have all been presented. This data, collected
from multiple sources and using varied collection methods have informed the indicators for
the factors influencing sustainability according to the theoretical framework. Analysis of this
data has provided valuable new information that will be interpreted and analysed through
converging and pattern matching techniques to compare the empirical findings to the research
propositions. The result of this process will be new knowledge pertaining to the factors
influencing sustainability of ENP services and recommendations for future practice and
research in the field.
132
133
Chapter 7 Discussion
7.1 Introduction
This research has used case study methodology to explore the health service innovation of
emergency nurse practitioner service. The research approach both addressed and revealed the
complexity of conducting research into emergent health services. The results presented in the
previous chapter show that across a range of data modalities and epistemological positions
case study methodology enabled an in-depth examination of service innovation within the
conceptual framework of Sustainability of Innovation.
This chapter reports the interpretation of results and identifies how these results can be
contextualised with reference to the Sustainability of Innovation framework that underpins
this research. The outcome will be development of new knowledge in relation to
sustainability of emergency nurse practitioner service and the utility of the Sustainability of
Innovation framework.
7.2 Emergency department staff
Increased confidence in service
This research has found that overall, the emergency multidisciplinary team were positive
regarding emergency nurse practitioner service; reporting that nurse practitioner care was
safe and of high quality and that the services met the needs of the local population. This is in
direct contrast to early reservations voiced by professional bodies such as the Australian
Medical Association about the introduction of nurse practitioner services who warned of
fragmented care, unsafe prescribing and increased risk of inadvertent patient outcomes
134
(VDHS, 2000). Research conducted by Tye and Ross (2000) recognised multidisciplinary
stakeholder concerns about ENP service implementation. Findings from this study however,
are consistent with more recent research completed by Jones, Christoffis, Smith and Hodyl
(2013) who explored emergency physicians and trainees perceptions of ENPs in Australia
and found that medical staff who had worked with ENPs were supportive of the role.
Changes in workforce perceptions show there is a new confidence by other disciplines in the
capacity of ENPs to provide a safe effective service. This confidence has developed over
time as ENP services have proven to deliver safe care.
The apparent shift in acceptance level of ENP services by emergency department staff was
further illustrated by emergency staff members who indicated a desire to be more involved in
decision making related to ENP services and the need to be informed of service changes.
Emergency department staff member’s lack of opportunity for involvement in decision
making could lead to strained inter-professional relationships. An organizational culture
supportive of teamwork and collaboration is determined in part by shared decision making
with all members of the health care team (Orchard, Curran and Kabene, 2005). This
important finding indicates opportunities for improved staff involvement in decision making
and team cohesion to enhance political sustainability of this service innovation.
Poor staff planning and involvement
The largest area of concern voiced by the emergency department staff was in relation to
management of ENP services; specifically workforce supply and planning for ongoing
service provision. This research showed that emergency department teams perceived the
current supply of ENP service staff was insufficient for consistent service delivery. ENP
staff reported experiencing the inadequate ENP staff numbers to cover service needs during
135
unplanned leave such as sick or compassionate leave. There has not been any research
conducted to inform optimal ENP service staff numbers or shortages, however research
recognises a severe shortage of nursing staff in general (Goudreau and Hardy, 2006; Collins
and Collins, 2007).
During staff shortages in health care settings alternative ‘work around’ arrangements are
often made (Debono et al, 2013). Nurses’ workarounds are actions taken by nurses to
temporarily ‘fix’ or circumvent a problem (Debono et al, 2013). Workaround strategies may
appear to work in the short term, however are not desirable as they often consist of unsafe
practices that do not necessarily support positive patient outcomes (Halbeslegen, Wakefield
and Wakefield, 2008). Examples of work around strategies were reportedly employed by
some ENP staff in this study such as, working beyond regular shift times and taking shorter
breaks or not taking breaks at all. These strategies are unsustainable and potentially
negatively impact upon patient safety and ENP service delivery.
Interpretation of the results provided by MDT questionnaires informed three factors
influencing sustainability of ENP services according to the theoretical framework.
Organizationally- ENP services were meeting the health care needs of the local population
but results indicated poor understanding of education and scope of practice of ENP services.
Workforce- MDT staff perceived ENP services to be needed, good quality and safe however,
expressed concern over staff numbers and ongoing planning for service provision.
Politically- ENP staff were supported well in their role by medical colleagues however, they
were not involved in decision making regarding the service and were not informed of changes
that impacted on their work. Acceptance and trust in ENP services have developed over time
and the service is considered high quality, adapt to local patient needs and receive support
136
from colleagues in the form of collaboration. Sustainability of ENP services may be
threatened by inadequate ENP staff numbers and strained inter-professional relationships due
to insufficient teamwork and organizational culture.
7.3 Emergency nurse practitioners
Emergency nurse practitioners participated in telephone surveys and in-depth individual
interviews, providing extensive information regarding ENP services and the factors that
influence sustainability of these services.
Excessive service restrictions
ENP services were experiencing excessive restrictions to practice which was preventing full
utilisation of service staff capabilities. ENPs cared for low acuity patients in fast track areas
or rapid assessment teams most of the time. Restriction of ENP services to care for patients
of low acuity has prevented full utilisation of a service that has proven ability to provide a
safe and effective service (Jennings et al, 2015). The ENP services in this study were staffed
by highly experienced, Masters educated nurses who were restricted to attend to a limited
patient population.
The second national census of Australian nurse practitioners (Middleton et al, 2011) reported
that NP services were being constrained by limitations to practice such as scope of practice
boundaries, lack of PBS and MBS provider numbers. At the time of Middleton et al’s (2011)
research only 9% of NPs had a MBS provider number and 10% had authority to prescribe
using the PBS. In comparison this study showed 16 % of ENPs had a MBS provider number
137
and 64% had a PBS prescriber number. These results suggest significant progress has been
made relative to some barriers specifically around access to PBS. Carryer and colleagues
(2007b) argue that guidelines and work protocols control and limit the effectiveness of
services. This research has found that processes, work practices and policies are still
preventing full utilisation of ENP service scope of practice.
The aim of introducing ENP services was originally to improve patient access and timeliness
of health care in emergency departments (Queensland Health, 2008). In 2011, key
performance indicators and targets such as the National Emergency Access Target (NEAT)
were introduced as a means of measuring ED performance (COAG, 2011b). Research
identified that NEAT targets have been driving improvements in patient access to emergency
departments (Lawton, Thomas and Morel, 2015) however, the impact that targets have on,
scope of practice and staff roles has not been examined. Key performance indicators and
NEAT targets may be inadvertently restricting the scope of ENP services.
The scope of practice of ENP services was described as discordant to the experience and
capability of ENPs who had been working for many years as senior nurses in emergency
departments. ENPs expressed concern about deskilling as their expertise and knowledge was
not fully utilised in their current role. Utilisation of skills and knowledge are closely linked
to job satisfaction and attrition from NP roles (De Milt et al, 2009). Unnecessary restrictions
placed on ENP services that prevent staff from using their skills and knowledge may lead to
poor staff satisfaction and eventually attrition from ENP services. Nurse practitioner job
satisfaction is directly linked to having control over one’s own practice and has been
identified as the most common reason an NP leaves their position (De Milt et al, 2010).
Organizational leadership is required to support inclusion of ENPs and emergency
138
department team members in decision making processes to ensure that services are used to
their full potential.
Limited support structures
ENP services are no longer a novel concept; the number of NPs in Australian emergency
services has increased dramatically over the past eight years (Middleton et al, 2011) and with
this increase has come an increased acceptance of this service innovation. ENP services have
been implemented within emergency departments with limited supportive organizational
structures and leadership to enhance service integration. Areas specifically noted are lack of
staff involvement in decision making, poor planning for ongoing service provision and
limited understanding of ENP service capacity. Additionally and consequently, ENP services
were not utilised to their full potential.
ENP staff had a strong sense of isolation characterised by lack of belonging to either the
nursing or medical team and poor group cohesion. There was a lack of inclusive workplace
meetings and minimal time to organize or attend networking opportunities with external
organizations. Greenhalgh and colleagues (2004) described cross-boundary spanners as staff
members who have significant ties both within and with other organizations and are able to
support the development of an innovation through external knowledge and networking.
ENPs are in the perfect position to be cross-boundary spanners, not only across the
multidisciplinary team but also inter-hospital between emergency departments.
Unfortunately marginal integration of ENP services had limited this opportunity. Given the
small numbers of staff within each ENP service cross-organizational networking is highly
influential to sustainability of this service and the isolation expressed by ENP service staff
139
was not surprising given the poor understanding of ENP services by management and lack of
inclusion in decision making processes.
The complex nature of health services and the diverse patient population attending
emergency departments reinforced the need for dynamic and flexible ENP services. ENP
staff often initiated changes to ENP services however unilateral decisions about service
provision were often made. Role conflict is thought to occur between professional groups
that share overlapping competencies and responsibilities (Mariano, 1998) and rather than
working in teams, profession groups tend to clump together and fail to consider opinions of
other groups (Orchard et al, 2005). ENPs and other emergency department staff had little or
no input into decisions about ENP services and the Director of Emergency Medicine often
made decisions independent of stakeholder input. This lack of group cohesion and shared
decision making is a barrier that impacts upon optimal service delivery.
Keating and colleagues reported in 2010 that medical and nursing staff understood ENP
services however, at an organizational level understanding was lacking. This research has
also reported that senior management staff members lack understanding of ENP service
capability and scope of practice. Lack of understanding of the NP service role by senior
management staff has been linked to poor professional collaboration and is recognised as
detrimental to interdisciplinary relations (Clarin, 2007). Poor understanding of ENP services
is shown in this study to be compounded by limited communication and dissemination of
information opportunities relating to ENP services. Full utilisation of ENP services is
dependent upon organizational understanding and interdisciplinary collaboration relating to
ENP service provision.
140
Sufficient workforce numbers and succession planning by the organization is essential to
integration and ongoing provision of a service. Succession planning in health care has
recently gained attention due to the pending health workforce shortage (Carriere, Muise,
Cummings and Newburn-Cook, 2009). This research has reported ENP concerns about the
number of staff currently in ENP services and the erratic succession planning that currently
exists. In an attempt to retain knowledge and experience, organizational leaders and
managers need to plan for staff succession. This process requires suitable mentoring,
funding, time and energy (Carriere et al, 2009) however, the alterative to planning may be
knowledge loss, poaching of experienced staff by other organizations, underprepared staff or
a depleted ENP service. If workforce succession for ENP services is not well planned there
will be limited staff members to replace those that leave and a long period of training before a
staff member is able to practice.
Creating an organizational culture and structure that supports interdisciplinary collaboration
is essential for ENP service provision. Orchard and colleagues (2005) posit that conflict
between healthcare team members can be reduced with an organizational shift away from
hierarchical structures toward patient centred decision making processes. This shift requires
a leadership style that promotes shared, informal and consultative decision making (Orchard
et al, 2005). Emergency department staff members need to be empowered to work with the
multidisciplinary team to make local decisions based on shared understanding and patient
centred goals.
141
Measuring service performance
ENP services were more frequently audited than any other health service. Extensive audits of
ENP staff practice on an individual level in regards to accuracy of: diagnostic requests,
prescriptions and diagnosis. This as well as, monthly reporting of key performance indicators
showed ENP services are assisting emergency departments to meet national targets. The
regular widespread examination of ENP service quality and exposure to ENP services has
engendered the trust of colleagues (Martin and Considine, 2005; Jones et al, 2013), this has
also been found to be the case in this study. ENPs judged their own service to be safe,
providing high quality, patient focused services. Prevailing research examining the quality
and safety of ENP services have been conducted through audits and surveys and consistently
report the safety and quality of ENP services (Carter & Chochinov, 2007; Wilson & Shifaza,
2008; Jennings et al, 2008; Gardner et al, 2013; Jennings et al, 2015).
Emergency department nurse practitioners provided extensive data that has informed the
factors influencing sustainability of ENP services. Whilst ENP services are standing up to in-
depth scrutiny that is often placed upon an innovation, the marginal support provided for
service integration and underutilisation of the service may impact upon sustainability.
Results from ENPs informed innovation-specific factors influencing sustainability of ENP
services according to the theoretical framework. There are significant barriers and
restrictions placed on ENP services with role/capability malalignment which was impacting
upon the innovation. Limitations are placed on ENP practice based on work area, having PBS
and MBS numbers and the authority to use these and, service scope of practice which is
locally mandated. Organizationally- inconsistent information sharing and communication,
limited networking opportunities, sluggish service adaptation and ENP service role and scope
were not understood. Workforce- insufficient staffing and succession planning and
142
disorganized education provision were recognised. Financially- there was poor budgetary
planning for ongoing service provision and politically- strained staff relations and poor group
cohesion was identified.
7.4 Documents relating to nurse practitioner service
Analysis of documents related to implementation and or governance of nurse practitioner
service in Queensland were most significant in their brevity. The documents available were
predominantly State or National Government documents and whilst they were found to
inform and guide ENP service implementation in some aspects, very few documents related
to implementation or governance at the local service level were found and this was reflected
in practice.
Organizational change processes neglected
Legislative boundaries, collaborative requirements and specific processes directly related to
patient care practices were clearly articulated within the documents analysed. Formal
processes closely aligned to patient care are easily documented in step by step processes as
opposed to the less concrete and informal interactions that occur between professionals in the
complex health care setting. Successful implementation of a service innovation is dependent
upon strong leadership and effective human resource management (Greenhalgh et al, 2004).
Orchard et al (2005) reported that a cultural shift is required when role changes are made in
health care settings to enhance cross disciplinary respect and collaboration. Orchard et al
(2005) argues that a collaborative practice model will assist the organization to implement
change and improve inter-profession relations. Staff members in executive and senior
management roles are not guaranteed to be champions of ENP services and therefore may not
143
be supportive or provide leadership. The documents broadly outlined the need for executive
staff leadership and support for implementation of nurse practitioner service however, clear
strategies to create a receptive organizational culture as suggested by Orchard and colleagues
(2005) did not exist.
Important aspects of operationalising ENP services such as funding arrangements, staff
numbers and succession planning and, organizational culture and readiness for the
implementation of a new service model were not considered at national or state level
documentation, and completely absent at local level. Failing to address these key issues may
lead to vagaries and neglect of accountability for ongoing service integration.
Analysis of documents relating to the implementation and governance of ENP services this
study has revealed a substantial lack of documentation to support ENP service integration.
Lemer et al (2015) recognised that often the content of a policy or strategy is less important
than the organizational environment in which it is implemented. Whilst the documents
address alignment to National, State and Local policy and legislative requirements in writing,
lack of documentation prevents evaluation of the policy or guideline in practice. Evaluation
of policies and guidelines as they are implemented in practice allows for amendment to
appropriately align the two and foster positive impact in the real context. Policies and
guidelines are more likely to be implemented into practice when they have been developed
with consideration of research evidence (Walt, Shiffman, Schneider et al, 2008). The
absence of documents and guidelines related to the implementation and governance of ENP
service could be an indication of the value placed upon these by clinician and management
staff at the local level.
144
Analysis of documents related to the implementation and governance of ENP services have
informed two factors influencing sustainability of ENP services according to the theoretical
framework. Politically- linkage between health policy and regional goals was evident
however clear understanding of the role and input expected of local and national champions
was not. Financially- funding sources were described as a local responsibility and no
expectations regarding budgetary planning for ongoing service provision were provided.
Direct measure of the innovation cost-effectiveness was not a requirement placed upon
service implementation.
7.5 Conclusion
Research conducted with emergency department staff, emergency nurse practitioners and
documentation related to ENP service implementation and governance has provided
extensive information to examine sustainability of this health service. Interpretation of the
results has revealed new knowledge in relation to ENP services. This information has been
considered in relation to the factors influencing sustainability of service innovation and in the
next chapter case study analysis of these interpreted results and pattern matching techniques
will be used to examine the findings in relation to the research propositions. This process
will provide new knowledge in relation to the factors that influence sustainability of ENP
services.
145
Chapter 8
Case Study Analysis
8.1 Introduction
Interpretation of the results has provided significant new knowledge about ENP services. A
recognised strength of case study methodology is the process of converging data from various
sources to enhance the validity of the findings. In order to examine ENP service
sustainability, the interpreted results have been converged to give greater meaning and
understanding. Pattern matching to compare the findings to the research propositions is the
final step in case study methodology. Conducting this case study has provided empirical
results that have been matched against the research propositions developed in relation to the
Sustainability of Innovation theoretical framework.
8.2 Convergence and pattern matching
Convergence in this study refers to drawing together results from each of the data sources to
provide extensive and in-depth information that can be compared using pattern matching
techniques to the research propositions. The convergence of results, illustrated in figure 8.1,
indicates variations from the original research operational framework that was presented in
chapter five. Operationalising the theoretical framework identified new connections between
data collection sources and factors of the framework that had not been previously anticipated.
These new connections are represented in the figure with broken lines.
146
Embedded Unit of Analysis Data collection source (subunit of analysis) Research Findings
Organizational
Workforce
Innovation specific
Embedded Unit of Analysis 1.
Emergency Department Staff
(MDT)
Embedded Unit of Analysis 3. Nurse practitioner service documents
Embedded Unit of Analysis 2.
Emergency Nurse practitioners
services
Interviews
Document analysis
Telephone Survey
Questionnaire
Funding sources are HHS responsibility, ongoing funding, budgetary planning was not evident, Business plans not available, Cost effectiveness of the innovation not directly measured
ENP service highly needed, very safe and of good quality, Insufficient workforce numbers and planning, ENP staff ongoing education was limited, Concerns about deskilling and underutilisation.
Improved awareness of ENP services but lack of organizational understanding about service, lack of staff involvement in decision making about ENP services, Insufficient networking and team cohesion.
Scope of practice barriers limit full utilisation of the ENP service, No MBS and PBS provider numbers limits practice
Supportive patient collaboration, ENPs felt isolated, Strong political links to key political agendas and targets, Collaborative practice processes by ENPs with medical and allied health were explicit, operational processes regarding ENP services not clear
Figure 8.1 Research findings converged to inform framework factors
Workforce
Political
Financial
147
8.3 Proposition 1- Meeting organizational factor indicators for
sustainability
The research proposition and expected pattern identified for organizational sustainability was:
Emergency nurse practitioner service meets the indicators of organizational factors for
sustainability. The Sustainability of Innovation framework recognised the following
indicators: effective communication, service adaption to the local context, staff understanding
of the innovation and participation in external networking. Converged results indicate that
ENP services did not meet all the organizational indicators of sustainability.
Communication
Although inter-professional collaboration and support for ENPs to provide patient care
appears effective, the broader culture within the emergency department was found to be
unsupportive and communication with executive staff, fragmented. Research by Gardesi and
colleagues (2009) found that communication may be defensive or strategic and can reflect
structural power dynamics within the health care setting. Communication requires two- way
interaction and may be compounded by the identified lack of meetings or clear
communication pathways within departments and may represent strategic power dynamics
(Gardesi and colleagues, 2009). ENP staff in this study reported a lack of staff meetings in
general and no inter-disciplinary meetings in their workplace. There were limited
opportunities for cross discipline communication which in turn will impact upon
understanding and interdisciplinary respect in the workplace. In order to reinforce ENP
service sustainability, an organizational culture supportive of inter-disciplinary
communication needs to be adopted.
148
Adaptation
ENP services were shown across multiple sources to be responsive to local population needs;
however, adaptation of ENP services was slow and not without challenges. This research
identified that attempts to make changes to the service were frequently challenged, not only
by the capacity of the service due to insufficient staff numbers but also by exclusion from
decision making processes and scope of practice barriers. Challenge to change often occurs
when the reason for change is poorly understood by those responsible for decision making
(Greenhalgh et al, 2004). Innovations that are adaptable to local needs are more likely to be
sustained (Sibthorpe et al, 2005b). Therefore in order to improve future sustainability of
ENP services, a structured framework for decision making processes related to service
provision that includes all key stakeholders needs to be implemented. Additionally,
adaptation may be enhanced through improved understanding of ENP service capability by
all staff.
Understanding
Emergency department staff members were aware of ENP services, but senior management
were reported to be unclear of ENP service role and scope of practice. Allnutt et al, (2010)
found that ambiguity of an innovative service may lead to under-utilisation. Lack of
understanding of ENP service role and scope by senior staff responsible for decision making
may be preventing full utilisation of ENP services and in turn, impede adaptation to meet
local needs. A shared understanding across the organization of skills, knowledge and
attributes relevant to an innovation will positively contribute to innovation sustainability
(May & Finch, 2009; Sibthorpe et al, 2005b). Management staff members need to have a
good understanding of ENP service role and scope of practice to support the ongoing
149
sustainability of ENP services. Strategies to improve understanding of role and scope of ENP
services and optimise service utilisation across the emergency department need to be
implemented.
Networking
Absent networking, poor group cohesion and a sense of isolation has been reported in this
study by ENPs. This may be compounded by the perceived limited communication from
management and lack of ENP staff involvement in decision making processes or attendance at
meetings. Absent partnerships between services of different organizations can also threaten
sustainability (Sibthorpe et al, 2005b) and Greenhalgh et al (2004) posit that the more
complex an innovation the more important it is to have inter-organizational networking to
support the service. ENP service staff support and mentorship, needs to be provided through
networking opportunities with ENPs from different organizations in order to enhance
sustainability of services.
ENP services did not meet the organizational factor indicators however have been sustainable
to date. The reasons for this are unknown however, there are substantial elements negatively
impacting upon the sustainability of ENP services that need to be addressed. Organizational
structures and processes that support full utilisation of the service, networking and team
cohesion, and involvement of all staff in decision making will not only enhance sustainability
but also improve effectiveness of ENP services to meet population health care needs.
150
8.4 Proposition 2 – meeting workforce factor indicators for sustainability
The research proposition and expected pattern identified for this factor was: Emergency nurse
practitioner service meet the indicators for workforce factors of sustainability. The
Sustainability of Innovation framework recognised the following indicators: staff planning,
provision of education and training for ENPs, staff perception of innovation need, and staff
perception of innovation safety and quality. Converged results indicate that ENP services did
not meet all the workforce indicators of sustainability.
Staff planning
Workforce supply and succession planning for ENP services was of concern due to the
impact low staff numbers had upon service delivery and workloads. ENP services did not
have enough staff to cover the requirements of their work unit and alternative strategies had
been employed by ENPs to manage the shortage. Workforce planning is the role of senior
management within emergency departments however, ongoing training of ENP candidates
and increasing service staff numbers is dependent upon funding which must come from the
existing nursing budget (Queensland Government, 2008). The need to take money from one
area to provide funding to support or expand existing ENP services may be impacting upon
suitable succession planning. Adequate numbers of motivated and capable staff are required
to sustain an innovation (Greenhalgh and colleagues, 2004). If ENP services continue to
have low staff numbers and erratic succession planning, job dissatisfaction and attrition may
result. Sibthorpe and colleagues (2005b) and Considine and Fielding (2010) recognised the
need for adequate staff and succession planning for a service to be sustained. To attract and
secure capable and motivated staff to ENP services strategic workforce planning and a
dedicated budget for ENP services is required.
151
ENP education
Despite emergency department staff confidence in ENPs to accurately prescribe and
diagnose, ENP services rarely utilise the high level of expertise and capability of staff
employed in these roles. Concern over loss of knowledge and skills was reported by ENPs in
this study and Greenhalgh et al (2004) recognise that sustainability of an innovation can be
directly correlated to capacity and competence of individual staff members. Regular
education was provided to nursing staff and medical staff at each of the research sites
however, no education specific to ENP service staff was available. ENPs are a different
service level to other nurses and medical staff and therefore have specific educational
requirements. Additionally, skills and knowledge previously attained by ENPs were being
lost through underutilisation. Adequate acquisition of knowledge and skills required to
perform a service innovation will support sustainability (Considine and Fielding, 2010;
Forster, 2011) whilst a lack of confidence or motivation will negatively impact upon
sustainability (Sibthorpe et al, 2005b). Inconsistency between expertise that ENP staff
possess and the role of ENP services has left ENPs feeling disillusioned and vulnerable.
Harnessing the capability of this highly qualified health workforce and providing adequate
support for ongoing education specific to the role is essential to ongoing service
sustainability.
Innovation need
ENP services were regarded by the emergency department staff as a highly needed service.
This was reportedly to be demonstrated by the impact ENP services had on emergency
departments meeting key performance indicators and targets as well as patient and colleague
satisfaction reports. Innovations consistent with values and needs of staff are more readily
152
adopted and acceptability of an innovation by the person responsible for implementing it has
been shown to strongly influence sustainability (Sibthorpe et al, 2005b). ENPs value the
service and substantial progress has been demonstrated in relation to ENP service
acceptability by the emergency department staff members in this research and this will
enhance the sustainability of ENP services.
Innovation Safety and Quality
Overwhelmingly, ENP services have been found to provide safe and high quality care. The
consistent message received from multiple sources support this claim. ENPs claimed to be
the most frequently audited health care professional and that the results of these audits were
favourable. Having processes in place to monitor the quality and outcome of the innovation
and regularly providing staff with this feedback is seen to enhance sustainability (Greenhalgh
et al, 2004). The positive outcomes associated with regular audits enhance ENP service
sustainability. An innovation that provides clear advantages, is of good quality and presents
little risk due to proven safety, will be more readily sustained (Greenhalgh et al, 2004). The
extensive literature reporting ENP service safety and quality and perceived safety of the ENP
service reported in this study will support ENP service sustainability.
ENP services partially met the workforce factor indicators. Strong support has developed for
ENP service need and quality of services provided by emergency department staff and
reinforced by audits and targets however, poor succession planning and low staff numbers
along with poor education provision may impact sustainability of ENP services into the
future.
153
8.5 Proposition 3- Meeting innovation specific factor indicators for
sustainability
The research proposition identified for this factor was: Emergency nurse practitioner service
meet the indicators for innovation specific factors of sustainability. The Sustainability of
Innovation framework recognised the following indicators: supports and barriers for the
innovation, measured quality and safety of the innovation and patient satisfaction with the
innovation. Converged results indicate that ENP services did not meet all the innovation
specific indicators of sustainability.
Supports and Barriers
Full utilisation of an ENP service is dependent upon clear understanding of the ENP role
(Lee, Jennings and Bailey, 2007). This research identified that there was confusion around
ENP service roles and scope. ENPs in this study worked predominantly with patients who
presented to the emergency department with low acuity illnesses or injuries. Despite ENP
staff being among the most highly educated and often most experienced nurses in the
emergency department, they were most frequently caring for the lowest acuity patients.
Research completed by Hayes, Bonner and Pryor (2010) examined the factors contributing to
nurse job satisfaction and found: autonomy of practice, organizational policies and
educational opportunities as some of the factors that determine nurse job satisfaction. Job
satisfaction has been closely aligned with staff intention to leave the NP role (De Milt,
Fitpatrick and McNulty, 2009) and high levels of staff attrition will leave health service
innovations vulnerable.
154
Maintaining expert knowledge and skills to treat patients attending an emergency department
is challenging when ENPs most frequently treat low acuity patients. ENPs were concerned
about loss of skills and underutilisation of ENP services. Some stated they were no longer
practicing as emergency nurses but primary care health nurses due to the scope and extent of
daily work practices. Research by Jones and colleagues in 2013 also found that ENPs were
concerned about becoming deskilled by continuing to work in highly restricted NP roles.
Continued dissatisfaction may lead to attrition of these highly skilled staff and vulnerability
of emergency nurse practitioner service sustainability.
Access to PBS prescriber numbers and MBS provider numbers, scope of practice restraints
and blockage by other health care professionals were other barriers to ENP services
identified. Most ENPs felt they were limited in their daily work and were not utilising their
full capacity. Poor staff morale and motivation are recognised as limiting sustainability of an
innovation (Sibthorpe et al, 2005b) and motivational issues may arise if ENPs skills remain
under-utilised and effectiveness of a service does not reach full potential. Less overtly, ENP
services were restricted by the process involved in adaptation or expansion of ENP services.
Strong medical dominance of the health care system and processes were controlling ENP
scope of practice. Williams (2005) reports that ENP scope of practice has been disseminated
by medical authorities in order to determine ENP practice. Policy and legislative changes
have allowed some health care professionals to expand their scope of practice (Duckett,
2000) however in reality, professional boundaries still largely remain. Excessive restrictions
to practice and workplace processes were preventing full ENP service utilisation and this will
impact on effectiveness and ultimately upon service sustainability.
155
Measured safety and quality
Safety and quality of the emergency nurse practitioner service was not measured in this
research due to the large amount of supporting evidence available that demonstrates nurse
practitioner services provide high quality, safe care to patients (Carter and Chochinov, 2007;
Wand and White, 2007; Jennings et al, 2015). The perceptions of both the emergency
department staff and ENP staff were congruent with the research that found ENP services
were safe and of high quality.
Patient satisfaction
Patient satisfaction with a service being provided is also imperative if it is to be sustained
however, again due to a body of evidence supporting both improved patient access to health
care services (O’Keefe and Gardner, 2005; Horrocks et al, 2002) and patient satisfaction with
care provided by nurse practitioner service (Gardner &Gardner, 2005; Carryer, et al, 2007a;
Jennings et al, 2008; Wilson and Shifaza, 2008) patient satisfaction was not examined in this
research. High level of stake holder satisfaction with the outcomes of an innovation was
recognised to impact positively upon the sustainability of that innovation.
ENP services partially met the innovation specific factor indicators for sustainability.
Extensive evidence to indicate the quality and safety of the innovation is highly supportive of
sustainability. Continued excessive restrictions placed upon the practice of ENPs may lead to
deskilling and consequently staff dissatisfaction and attrition. Barriers preventing full
utilisation of service capacity may be threatening sustainability or impacting indirectly
through staff job satisfaction.
156
8.6 Proposition 4 - Meeting political factor indicators for sustainability
The research proposition and expected pattern identified for the political factor was:
Emergency nurse practitioner service meet the indicators for political factors for
sustainability. The Sustainability of Innovation framework recognised the following
indicators: policy alignment to innovation, regional plan and goal alignment, national and
local champion support and staff involvement in decision making related to ENP services.
Converged results indicate that ENP services did not meet all the political indicators of
sustainability.
Policy Alignment to innovation
Analysis revealed links between National, State and Local policy were clearly documented
within guidelines and policy documents about the implementation of nurse practitioner
service. ENP services are assisting emergency departments to meet key political agendas
such as reducing patient waiting times in emergency departments. Greenhalgh et al (2004)
identified that a strong political focus on one particular policy will influence sustainability of
an innovation related to this policy. ENP service efficiency to assist emergency departments
to meet imposed targets and key performance indicators are strongly driving the
implementation of ENP services and enhancing service sustainability.
Regional plan and goal alignment
Documents outlined NP service linkage to regional plans and goals with recommendations to
form a District Steering Committee to ensure a local context and benefit was maintained. At
a local level evidence of a District Steering Committee involvement was not found. ENP
157
services were reported to be well aligned to local population needs by emergency department
staff and ENPs alike, however limitations placed upon adaption to evolve with population
needs are being impaired. Innovations that are well linked to regional health goals and
planning are more likely to be routinised according to Greenhalgh and colleagues (2004),
however evaluation of alignment was limited due to absent local documentation. Patient
outcome goals, key performance indicators and targets were driving ENP service according
to ENPs interviewed and this alignment is complimentary to sustainability of the service.
Local and national champion involvement
Leadership and support for ENP services lacked a local or national champion.
Overwhelmingly, ENPs felt they ‘did not fit in’ with either the nursing or the medical team
and that they fend for themselves. ENPs in this study had limited contact and networking
with ENPs from other departments and strained relationships at the local level with senior
management. Positive organizational leadership creates a culture that fosters change and the
implementation of an innovation is dependent upon having strong leadership to drive and
advocate for the service. Limited focus on the implementation and organizational support
required for the adoption of ENP services was evident in this research and this has led to poor
team work and cohesion in emergency departments. Sustainability is enhanced with top level
managers display a supportive positive attitude toward an innovation (Greenhalgh et al,
2004). ENP services in this research did not experience a strong local champion to advocate
the service.
158
Decision making
Failure to include staff from all stakeholder levels in decision making has proven to impact
negatively upon the sustainability of an innovation (Greenhalgh et al, 2004; May, 2006;
Chambers et al, 2013). However in this study, staff reported very little or no involvement in
the implementation of ENP services and both ENPs and the multidisciplinary emergency
department staff were not included in decision making processes. Chambers and colleagues
(2013) identified that continuous stakeholder involvement in adaption processes should help
address evolving issues and therefore improve sustainability of an innovation. Failure to
include ENPs and emergency department staff in decision making has two consequences;
firstly, the risk of an incorrect decisions being made due to insufficient stakeholder
involvement and secondly, reduced cross disciplinary shared understanding and goal setting.
If left unaddressed, lack of staff involvement in decision making processes may impact upon
the sustainability of ENP services.
ENP services partially met the political factor indicators and to date have been sustained.
Lack of organizational level support, policies, strategic plans and goals, lack of local or
national champion to advocate and limited involvement in decision making processes
regarding the service may negatively impact upon the sustainability of this service in the long
term. ENP services do however, strongly support the health policy agenda and have
improved emergency department results for key performance indicators and this may support
the ongoing sustainability of the service.
159
8.7 Proposition 5 - Meeting financial factor indicators of sustainability
The research proposition and expected pattern identified for this factor was: Emergency nurse
practitioner service meet the indicators for financial factors of sustainability. The
Sustainability of Innovation framework recognised the following indicators: innovation
funding, budgetary planning and evaluation of the innovations cost effectiveness. Converged
results indicate that ENP services did not meet all the financial indicators of sustainability.
Funding
Examination of the documents related to nurse practitioner service showed funding sources
for ENP services poorly articulated. The onus was placed upon individual district health
services to find funding for ENP services from existing revenue. This situation may place
financial strain on the department and result in one service being sacrificed to implement
another. An innovation that has a dedicated, ongoing and adequate budget sufficient to meet
the needs of the innovation is more likely to be routinised (Greenhalgh et al, 2004). Lack of
documents prevented analysis of funding for ENP services at the local level however funding
for ENP positions was a concern raised by the participants in this study. Ambiguous funding
of innovations seriously threatens the sustainability of an innovation (Sibthorpe et al, 2005).
Funding procedures that segregate budget based on the staff membership rather than the
provision of an entire service by a department may add to contention surrounding ENP
service funding. A dedicated ENP service budget needs to be allotted to allow for ENP
workforce planning and improved sustainability.
160
Budgetary planning
A complete absence of any evidence suggesting that there is budgetary planning for ongoing
ENP services was found during document analysis and reiterated by ENP interviews. ENPs
were concerned about funding for NP candidate positions which were highly volatile and
dependent upon the Government elect. Temporary or unstable funding arrangements leave an
innovation vulnerable and unsustainable (Wiltsey Stirman et al, 2012; Considine and
Fielding, 2010). Examination of the budgetary planning for ENP services was not possible
due to the lack of local document availability. Some services were training candidates and
this suggests some workforce planning and that funding is gained through some avenue.
Emergency department staff reported not knowing about planning for future ENP services.
The inability to access any budgetary planning documents and a lack of transparency
surrounding ENP service planning creates uncertainty for the future of ENP services.
Evaluation
Measuring cost effectiveness whether it be a model of care or a new treatment option, is
imperative in the current health care environment where resources are limited and expenses
scrutinised. The cost effectiveness of the ENP services in this study had not been directly
measured. Lack of research and information to demonstrate the financial value of programs
will leave initiatives vulnerable (Sibthorpe et al, 2005b). Minimal research has been
completed in relation to cost effectiveness of ENP services in general (Carter and Chochinov,
2007; Jennings et al, 2015) however, meeting key performance indicators (KPIs) and targets
were recorded and compared. These indicators along with other auditing strategies such as,
accuracy of prescriptions, diagnostic requests and treatments had provided an indication of
161
some cost benefit offered by ENP services. Lack of research demonstrating cost
effectiveness of ENP services may reduce sustainability of this innovation.
It was unclear if ENP services met the financial factor indicators due to the absence of
documentation. Lack of documentation to support practices may indicate an attitude of
management staff of their considered importance and applicability to practice or, indicate the
level to which policies are integrated into provision of services. This may also be another
demonstration of a ‘work around’ by the health care sector to manage a situation that is
poorly financially and organizationally supported.
8.8 Sustainability of emergency nurse practitioner service
ENP services in this study met the factors that influence sustainability of innovation to
varying degrees. ENP services did not meet all indicators of any factor influencing
sustainability; therefore this may indicate that if at least some indicators of each factor are
met the innovation is sustainable. ENP services in this study have been sustained to date and
reasons for this were not clear however, ENP services strongly support emergency
departments to meet political agendas and are a valued service by all stakeholders. Staff
member preparedness to problem solve and work with limited resources to ensure patient
safety and positive outcomes may be impacting. Staff working in emergency departments
report working through problems that eventuate or where there are gaps in the service,
implying that health service delivery is reliant upon the attributes of staff members to ‘do
what is needed’ to meet patient needs.
162
Limited organizational level support structures for ENP services have been identified in this
research in the areas of: dedicated funding structure, clear leadership and lines of
accountability for workforce planning and education and, development of an organizational
culture that supports ENP services. The impact of this lack of support has been poor team
work, workforce relations and decision making processes resulting in reduced understanding
of ENP service capacity preventing full utilisation of a highly experienced and skilled
workforce. Organizational level structures need to be initiated to not only improve
sustainability of this health service delivery model but also provide the population with
efficient ENP services.
8.9 Operationalising the framework
Applying the Sustainability of Innovation framework to the context of the emergency
department nurse practitioner service has provided some insights for the future use of the
framework. Operationalising the theoretical framework supported and reinforced much of the
previous research findings and published literature that informed the initial adaptation of the
framework. In particular, research into service innovation by Greenhalgh and colleagues’
(2004) and, Sibthorpe and colleagues (2005b) research exploring primary health care
innovation sustainability. Program drift as posited by Wiltsy Stirman, and colleagues in 2012
was clearly evident during the utility of this framework to the dynamic health services
environment. Application of the framework to a research study in a complex health care
context has informed recommendations for changes and application of this theoretical
framework in future research.
163
In general, some of the indicators across each of the five factors were found to be vague or
poorly defined. This resulted in further examination by the researcher to specify more clearly
the indicators during the research to ensure that the intended meaning remained consistent
throughout the study. An example of this is the organizational factor indicator of external
networking opportunities. Once the research began it became clear that this indicator was
referring to staff members who were implementing the innovation networking with external
organizations. Other factor indicators also required clarification of concept during the study.
Some deficits in the theoretical framework factor indicators were also noted. In particular
innovation-specific factors were found to be lacking an impacting indicator; namely
legislation supporting the innovation. Health Workforce Australia (2013) recognised the
supportive or restrictive impact that legislation can have on a health workforce innovation.
Whilst the framework recognised alignment of the innovation to policy and planning, and
innovation adaption to the local context, nowhere in the framework acknowledged the impact
of legislation on the sustainability of the ENP service. The overly restrictive impact that
legislation was having upon ENP services was evident in the research findings.
Additionally, another area that had been neglected by the theoretical framework was that of
satisfaction of the ENP service staff. The findings of this research indicate that ENP staff
members were dissatisfied with their role and scope of practice. Workforce satisfaction has
been shown to directly impact upon staff attrition (De Milt et al, 2009) and consequently
service sustainability. Therefore, the workforce factor of the theoretical framework should
include an indicator that reflects staff satisfaction with their role.
164
The Sustainability of Innovation framework has been demonstrated to accurately inform
factors that influence sustainability of ENP services. Clear parameters around the use of this
framework are yet to be determined as highlighted in this study. For example which, if any,
factors are independent determinants of sustainability or are more heavily influential. An
innovation that strongly meets indicators for some factors of the framework may compensate
or negate the need to meet indicators of other factors. As the emergency nurse practitioner
service was seen to be providing a high quality safe service that was assisting the department
to meet key performance indicators, unmet ENP staff need for ongoing education or
succession planning shortcomings may have been overlooked. How long can an innovation
be sustained if all or some of the factors are not met?
8.10 Strengths and limitations of this study
This research has utilised the Sustainability of Innovation theoretical framework to explore
factors that influence sustainability of emergency department nurse practitioner service. The
theoretical framework that was developed for this research, along with data collection
instruments were supported by strong evidence in the literature review. Additional to this,
large numbers of participants and higher than average response rates to surveys and
individual interviews provided rich data that will inform future practice and policy.
Thorough description of the processes taken in order to complete this research allows for
replication in other contexts or service innovations. Further strength is identified through the
use of case study methodology which has allowed for multiple units of analysis across
multiple sites, data collection sources and methods of analysis which in turn has increased the
validity and reliability of this research.
165
Case study methodology is highly regarded for its ability to explore a case in-depth and
provide highly meaningful data however, it has also been criticised for the lack of widely
generalisable results to wider populations and context. This study was limited in scope to
predominantly one geographical area, metropolitan emergency departments, and therefore it
is difficult to translate the findings to urban or remote areas. Data were collected during one
short time period and therefore information provided at that time may no longer be relevant
in the dynamic emergency department work environment.
Additionally, the use of interviews and surveys as data sources in this research has limitations
such as the unavoidable interaction of the researcher with the participants and the data
(Denscombe, 2014). Interviewer bias was minimised in this research by the use of prompt
guides and researcher awareness. Finally, there was only a minimal amount of
documentation available for analysis, in particular documents related to the local governance
and implementation ENP services. The lack of documentation was a potential limitation to
the findings of this study, however did due to its absence, provide some knowledge and
insight.
Notwithstanding these limitations, this research provides new knowledge in relation to
sustainability of emergency department nurse practitioner service. This knowledge is
transferable and can effectively inform future research into factors that influence
sustainability of health service innovations.
166
8.11 Conclusion
ENP services are expanding across Australian emergency departments as an innovative
service model. The pattern matching process has allowed comparison of the research
findings to the propositions for sustainability across the five factors: political, organizational,
workforce, financial and innovation specific. Comparison of the anticipated outcome directly
measured against the empirical results has revealed substantial new knowledge in relation to
sustainability of ENP services. This research has found that ENP services are meeting some
indicators for each of the factors influencing sustainability and other elements are supporting
or hindering ENP services. In the following chapter conclusions will be drawn and
recommendations made for changes to enhance ENP service sustainability and adaptations to
the Sustainability of Innovation theoretical framework for use in future research.
167
Chapter 9
Summary and recommendations 9.1 Summary
This research has broken new ground using an untested theoretical framework to evaluate a
service innovation. Scant evidence exists informing the evaluation of nurse practitioner
service as a service level against evidence based criteria. This research has addressed this
gap in health service research. Australia is in the midst of major health service reforms. It is
expected that by the year 2020 Australia will be spending 15% of Gross Domestic Product on
healthcare (Butler et al, 2008). Governments around the world are responding to the situation
by implementing reform policies in an attempt to meet health care needs in a cost effective
manner. A multitude of health service innovations are being implemented at local, state and
national levels. The implementation of these innovations is costly in terms of human and
fiscal resources and, not all health service innovations are effective at meeting population
needs or are able to be maintained long term. Emergency nurse practitioner services are a
health service innovation that has experienced a rapid uptake within Australian emergency
departments. The aim of this research project was to explore the factors influencing
sustainability of this health service innovation.
Existing research indicates that emergency nurse practitioner service provides safe, high
quality and cost-effective care (Carter and Chochinov, 2007; Jennings et al, 2008; Wilson and
Shifaza, 2008; Jennings et al, 2015) and receives high levels of patient acceptance and
clinical outcomes (Wand and Fisher, 2006). Despite this, some nurse practitioner services
have not been sustained and the reason for this is unknown. Published studies that have
168
evaluated sustainability of innovations in the context of acute health care services are very
limited.
Sustainability research is grounded in the Diffusion of Innovation theory as posited by
Rogers (1995). This theory has provided a foundation for many models that have been
developed to examine diffusion, adoption and sustainability of innovations in a number of
paradigms (Rogers, 2004). The development of the Sustainability of Innovation theoretical
framework was informed by published literature surrounding sustainability and utilised in
this research project to examine the factors that influence sustainability of emergency nurse
practitioner service.
A proof of concept study reported in chapter 4 identified that the complexity of health care
innovations require a methodology that allows in-depth examination of multiple factors and
data sources in order to provide meaningful results. The methodology chosen to meet the
complexity inherent in this study was case study methodology. Multiple units of analysis in
this research approach provided data via variable data collection methods to inform the
examination of factors of the theoretical framework. Converging results and pattern
matching against propositions improved internal validity of the results that informed the
factors influencing the emergency department nurse practitioner service sustainability.
The results showed that ENP services in this study met some of the indicators of each of the
five factors of the sustainability of innovation framework. ENP services were found to be
providing a high quality service that is perceived to meet the needs of the local population
however, it is marginally supported by the organization and underutilised. Excessive
169
restrictions on ENP service practice and isolation of ENP staff may lead to dissatisfaction and
attrition therefore placing ENP service sustainability at risk.
This research is the first evaluation of factors influencing the sustainability of ENP services
that has reported use of a theoretical framework and has provided valuable information on the
factors that influence sustainability of emergency nurse practitioner service. The research
was conducted using a recognised methodology upon which future research can build and
further develop the knowledge base in this field. Additionally, operationalising the
sustainability of innovation framework has provided insights and recommendations for
changes to the framework for future research into sustainability of health service innovations.
9.2 Conclusion and recommendations – ENP service
The purpose of conducting this research was to examine the factors influencing sustainability
of the ENP service using the Sustainability of Innovation framework to examine service
innovations. This study has revealed that ENP services met some of the indicators for all of
the five factors influencing sustainability. Results show that ENP services deliver high
quality, safe and patient focused care. There is also improved acceptance by emergency
department staff of ENP service delivery models and collaboration for patient care across
disciplines is effective. ENP services have assisted emergency departments to meet key
performance indicators such as the National Emergency Access Targets and are valued by the
team however, some key factors are absent and if left unaddressed will impact negatively on
the sustainability of ENP services.
Supportive organizational culture and leadership for integration of ENP services has been
assumed rather than strategically developed resulting in communication barriers, erratic
170
attendance at workplace meetings and poor dissemination of information. This has left both
ENPs and emergency staff without a voice and has prevented team cohesion, ownership of
ENP services, collaborative decision making and has compounded misunderstandings of ENP
service roles. I conclude that organizational structures have not been implemented to
support the integration of ENP services within emergency departments.
Therefore I recommend:
• Each organization needs to provide a culture supportive of ENP service integration
through
o A strong local leader to advocate for ENP service integration
o Regular cross disciplinary and inter-level staff meetings to foster team
cohesion, improve communication, role understanding and decision making
o Emergency department service goals to be developed annually based on
common understanding of population needs and best cross disciplinary
approach to provide health services
Additionally, restrictive barriers to the scope of practice of ENP service are preventing the
full utilisation of these services. Highly experienced ED staff attending to low acuity patients
has left ENP staff frustrated and concerned about the loss of clinical expertise. ENPs have
reported decreased job satisfaction when not utilising the full extent of their experience and
skills. I conclude that ENP services have not been fully utilised preventing optimal
service delivery.
Therefore I recommend:
• Ensure ENP service scope of practice is utilised to full potential through
171
o Regular review of practice scope in light of common departmental goals with
all key stakeholder involvement.
o Multidisciplinary team member collaboration to optimise the full potential of
ENP services to support health care delivery.
Poor workforce planning and no dedicated budget to fund a consistent service was
concerning for emergency department and ENP service staff alike. Lack of service staff had
impacted in areas such as: consistent service provision, attendance by ENP staff at work unit
meetings and educational opportunities. Small numbers of staff working in ENP roles in
different hospitals has added to the sense of professional isolation. Workaround strategies
were being employed in many cases to meet the workload and ensure patient outcomes
however this practice is not favourable long term. I conclude that insufficient funding and
poor workforce planning has led to insufficient ENP service staff numbers and this was
impacting upon the consistency of service provision, workloads and ENP staff
networking. Additionally, ENP service staff members were not provided with sufficient
educational opportunities congruent with their service level and were reluctant to leave
patients if there were no staff to take over. I conclude that ENP services are under
supported in the workplace in relation to education provision and relief to attend
educational and research opportunities.
Therefore I recommend:
• A dedicated department budget specific for ENP service provision that is stable and
ongoing to allow for workforce planning through
o Increased ENP service staff to allow for consistent provision of a high quality
services that meet population needs and enables ENP staff leave for
educational events and conferences.
172
o Collaborative networking between ENP staff from multiple emergency
department sites through monthly meetings to improve support, networking
and professional development opportunities.
o ENP staff members have rostered non-clinical time for attendance at
educational conferences and events congruent with ENP service level needs.
9.3 Conclusions and recommendations – Sustainability of Innovation
framework
Operationalising the Sustainability of Innovation framework has provided new understanding
that has informed recommendations for adaption of the original framework presented in
chapter four. Improvements for the future use of the framework to examine sustainability of
health service innovations have been identified.
The five factors of the sustainability framework were assumed to be inter-related at
commencement of this study. However, the interactions were unknown and as research
progressed, relationships between sources and factors emerged. The interaction between
factors is diagrammatically represented with bidirectional arrows and was evident in the
application of the framework to evaluate sustainability of the ENP service. Factor indictors
were frequently co-dependent and interactive. Therefore whilst the framework was highly
effective for guiding data sources and collection during this research, caution is advised
during analysis of results. Overuse of the theoretical framework during interpretation of
results could prove to be restrictive and prevent meaningful outcomes. The advantage of case
study methodology and pattern matching technique is that the approach supports
identification of multiple and compounding effects of the results to inform the overall
research question. Convergence and pattern matching enhanced the utilisation of all the data
173
collected to each of the factors of sustainability, allowing for an in-depth analysis of ENP
service sustainability.
Chambers, Glasgow and Stange (2013) recognised continual program drift; this is when an
innovation changes or adapts from how it was originally implemented. Ongoing evaluation,
flexibility and adaptation of ENP services were evident and should be recognised in the
theoretical framework as a supporting indicator of sustainability. Therefore service
innovation drift has been illustrated through the shading behind the framework factors
representing the dynamic nature of each factor which enhances sustainability. For example,
under the innovation drift concept, workforce indicator staff planning would not be examined
as a static situation but as ongoing and dynamic, suitable to adapting to the changing needs of
the service innovation to meet local needs. Therefore I recommend that future research
utilising the Sustainability of Innovation framework, consider each indicator as a
dynamic rather than static situation.
Completing the research recognised that indicators used for each of the factors were poorly
defined and not easily applied to the context. Additionally, analysing the results highlighted
some indicators that had not been considered in the original Sustainability of Innovation
framework. For example, legal constraints and enablers impact upon innovation specific
factors and staff job satisfaction was also identified as an emerging influence and evidence
suggests that this impacts upon sustainability of an innovation. Therefore I recommend
more explicit terms used for the factor indicators and the addition of some indicators in
the theoretical framework to support utility for future research. The changes suggested
to improve clarity of the indicators have been illustrated in blue text and the recommended
additional indicators are illustrated in red in Figure 9.1.
174
• •
Figure 9.1 Sustainability of innovation framework with recommended alterations.
The healthcare environment is complex and dynamic and any innovation introduced into this
context must allow for flexibility and adaptation and this is reflected in this framework and
the operational definition of sustainability. Measuring ‘sustainable’ in terms of the
innovation purpose and desired outcomes is more beneficial than measuring the completion
of a specific process in a certain way.
• Innovation is supported by legislation and guidelines that are used in practice
• Barriers to the innovation are effectively managed
• The innovation is evaluated as safe and of good quality
• Funding sources are identified, secure and ongoing
• budgetary planning for continuation of the innovation are in place
• Evaluation strategies to examine cost effectiveness are planned and conducted
• Clear local, state and national policy alignment with innovation
• Articulated links with regional health plans, goals and vision
• Local champions and senior staff support for the innovation
• Staff involvement in implementation and decision making processes.
• Interdepartmental and intradepartmental communication processes are in place
• The innovation adapts to suit the local population needs
• Staff have a clear understanding of the innovation goals and operation
• Innovation staff network with external organizations
• Workforce recruitment, succession and leave planning in place
• Education and training provisions and processes are available
• Staff perceive the innovation is needed, safe and has a positive impact on patient outcomes
• Staff role satisfaction
175
9.4 Recommendations for further research
Evidence and literature underpinned the development of the Sustainability of Innovation
framework operationalised in this study. Given that each of the research sites in this study
are fully operational and yet only partially meet each of the theoretical framework factors,
further research into the relative importance, and dose interaction of each of these factors is
recommended. Can an innovation that meets all the indicators in one factor of the theoretical
framework sustain without any indicators of another factor? Further examination of ENP
services and the level of compliance to the indicators in the factors of sustainability would be
beneficial to inform this question.
Retrospective studies of health services that have ceased to be operational using the
Sustainability of Innovation framework would be useful and provide valuable insight to
identify where unsustained services met or failed to meet the factors. Comparison of results
from the unsustained service to those currently operating would also add to the understanding
of sustainability, and may provide answers related to relative importance, critical nature and
dose.
Additionally, it is noted that there are currently very few studies that have reported on the
cost effectiveness of ENP services. Given the current health reforms and financial climate in
which they are being introduced, research in this area is recommended to provide
understanding of the impact cost effectiveness may have on sustainability of ENP services.
176
9.5 Closing Comments
This research has made a significant contribution to the body of knowledge surrounding
sustainability of health service innovation. Minimal research had previously been completed
exploring sustainability of the innovation of emergency nurse practitioner service and this
study has provided valuable insights in this field. The Sustainability of Innovation
framework has been operationalised and clear guidelines have been provided regarding the
process taken to allow future replication in other contexts. Following the application to the
emergency nurse practitioner context further recommendations for changes to this framework
have emerged. This research project aimed to increase awareness of the factors that influence
sustainability of health service innovations, in particular emergency nurse practitioner
service. The findings suggest that ENP services partially meet the factors of sustainability
however, there are areas of concern surrounding the full utilisation of the service, the
variance between the perceived and actual role of the ENP and, workplace and professional
support and networking in which ENP services exist. This research has resulted in greater
understanding of the factors that influence sustainability of emergency nurse practitioner
service and it is anticipated that this foundation will be used for further research, informing
policy development and workplace practices.
177
178
179
References
Abercrombie, N., Hill, S. and Turner, B. S. (1984) Dictionary of sociology. Harmondsworth,
UK. Penguin.
Adams, C. (2010) Dying with Dignity in America: The Transformational Leadership of
Florence Wald. Journal of Professional Nursing. Vol. 26. No 2. Pp 125–132.
Anderson, R. (2004) Coordinated Care Trials. Health Policy Developments. Centre for
Health, Economics and Evaluation (CHERE), University of Technology Sydney.
Allnutt, J., Allnutt, N., McCaster, R., O’Connell, J., Middleton, S., Hillege, S., Della, P.,
Gardner, G. and Gardner, A. (2010) Clients’ understanding of the role of nurse practitioners.
Australian Health Review. Vol. 34. Pp 59-65.
Almutairi, A., Gardner, G. E. and McCarthy, A (2013) Practical guidance for the use of a
pattern-matching technique in case-study research: A case presentation. Nursing and Health
Sciences. Vol 16. No 2. Pp 239-244. Doi: 10.1111/nhs.12096.
Ament, S. M. C., Gillissen, F., Moser, A., Maessen, J. M. C., Dirksen, C. D., von Meyenfeldt,
M. F. and van der Weijden, T. (2014) Identification of promising strategies to sustain
improvements in hospital practice: a qualitative case study. BMC Health Services Research.
Vol. 14. Pp 641-653.
American Association of Nurse Practitioners (2013) Nurse Practitioner State Practice
Environment. Available at www.APRN.org Accessed 20th February, 2015.
180
American Association of Nurse Practitioners (2015) Nurse Practitioner Fact Sheet. Available
at http://www.aanp.org/all-about-nps/np-fact-sheet Accessed 20th February, 2015.
Anthony, S. and Jack, S. (2009) Qualitative case study methodology in nursing research: an
integrative review. Journal of Advanced Nursing. Vol. 65. No 6. Pp 1171-1181.
Aston, H (2015) Abbott government’s rebadged Medicare Locals tied up in legal stoush over
name. The Sydney Morning Herald- Federal Politics. July 1.
Australasian College for Emergency Medicine (2005) Guidelines on the Implementation of
the Australasian Triage Scale in Emergency Departments. Available at
www.acem.org.au/media/policies.../g24_implementation__ats.pdf (accessed 17 January
2013).
Australian College of Nurse Practitioners (2012). Available at http:///www.acnp.org.au
(accessed 5 September 2012).
Australian Council of Nurse Practitioners (2012) What is a Nurse Practitioner? Available at
www.acnp.org.au/ (Accessed 8 Nov 2012).
Australian Department of Health. (2013) Casemix. Available at
http://www.health.gov.au/casemix (Accessed 19 January 2015)
181
Australian Department of Health. (2011) Medicare Locals. Available at
http://www.health.gov.au/internet/main/publishing.nsf/Content/medicare-locals (Accessed
19 January 2015).
Australian Government (2008). Close the Gap on Indigenous Disadvantage. Available at
https://www.coag.gov.au/closing_the_gap_in_indigenous_disadvantage .
Accessed 19th January, 2015
Australian Government. (2008) National Disability Strategy Discussion Paper. Canberra:
ACT.
Australian Government. (2008) National Healthcare Reform Agreement, Canberra: ACT.
Australian Government. (2011) Australian National Preventive Health Agency. Strategic
Plan 2011-2015. Canberra: ACT.
Australian Government. (2013) Living Longer Living Better. Canberra: ACT.
Australian Government, Department of Health (2012) Chronic Diseases. Available at
http://www.health.gov.au/internet/main/publishing.nsf/Content/chronic#pre Accessed 29
October, 2014.
Australian Government, Department of Health (2014) Review of Medicare Locals. Available
at http://www.health.gov.au/internet/main/publishing.nsf/Content/review-medicare-locals-
final-report Accessed 27 July, 2015.
182
Australian Government, The Treasury (2015) 2015 Intergenerational Report- Australia in
2055. Available at
http://www.treasury.gov.au/PublicationsAndMedia/Publications/2015/2015-
Intergenerational-Report/HTML/Executive-Summary Accessed 7 January, 2016
Australian Health Ministers’ Conference (2008) National E-Health Strategy summary.
Available at www.ahmac.gov.au/cms.../National%20E-Health%20Strategy.pdf Accessed 29
Sept, 2012.
Australian Institute of Health and Welfare (2005). The National Health Survey 2004-05.
Canberra: AIHW.
Australian Institute of Health and Welfare (2010). Life Expectancy. Available at
http://www.aihw.gov.au/deaths/life-expectancy/ Accessed 16 Dec, 2014.
Australian Institute of Health and Welfare (2012). Health expenditure Australia 2010–11.
Health and Welfare expenditure series No. 47. Cat. No. HWE 56. Canberra: AIHW.
Australian Institute of Health and Welfare (2013). National Partnership Agreement on
Improving Public Hospital Services: National Emergency Access Target. METeOR 489441.
Canberra: AIHW. Available at
http://meteor.aihw.gov.au/content/index.phtml?itemId=tag.DownloadBoxMetadataItems&me
dia=wpml&type=list&items[]=489441&form=short Accessed 1st Mar, 2015.
183
Australian Medical Association (2005). AMA Position Statement: Independent Nurse
Practitioners. Available at http://www.ama.com.au/web.nsf/doc/WEEN-
6FK4BX/$file/AMA_Independent_Nurse-Practitioner_Position_Statement.pdf Accessed 5
Apr, 2012.
Australian Medical Association (2009). Response to the health Legislation Amendment
(Midwives and Nurse Practitioners) Bill . Available at https://ama.com.au/node/4841
Accessed 10 Jun, 2012.
Australian Nursing and Midwifery Accreditation Council, (2014) Consultation Paper 2.
Review of Nurse Practitioner Accreditation Standards. Canberra: Australian Nursing and
Midwifery Council.
Australian Nursing and Midwifery Council, (2006) National Competency Standards for the
nurse practitioner. Canberra: Australian Nursing and Midwifery Council.
Australian Nursing Federation (2011). A snapshot of nurse practitioners in Australia.
Available at
http://anf.org.au/documents/reports/Fact_Sheet_Snap_Shot_Nurse_Practitioners.pdf
Accessed 24 Mar, 2012.
Australian Nurse Practitioner Association (2009) Submission from the Australian Nurse
Practitioner Association to the National Health and Hospital Reform Commission. Available
at
184
https://acnp.org.au/sites/default/files/docs/014_australian_nurse_practitioners_association_su
bmission.pdf Accessed 21 May, 2014.
Avan, B, I. and White, F. (2001) The Proposition: An insight into research. Journal of
Pakistan Medical Association. Available at
http://www.jpma.org.pk/full_article_text.php?article_id=2499 Accessed 28th Feb, 2015.
Baird, C. (2000). Taking the mystery out of research: the pilot study. Orthopaedic Nursing.
Vol. 19. No. 2. Pp 42-48.
Banna S., Hasan H., and Meloche J. (2010) A subjective evaluation of attitudes towards
Ehealth. International Conference on Innovation and Management. Penang, Malaysia
Banta, D. (2003) the development of health technology assessment. Health Policy. Vol. 63.
No 2. Pp 121-132.
Baxter, P and Rideout, E. (2006) Second-year baccalaureate nursing students’ decision
making in the clinical setting. Clinical Decision Making, Vol. 45. No 4. Pp 121-127.
Bauer, J (2010) Nurse practitioners as an underutilized resource for health reform: Evidence-
based demonstrations of cost-effectiveness. Journal of the American Academy of Nurse
Practitioners. Vol. 22. Pp 228-231.
185
Bergen, A and While, A. (2000) A case for case studies: exploring the use of case study
design in community nursing research. Journal of Advanced Nursing. Vol. 31. No 4. Pp 926-
934.
Black, A. D., Car, J., Pagliari, C., Anandan, C., Cresswell, K., Bokum, T., McKinstry, B.,
Procter, R., Majeed, A and Sheikh, A. (2011) The impact of eHealth on the Quality and
Safety of Health Care: A Systematic Overview. PLoS Medicine. Vol 8. No 1
Bowling, A. (1997). Measuring Health: A Review of Quality of Life Measurement Scales,
2nd ed. Buckingham: Open University Press.
Bowling, A. (2009). Research methods in health. Investigating health and health services.
3rd ed. New York USA. Open University Press.
Boxall, A. and Buckmaster, L.(2009) Options for reforming Australia’s health system. Social
Policy Section.. Available at
http://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Librar
y/pubs/BN/0809/HealthReform Accessed 10th Mar, 2013.
Brace, N., Sheely, B., Connor. D. and Martin, C. (2012). Barriers to Attendance at
Continuing Nursing Education Presentations. Nursing Research eJournal for Integrated
Delivery Systems. Available at:
186
http://www.thepermanentejournal.org/files/nursing/ContinuingNursingEducation.pdf
Accessed 1st March, 2015.
Bray, Y. M. and Goodyear-Smith, F. A. (2007) A migrant family’s experience of palliative
care. Journal of Hospice and Palliative Nursing. Vol. 9. No 2.pp 92-99.
Brickmann, S. (2013) Qualitative Interviewing, Understanding Qualitative Research.
Oxford. Accessed online on 3rd Oct, 2014.
http://reader.eblib.com.au.ezp01.library.qut.edu.au/(S(osbkjwjtd2qt52a4df5asyon))/Reader.as
px?p=1274289&o=96&u=T6Lo5jCaFe538sxY28D%2f0A%3d%3d&t=1412301837&h=1F5
EB8171A5852E631EEC543A0A1345BBB6BF05F&s=15759342&ut=245&pg=1&r=img&c
=-1&pat=n&cms=-1&sd=1
Brown, S and Grimes, D. (1995) A meta-analysis of nurse practitioners and nurse midwives
in primary care. Nursing Research. Vol. 44. No. 6. Pp. 332-339.
Boxall, A and Buckmaster, L (2009) Options for reforming Australia’s health system.
Available at
http://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Librar
y/pubs/BN/0809/HealthReform Accessed 21 Jan 2015.
Buchanan, D., Fitzgerald, L., Ketley, D., Gollop, R., Jones, J., Lamont, S., Neath, A and
Whitby, E. (2005) No going back: A review of the literature on sustaining organizational
change. International Journal of Management Reviews. Vol. 7. No 3. Pp 189-205.
187
Bush, R., Lord, E. and Borrott, N. (2009) Diffusion of Innovations. Applying concepts in
Primary and General Practice. The Healthy Communities Research Centre. The University of
Queensland. A report for the IWMDGP.
Buykx, P., Humphreys, J. S., Tham, R., Kinsman, L., Wakerman, J., Asaid, A. and Tuohey,
K. (2012) How do small rural primary health care services sustain themselves in a constantly
changing health system environment? BMC- Health Services Research. Vol. 12. Vol 81.
Calpin-Davies, P. J and Akehurst, R. L (1999) Doctor-nurse substitution: the workforce
equation. Journal of Nursing Management. Vol. 7. Pp 71-79.
Canadian Nurses Association. (2005) Canadian Nurse Practitioner Core Competency
Framework CNA, Ottawa.
Canadian Nurses Association (2011) Collaborative integration plan for the role of nurse
practitioners in Canada. Available at http://www2.cna-
aiic.ca/CNA/resources/bytitle/default_e.aspx Accessed 14 May, 2012.
Carriere, B., Muise, M., Cummings, G., Newburn-Cook, C (2009) Healthcare Succession
Planning: An Integrative Review. Journal of Nursing Administration. Vol. 39. No 12. Pp.
548-555.
Carryer, J., Gardner, G., Dunn, S. and Gardner, A. (2007a) The core role of the nurse
practitioner: practice, professionalism and clinical leadership. Journal of Clinical Nursing.
The Authors. Journal compilation. Pp 1818-1825.
188
Carryer, J., Gardner, G., Dunn, S. and Gardner, A. (2007b) The capability of nurse
practitioners may be diminished by controlling protocols. Australian Health Review. Vol. 31.
No. 1. Pp 108-115.
Carter, A. and Chochinov, A.(2007) A systematic review of the impact of nurse practitioners
on cost, quality of care, satisfaction and wait times in the emergency department. Journal of
Emergency Medicine. Vol. 9. No 4. Pp 286-295.
Cashin, A., Waters, C., O’Connell, J., Christofis, L., Lentakis, A., Rossi, M., and Crellin, D.
(2007) Clinical initiative nurses and nurse practitioners in the emergency department: What’s
in a name? Australasian Emergency Nursing Journal. Vol. 10. Pp 73 – 79.
Centre for Strategic Economic Studies (2009) The Impact of PBS reforms on PBS
Expenditure Savings: Actual and Projected from 2008-09 to 2017-18. Victoria University.
Australia
Chambers, D. A., Glasgow, R. E. and Stange. K.C (2013) The dynamic sustainability
framework: addressing the paradox of sustainment amid ongoing change. Implementation
Science. Vol. 8. Pp 117-128.
Chang, A. M., Gardner, G. E., Duffield, C and Ramis, M. A (2011) Advanced practice
nursing role development: factor analysis of a modified role delineation tool. Journal of
Advanced Nursing. Doi: 10.1111/j.1365-2648.2011.05850.x
189
Cheung, K., Mirzaei, M. and Leeder, S. (2010) Health Policy analysis: a tool to evaluate in
policy documents the alignment between policy statements and intended outcomes.
Australian Health Review. Vol. 34.pp 405-413.
Christofis, L. (2001). Nurse practitioners: an exploration of the issues surrounding their role
in Australian emergency departments. Australasian Emergency Nursing Journal. Vol. 4. No
2. Pp 15-20.
Clarin, O. A. (2007). Strategies to overcome barriers to effective nurse practitioner and
physician collaboration. The Journal for Nurse Practitioners. Vol. 3. No 8. Pp 538-548.
Collins, S. K. and Collins, K. S (2007). Changing workforce demographics necessitates
succession planning in health care. Health Care Management. Vol 26. No. 4. Pp 318-325.
Commonwealth Department of Health and Aged Care. (2001)The Australian Coordinated
Care Trials: final technical national evaluation report on the first round of trials. Canberra:
AGPS.
Cookson, R. (2005). Evidence-based policy making in health care: what is it and what it isn’t.
Journal of Health Services Research and Policy. Vol. 10. Pp 118-121.
Council of Australian Government. (2011a) 2010-2020 National Disability Strategy-An
initiative of the Council of Australian Government. Canberra. ACT.
190
Council of Australian Government (2011b) National Health Reform Agreement. Canberra.
ACT. Available at
http://www.federalfinancialrelations.gov.au/content/npa/health_reform/national-workforce-
reform/national_partnership.pdf Accessed 20th Feb, 2015.
Considine, J. and Fielding, K. (2010) Sustainable workforce reform: case study of Victorian
nurse practitioner roles. Australian Health Review. Vol 34. Pp 297-303.
Considine, J., Martin, R., Smit, D., Winter, C. (2006) Defining the scope of practice of the
emergency nurse practitioner role in a metropolitan emergency department. International
Journal of nurse practitioners. Vol. 12. Pp 205-213.
Cooke, M., Wilson, S. and Pearson, S. (2002) The effect of a separate stream for minor
injuries on accident and emergency department waiting times. Emergency Medicine Journal.
Vol. 19. No 1. Pp 28-30.
Debono, D. S., Greenfield, D., Travaglia, J. F., Long, J, C., Black, D., Johnson, J. and
Braithwaite, J. (2013). Nurses’ workarounds in acute healthcare settings: a scoping review.
Biomed Central, Health Services Research. Vol 13. Pp 175- 194.
De Milt, D. G., Fitzpatrick, J. J. and McNulty, R. (2009). Nurse practitioners’ job satisfaction
and intent to leave current positions, the nursing profession, and the nurse practitioner role as
a direct care provider. American Academy of Nurse Practitioners. Doi: 10.1111/j.1745-
7599.2010.000570.x
191
Denscombe, M (2014) The Good Research Guide: for small-scale social research projects.
5th Ed. McGraw Hill Education. Open University Press. New York.
Department of Human services (2004) Nurse practitioner Implementation Advisory
Committee. Victorian Nurse Practitioner Project. Melbourne. Department of Human Services
Department of Health and Ageing. (2012) PBS Information. Last updated 1.12.12.
http://www.pbs.gov.au/info/general. Accessed 5th Dec, 2012.
Department of Health and Ageing, (2009) Primary health care reform in Australia;
Report to Support Australia’s First National Primary Health Care Strategy, ACT Australia.
Department of Health and Ageing, (2008) The State of our Public Hospitals. Available at
www.health.gov.au/internet/.../Our%20emergency%20departments.pdf Accessed 26 Jan,
2013.
Drennan, J., Naughton, C., Allen, D., Hyde, A., Felle, P., O’Boyle, K., Treacy, P. and Butler,
M. (2009). Independent evaluation of the nurse and midwife prescribing initiative, University
College Dublin, Dublin. Available at
http://www.lenus.ie/hse/bitstream/10147/89103/1/NatIndependentEvaluation.pdf Accessed
28th Feb, 2014.
Driscoll, A., Worrall-Carter, L., O’Reilly, J and Stewart, S. (2005) A Historical Review of
the Nurse Practitioner Role in Australia. Clinical Excellence for Nurse Practitioners. Vol. 9.
No. 3 Pp. 141 – 152.
192
Duckett, S. J. (2000) The Australian health workforce: facts and futures. Australian Health
Review. Vol.23. No.4. Pp 60-77.
Duckett, S. J. (2002) Australian hospital services: An overview. Australian Health Review.
Vol.25. No.1. pp 2-18.
Duckett, S. J. (2005) Interventions to facilitate health workforce restructure. Australia and
New Zealand Health Policy. Vol. 2. No.14.
Duckett, S. J. (2008) The Australian health care system: reform, repair or replace? Australian
Health Review. Vol.32. No.2. pp322-329.
Duffield, C., Gardner, G., Chang, A and Catling-Paull, C. (2009) Advanced nursing practice:
A global perspective. Collegian. Vol. 16. No 2. Pp 55-62. Doi:10.1016/j.colegn.2009.02.001
Dunn, L (1997). A literature review of Advanced clinical nursing practice in the United
States of America. Journal of Advanced Nursing. Vol. 25. Pp 814 – 819.
Elo, S. and Kyngas, H. (2007) The qualitative content analysis process. Journal of Advanced
Nursing. Vol. 62. Pp 107-115.
Esterman, A. J. and Ben-Tovim, D. I. (2002) the Australian coordinated care trials: success or
failure? Medical Journal of Australia. Vol. 177. Pp 469-470.
193
Evashwick, C. and Ory, M. (2003). Organizational characteristics of successful innovative
health care programs sustained over time. Family and Community Health. Vol. 26. No. 3. Pp
177-193.
Flyvbjerg, B (2006) Five Misunderstandings About Case-Study Research. Qualitative
Inquiry. Vol. 12. Pp 219-245.
Forster, D., Newton, M., McLachlan, H. and Willis, K. (2011). Exploring implementation
and sustainability of models of care: can theory help? Biomedical Central Public Health. Vol.
11. Supp 5: S8.
Fox, A. R., Gardner, G. and Osborne, S. (2015) Theoretical frameworks to support health
services research. Australian Health Review. Vol. 39. Pp 70-75. Doi.org/10.1071/AH14031
Fuller, J, Harvey, P and Misan, G. (2004) Is client-centred care planning for chronic disease
sustainable? Experience from rural South Australia. Health and Social Care in the
Community. Vol. 12. No. 4. Pp 318-326.
Gardezi, F., Lingard, L., Espin, S., Whyte, S., Orser, B and Baker, R (2009) Silence, power
and communication in the operating room. Journal of Advanced Nursing. Vol. 65. No 7. Pp
1390-1399. Doi: 10.1111/j.1365-2648.2009.04994.x
Gardner, A and Gardner, G. (2005) A trial of nurse practitioner scope of practice. Journal of
Advanced Nursing. Vol. 49. No. 2. Pp 135-145.
194
Gardner, A., Gardner, G., Middleton, S and Della, P. (2009) The status of Australian nurse
practitioners: the first national census. Australian Health Review. Vol. 33. No 4. Pp 679 –
689.
Gardner, G., Carryer, J., Dunn, S and Gardner, A. (2004) Nurse Practitioner Standards
Project: Report to Australian Nursing and Midwifery Council. Australian Nursing and
Midwifery Council. Dickson, ACT.
Gardner,G,. Dunn, S., Carryer, J. and Gardner, A. (2006) Competency and capability:
imperative for nurse practitioner education. Australian Journal of Advanced Nursing. Vol.
24. No. 1. Pp 8-14.
Gardner, G., Gardner, A and O’Connell, J. (2013) Using the Donabedian framework to
examine the quality and safety of nursing service innovation. Journal of Clinical Nursing.
Vol 23. No 1-2. Pp 145-155. Doi: 10.1111/jocn.12146.Epub2013. Jul 3.
Gardner, G., Gardner, A., MacLellan, L and Osborne, S. (2003) Reconceptualising the
objectives of a pilot study for clinical research. International Journal of Nursing Studies.
Vol. 40. No. 7. Pp. 719-724.
Gardner, G., Gardner, A., Middleton, S., Considine, J., Della, P. and FitzGerald, G. (2013)
Emergency Department Nurse Practitioner Project- A prospective evaluation of the impact of
the nurse practitioner role on emergency department service and outcomes (ED-PRAC)
Project Outline flyer. Available at
195
https://acnp.org.au/sites/default/files/docs/edprac_project_info_flyer_v91013doc.pdf
Accessed 20th Feb, 2015.
Gardner, G., Gardner, A., Middleton, S., Della, P (2009) AUSPRAC Nurse Practitioner
Research Toolkit. Available at,
http://www.nursing.health.wa.gov.au/docs/reports/AUSPRAC_NURSE_PRACTITIONER_R
ESEARCH_TOOLKIT.pdf Accessed 10 Oct, 2012.
Gardner, G., Gardner, A., Middleton, S., Della, P., Kain, V. and Doubrovsky, A. (2010) The
work of nurse practitioners. Journal of Advanced Nursing. Vol. 66. No 10. Pp 2160-2169.
Goudreau, K. A. and Hardy, J. (2006) Succession planning and individual development.
Journal of Nursing Administration. Vol.36. No. 6. Pp 313-318.
Graneheim, U. H. and Lundman, B. (2004) Qualitative content analysis in nursing research:
concepts, procedures and measures to achieve trustworthiness. Nurse Education Today. Vol.
24. Pp 105-112. Doi 10.1016/j.nedt.2003.10.001
Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P. and Kyriakidou, O. (2004) Diffusion of
Innovations in Service Organizations: Systematic Review and Recommendations. Milbank.
Vol. 82. (4). Pp 581-629.
Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P. and Kyriakidou, O. (2005) Diffusion of
Innovations in Service Organizations: A Systematic literature review. Blackwell publishing
Ltd. Vic. Australia.
196
Gruen, R. L, Weeramanthri, T. S. and Bailie, R. S. (2002) Outreach and improved access to
specialist services for indigenous people in remote Australia: the requirements for
sustainability. Journal of Epidemiology and Community Health. Vol. 56. Pp 517-521.
Halbesleben, J. R., Wakefield, D.S. and Wakefield, B. J (2008). Workarounds in health care
settings: literature review and research agenda. Health Care Management Review. Vol 33.
No 1. Pp 2-12.
Hall, J, P and Viney, R, C (2008) National health reform needs strategic investment
in health services research. Medical Journal of Australia. Vol. 188. No 1. Pp33-35.
Hall J. (2005) Health care workforce planning: can it ever work [editorial]?
Journal of Health Service Research and Policy. Vol.10. pp 65-66.
Hanson, H., Salmoni, A. and Volpe, R. (2009) Defining Program Sustainability: Differing
Views of Stakeholders. Canadian Public Health Association. Vol. 100. No 3. P 304 – 309.
Harris, D and Chaboyer, W. (2002) The expanded role of the critical care nurse: A review of
the current position. Australian Critical Care. Vol. 15. No. 4. Pp 133–137.
Hayes, B., Bonner, A. and Pryor, J. (2010). Factors contributing to nurse job satisfaction in
the acute hospital setting: A review of recent literature. Journal of Nursing Management. Vol.
18. Pp 804-814.
197
Health Workforce Australia (2012a) Expanded Scopes of Practice Program. Available at,
http://www.hwa.gov.au/our-work/boost-productivity/expanded-scopes-practice-program
Accessed on 20th Jan, 2015.
Health Workforce Australia (2012b) Health Workforce 2025- Doctors, Nurses and Midwives.
Available at, https://www.hwa.gov.au/our-work/health-workforce-planning/health-
workforce-2025-doctors-nurses-and-midwives Accessed on 20th Mar, 2015
Health Workforce Australia (2014) Australia’s Future Health Workforce- Nurses Detailed.
Available at,
https://www.health.gov.au/internet/main/publishing.nsf/Content/34AA7E6FDB8C16AACA2
57D9500112F25/$File/AFHW%20-%20Nurses%20detailed%20report.pdf Accessed on 7th
Jan, 2016.
Hesse-Biber, S. and Leavy, P (2006) The Practice of Qualitative Research. Sage Publishers.
North America.
Horrocks, S., Anderson, E and Salisbury, C. (2002) Systematic review of whether nurse
practitioners working in primary care can provide equivalent care to doctors. British Medical
Journal. Vol. 324. Pp 819-823.
Horvath, J (2014) Review of Medicare Locals. Available at
http://www.health.gov.au/internet/main/publishing.nsf/Content/medicare-locals Accessed
20th Jan, 2015.
198
Hsieh, H and Shannnon, S, E. (2005). Three Approaches to Qualitative Content Analysis.
Qualitative Health Research. Vol. 15. No 9. Pp 1277-1288.
Humphreys, J., Wakerman, J. and Wells, R. (2006). What do we mean by sustainable rural
health services? Implications for rural health research. Australian Journal of Rural Health.
Vol. 14. Pp 33-35
International Council for Nurses (2000). Implementing Nurse Prescribing: A review of
current practices internationally. International Council of Nurses. Geneva, Switzerland
International Council for Nurses (2006). Fundamentals of Nursing. International Council of
Nurses. Geneva, Switzerland
Jenkins, M. and Torrisi, D. L. (1995) Nurse practitioners, community nursing centers and
contracting for managed care. Journal of American Academic Nurse Practitioners. Vol. 7.
Pp 119-123.
Jennings, N., Clifford, S., Fox, A. R., O’Connell, J and Gardner, G (2015) The impact of
nurse practitioner services on cost, quality of care, satisfaction and wait times in the
emergency department - a systematic review. International Journal of Nursing Studies. Vol.
52. No. 1. Pp. 421-435.
Jennings, N., O’Reilly, G., Lee, G., Cameron, P., Free, B. and Bailey, M. (2008) Evaluating
outcomes of the emergency nurse practitioner role in a major urban emergency department,
Melbourne, Australia. Journal of Clinical Nursing. Vol.17. Pp 1044-1050.
199
Johnston, K., Hays, C., Center, H. and Daley, C. (2004) Building capacity and sustainable
prevention innovations: a sustainability planning model. Evaluation and Program Planning.
Vol. 27. Pp 135-149.
Jolly, R (2013). Budget Review 2012-13 Index. E-Health. Parliament of Australia. Canberra.
Keating, S., Thompson, J. and Lee, G. (2010) Perceived barriers to the sustainability and
progression of Nurse Practitioners. International Emergency Nursing. Vol. 18. No. 3. Pp 147-
153.
Kenny, A. and Duckett, S. J. (2004). A question of place: medical power in rural Australia.
Social Science and Medicine. Vol. 58. Pp 1059-1073.
Kirch, W. (2008). Encyclopedia of public health. New York. Springer.
Lawton, L., Thomas, S and Morel, D. G (2015) Trends in access block 2011 to 2013: The
Redcliffe National Emergency Access Target experience. Emergency Medicine Australasia.
Vol. 27. Pp 11-15. Doi: 10.1111/1742-6723.12345.
Lee, G., Jennings, N and Bailey, M. (2007) An exploration of staff knowledge on the nurse
practitioner’s role in the emergency department. Accident and Emergency Nursing. Vol. 15.
Pp 79-87. Doi:10.1016/j.aaen.2007.01.002
200
Lemer, C., Cheung, R., Viner, R and Wolfe (2015) Health policy research: successes and
challenges. Achieve of Diseases in Childhood. Vol. 100. Pp 376-379.
Doi:10.1136/archdischid-2014-306042
Lindenauer, P. K., Pekow, P. S., Lahti, M. C., Lee, Y., Benjamin, E. M and Rothberg, M. B
(2010) Association of Corticosteroid Dose and Route of Administration With Risk of
Treatment Failure in Acute Exacerbation of Chronic Obstructive Pulmonary Disease.
Journal of American Medical Association. Vol. 303. No 23. Pp 2359 - 2367.
Lowe, G. (2010). Scope of emergency nurse practitioner practice: where to beyond clinical
practice guidelines. Australian Journal of Advanced Nursing. Vol. 28. No 1. Pp 74-82.
Mancini, J, A. and Marek, L. (2004) Sustaining community-based programs for families:
conceptualization and measurement. Family relations. Vol. 53. No. 4. Pp 339- 47.
Marcus, D. (1999) Coordinating Care in an Uncoordinated Health System: The Development
and Implementation of Coordinated Care Trials in Australia. Social Policy Group. Available
at
http://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Librar
y/Publications_Archive/CIB/cib9899/99CIB11#Problems Accessed 20th February, 2015.
Mariano, C (1998). The case for interdisciplinary collaboration. Nursing Outlook. Vol. 37 no
6. Pp 285-288.
Martin, R. and Considine, J (2005) Knowledge and attitudes of ED staff before and after
implementation of the emergency Nurse Practitioner role. Australasian Emergency Nursing
Journal. Vol. 8. Pp 73-78.
201
Martin, S (2013) Healthcare: Reform or ration. The Committee for Economic Development of
Australia. Melbourne, Australia
May, C (2006) A rational model for assessing and evaluating complex interventions in health
care. BMC Health Services Research. Vol 6. Pp 1-11.
May, C, Murray, E., Finch, T., Mair, F., Treweek, S., Ballini, L., Macfarlane, A. and Rapley,
T. (2010) Normalization Process Theory On-line Users’ Manual and Toolkit. Available at
http://www.normalizationprocess.org [accessed on 5th November 2012].
May, C. and Finch, T. (2009) Implementing, embedding and integrating practices: an outline
of normalization process theory. Sociology. Vol.43. pp 535-554.
Medicare Australia (2013) What is Medicare? Available at
http://www.medicareaust.com/medicareandyou-dental/screenreader/module1.html. Accessed
26 January 2013.
Medicines Australia (2009) PBS Reforms- Are they working? The Evidence. Medicines
Australia Occasional Paper Series. No 1. Deakin. ACT
Middleton, S., Gardner, G., Gardner, A., Della, P., Gibb, M., Millar, L. (2010) The first
Australian nurse practitioner census. International Journal of Nurse Practitioners. Vol.16. no
5. pp 517 – 524.
202
Middleton, S., Gardner, A., Gardner, G. and Della, P. (2011) The status of Australian nurse
practitioners: the second national census. Australian Health Review. Vol.35. pp 448 – 454.
Mills, J., Chamberlain-Salaun, J., Henry, J., Sando, J., and Summers, G. (2012) Nurses in
Australian acute care settings: experiences with and outcomes of e-health. An integrative
review. International Journal of Management and Information Technology. Vol. 3. No 1. Pp
1-8.
Ministerial Taskforce on Nursing (1998). Report of the ministerial taskforce on nursing.
Releasing the potential of nursing. Wellington, New Zealand: Ministry of Health. 1-28.
Available at: http://www.moh.govt.nz/moh.nsf/wpg_Index/Publications-
Report+of+the+Ministerial+Taskforce+on+Nursing (accessed Oct 2012)
Misener, T.R. and Cox, D.L (2001) Development of the Misener Nurse Practitioner Job
Satisfaction Scale. Journal of Nursing Measurement. Vol. 9. No 1. Pp 91-108.
Mills, A. J., Durepos, G & Wiebe, E. (2010) Encyclopedia of case study research. Thousand
Oaks, CA: Sage Publications.
Morgan, S.(2010). What are the differences in nurse practitioner training and scope of
practice in the US and UK? Nursing Times. Vol. 106. No 27. Pp 21-24.
203
Murry Cram, J. and Nieboer, A. P (2013) Short and long term improvements in quality of
chronic care delivery predict program sustainability. Social Sclience and Medicine. Vol.
101. pp. 148-154.
Murray, C., Lauer, J., Tandon, A. and Frenk J. (2000) Measuring overall Health System
Performance for 191 Countries. Discussion Paper Series No. 30. World Health
Organization. Geneva.
Mushlin, A. and Ghomrawi, H, (2010) Health Care Reform and the Need for Comparative-
Effectiveness Research, The New England Journal of Medicine. Vol. 353. No. 14. E6 1-3.
National Health and Hospital Reform Commission, (2009) Beyond Blame Game:
Accountability and performance benchmarks for the next Australian Health Care
Agreements’, Available at
http://www.health.gov.au/internet/nhhrc/publishing.nsf/Content/504AD1E61C23F15ECA257
4430000E2B4/$File/BeyondTheBlameGame.pdf ( Accessed 16 October 2012).
National Health Performance Authority, (2014) Emergency Department Services. Available at,
http://www.myhospitals.gov.au/hospital/ipswich-hospital/services/emergency-
department/number-of-patients (Accessed 30 September 2014).
National Prescribing Services (2013) Pharmaceutical Benefits Scheme. Available at
http://www.nps.org.au/glossary/pharmaceutical-benefits-scheme-pbs Accessed 26 January,
2013.
204
Nicholls, D., Gaynor, N.,Shafiei, T., Bosanac, P and Farrell, G. (2011). Mental health nursing
in emergency departments: the case for a nurse practitioner role. Journal of Clinical Nursing.
Vol. 20. Pp 530-536.
NSW Department of Health. (2000). Nurse Practitioner services in rural/remote area health
services implementation policy. Sydney, Australia: Author
Nordqvist, C., Timpka, T. and Lindqvist, K (2009). What promotes sustainability in Safe
Community programmes? BMC Health Services Research. Vol. 9. No 4.
Nursing and Midwifery Board of Australia, (2014). Nurse and Midwife Registrant Data:
September, 2014. Available at http://www.nursingmidwiferyboard.gov.au/Registration-and-
Endorsement.aspx Accessed 20th February, 2015.
Nursing and Midwifery Board of Australia, (2014b). Guidelines on endorsement as a nurse
practitioner . Available at http://www.nursingmidwiferyboard.gov.au/Registration-and-
Endorsement/Endorsements-Notations.aspx Accessed 20th February, 2015.
O’Connell, J. and Gardner, G. (2012) Development of clinical competencies for emergency
nurse practitioners: A pilot study. Australasian Emergency Nursing Journal. Vol 15. Pp
195-201.
O’Keefe, E and Gardner, G. (2004) Researching the sexual health nurse practitioner scope of
practice: A blueprint for autonomy. Australian Journal of Advanced Nursing. Vol. 21. No. 2.
Pp 33-41.
205
Olsen, I. (1998). Sustainability of health care: a framework for analysis. Health Policy and
Planning. Vol. 13. No 3. Pp 287-295.
Orchard, C. A., Curran, V. and Kabene, S (2005) Creating a Culture for Interdisciplinary
Collaborative Professional Practice. Medical Education Online. Available at
http://www.med-ed-online.org Accessed 25 May, 2015.
Patton, M. Q. (2002) Qualitative Evaluation and Research Methods. 3rd ed. London. Sage
Publications.
Platt, J. (1992) “Case Study” in American methodological thought. Current Sociology. Vol.
40. No 1. Pp 17-48.
Pluye, P., Potvin, J., Denis, L and Pelletier, J (2004). Program sustainability: focus on
organizational routines. Health Promotion International. Vol. 19. No. 4. Pp 489-500.
Pluye, P., Potvin, L., Denis, J., Pelletier, J and Mannoni, C. (2005). Program sustainability
begins with the first events. Evaluation and Program Planning. Vol. 28. Pp 123-137.
Podger, A and Hagan, P. (1999) Reforming the Australian Health Care System. The Role of
Government. Commonwealth Department of Health and Aged Care
Productivity Commission. (2005) Australia’s Health Workforce: Research Report.
Australian Government, Commonwealth Department of Ageing. Canberra, ACT
206
Queensland Government. (2011) Clinical Governance for Nurse Practitioners in Queensland
– A Guide. Queensland Government, Brisbane. Office of Chief Nursing Officer,
www.health.qld.gov.au/ocno/content/np_home.htm Accessed 12th April 2012.
Queensland Government. (2011) Clinical Services Capability Framework Version 3.0.
Queensland Health. Available at http://www.health.qld.gov.au/cscf/docs/1_fundamentals.pdf
Accessed 28 December 2012.
Queensland Health (2008) Queensland Nurse Practitioner Implementation Guide. Available at
http://centreforpallcare.org/assets/uploads/Qld_Nurse_Practitioner_Implementation_Guide.pdf.
Accessed 27th February 2014.
Queensland Health (2012) Hospital and Health Service Profiles. Available at
http://www.health.qld.gov.au/services/ Updated 20 February 2012. Accessed 24 January
2013.
Queensland Health (2015) Nursing and Midwifery Office Queensland: Nurse Practice Scope
Register. Available at http://www.health.qld.gov.au/nmoq/nurse-practitioner/practice-
scope.asp Updated 27th January 2015. Accessed 27th February 2015.
Queensland Health (2013) Strengthening health services through optimising nursing: strategy
and action plan (2013-2016). Available at
http://www.health.qld.gov.au/nmoq/documents/strengtheninghltservicesplan.pdf Accessed
27th February 2015.
207
Read, S. M. and George, S. (1994) Nurse practitioners in accident and emergency
departments: reflections on a pilot study. Journal of Advanced Nursing. Vol 19. Pp 705-716.
Research Australia, 2011, Shaping Up: Trends and Statistics in Funding Health and Medical
Research, Occasional Paper Series: Two, Melbourne.
Reveley, S. (2001) Clinical nurse specialists, nurse practitioners and levels of practice: what
does it all mean? In Nurse Practitioners: Developing the Role in Hospital Settings (Reveley,
S., Walsh, M and Crumbie, A. eds) Butterworth-Heinemann, Oxford, pp. 28-37.
Roberts, K. and Taylor, B (1997). Nursing Research Processes: an Australian Perspective.
Nelson ITP. Melbourne.
Rogers, E. M. (1995) Diffusion of innovations, 4th edition. New York: Free Press.
Rogers, E, M. (2004) A Prospective and Retrospective Look at the Diffusion Model. Journal
of Health Communication. Vol. 9 pp.13-19.
Roxon, N. (2009). Midwives/Nurse Practitioner Amendment. Media release, 5 November
2009. Canberra: Department of Health and Ageing. Available at
http://www.health.gov.au/internet/ministers/publishing.nsf/Content/2058DEFA0189D8CA25
766500168B86/$File/nr201.pdf. Accessed 12 January 2011.
Royal College of Nursing (2010) Submission to the Prime Minister’s Commission on nursing
and midwifery. RCN London.
208
Ryan, B. and Gross, N. (1943) The Diffusion of hybrid seed corn in two Iowa communities.
Rural Sociology. Vol. 8. Pp. 15-24.
Sarriott, E., Winch, P., Ryan, L et al (2004). Qualitative research to make practical sense of
sustainability in primary health care projects implemented by non-governmental
organizations. International Journal of Health Planning and Management. Vol 19. Pp 3-22.
Scheirer, M. (2005). Is sustainability possible? A review and commentary on empirical
studies of program sustainability. American Journal of Evaluation. Vol. 26. No 3. Pp 320-
347.
Schofield, D., Page, S., Lyle, D and Walker, T. (2006) Ageing of the baby boomer
generation: how demographic change will impact on city and rural GP and nursing
workforce. Rural and Remote Health. Vol. 6. Available from: http://rrh.deakin.edu.au.
(Accessed 19 January 2012).
Schofield, D and Beard, J. (2005) Baby boomer doctors and nurses: demographic change and
transitions to retirement. Medical Journal of Australia. Vol. 183. Pp 80-83.
Searle, J. (2007) Nurse practitioner candidates: Shifting professional boundaries.
Australasian Emergency Nursing Journal. Vol.11. pp 20-27.
Shediac-Rizkallah, M and Bone, L. (1998) Planning for the sustainability of community-
based health programs: conceptual frameworks and future directions for research, practice
and policy. Health Education Research. Vol. 13. No 1. Pp 87-108.
209
Sherwood, G., Brown, M., Fay, V and Wardell, D. (1997) Defining nurse practitioner scope
of practice: expanding primary care services. Internet Journal of Advanced Nursing Practice.
Vol. 1. No 2. Available at www.ispub.com/journals/IJAN (Accessed March 2012)
Sibthorpe, B., Glasgow, N & Wells, R. (2005a) Questioning the sustainability of primary
health care innovation. Medical Journal of Australia. Vol. 183. No. 10 pp S52 – S53.
Sibthorpe, B., Glascow, N. and Wells, R. (2005b) Emergent themes in the sustainability of
primary health care innovation. Medical Journal of Australia; Vol. 183 (10) pp s77-s80.
Simons, H. (2009). Case Study Research in Practice. London. Sage Publications.
Spitzer, W. O. (1978) Evidence that justifies the introduction of new health professional. In
The Professions and Public Policy (Slayton P. & Trebilcock M. J., eds), University of
Toronto Press, Toronto. Pp 211-236.
Stake, R (1995) The art of case study research. Thousand Oakes, CA: Sage Publications Ltd.
Stake, R (2008) sited in Denzin NK & Lincoln, YS (ed) Strategies of Qualitative Inquiry 3rd
Ed. London. Sage Publications Ltd.
Taylor, M. (2008). Australian Health Care Reform: A place for nurse practitioners?
Australian Nursing Journal. Vol. 15. No 6. Pp 20 – 23.
210
Taylor, M. and Hill, S (2014). Consumer expectations and healthcare in Australia. Australian
Healthcare and Hospitals Association. No. NLCG- 3.
Tham, R., Humphreys, J., Kinsman, L., Buykx, P., Asaid, A., Tuohey, K. and Riley, K
(2010). Evaluating the impact of sustainable comprehensive primary health care on rural
health. Australian Journal of Rural Health. Vol. 18. Pp 166-172.
Tuckett, A., Winters-Chang, P., Bogossian, F and Wood, M. (2014). ‘Why nurses are leaving
the profession….lack of support from managers’: What nurses from an e-cohort study said.
International Journal of Nursing Practice. doi:10.1111/ijn.12245
Tye, C and Ross, F. Blurring boundaries: professional perspectives of the emergency nurse
practitioner role in a major accident and emergency department. Issues and innovations in
nursing practice. Vol 31. No 5. Pp 1089-1096.
United States Department of Health and Human Services (2014) The Number of Nurse
Practitioners and Physician Assistants Practicing Primary Care in the United States: Primary
Care Workforce Facts and Stats. No. 2. Agency for Healthcare Research and Quality.
Rockville, MD.
http://www.ahrq.gov/research/findings/factsheets/primary/pcwork2/index.html
Valente, T. W. (1996) Social Network Thresholds in Diffusion of Innovations. Social
Networks. Vol. 18. No 1. Pp 69-89.
Van Der Weyden, M, B. (2002) Australian health policy research and development:
211
where is it [editorial]? Med J Aust. 177: 586.
Victorian Department of Health (2014). Closing the Gap in Aboriginal health outcomes
initiative: final evaluation report. Available at: http://apo.org.au/research/closing-gap-
aboriginal-health-outcomes-initiative-final-evaluation-report Accessed 19 January, 2015.
Victorian Government Department of Human Services (2000). The Victorian nurse
practitioner project: Final report of the taskforce. Melbourne, Australia: Policy Development
and Planning Division.
Victorian Government Department of Human Services (2011). National Health Reform.
Melbourne, Australia: Policy Development and Planning Division.
Wand, T. and Fisher, J (2006) The mental health nurse practitioner in the emergency
department: An Australian experience. International Journal of Mental Health Nursing. Vol.
15. Pp 201-208.
Walt, G., Shiffman, J., Schneider, H., Murray. S. F., Brugha, R and Gilson, L (2008). ‘Doing’
health policy analysis: methodological and conceptual reflections and challenges. Health
Policy and Planning. Vol 23. Pp 308-317. Doi:10.1093/heapol/czn024.
Wand, T. and White, K (2007) Progression of the mental health nurse practitioner role in
Australia. Journal of Psychiatric and Mental Health Nursing. Vol. 14. Pp 644-651.
212
Weiland, S. A. (2008) Reflections on independence in nurse practitioner practice. Journal of
American Academic Nurse Practitioner. Vol 20. No 7. Pp 345-352.
Wengraf, T. (2001) Qualitative Research Interviewing. Thousand Oaks, California: Sage
Publishing
Wilson, A and Shifaza, F (2008) An evaluation of the effectiveness and acceptability of nurse
practitioners in an adult emergency department. International Journal of Nursing Practice.
Vol. 14. Pp 149-156.
Wiltsey Stirman, S., Kimberley, J., Cook, N., Calloway. A., Castro. F. and Charns, M (2012)
The sustainability of new programs and innovations: a review of the empirical literature and
recommendations for future research. Implementation Science. Vol 7. Pp 17- 36.
Winter, C., Jenkins, J. and Stergiou, H. (2006) Rapid Assessment Team and Fast Track.
Better State of Hospitals Conference. Available at,
http://www.health.vic.gov.au/archive/archive2009/bshconference/ppts/stergiou_helen.pdf
Accessed, 26 January, 2013.
World Health Organization (2000) World health report. Available at
http://www.who.int/whr/2000/media_centre/press_release/en/ Accessed, 28 January, 2014.
Wynne, R. ( 2003) Clinical nurses’ response to an environment of health care reform and
organizational restructuring. Journal of Nursing Management. Vol. 11. Pp 98 – 106.
213
Yin, R. (2014). Case Study Research Design and Methods. 5th Ed. London. Sage
Publications Ltd.
214
APPENDIX A:
Ethics approval ED-PRAC HREC/11/QHC/45
215
APPENDIX B
Queensland University of Technology Human Research Ethics Committee Approval 1200000717
ETHICS APPROVAL
From: QUT Research Ethics Unit Sent: Thursday, 10 January 2013 11:05 AM
To: Amanda Fox
Subject: Ethics Application Approval -- 1200000717 Dear Prof Glenn Gardner Project Title: A prospective evaluation of the impact of the nurse practitioner role on emergency department service and outcomes [Part A1] Ethics category: Human - Administrative Review QUT approval number: 1200000717 ( HREC approval number: HREC/11/QHC/45 ) QUT clearance until: 31/12/2014 (as per HREC approval) We are pleased to advise that your administrative review application has been reviewed by the Chair, University Human Research Ethics Committee (UHREC), and confirmed as meeting the requirements of the National Statement on Ethical Conduct in Human Research (2007). I can therefore confirm that your application has received QUT administrative review approval based on the approval gained from Human Research Ethics Committee (HREC), approval number HREC/11/QHC/45. We note this HREC has awarded the project ethical clearance until 31/12/2014. CONDITIONS OF APPROVAL Please ensure you and all other team members read through and understand all UHREC conditions of approval prior to commencing any data collection: - Standard: Please see attached or www.research.qut.edu.au/ethics/humans/stdconditions.jsp - Specific: None apply VARIATIONS HREC should be considered the lead HREC in terms of the ethical review of this project. As such, all variations must first be approved by HREC before submission to QUT for ratification. Please submit to QUT using our
216
online variation form: www.research.qut.edu.au/ethics/humans/var/
MONITORING Please ensure you also provide QUT with a copy of each adverse event report and progress report submitted to HREC. Administrative review decisions are subject to ratification at the next available UHREC meeting. You will only be contacted again in relation to this matter if UHREC raises additional questions or concerns. Please don't hesitate to contact us if you have any queries. We wish you all the best with your research. Kind regards Janette Lamb on behalf of the Chair UHREC Research Ethics Unit | Office of Research | Level 4 88 Musk Avenue Kelvin Grove | Queensland University of Technology p: +61 7 3138 5123 | e: [email protected] | w: www
217
APPENDIX C
NURSE PRACTITIONER SERVICE PATTERNS
Please fill out separately for each nurse practitioner employed by the Emergency
Department
1. Do you cover all ATS categories (1-5)?_____________________
If no, what ATS categories do you cover?____________________
2. Indicate the amount of time you spend in each of the following service area/care models in
a week.
Areas None of
the time
Some of
the time
Often Most of
the time
All of the
time
Triage
Resuscitation
Acute Care
Ambulatory/Fast Track
Rapid Assessment Team
Alternative NP role/ activities:
218
3. Nurse practitioner parameters of practice
3.1) Do you have a PBS number? Yes/ No (please circle)
If no, to what extent does this limit your practice?
1 2 3 4 5
Not at all limiting Extremely limiting
3.2) Do you have a Medicare provider number? Yes/No (please circle)
If no, to what extent does this limit your practice?
1 2 3 4 5
Not at all limiting Extremely limiting
3.3) To what extent does the refusal of your referrals limit your practice?
1 2 3 4 5
Not at all limiting Extremely limiting
3.4) To what extent are you limited by your scope of practice?
1 2 3 4 5
Not at all limiting Extremely limiting
3.5) Are you authorised to sign your patients work cover forms? Yes/ No
If no, to what extent does this limit your practice?
1 2 3 4 5
Not at all limiting Extremely limiting
3.6) What percentage of your time is available for non-clinical activities?
_____________________________________________%
219
APPENDIX D:
Ethics Approval- HREC/13/QPCH/204 Enquiries to: Office Ph: Our Ref:
R&[email protected] (07) 3139 4198 (07) 3139 4500 Approval Amendments
25 November 2013 Human Research Ethics Committee
Metro North Hospital and Health Service The Prince Charles Hospital
Administration Building, Lower Ground Rode Road, Chermside QLD 4032
Ms Amanda Fox 18 Frances Ave WOOLOOWIN QLD 4030
Dear Ms Fox HREC/13/QPCH/204: Factors influencing sustainability of health service innovation - Emergency Nurse Practitioner Service I am pleased to advise that The Prince Charles Hospital Human Research Ethics Committee reviewed the amendments submitted and upon recommendation, the Chair has granted approval for the following:
• Participant Information Sheet and Consent Form Version 2 dated 1 November 2013 • Consent Form Version 2 dated 1 November 2013
This information will be tabled at the HREC meeting on 23 January 2014 for noting. A copy of this approval must be submitted to the relevant Hospital & Health Service Research Governance Officer/s or Delegated Personnel, along with Site Specific documentation, for CEO or Delegate authorisation for each site. List of approved Sites: No. Site 1. Redland Hospital 2. Redcliffe Hospital 3. Ipswich Hospital Patient information collected and distributed as part of the previously approved research has been approved in accordance with Section 62 of the Health Services Act and the recent amendments to the Public Health Act Sections 282 and 284. Any change to the collection and or distribution will need to be reviewed by the HREC. This HREC is constituted and operates in accordance with the National Health and Medical Research Council’s (NHMRC) National Statement on Ethical Conduct in Human Research (2007),
220
NHMRC and Universities Australia Australian Code for the Responsible Conduct of Research (2007) and the CPMP/ICH Note for Guidance on Good Clinical Practice. Please be advised that in the instance of an investigator being a member of the HREC, they are absented from the decision making process relating to that study. On behalf of the Human Research Ethics Committee, I would like to wish you every success with your research endeavour. Yours truly, Anne Carle A/Executive Officer – Research, Ethics and Governance Unit The Prince Charles Hospital
221
APPENDIX E
Multidisciplinary team participant information and instructions
PARTICIPANT INFORMATION AND CONSENT INFORMATION
(Multi-disciplinary team)
Full Research Title: Factors influencing sustainability of healthcare innovation: emergency nurse practitioner service
Principal Researcher:
Ms Amanda Fox
Lecturer/Unit Coordinator
School of Nursing
Queensland University of Technology
Brisbane
(07) 3138 3884
Principal Supervisor:
Dr Glenn Gardner
Professor of Clinical Nursing
Queensland University of Technology
Brisbane
(07) 3636 2140
Associate Supervisor:
Dr Sonya Osborne
Senior Lecturer
Queensland University of Technology
Brisbane
(07) 3138 3785
222
Your consent
I wish to invite you to participate in the above study. This participant information document
contains detailed information about the study. Its purpose is to explain to you as openly and
clearly as possible the procedures involved in this study before you decide whether or not to
take part.
Please read the participant information carefully. Feel free to ask questions about any
information in the document by contacting the principal researcher.
Introduction
The Australian health care system is under increasing pressure to provide the population with
access to efficient and cost-effective health care. Many health service innovations have been
implemented in an attempt to meet growing demands, however, the sustainability of these
innovations has not yet been evaluated.
The emergency department nurse practitioner service is the most frequently implemented
model in Australia. This research seeks to examine the factors influencing sustainability of
emergency department nurse practitioner service. The results of this research will be used to
inform health policy development and to guide future implementation and evaluation of
sustainability of innovative health services.
The researcher is requesting your involvement because you are working as a health care
professional in an emergency department that uses an emergency nurse practitioner service
model. Data collection methods include:
• A multidisciplinary team survey will be conducted with all staff working in the
emergency department, excepting nurse practitioners
• Individual interviews will be completed with emergency department nurse
practitioners
• Document analysis will be completed on all relevant documents pertaining to the
emergency nurse practitioner service.
Participation
Your participation in this study is voluntary. If you agree to participate this will in no way
impact upon your current or future relationship with your employer or colleagues.
223
Your participation will involve completion of a 30 item, Likert style questionnaire. It is
anticipated that it will take approximately 30 mins to complete this questionnaire.
Submission is via a sealed return box that is in your work unit.
Expected benefits
There may be some benefit to you from participation in this study. This research is of benefit
to the health care system in general, identifying factors that influence sustainability and
therefore adding to the body of knowledge to improve health services in the face of rising
costs and demand. This research will benefit future research processes by identifying
research methods suitable to examine innovation sustainability ensuring the most appropriate
use of resources.
Risks
There are negligible risks associated with your participation in this study. These risks are
limited to those related to normal day-to-day living.
Costs
Participation in this study will not cost you anything, nor will you be paid.
Confidentiality
The findings from the study will be reported in study reports and publications. Your identity,
the identity of your workplace, patients and colleagues will not be disclosed in any
documents, reports or publications during and after completion of this research. All data will
be treated confidentially. The names of individual persons and workplace details are not
required in any of the responses.
Consent to participate
If you agree to participate in this study I ask that you complete the enclosed questionnaire and
deposit it in the fully sealed return box within your work unit. This information sheet is for
you to keep.
Questions/ further information about the study
Please contact the principal researcher named above to have any questions answered or if you
require further information about the study.
224
Concerns/ complaints regarding the study
This study has been reviewed and approved by The Prince Charles Hospital Human Research
Ethics Committee and the Queensland University of Technology Research Ethics Committee.
Should you wish to discuss the study with someone not directly involved, in particular in
relation to matters concerning policies, information about the conduct of the study or your
rights as a participant, or should you wish to make an independent complaint, you can contact
either of the following:
1) Executive Officer, Human Research Ethics Committee on telephone (07) 3139 4500
or email R&[email protected]
2) Queensland University of Technology Research Ethics Unit on (07) 3138 5123 or
email [email protected]. The QUT Research Ethics Unit is not connected with
the research project and can facilitate a resolution to your concern in an impartial
manner.
Should you wish to speak to a member of the research team regarding the study please
contact the Principal Researcher, Ms Amanda Fox on 07 3138 3884, or [email protected].
225
APPENDIX F
Part A: Multi-disciplinary team questionnaire
Emergency nurse practitioner services
This questionnaire is designed to elicit your views on the nurse practitioner service in your work area. Each item has 5 possible responses. The responses range from 1 (strongly disagree) to 5 (strongly agree). If you have no opinion, choose response 3.
Please read each statement. Mark the one response that most clearly represents your degree of agreement or disagreement with the statement. Please respond to all of the statements.
Strongly disagree
Disagree No opinion
Agree Strongly agree
1 I fully understand the nurse practitioner service 1 2 3 4 5
2 Nurse practitioner services are good for
patients
1 2 3 4 5
3 Overall the introduction of nurse practitioner
services in Queensland Health has been
successful
1 2 3 4 5
4 Nurse practitioner services meet the needs of
patients in my department
1 2 3 4 5
5 Nurse practitioner prescribing increases the risk
of incorrect treatment
1 2 3 4 5
6 Nurse practitioner prescribing is necessary 1 2 3 4 5
7 Nurse practitioner services offer safe care 1 2 3 4 5
8 I trust the nurse practitioner service to diagnose
correctly
1 2 3 4 5
9 I am worried that the nurse practitioner service
staff do not have the knowledge to prescribe
1 2 3 4 5
10 The nurse practitioner service in my work area
has a positive impact on patient care
1 2 3 4 5
11 Nurse practitioner services are easy for patients
to access
1 2 3 4 5
12 There is a need for more nurse practitioner
services in Queensland
1 2 3 4 5
13 Nurse practitioners are adequately educated
and prepared for their role
1 2 3 4 5
14 The nurse practitioner service can refer patients
directly to medical specialists
1 2 3 4 5
226
15 The nurse practitioner service has good access
to medical colleagues for consultation and
support
1 2 3 4 5
16 The nurse practitioner service results in
improved health service for patients in
emergency
1 2 3 4 5
17 Nurse practitioners receive adequate training
for their role
1 2 3 4 5
18 I fear that nurse practitioners will make an
incorrect diagnosis
1 2 3 4 5
19 Nurse practitioner services are not necessary,
patients can receive all their treatment from a
doctor
1 2 3 4 5
20 The introduction of nurse practitioner services
has reduced delays in patient care in my unit
1 2 3 4 5
21 The introduction of nurse practitioner services
has reduced delays in initiating patient
treatment
1 2 3 4 5
22 The introduction of nurse practitioner services
has freed up doctors’ time
1 2 3 4 5
23 The introduction of nurse practitioner services
has had a positive impact on inter-professional
relationships
1 2 3 4 5
24 The nurse practitioner service is safe 1 2 3 4 5
25 The nurse practitioner service has reduced the
need for patients to return to see their doctor as
frequently as previously
1 2 3 4 5
26 The nurse practitioner service is supported by
doctors in their role
1 2 3 4 5
27 I am consulted about issues relating to nurse
practitioner services that impact upon my work
1 2 3 4 5
28 I am kept informed of changes to nurse
practitioner services that impact upon my work
1 2 3 4 5
29 The nurse practitioner service have enough
staff to cover the requirements of my unit
1 2 3 4 5
30 Workforce planning is in place to ensure
sufficient nurse practitioner staff are available
to cover leave and attrition
1 2 3 4 5
227
Part B: Professional Profile
Please answer the following questions as they apply to you and your employment. Where indicated please tick the appropriate box.
Please indicate your role in relation to the nurse practitioner service in your department (please tick as many as apply):
Director or Assistant Director of Nursing
Clinical nurse consultant/ nurse unit manager
Clinical nurse/ clinical teacher
Registered nurse
Enrolled nurse
Member of allied health services
Medical practitioner
Hospital pharmacist
Other (please specify)
Very involved
Somewhat involved
Minimal involvement
No involvement
1 Please indicate your level of involvement in the introduction of the nurse practitioner service
1 2 3 4
2 Please indicate your current level of involvement in the daily clinical work of the nurse practitioner service
1 2 3 4
228
Thank you for taking the time to complete this questionnaire. Your assistance in providing this information is very much appreciated. If there is anything else you would like to add about the nurse practitioner service, please do so in the space provided below
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
If you have any queries regarding this questionnaire please do not hesitate to contact:
Amanda Fox
(PhD candidate)
QUT, School of Nursing
Kelvin Grove Campus
Victoria Park Rd, Kelvin Grove, 4059
0411163325
Adapted with permission from Gardner, Gardner, Middleton and Della (2009), ‘Evaluating the Nurse Practitioner Role-Multi-disciplinary team questionnaire’ from The Australian Nurse Practitioner study, the Nurse Practitioner Research Toolkit.
229
APPENDIX G:
Reminder notice to complete questionnaire
Please don’t forget to
submit your ENP service questionnaire !
Return to the reply box to have your say.
230
APPENDIX H:
Subscale Factors Item Question on the nurse practitioner multidisciplinary team questionnaire.
Organizational Meeting
local
population
Needs
3
4
11
16
20
Overall the introduction of nurse practitioner services in Queensland Health has been
successful.
Nurse practitioner service meets the needs of patient in my emergency department.
Nurse practitioner services are easy for our patients to access
The nurse practitioner service results in improved health service for patients in
emergency
The introduction of nurse practitioner service has reduced delays in patient care in my
unit.
Workforce Education
and training
9
13
17
(Reversed) I am worried that the nurse practitioner staff do not have the knowledge to
prescribe
Nurse practitioners are adequately educated and prepared for their role.
Nurse practitioners receive adequate training for their role
ENP service
need
6
12
19
Nurse practitioner service prescribing is necessary.
There is a need for more nurse practitioner services in Queensland.
(Reversed) Nurse practitioner services are not necessary, patients can receive all their
treatment from a doctor.
ENP
services are
safe
5
7
8
18
24
(Reversed) Nurse practitioner prescribing increases the risk of incorrect treatment.
Nurse practitioner service offers safe care
I trust the nurse practitioner service to diagnose correctly
(Reversed) I fear that nurse practitioners will make an incorrect diagnosis.
The nurse practitioner service is safe.
Impact and
quality of
ENP
services
2
10
21
25
Nurse practitioner services are good for patients
The nurse practitioner service in my work area has a positive impact on patient care.
The introduction of nurse practitioner services has reduced delays in initiating patient
treatment.
The nurse practitioner service has reduced the need for patients to return to see their
doctor as frequently as previously.
Political Supportive
professional
relationships
15
23
26
The nurse practitioner service has good access to medical colleagues for consultation and
support.
The introduction of nurse practitioner services has had a positive impact on inter-
professional relationships.
The nurse practitioner service is supported by doctors in their role.
226
APPENDIX I
Nurse Practitioner Participant Information
PARTICIPANT INFORMATION FORM
(Emergency nurse practitioner)
Full Research Title: Factors influencing sustainability of healthcare innovation: emergency nurse practitioner service
Principal Researcher:
Ms Amanda Fox
PhD candidate,
School of Nursing
Queensland University of Technology
Brisbane
(07) 3138 3884
Principal Supervisor:
Dr Glenn Gardner
Professor of Clinical Nursing
Queensland University of Technology
Brisbane
(07) 3636 2140
Associate Supervisor:
Dr Sonya Osborne
Senior Lecturer
Queensland University of Technology
Brisbane
(07) 3138 3785
227
Your consent
This project is being undertaken as part of a PhD for Amanda Fox, student at the Queensland
University of Technology. I wish to invite you to participate in the above study. This
participant information document contains detailed information about the study. Its purpose
is to explain to you as openly and clearly as possible the procedures involved in this study
before you decide whether or not to take part.
Please read the participant information carefully. Feel free to ask questions about any
information in the document by contacting the principal researcher.
Introduction
The Australian health care system is under increasing pressure to provide the population with
access to efficient and cost-effective health care. Many health service innovations have been
implemented in an attempt to meet growing demands, however, the sustainability of these
innovations has not yet been evaluated.
The emergency department nurse practitioner service is the most frequently implemented
model in Australia. This research seeks to examine the factors influencing sustainability of
emergency department nurse practitioner services. The results of this research will be used to
inform health policy development and to guide future implementation and evaluation of
sustainability of innovative health services.
The researcher is requesting your involvement because you are working as a health care
professional in an emergency department that uses an emergency nurse practitioner service
model. Data collection methods include,
• A multidisciplinary team survey will be conducted with all staff working in the
emergency department, excepting nurse practitioners
• Individual interviews will be completed with emergency department nurse
practitioners
• Document analysis will be completed on all relevant documents pertaining to the
emergency nurse practitioner service.
228
Participation
Your participation in this study is voluntary. If you agree to participate this will in no way
impact upon your current or future relationship with your employer or colleagues.
Your participation will involve an individual face-to-face interview that will take
approximately 45 mins to complete. The interview will be conducted during work time in a
room separate from other unit activities and staff. With your permission, the interview will
be audio recorded to assist with accurate transcription of information. If you would prefer not
to have the interview audio recorded please alert the interviewer at the time of interview.
Expected benefits
There may be some benefit to you from participation in this project. This project is of benefit
to the health care system in general addressing sustainability to improve health services in the
face of rising costs and demand. This research will benefit economically but also future
research processes by identifying research methods suitable to examine innovation
sustainability ensuring the most appropriate use of resources.
Risks
There are negligible risks associated with your participation in this study. These risks are
limited to those related to normal day to day living.
Costs
Participation in this study will not cost you anything, nor will you be paid.
Confidentiality
The findings from the study will be reported at conferences, in study reports and publications.
Your identity, the identity of your workplace, patients and colleagues will not be disclosed in
any documents, reports or publications during and after completion of this research. All data
will be treated confidentially. The names of individual persons and workplace details are not
required in any of the responses. Audio recorded information will be destroyed once the
information has been transcribed into text. Electronic data will be stored on a password
protected database accessible only to the principal researcher. Hard copy data will be stored
in a locked filing cabinet only accessible to the principal researcher. Data collected during
this study will not be used for any research other than this project.
229
Consent to participate
If you agree to participate we will ask you to sign a written consent form (enclosed) to
confirm your agreement. This information sheet and a signed copy of the consent form are
for you to keep.
Withdrawing consent
Participants may withdraw consent to participate in this research at any time without
comment or penalty. If you have agreed to participate but wish to withdraw consent, we ask
you to sign a written withdrawal of consent form (enclosed) to confirm your change in
agreement. You can withdraw from participation without comment or penalty. This
information sheet and a signed copy of the consent form is for you to keep.
Questions/ further information about the study
Please contact the principal researcher named above to have any questions answered or if you
require further information about the study.
Concerns/ complaints regarding the study
This study has been reviewed and approved by The Prince Charles Hospital Health Service
District Human Research Ethics Committee and the Queensland University of Technology
Research Ethics Committee. Should you wish to discuss the study with someone not directly
involved, in particular in relation to matters concerning policies, information about the
conduct of the study or your rights as a participant, or should you wish to make an
independent complaint, you can contact either of the following:
1) Executive Officer, Human Research Ethics Committee on telephone (07) 3139 4500
or email R&[email protected] .
2) The Queensland University of Technology Research Ethics Unit on (07) 3138 5123 or
email [email protected]. The QUT Research Ethics Unit is not connected with
the research project and can facilitate a resolution to your concern in an impartial
manner.
Should you wish to speak to a member of the research team regarding the study please
contact the Principal Researcher, Ms Amanda Fox on 07 3138 3884, or [email protected].
230
APPENDIX J
Nurse Practitioner Consent Form
CONSENT FORM
Full Study Title: Factors influencing sustainability of healthcare innovation: emergency
nurse practitioner service.
Ethics approval no. HREC 13-204
By signing below, you are indicating that
You have read and understand the Participant Information regarding this project and have had
the opportunity to ask questions and all questions have been answered satisfactorily.
1. I freely agree to participate in this study according to the conditions in the
Participant Information.
2. I understand that I can withdraw my participation from the study at any time
during the study without comment or penalty.
3.
I will be given a copy of the Participant Information to keep and I can contact the Executive
Officer, Human Research Ethics Committee on (07) 3139 4500 or email
R&[email protected] if I have concerns about the ethical conduct of the project.
The researcher has agreed not to reveal my identity, personal details and the identity of my
organization if information about this study is published or presented in a public form.
Participant’s Name (printed) …………………………………………………….
Signature: Date:
231
APPENDIX K
Ethics approval HREC/11/QHC/45/AM03
232
APPENDIX L
Interviews – Topic Prompts.
Two main questions and a series of prompts were used to explore the organizational and
workforce factors influencing sustainability of emergency nurse practitioner service.
Q1. Tell me about communication and decision making processes in relation to nurse
practitioner service in your work area?
Prompts used-
Tell me about-
a. communication within the department; and with other departments
b. Who is involved in decision making about emergency nurse practitioner service?
c. Do nurse practitioners from your work unit network with other hospital ENP services?
d. Is the service flexible to meet local needs?
Q2. What are nurse practitioner perceptions of safety, quality and value of nurse
practitioner service and the workforce management, education and training related to this
service?
Prompts used-
Tell me about-
e. staffing and recruitment; attrition and leave planning for NP services.
f. Training and ongoing education?
g. Is the emergency nurse practitioner service meeting the needs of your work unit?
h. Does the emergency nurse practitioner service provide a safe service?
233
APPENDIX M Categorisation matrix
Name of Document: Date of Document: Number:
Purpose of Document: Author:
Characteristics: Key theme Terms looked for Theme discussed in document:
Evidence based:
Achievement mechanism discussed:
Context:
National, state and local policy alignment with the innovation
There are links between policy (National, State or local) and emergency nurse practitioner service
Australia Queensland local (research site specific) policy Nurse practitioner nurse practitioner service
Linkage of innovation to regional health goals
There are clear links between emergency nurse practitioner service and regional health goals
Nurse practitioner service Nurse practitioners Regional local Goals/aims strategies
Local Champion/ Supportive professional relationships
There is local support for the emergency nurse practitioner service
Champion Professional relationships local culture local support collaboration
234
Characteristics: Key theme Terms looked for Theme
discussed in document:
Evidence based:
Achievement mechanism discussed:
Context:
Staff involvement in decision making
All staff are included in decision making around emergency nurse practitioner services
Decision making processes staff meetings inclusivity in decision making
Funding
Clear evidence of funding for emergency nurse practitioner services
Funding budget business case tenders
Budgetary planning for continuation
Clear budgets are set for emergency nurse practitioner service continuation
Funding budget Financial planning Fiscal management Business planning
Evaluation of the cost effectiveness
Strategies are in place to evaluate cost effectiveness of the emergency nurse practitioner service
Evaluation Cost effectiveness Cost benefit value for money
235
Appendix N
If they want the service to be sustainable long term then they need to implement a strategy to provide us with education and provide us with support P.1
A strategy for education provision and support needed
Disorganized education
Marginal Integration
No education officially for NPs in the hospital. P.6 No NP education provided
From a NP specific education (the organization provides) nothing that I am aware of. P.9
No specific NP education provided by organization
Once again that is what nursing does very badly from a professional development point of view, absolutely appalling. P.6
Nursing professional development appalling
Educators are a level below us and to train levels above them is a little daunting, whether or not they think their knowledge is not as extensive as the ENP training. P. 7
Educators daunted at educating a higher level NP
Education wise there is not a lot provided by the organization itself. P.4
Education not provided by the organization
There have been talks and meetings about how they can provide education for us but it was just a brainstorming session and nothing has been developed from there. P.5
Brainstorming on how to provide education but nothing has happened.
I think the biggest problem for Nps in Australia is accessing ongoing quality education and training that is RELEVANT for an ENP. P. 2
Problem in Australia to access quality relevant ENP education
You still feel like your training even though you’ve come back fully qualified. P.8
still training once qualified. Role/ capability
misalignment Our requirements are beyond the level that is currently being provided to nursing staff and they are a level below us from a nurse education point of view. P. 7
Requirements beyond the nurse educator level
Personally, I think they (ENPs) need more primary care training. P. 8
Need more primary care
When I was an emergency nurse I rarely looked into ears or throats, but since becoming an ENP I have to look at them and know what they look like. All that background training and with the focus of the service now I think it is probably a waste of all those years of training in ED. I think more training in primary care or GP service would help. P.9
Training inappropriate to the final ENP role
I do think it is a bit of a waste and that is why we are trying to involve ourselves in the acute side and maintain our skills in a way. P.8
Waste of skills and knowledge
You need to learn a whole new set of patient presentations that you have never even looked at before because they were of no real significance to you. P. 10
Need to learn a whole new set of skills and patient presentations
You didn’t look into their ears, but when you start as a nurse practitioner you are really vulnerable because you suddenly don’t know anything. P. 11
ENP vulnerable because you don’t know anything
I think you do need to (have the knowledge) to recognise something that appears minor becoming something much worse. P. 8
High level of knowledge is needed
I think you need high level of assessment skills. P. 1 High level of assessment skills
When I first started I didn’t know one fracture from the other, it is this massive learning curve. P. 2.
When I first started it was a massive learning curve
236
Publication generated from this research.
Fox, A. Gardner, G. and Osborne, S.(2015). A theoretical framework to support research of health service innovation. Australian Health Review. Vol. 39.pp 70-75.
Abstract
Health service managers and policy makers are increasingly concerned about the
sustainability of innovations implemented in health care settings. The increasing demand on
health services requires that innovations are both effective and sustainable however research
in this field is limited with multiple disciplines, approaches and paradigms influencing the
field. These variations prevent a cohesive approach and therefore the accumulation of
research findings in development of a body of knowledge. A theoretical framework serves to
guide research, determine variables, influence data analysis and is central to the quest for
ongoing knowledge development. If left unaddressed, health services research will continue
in an ad hoc manner preventing full utilisation of outcomes, recommendations and
knowledge for effective provision of health services. The purpose of this paper is to provide
an integrative review of the literature and introduce a theoretical framework for health
services innovation sustainability research based on integration and synthesis of the literature.
Finally recommendations for operationalising and testing this theory will be presented.
What is known about the topic? Providers of health services are rapidly implementing
innovations in an effort to provide effective health care. Little research has been conducted
to evaluate the sustainability of these health service innovations.
What does this paper add? This paper aims to present integration and synthesis of the
current body of knowledge to present a theoretical framework that would be effective to
evaluate the sustainability of health service innovations.
237
What are the implications for the practitioner? An improved body of knowledge
surrounding the sustainability of health service innovations generated from research and
consequently more appropriate use of resources and improved provision of health service.
Keywords
Health services research, innovation sustainability, theoretical framework development
Background
Spiralling health care costs and increased consumer demand have seen a rapid introduction of
many health service innovations. Despite great interest and need to understand these
innovations, research into sustainability is scant and fragmented. There is a need for research
that is embedded in appropriate theoretical framework and presents clear methodology for
replication to extend the body of knowledge. Health services research typically spans
multiple disciplines, many of which have conflicting or varied preferences in relation to
research concepts, approach and perspectives. Health services research is complex, partly
due to the large number of occupational groups, disparity of influence between employee
groups and changing patient acuity which prevents standardising some processes.1 As such,
health services research has many stakeholders and research in this field draws upon methods
from several disciplines and paradigms.1 The challenge is to successfully synthesise the
research findings from these varied sources to effectively meet the needs of health service
managers and policy writers attempting to meet current service needs. The purpose of this
paper is to present an integrative review of research into sustainability of health service
innovation and to propose a theoretical framework to guide future research in this field.
238
Methods
A comprehensive search was undertaken to locate both published and grey literature in
databases including Medline, CINAHL, PubMed and the Cochrane Library. Key subject
words and terms used were combined, adapted and spelling altered to suit the needs of the
database searched. Synonyms of the key terms were identified using each database thesaurus
options to ensure all terms were broad enough to capture the research pertaining to the field
of health service innovation, sustainability and theoretical framework. A manual search
through the reference lists of the identified articles was then conducted to identify further
relevant studies.
Table 1. A summary of the themes and key words used in the literature review.
concept Setting Topic
Sustain* Health service* Theoretical framework
Institutional* Health service research Conceptual framework
Routini* Health service innovation Framework
The initial search returned 334 articles. Inclusion criteria were; peer-reviewed research that
used or recommended a theoretical framework/concept to examine sustainability of a health
service innovation. Articles were excluded based on duplication, if sustainability was
referred to in the sense of environmental sustainability or sustainability of a patient outcome
following an intervention. The review method consisted of perusal of the abstract of each
article and where eligibility could not be ascertained the full text of the article was sourced.
Studies were then examined in full text for quality and those based on poor methodological
quality were excluded. Following this process a total of 23 studies met the criteria.
239
Results
Definitions lack clarity
In the case of health service innovation sustainability, the literature review identified minimal
empirical research. The research that has been completed is mostly lacking in rigor2 and a
theoretical or conceptual framework. The definition of sustainability is controversial and
much debated with many varied definitions throughout the literature.2 The same variability
was found in the literature related to health service innovation. A systematic review by
Greenhalgh et al, yielded a conceptual model of the determinants of diffusion, dissemination
and implementation of innovations in service organizations, however, despite the original
research question related to sustainability, the scarcity of research addressing sustainability
prevented Greenhalgh and colleagues from including this concept in their work.3 Following
this publication, further research has emerged however, clarity of definition and research
informed by and informing theory are still lacking.3 Predominantly the research consists of
descriptive publications relating to health program implementation, sustainability of
community based programs, health systems in low income countries and theories related to
change behaviour and management.4-7 Variation between operational definitions of
sustainability made comparison difficult and less than half of the studies appeared to be
guided by a conceptual model or framework.2
Use of theoretical underpinnings
Application of a theoretical framework in research may prevent repetition of previously
explored concepts, adding to, rather than replacing or repeating previous research and can
inform a thorough examination of the phenomena to be studied. A framework is necessary
to bind together all aspects of the research and can be likened to a research compass which
guides the research question, implementation strategies and evaluation process of any
240
research. 8 Systematic structure, rationale and justification for how and why research will be
undertaken and transferability of research processes across contexts and settings is made
possible by the employ of theoretical frameworks.8 Research that is not embedded in theory
results in questionable contribution to knowledge. Expansion of a solid research paradigm
and body of knowledge is developed by replication, comparison and systematic reviews of
health services research. However, this can only occur with clear articulation of theoretical
frameworks and methodological approaches.
A systematic review into the sustainability of new programs and innovations found few
comprehensive or methodologically rigorous studies.2 Research into health services
sustainability has previously presented a pragmatic rather than academic perspective and has
often been presented as grey reports which lack guidance about theoretical frameworks or
research processes taken.3 All research is guided, either explicitly or implicitly by existing
body of knowledge in the field however, when a field of research is in its infancy, the
methods used to gain a body of evidence need to be formalised and justified to support
validity of concepts and development of the paradigm.9 To date, there has been limited
research examining sustainability of innovative health service delivery models within acute
health care settings.
Theoretical frameworks for health service sustainability
Initially, the sustainability of innovation concept can be traced back to Everett Rogers’
Diffusion of Innovation theory.10 Roger’s work has been highly influential across many
domains and disciplines including and leading to, the work of Greenhalgh and colleagues in
2003 into service innovations among others.3 The Child Survival Sustainability Assessment
(CSSA) framework was specifically designed to examine programs in the context of
developing countries11 and the Sustainability Analysis Methodology (SAP) was designed by
241
Blanchet and Girois7 specifically for low income countries implementing health programs.
The Normalization Process Theory was presented by May and colleagues in 2009 as an
effective method of implementing, embedding and integrating practices.12 In 2013, Chambers
and colleague challenged the concept that sustainability was an endpoint and introduced the
Dynamic Sustainability Framework (DSF), positing a framework that involves continual
adaptation as a result of learning, problem solving and evolution.13 This framework is yet to
be operationalised but this concept and others have been influential in the construction of the
Sustainability of Innovation Framework discussed below.
Discussion
Construction of a theoretical framework
Expert researchers working in established fields knowingly conduct research from a well-
grounded theoretical base that has been established through years of research and knowledge
development. For novice researchers and those working in emerging fields it is essential that
the use of theory is made explicit, not only for paradigm construction but also to hone
research skills and ingrain robust practice amongst inexperienced researchers. Selection or
construction of a relevant theoretical framework is a process often found arduous by novice
researchers however, is an essential component to the novice researchers’ learning pathway.
The process requires identification of key research concepts and clarification of these as they
exist and inform the proposed research idea or question. Careful examination and analysis of
existing theories and prominent authors in the field allows the researcher to determine the
appropriateness of a particular theory to the pending research. Synthesis of these ideas by the
researcher will inform construction or selection of a theoretical framework most appropriate
for the proposed research
242
The Sustainability of Innovation Framework
Completing this integrative review has informed the theoretical background to the
development of this framework. The sustainability of innovation framework combines the
concepts presented by Greenhalgh and colleagues’ systematic review of service innovation,3
and the Dynamic Sustainability Framework of Chambers and colleagues13 to provide a
theoretical framework suitable for the examination of sustainability of any health service
innovation. The sustainability of innovation framework consists of five factors that have
been constructed by synthesis of theoretical propositions of the above cited prominent authors
in the field and additional current literature. These factors are political, organizational,
financial, workforce and innovation related; each is been briefly explained.
Political Factors
Research suggests that a political focus on one particular policy will strongly influence the
sustainability of an innovation related to this policy and innovations well linked to regional
health planning and national policy directions are more likely to be routinised.3, 6 These
policies change with the change of government as does funding provision surrounding these
policies. Political sustainability is thought to be enhanced when upper level management staff
and organizational culture supports the innovation.2, 6 Therefore, questions regarding
alignment, links, flexibility and staff involvement are the major focus of the political
segment.
Organizational Factors
Flexibility and adaptation of the innovation to suit the local context and organization has been
acknowledged as supporting innovation sustainability.2, 3, 10 Chambers and colleagues argue
that sustainability of innovation is enhanced when continual improvement and refined to suit
the context.13 Agreed operational governance within an organization12 and effective
243
communication within and across departmental boundaries in an organization will enhance
sustainability.6 A lack of meetings and teamwork has led to a lack of support for innovation
and poor sustainability.6 As a result the organizational factors of the framework strongly
focuses on identifying existing communication and networking strategies.
Financial Factors
Financial factors influencing sustainability are the provision of funding and budgetary
planning for ongoing resources, human and consumable as well as a demonstrated cost-
effectiveness of the innovation. Research that has been completed on programs and projects
often found sustainability was impacted once external funding ceased. Innovations
introduced as trials or projects often are not sustained long term, due to the temporary
funding associated with trials.14 An innovation that has a dedicated, ongoing and adequate
budget sufficient to meet the needs is more likely to be routinised by the organization.3
Lack of research evaluating the financial value and cost effectiveness of innovations often
leave innovations vulnerable.6 The financial factors of the theoretical framework therefore
ascertain funding sources, planning and evaluation strategies of the innovation.
Workforce Factors
Research has found that minimal staff and role changes and staff training that is timely with
use of high quality training resources, supports sustainability of an innovation.3 Innovations
consistent with values and needs of staff are more readily adopted6 and employee perception
of the value of an innovation strongly impact upon routinisation.6, 14 Lack of continuity or
not having adequate staff to implement an innovation is a threat to sustainability.6 Single
staff member service models found ability to meet demands proved difficult and annual
leave, parental leave and staff attrition made innovations vulnerable particularly where
succession planning has not been initiated.14 Having processes in place to monitor the quality
244
and outcome of the innovation and regularly providing staff with feedback is seen to enhance
routinisation.3 Staff attrition, continuity and employment models along with staff attitudes
and perceptions as to the innovation quality are key to the workforce factors in the theoretical
framework.
Innovation Specific Factors
The nature and type of innovation will play a role in sustainability.2 Important features of an
innovation are fluidity and adaptability to respond to changes in funding and service
requirements based on local decision making and need.3, 6 Latest research suggests that
innovations are constantly evolving to suit context needs and this change is inevitable for
sustainability.13 The acceptability, quality and safety of the innovation to the stakeholders
can be directly linked to sustainability. Ongoing evaluation using measures relevant to
stakeholders to evaluate the quality of an innovation is imperative.13 As a result, integration
of these research findings the innovation specific factors focus on identifying support and
barriers to the innovation and evaluation strategies of the innovation itself.
The five factors can be operationalised and guide research to explore the dynamics
influencing sustainability of health service innovation. The factors are not discrete areas but
rather a collection of characteristics that are dynamic and may interact with each other. The
framework represents the dynamic nature of sustainability as suggested by Chambers and
colleagues13 as the innovation is optimised within the relevant context to enable rather than
prevent sustainability. The framework characteristics are conceptual and sufficiently robust
to guide the research, identify variables, data collection and evaluation methods that should
be used (see Figure 1).
245
Figure 1. Sustainability of Innovation Theoretical Framework.
Health service innovations exist in real life, often complex environments and as such data
collected relating to a factor from one area may provide insights into characteristics that
impact on one or more of the other factors within the framework. Interactions between
components of a framework may not be fully understood until after practical utilisation and
evaluation of research results. Empirical research allows for collection and examination of
• Staff recruitment processes, succession and leave planning
• Education and training provisions and processes
• Staff perception of innovation need
• Staff perception of innovation safety and quality
• Support for the innovation • Barriers to the innovation • Safety and quality of innovation
• Funding sources identified and secure
• budgetary planning for continuation of the innovation
• Evaluation strategies to examine cost effectiveness are in place
• Government and local policy alignment
• Links with regional health plans, goals and visions
• Local and national champion involvement
• Staff involvement in the implementation and decision making
• Interdepartmental and intradepartmental communications
• Adaptation of the innovation to local context and perceived need
• Existence of networking opportunities with external organizations
246
unforeseen additional information, inadequacies and complications that may only arise during
implementation of the research.
Recommendations
This theoretical framework may be appropriate to examine sustainability across different
research methodologies and various service innovations. Given the minimal amount of
empirical research in this field, testing of the framework is recommended across a broad
range of health service innovations. Additionally, this specific theoretical framework, whilst
based on highly regarded theoretical background information, is only a starting point and may
look considerably different following practical application, evaluation, revision and
development. Limitations are recognised by the over dependence on theoretical frameworks
developed within the community health domain and international programs that dominate the
existing small body of knowledge. Operationalising this proposed framework in a number of
contexts will provide a broader understanding and development of these concepts. This leads
to new knowledge development where theory informs research processes and in turn is
informed by research findings.
Conclusion
Whilst health services research is an emergent field, strong theoretical links need to be made
in an attempt to establish a sound knowledge base. The current paucity of research and
therefore evidence on which to develop a paradigm for health service research is recognised.
This article has explored the rationale for use of theoretical frameworks, their importance for
novice researchers and emerging research fields and has presented the developmental process
to construct a framework to explore health service innovation sustainability. Testing of
frameworks with research using appropriate methodology is required across many health
services to identify inadequacies and refine theory. If future research in this field is to
247
effectively inform health services, policy and implementation of innovations, theoretical
frameworks must be employed and tested. Researchers are urged to scaffold their work in
strong, evidence based theoretical frameworks to ensure synthesis of findings and
development in the health services research paradigm.
Competing interests
The authors declare that there are no competing interests or funding associated with this
article.
Authors’ contribution
AF wrote the initial draft, while GG and SO made substantive contributions to conception
and design and all authors have been involved with critical revision of the manuscript. All
authors read and approved the final manuscript.
248
Reference List
1. Black N. Health services research: saviour or chimera? Lancet 1997; 349: 1834-
1837.
2. Stirman SW, Kimberley J, Cook N, Calloway A, Castro F, Charns M. The
Sustainability of new programs and innovations: a review of the empirical
literature and recommendations for future use. Imp Sci 2012; 7: 17.
3. Greenhalgh T, Robert G, Macfarlane F, Bate P. Kyriakidou O. Diffusion of
Innovations in Service Organizations: Systematic Review and Recommendations.
Milbank 2004; 82: 581-629.
4. Schierer M A, Dearing JW. An Agenda for research on Sustainability of public
health programs. Am J Public Health 2011; 101(11) 2059-2067.
5. Shediac-Rizkallah, M, C and Bone, L, R. Planning for the sustainability of
community-based health programs: conceptual frameworks and future directions
for research, practice and policy. Health Edu Res 1998; 13(1):87-108.
6. Sibthorpe B, Glascow N, Wells R. Emergent themes in the sustainability of
primary health care innovation. Med J Aust 2005; 183(suppl 1):77-80.
7. Blanchet K, Girois S. Selection of sustainability indicators for health services in
challenging environments: Balancing scientific approach with political
engagement. Ev and Prog Plan 2013; 28-32.
8. Ringsted C, Hodges B, Scherpbier A. ‘The research compass’: An introduction to
research in medical education: AMEE Guide No. 56. Res in Med Ed 2011; 33:
695-709.
9. Bowling A. Research Methods in Health Investigating Health & Health Services.
3rd edition. New York: Open University Press; 2009.
249
10. Rogers E. A Prospective and Retrospective Look at the Diffusion Model. J Health
Com 2004; 9:13-19.
11. Sarriot EG et al. A methodological approach and framework for sustain
assessment in NGO – implemented primary health care programs. Int J Health
Plann Man 2004; 19(1): 23-41.
12. May C, Finch T. Implementing, embedding and integrating practices: an outline of
normalization process theory. Sociology 2009; 43: 535-554.
13. Chambers D, Glasgow R, Strange K. The dynamic sustainability framework:
addressing the paradox of sustainment amid ongoing change. Imp Sc 2013; 8: 117.
14. Considine, J and Fielding K. Sustainable workforce reform: case study of
Victorian nurse practitioner roles. Aust Health Rev 2010; 297-303.