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Student number: -0207586
Dissertation
The training and development of Assistant Practitioners(AP): An action research
project to develop a tool to evaluate the impact of the AP role in practice and
inform service development within NHS and Non -NHS organisations.
“A dissertation presented in the University of Bolton in partial
fulfilment of the requirements for the degree of M.Ed. (Professional
Development)”.
By David Andrew MorrisJuly 2016
Total word count excluding acknowledgments, appendices and bibliography (21,898)
Student number: -0207586
Table of ContentsAcknowledgements.......................................................................................................3
Abstract............................................................................................................................4
CHAPTER 1: Introduction to the Study........................................................................5
Aims and Objectives.....................................................................................................5
Aims: -..............................................................................................................................5
Objectives: -....................................................................................................................5
Rationale..........................................................................................................................5
Intended Methodology..................................................................................................6
Chapter Two: Literature Review.....................................................................................9
Background...................................................................................................................10
Reviewing the evidence.............................................................................................11
Evaluation of the AP role...........................................................................................13
Workforce planning verses evolution.....................................................................16
Registration and Regulation of the AP...................................................................18
The AP: Foundation Degrees and Work-based Learning...................................20
Work-based learning theory......................................................................................22
Impact Evaluation Process........................................................................................24
Evaluating training Programmes for the AP role.................................................27
Summary........................................................................................................................29
Chapter Three: Methodology........................................................................................30
Ethics..............................................................................................................................30
Why an action research approach?.........................................................................31
Identifying the problem..............................................................................................32
The search cycles........................................................................................................32
Phase One of the research process........................................................................32
Phase Two Piloting the tool.......................................................................................34
Phase Three: Tool review and redesign.................................................................36
Future phases of the research. Making the Impact evaluation tool a resource for practice....................................................................................................................36
Summary........................................................................................................................36
Chapter 4: Findings and data analysis.......................................................................37
Phase one part one: Secondary research and Scoping the AP role and evaluation methods. (Objective 1)...........................................................................38
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Phase one part two: Developing an initial market research questionnaire to establish stakeholder’s priorities (Objective 2)....................................................40
Analyses of the questionnaire results....................................................................42
(Table 1 Roles of Respondents)..............................................................................43
(Table 2 Types of Organisations).............................................................................43
(Table 3 Service Area)...............................................................................................44
Table 4 (Financial considerations of developing the AP role)..............................45
Table 5 (impact on patient care)..............................................................................45
Table 6 (Training and education of the role)...........................................................45
Table 7 (Type of training /education programme)..................................................45
Table 8 (Impact on teams/service)..........................................................................45
Table 9 (Staffing of the roles)...................................................................................45
Table 10 (Useful resources on the AP role)...........................................................46
Table 11 (Compatibility with national priorities and workforce opportunities)....46
Phase Two: Developing and pilot of the draft impact evaluation tool............46
Analysis of the results of the draft impact evaluation tool and process.......46
Phase Three: Redesigning the impact evaluation tool and final version......49
Validity and Reliability................................................................................................50
Summary........................................................................................................................51
Chapter 5: Discussion and Analysis...........................................................................52
The AP role....................................................................................................................52
Sustainability and expansion of the role................................................................55
Education and training...............................................................................................55
Impact evaluation.........................................................................................................56
Summary........................................................................................................................57
Chapter 6: Conclusions and Recommendations.....................................................58
Recommendations.......................................................................................................60
Final thoughts...............................................................................................................60
Bibliography......................................................................................................................62
List of Appendices...........................................................................................................72
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Acknowledgements Many thanks to Alison Doyle, Interim Deputy Head of the Work-based Education Facilitators (WBEF) network, for her input as a core member of the action research group.
Carolyn Jackson, Interim Head of the WBEF network, for her input into future marketing of the impact evaluation tool.
Suzanne Pearson WBEF for piloting the impact evaluation tool and contribute to the redesign.
Chris Morris Service Manager for piloting the impact evaluation tool.
To Lynda Leighton, Paul Barber and Julia Stevenson WBEF Network for being part of a focus group to evaluate the newly drafted impact evaluation tool and offering their comments and suggestions for its design.
Finally, my partner Steve for his patience and support.
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AbstractThis research study looks at how resources can be produced to assist managers
making decisions about developing the role of the Assistant Practitioner(AP). It
investigates evaluations of the AP role to date and considers how an impact
evaluation tool can be produced to inform practice. The tool looks at how a mixed
methods approach can be utilised to create evidence that is both qualitative and
quantitative in nature. The aims of the study are to provide managers with evidence
based resources that can inform their decision making when contemplating the
training and development of non-registered staff into the role of AP and develop a
tool that will evaluate the impact of the AP role within a service area. The study
examines the stages taken to develop a tool that can be applied to the AP role but is
also generic in nature and can be utilised in any area considering role development
within their teams
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CHAPTER 1: Introduction to the Study
Impact and Evaluation of the AP Role in the National Health Service (NHS) and Non
National Health Service Organisations
The training and development of Assistant Practitioners(AP): An action research project to
develop a tool to evaluate the impact of the AP role in practice and inform service
development within NHS and Non -NHS organisations.
Aims and ObjectivesAims: -
1. To provide managers with evidence based resources that can inform their
decision making when contemplating the training and development of non-
registered staff into the role of AP
2. To develop a tool that will evaluate the impact of the AP role within a service
area.
Objectives: -1. To scope out the current literature in relation to impact evaluations of new
roles within service areas
2. Design an initial market research tool to ascertain stakeholder’s priorities
when considering the development and introduction of new roles within their
service.
3. Utilise the findings of the initial survey to construct an impact evaluation tool
to gather both qualitative and quantitative evidence of the impact of the role.
4. Assist managers to make informed decisions with regards to the future
training and development of their non-registered staff within their service
area (see appendix 1).
RationaleThe topic was highlighted as an area of investigation in the operational plan of the
Work-based education facilitator (WBEF) network. The WBEF network is
commissioned by Health Education England -North West Office. Its primary function
is the promotion, development and support of the Trainee Assistant Practitioner
(TAP) and AP across the North West. Its wider remit is in relation to Bands 1-4 1staff
within the NHS and non NHS organisations. The Network is unique to the North
1 Bands 1-4 refer to the grades of staff within the NHS who characteristically are non-registered practitioners. The AP role usually sits at Band 4 within Agenda for Change and level 4 of the careers framework.
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West; however, the introduction of the AP role is a national initiative which has been
implemented with varying success across the United Kingdom.
Smith and Brown (2012) consider the introduction of assistant practitioners into the
health and social care workforce stating, “The introduction in 2002 of the Assistant
Practitioner role in health and social care aimed to provide a new type of worker
who could provide direct health and social care under the direct supervision of a
Registered Professional” (p.6). NHS Employers (2015) describe the role as non-
occupationally specific and discuss how AP s work across a number of disciplines.
As Smith and Brown (2012) indicate, one of the primary functions of the AP role is
the provision of patient care and there is a vast array of literature evaluating the AP
role and the types of activities they are involved in. However, it could be argued that
the vast majority of the evidence is anecdotal and falls short in measuring the
impact of the role in terms of cost effectiveness, direct effect on patient throughput2,
the AP contribution in achieving local, national targets and its measure against the
original workforce vision or generally accepted definition. Their impact in relation to
cost benefits, service efficiencies and quantifiable effects on the patient experience
is lacking. Spilsbury et al. (2009) indicated that the AP role had not been introduced
in some Trusts because of the lack of evidence of the effectiveness. It was noted by
the WBEF network that it would be useful to develop a tool that not only gathered
qualitative information but also facts and figures in relation to the impact of the role,
particularly regarding cost and patient outcomes.
Intended Methodology An action research approach was agreed as fitting to facilitate the progress and
conclusion of the project. This approach was identified as an appropriate method in
line with several requests from managers that information centring on the impact of
the role be made available as a resource. Cohen et al. (2013) advocates that action
research is a robust method of problem solving and instigating change. The
development of an evaluation tool which measured the impact of the AP role, was
identified as a priority for the network, thus providing appropriate resources to
individuals with workforce planning and role design as part of their remit. Although
the primary focus of the tool design would be to evaluate the role of the AP, the
network considered a generic model might be useful. Working collaboratively with
colleagues would refine research methods and shape the design of the final tool.
Learning from previous inquiry, evaluating the knowledge gained and incorporating
2 This relates to the flow of patients as well as numbers of patients seen in a given period of time.
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its findings as the research progressed, would inform the end product. Winter and
Munn-Giddings (2002) acknowledge the role of action research as a process of
continuous inquiry and development. The action research group primarily consisted
of two permanent members and utilised input from others where appropriate.
An initial Political, Economic, Social and Technological (PEST) analysis was
conducted to focus on the potential design of an initial market research
questionnaire which would precede the eventual impact evaluation tool. PEST
analysis is often used in business to look at market potential (CIPD, 2015). Adapting
this model would assist in determining what areas to consider in the initial design of
the questionnaire to establish priority areas identified by stakeholders when
considering the development and introduction of new roles (see appendix 2).
A mixed method approach was utilised in the completion of the research study,
which was carried out in three phases. Phase one would include desk top research
assessing current evidence with regards to innovative roles within the NHS and non
NHS sector and the evaluation of said roles. A scoping exercise would be
conducted to establish how new roles had been evaluated with particular reference
to the AP role. This would also include identifying any potential tools that had
already been written and tested. Concurrently, a questionnaire would be devised to
establish the type of information considered most useful and so be explicit in the
design of the final tool. Participants would be identified through the WBEF data base
system and invitation to complete a questionnaire via survey monkey 3would be
disseminated to appropriate individuals. The issue of consent was addressed as
participants were asked to affirm consent to take part in the study and for inclusion
in this dissertation.
Phase one part two of the study analysed the results from the questionnaire. This
informed the design of the impact evaluation tool. The tool will be used to collate
both qualitative and quantitative evidence in service areas where the AP role is
established.
Phase two of the study took the opportunity to pilot the tool by selecting a service
area and using the tool to guide a member of the WBEF network through a semi-
structured interview with an identified stakeholder. To ensure objectivity and avoid
bias an impartial member of the team was asked to conduct the interview. Guidance
3 Survey Monkey is a web based resource that allows a variety of questionnaire designs and different formats often not available from paper based questionnaires
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notes were devised for both the interviewee and interviewer. A process map was
also devised to ensure consistency in approach with the final impact evaluation tool.
Phase three of the research study was the finalised tool to be ready for use by the
network.
Future use of the impact evaluation results would produce information sheets,
support briefing sessions, whilst offering managers who have introduced the role, an
opportunity to analyse its impact and efficacy. One aspect of an impact evaluation
assessment is to consider the future growth or reproduction of an intervention
(OECD, n.d.; Rogers, 2012).
Ethical consideration was given at all stages of the project, with ethical approval
being obtained from the University and employing organisation. This will be
considered more fully in chapter three.
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Chapter Two: Literature Review
The literature review constituted a broad based approach. The study would initially
involve a scoping exercise to establish whether there were examples of impact
evaluation tools in existence. In the first instance phrases such as ‘Designing an
impact evaluation tool for new roles’ produced poor or inappropriate results. Data
bases with a health focus such as Cumulative Index to Nursing and Allied Health
Literature (CINAHL), British Nursing Index (BNI) and Medline returned zero results
when this phrase was entered. However, entering less specific criteria such as,
‘evaluating new roles’, ‘impact of the Assistant Practitioner role’, ‘Assistant
Practitioners’, ‘developing support workers’ and ‘impact evaluation’ resulted in a
range of research studies that could help establish the current evidence base in
relation to the introduction of new roles in health and social care had been
evaluated. and its impact measured.
The concept of impact evaluation as a process was also perused. Much of the
literature examined was generated by commerce and charitable organisations.
However, the principles of ‘change’ or ‘programme theory’ were transferable to
evaluate the impact of the AP role in general. The impact evaluation process was
adapted to directly influence the design of the impact evaluation tool, in gathering
both qualitative and quantitative information. This would provide a fuller
understanding of how robust impact evaluation can be facilitated and effectiveness
of any new roles assessed. A historical review of the NHS was briefly considered to
appreciate the frequency of change in health and social care since its inauguration
on the 5th July 1948 (NHS Choices, 2015). The introduction of new roles in both the
NHS and Social Services in response to changes such as demand, public
expectation, demographics, staff shortages, technology to name but a few
influences have resulted in a dynamic ever evolving workforce.
The findings of the survey monkey questionnaire, elicited the priorities of
stakeholders when considering the development of new roles, question eight asked
them to consider the training/education programme that might underpin new role
development. Overwhelmingly participants agreed that any programme of study or
training should incorporate work based competencies and work based learning.
Equally, question ten confirmed that respondents believed information on ‘growing
your own’ and ‘recognising talent within teams’ was a high priority, whilst question
eleven demonstrating that contributors believed offering career progression and
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alignment to national agendas were highly influential in their decision making
process. Mindful of this, investigation into research on work based learning and
initiatives such as ‘the talent for care’ HEE (2014), and ‘widening participation’ HEE
(2014a), were also considered as appropriate components of the literature search.
Background The NHS Plan 2002, acknowledged the pressures on the NHS and the need for a
major shift in health care provision, identifying the need for nurses and other staff to
extend their skill set. It advocated the need to utilise the skills of all grades of staff in
the NHS, offer opportunities for career development and education and training.
Many of the commitments stated in the NHS Plan are still prevalent. Many of the
issues raised still challenge the provision of health and social care today. The plan
commits to the joined up working between health and social care as opposed to
working in silos. (DOH, 2002; Stewart- Lord et al., 2011) Many of the themes
discussed in the NHS Plan are echoed in the governments ‘Five Year Forward
View’, which commits to joined up integrated services between health, social care
and the tertiary sector4. (NHS England, 2014) The NHS Plan advocated the
breaking down of professional boundaries and optimising the talents of the
workforce. It can be argued that this philosophy underpinned the creation of the AP
role. (DOH, 2002)
The AP role was created in 2002 as part of a project entitled ‘Delivering the
Workforce’. As in many areas of the country, the North West was experiencing
significant challenges in maintain an effective health service workforce. Kilgannon
and Mullens (2008), proclaim that “Vacancies were increasing and pressure was
mounting for a more flexible and productive workforce” (p.523) Miller et.al. (2014)
reiterate that staff shortages, lack of registered professionals and growing emphasis
on skills mix, remain potent drivers for introducing the role. As part of delivering the
workforce project, the role was initially introduced in Greater Manchester, followed
by Cumbria and Lancashire and finally Cheshire and Merseyside.
Kilgannon and Mullens (2008) discuss the introduction of the AP role arguing that a
strategic approach to developing the AP in Greater Manchester ensured
consistency in standards. Prior to the initiative, training and development of the
support worker workforce was fragmented and inconsistent. The new role coincided
with the launch of foundation degrees whose characteristics of employer
4 Tertiary sector for the purposes of this study refers to the work of private, independent and voluntary sector organisations(PIVO).
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involvement, a combination of academic and work based learning, appealed as the
preferred vehicle to develop the role that was envisaged. Miller (2013) noted there
was a wide variance in the qualifications for APs, this was subsequently clarified by
Miller et al. (2015), noting that although there are still many qualification routes to
becoming an AP, currently the foundation degree is still the preferred option. They
do however air caution and note that many Local Education and Training Boards
(LETB) have diverted funding away from foundation degree qualifications, with
many employers feeling that on completion staff still required ‘top up’ training from
the organisation to be fit for purpose.
From the outset the intention was for the newly designed role to undertake extended
skills and greater responsibility. Kilgannon and Mullens (2008) articulate: “It was
also important to ensure that if the new role was to undertake some of the
responsibilities of a registered practitioner, and the education package was credible”
(p.513). This fundamental concept is still a driving principle in the current
development of the role and plays a significant part in the evaluation data available.
Wakefield et al. (2010) support such comments adding, “The rationale for
introducing the role was help sustain effective, efficient health care services across
the NHS and free up registered nurses to take on new expanding roles” (p.17).
Miller et.al. (2014) expand on this and indicate that: “Having simpler tasks
undertaken (under supervision) by Assistant Practitioners is one way in which the
throughput of patients can be increased” (p12).
Reviewing the evidence Since 2002 there have been numerous evaluations of the AP position across
different disciplines and from a national perspective. One aspect of the literature
review was to examine how the evaluations have been conducted, what methods
were used, what tools have been developed to capture the information. The primary
focus of the literature review concerns the AP role however; evaluations of other
innovative roles have also been considered with regards to transferable
characteristics that might assist in the production of a generic impact evaluation tool
with potential to be applied across numerous settings.
This study was particularly interested to consider how quantitative data was
collected as part of any of the studies, as this was an area that stakeholders
showed a particular interested in. Part of the project’s remit was developing a
resource to capture statistical evidence and qualitative narrative. This would offer
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stakeholders where the role has been developed, opportunity to evaluate objectively
how influential the role has been in their service.
Benson and Smith (2007) from the University of Manchester carried out an
evaluation of the role of the AP across pilot sites in Greater Manchester, evaluating
health and social care. Benson and Smith’s work can be seen as the first substantial
evaluation of the AP role. The study reported some positive results from the project
highlighting that some qualified APs were utilising their newly acquired skills.
Comments on working across professional boundaries and greater patient
satisfaction were also highlighted.
There were instances where the role had not been embraced or had caused
confusion for both the registered and non-registered staff. Overall the report was
positive given the expectations at that time. However, Benson and Smith noted that
there was uncertainty surrounding the role from some quarters with some
professions unsure about the AP role itself and level of responsibility that might be
delegated. Miller et al. (2015) highlight in some instances this is still the case,
resulting in underutilisation of the role with professional attitudes sometimes
hindering progress. Confusion over what an AP can and cannot do, remains. They
argue “Where there is a lack of clarity concerning these roles it is unlikely that
organisations will achieve the full benefits of these roles” (p.25). They state that this
sometimes is a result of registered staff being reluctant to delegate more
straightforward tasks and procedures. Wakefield et al. (2009) add to the discourse
noting the increasing number of patients with complex needs and pressures on
registered staff concluding, “In response to the predicated crisis in professional
workforce resources and freeing up registered practitioners to complete more
complex caring work, a new type of health care worker was proposed: the AP”
(p.227). However, Miller et al. (2015), argue that given the current economic
climate, many registered staff have lacked the opportunity to develop themselves
and this has compounded the difficulties in devolving more responsibility to APs.
Lack of clarity, confusion, misunderstanding of the AP role spurred Skills for Health
in 2009 to formulate a definition of an AP. The definition was widely accepted and to
a large extent still referred to. Coupled with the development of the AP core
standards, the intention was to grow confidence in the AP role. Therefore, it was
envisaged that a set of core competencies that all APs must attain, regardless of
specific disciplines, would provide added reassurance of the minimum skills of all
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post holders in England. Equally, this would offer some degree of transferability and
portability of the role. (Skills for Health, 2009) Consequently, APs were defined as: -
An Assistant Practitioner is a worker who competently delivers health and social care to and for people. They have a required level of knowledge and skill beyond that of the traditional healthcare assistant or support worker. The Assistant Practitioner would be able to deliver elements of health and social care and undertake clinical work in domains that have previously only been within the remit of registered professionals. The Assistant Practitioner may transcend professional boundaries. They are accountable to themselves, their employer, and more importantly, the people they serve (Skills for Health, 2009a p.1).
Evaluation of the AP role Benson and Smith (2007) favoured a mixed method of data collection the evidence
was predominately qualitative in nature, with a reliance on interviews as the
preferred research method in the evaluation. Although the study provided a
comprehensive overview of the ‘Delivering the Workforce’ initiative and thematic
analysis of the results helps evaluate the positives and the negatives of the AP role,
statistical information such as cost benefits, patient throughput, service efficiencies
that can be directly attributed to the role was sparse.
Following Benson and Smiths work there has been a plethora of evaluations at
regular intervals across the United Kingdom. Miller et al. (2015) commence their
very comprehensive evaluation of the AP role in the NHS stating the following;
“There is a growing recognition of the value of these posts. Stakeholders can clearly
articulate the benefits of introducing the Assistant Practitioner role which includes
improvements in quality, productivity and efficiency” (p.3). This sentiment is echoed
in many other studies of the AP role. (Wilson, 2008; Allen et. al., 2012; Skills for
Health,2016a) However, National Institute for Health and Care and Excellence
(NICE) safe staffing levels have focused on registered staff and patient ratios
(NICE, 2014). This has unnerved some managers regarding the utilisation of
support roles, conversely managers have also indicated a preference for an AP in
the clinical area as opposed to registered agency staff. (Miller et al. 2015)
A national survey by Spilsbury et al. (2009), elicited an 85% response rate from
Directors of Nursing (DoN). They confirmed that 46% of NHS Trusts had already
introduced the role of the AP with a further 22% planning to introduce the role. In
32% of the organisations that responded it was noted that there was resistance to
the role, with DoN highlighting that there was a lack of effective evidence to support
the introduction of the role. This study examined how APs were developed and
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deployed, their impact on organisations, patient management and transfer of
activities from the registered nurse (RN) to the health care support worker(HCSW)
role. They noted the uneven distribution of APs nationally, with 84% of trusts based
in the North West having APs in their organisations. The debate on differences
between bands 3 and 4 caused confusion, this was compounded by the current
tradition of extended roles for Bands 2 and 3, which in some Trusts led the DoN
failing to see the value of the AP. Most of the Trusts confirmed that the APs had
been developed from the existing workforce but they could see little opportunity for
development within the role, other than accessing pre-registration courses. One
DoN expressed that they could not understand why anyone would train to
foundation degree level and not want to become a qualified nurse. However, it was
acknowledged that the AP role was becoming more prevalent, often in response to
service demand. The Royal College of Nursing (RCN) concluded that the AP role
was not a threat to that of the RN but rather a complimentary role. They advocated
the use of APs but aired caution that they must not be introduced merely as a cost
cutting exercise. (RCN 2009)
Wakefield et al. (2010) carried out an evaluation of the role by comparing and
contrasting twenty-seven job descriptions across organisations, measuring against
policy vision identified as working under supervision and reporting concerns to the
registered staff. They confirmed a blurring of roles, with APs often working outside
of policy and taking on responsibilities of the registered professional. Mackey and
Nancarrow (2005) noted this as a cause of resentment, in their study of APs in
occupational therapy in Australia.
Allen et al. (2012) discuss their experiences of the introduction of APs in critical
care. Although the role was generally evaluated positively, with registered
professionals acknowledging the skills that some of the APs had, ambiguity around
the role was identified as a concern. Respondents commented on the excellent
standards of care demonstrated by APs. “…having the Assistant Practitioner on
duty helped the registered staff to provide care in a more efficient way” (p.17).
However, there was conflicting opinions by staff as to the level of responsibility the
APs should undertake. Some senior staff felt the APs took on too much
responsibility, conversely the APs themselves generally evaluated that they
considered it was about right. Senior staff felt that they could not develop the role
any further and were mindful that there were limitations as to what patients the APs
could take responsibility for. Some senior staff stated they felt the role had made no
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difference. Registration was highlighted as an issue and the lack of professional
accountability, this is still a recurring theme in evaluating the effectiveness of the AP
role. Miller et al. (2013) predicted the likely growth and expansion of the AP role.
She calls for more extensive research into numbers of APs along with greater
clarification of the roles. She identifies a lack of a national specification for the role
and a wide variance in the level of qualifications that APs possess, in some
instances holding no recognised qualification whatsoever.
Miller et al. (2014) embarked on a study of APs in Wales. They advocate that the
role had brought benefits to the health service in Wales. Simpler funding
arrangements had enabled developments across acute and community services.
They noted that the AP title was inconsistently used, with a variety of job roles that
could be cross referenced to the level four descriptor 5 of the careers framework for
the NHS (Skills for Health, 2010). They noted comments from a variety of
respondents that the APs had brought both cost efficiencies and increased capacity
within the sector. Such claims lacked tangible evidence of this with no indication of
exact figures in relation to cost efficiencies. Once again it was highlighted that there
was a lack of consistency in implementation of the roles and a variance in the tasks
and procedures the APs and equivalent level four practitioners undertook. This has
led to many organisations developing local guidance and implementation toolkits,
however, many organisations did not have this in place.
Miller et. al. (2015) unearthed a wide acceptance from those they interviewed, that
APs can have a very significant impact in their work areas. They acknowledge
currently most evidence of AP assimilation into the workforce has been in the acute
setting, however recommend the role is extended and embraced more widely into
community settings. The closer integration of health and social care with less
complicated funding arrangements, gives rise to new opportunities for APs.
Changes in technologies have resulted in more tasks and procedures becoming
straightforward enabling increased opportunities for level four practitioner. APs
carrying out more straightforward tasks result in greater patient throughput. Some
posts have been introduced in response to national targets and strategies, others it
appears were as a result of funding being available. Cost benefit analysis and
5 Career Framework Level 4 People at level 4 require factual and theoretical knowledge in broad contexts within a field of work. Work is guided by standard operating procedures, protocols or systems of work, but the worker makes judgements, plans activities, contributes to service development and demonstrates self-development. They may have responsibility for supervision of 4 some staff. Indicative or Reference title: Assistant/Associate Practitioner (Skills for Health 2010)
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impact on capacity is only carried out in a small minority of departments, so
hindering the true impact evaluation of the role to be robust.
Workforce planning verses evolutionMiller et al. (2015) identify the AP role as the way forward in addressing the
recruitment crisis currently faced in the NHS. They discuss the successful
implementation of the AP role concluding there are more positive results if the AP
role is introduced as part of workforce planning as opposed to evolution. In many
circumstances the AP role is seen as a development opportunity for staff as
opposed to establishing a clear vision of their impact on services. This can lead to
the delegation of duties being at the discretion of individuals rather than an agreed
vision of the AP’s scope of practice6(SoP). This can distort the true potential of the
role in clinical areas. They draw on an example from tissue viability reporting that
the APs were not allowed to perform any of the skills they had learnt under the
leadership of one specific individual. Once the individual had left they were allowed
to practice in line with their skills set and competencies.
Perceived risk also played a significant role in restricting the APs SoP. In many
organisations medicines administration has been a problematic area, with Trusts
reluctant to delegate this procedure to non-registered staff. However, Miller et al.
(2015) highlight a pilot study where APs were administering medication, reports
indicated that APs were more cautious when administering medication, highlighting
in the course of the pilot there had been zero medication errors by them. They
confirmed that one occasion, the AP identified a medication error made by the
registrant. Therefore, perception of risk and delegation of duties based on
personality, in contrast to objective decision making as part of a planned strategy,
reinforces that the role is more successful introduced as part of workforce planning.
Miller et al. (2015) highlight radiography as an area where the AP role is part of a
national strategy around workforce planning and considered to have a positive
impact. Radiography as a profession have made great strides to shape and define
the AP role within its discipline and acknowledge this level of practitioner as part of
strategic view. The Society of Radiographers 7(SoR) have produced a SoP for APs
in this clinical area. This has help establish the role within radiographic services and
offered guidance to the registered professional on delegation (SoR, 2012).
6 Scope of practice refers to the procedures and tasks health care workers can undertake.7 Society of Radiographers refers to the professional body and union which supports most radiographers.
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Stewart-Lord et al. (2011) discuss the introduction of the AP role in radiography and
changes to the workforce programme in response to expectations of supply and
demand within the profession. Evaluation of role design between 2001 and 2005
established the role of the radiographer taking on some of the responsibilities of the
radiologist and so offering opportunities for APs to assimilate some of the
radiographer’s roles into their SoP. The profession developed a four tier approach
embracing four levels of practitioners, level one APs, two practitioners, three
advanced practitioners and four consultant radiographers. The extended use of the
AP would provide the catalyst for the progression of the registered practitioner
offering development opportunities within the profession, whilst also addressing the
increasing expectation of public demand. Appropriate opportunities were identified
within the diagnostic and therapeutic fields. Their study analyses the effectiveness
of the workforce strategy and utilisation of the role. They established that despite
professional guidance and documentation being available to guide the
implementation and use of the AP, in some areas and in some circumstances, it
was still based on individual’s personal experience and perceptions of the role. They
argued that there was still a need for more systematic approach to implementation
of the AP.
This study initially identified 226 radiography sites of which 121 employed APs, 85
were in diagnostic and 27 therapeutic. There was an overall response rate of 83
(74.1%). In diagnostic radiography the majority of respondents worked in general x-
ray, theatre and nuclear medicine were the least likely area of practice. The study
looked at whether the SoP developed by SoR was consistently applied. The
majority of APs had been developed from the existing workforce. The results
concluded that 9.7% in diagnostic services always worked outside their scope of
practice, whilst 47.8% felt they never did. In therapeutic radiography 8.5% identified
themselves as working outside of the recommendations with 31.9% assessing this
was never the case. Regarding confidence in their own competence, 79% of APs in
diagnostic services and 75% in therapeutic servicers felt secure in their skills to
carry out their duties. The vast majority reported that they were involved in decision
making. The area where APs were least supervised in diagnostic radiography was
plain film. In therapeutic environments this was patient support, information and
quality assurance. Significantly, those working outside of their scope of practice felt
they were performing duties that exceeded their AP role. Stewart- Lord et al. (2011)
concluded “APs in radiography continue to work in areas outside their scope of
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practice and without direct supervision” (p.198). In much of the literature from other
disciplines the opposite appears to be true, with individuals regularly identifying the
lack of opportunity to perform all their skills being the case (Miller et al. 2015).
The SoP developed by the SoR does show commitment from the profession in
attempting to regulate APs and establish the role as part of a national strategy,
however evidence would suggest it is not always being consistently applied.
Therefore, it might be argued that the role of workforce planning is inconclusive
(Stewart-Lord et al., 2011).
Registration and Regulation of the AP Registration and lack of regulation is consistently highlighted as a barrier to the
optimum use of APs (Wakefield et al., 2009; Steward-Lord et al., 2011; Allen et al.,
2012; Allen and Wright, 2012; Miller et al., 2015). The Francis Report in 2013
recommended the registration of support staff but this was rejected by the then
coalition government their response concluded “‘Regulation is no substitute for a
culture of compassion, safe delegation and effective supervision. Putting people on
a centrally held register does not guarantee public protection” (DoH, 2013, p.72).
Currently there are no plans by government to register staff below band 58 despite
80% of HCSWs, including APs, who according to Unison (cited in Miller et al.,
2015), believing they should be. Many professionals highlighted the lack of
registration being an obstacle to confident delegation of duties and ultimate
accountability. Miller et al. (2015) discuss professional concerns over regulation and
registration and stipulate: “…continuing concern regarding the non- registration of
Assistant Practitioners is known to have impeded progress in some areas” (p.20).
Conversely, Miller et al. equally argue their lack of registration can be seen as a
positive, meaning APs can work across professional boundaries and not be
restricted to one profession. Vaughn et al. (2014) contribute stating whilst most
articles they had considered in their literature review had called for registration of
APs, there was little evidence that this would support patient safety.
Some professionals remarked that educational programmes which did not lead to
registration lacked credibility. Educational content and training programmes were
not routinely standardised. The level of study and content varied considerably
adding to a lack of confidence in the abilities of APs. From an employment
perspective, transferability of the qualification was not as clear as it was for
registered staff. As a result of Francis (2103) and Cavendish (2013) many
8 Band 5 staff are usually registered professionals within the health service such as a staff nurse
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employers have been apprehensive with regards to inadequate training of staff
(Miller et al., 2015)
Skills for Health (2015) examined the broad range of roles that support staff were
engaged in. They estimated that 2.1 million individuals were employed by the NHS
mostly in professional roles. However, approximately 40% of that figure are in
support roles, with around 17% providing direct patient care. They identify staffing
as the largest major expenditure within the health service. Transference of duties is
nothing new in health. The move to all graduate nursing has helped move this along
with more and more work being delegated to the support staff. They identify “…with
the correct governance and clarity of roles and responsibilities; as well as
recognition of competence, support workers and Assistant Practitioners can
enhance quality and efficiency of care” (p.13). They consider the demographic
profile of the country and project that by 2037 the United Kingdom will have a
population of approximately 73,000,000. This will be combined with longer life
expectancy and an increase of people living with long term conditions. This 30% of
the population will account for 70% of the health service’s spending. They suggest
given the small difference in wages between bands 3 and 5 (which is approximately
£6,000) alternative thinking is often ignored locally. However, this differential on a
national scale amounts to significant savings. “Making better use of support staff
can also make a significant contribution to saving money and help improve patient
care” (p.14).
Skills for Health advocated that with good planning and support the AP role can
carry out many of the roles of their registered colleagues. They estimate that if 1%
of work was transferred from registrants to APs and support workers this could
result in £100,000,000 saving across the NHS. They champion the Band 4 role
suggesting that most of these staff members can work with minimal supervision.
Development of support staff can have a positive impact on both economics and
quality. (Skills for Health, 2016)
A subsequent publication by Skills for Health investigate the possibilities of
optimising the use of support workers, examines the need to look outside of working
in traditional cultures. They recognise the clear case for developing the support
workforce. They suggest that work is needed to look at future workforce
requirements and review of skills mix need to be carried out at a deeper level. They
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advocate the need for support workers to have parity of esteem in recognition of
their contribution to health care. (Skills for Health, 2016a)
Powel et al. (2016) researched the impact APs in GP practices, discovering that the
introduction of the role had reduced appointments for patients with the practice
nurse from twenty minutes to ten.
The AP: Foundation Degrees and Work-based LearningThere is no single route or programme to develop the AP role. Levels of
qualification underpinning the role varies considerably. The title of AP is not
protected and as such staff can be defined as an AP holding any number of
qualifications or none. Apprenticeships, diplomas, national vocational qualifications
and foundation degrees are some of the development programmes leading to the
title of AP. Miller et al. (2015) report that Skills for Health indicated that the role
should be underpinned by a level five qualification as indicated in the qualifications
and credit framework, sitting just below bachelor’s degrees. (Accredited
Qualifications, 2012). There is the suggestion that as foundations degrees have in
many instances become more generic, the AP is emerging unfit for practice. This in
itself has led to a lack of confidence amongst some employers. Uncertainty around
course content or qualification level has led to issues of transferability amongst
employers. However, in juxtaposition bespoke foundation degrees, tailored
specifically to service needs can be limiting when compared with a generic model.
Some Higher Education Institutes(HEI) have discontinued their foundation degree in
health and social care completely, assessing them as economically unviable. To this
extent organisation are considering the development of ‘professional diplomas’ as a
viable, more practical alternative. Trailblazer apprenticeships9 are also being hailed
as an appropriate method of developing APs. The literature indicates that there is
great discussion surrounding development opportunities for the AP. (Miller et al.,
2015)
Seagraves et al. (1996) carried out a study of work-based learning in small
companies. Their research highlighted a great deal of anomalies surrounding this
style of learning and structure of the programme. They identify that work-based
learning has improved access opportunities to learning and improvements on
performance and economic success.
9 Trailblazer Apprenticeships are developed with employers working in that particular sector to create apprenticeship standards for particular roles.
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Defining work-based learning they conclude it as learning that improves an
individual’s ability to do their job. They acknowledge that the application of the term
varies widely and is utilised to describe a host of different learning situations.
Therefore, they conceptualise said term under three distinct headings:
a) learning for work
b) learning at work
c) learning through work (p.6)
The study highlights that in many instances the success of work-based learning
initiatives have rested on the tenacity and enthusiasm of individuals who champion
the cause within individual organisations. Many organisations however, appeared
reluctant to change their working practices or reshuffle workloads to allow for
successful progression and implementation. This was often compounded with
inadequate or inappropriate mentorship. Perception of the programmes amongst
some organisations envisaging a speedy way to qualify staff, were in most cases
incorrect. They identify these as a major reason for attrition amongst the learners.
Boud et al. (2001) describe work-based learning as an approach to education that
involves bringing together HEIs with employers to develop learning opportunities in
the workplace. They discuss the wide variation in design, in some instances
indicating only minor differences to established programmes, whereas others they
claim have “…developed new pedagogies of learning” (p.5). They identify six
characteristics that they feel all work-based leaning programmes share; partnership
working; earners are usually employed; infrastructure needs to be present in the
workplace and the organisational needs form part of the curriculum; learner’s needs
are established and reflected in the curriculum; a substantial element of the learning
should be in the workplace; and academic standards maintained by the HEI.
Richards (2002) claimed there was a new interest in work-based learning, with HEIs
considering how best to prepare students for the world of work. She noted that
widening access had led to new relationships with students, employers and HEIs,
along with a more balanced approach to the integration of academia and vocational
goals set within programmes. Smith and Brown (2012) consider the emergence of
foundation degrees, identifying the qualification as work based learning and applaud
the flexible approach, characteristic of the programme, in meeting employer needs.
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The programme embraced both academic standards and work-based
competencies.
Harvey (2009) conducted a comprehensive review of a wide variety of research and
maintained “Lack of understanding of foundation degrees amongst employers is a
major challenge for institutions attempting to develop partnerships with employers”
(p. 35). He maintains that employers would engage in programme design, if they
could clearly see the benefits to their business. Mentorship is acknowledged as a
cornerstone of work-based learning. however, difficulties around consistent
mentorship was a constant theme with some learners reporting very poor standards
leading to problematic assessment of work based elements.
Wright et al. (2010) join the discourse examining the situation in Scotland identifying
relationships with HEIs and stakeholders had changed with the expansion of work-
based learning. They too note with the progression of the widening participation
agenda, learner centred approach, flexibility in programme delivery and adapting to
the demand for skills in the workplace, HEIs have extended their repertoire of work-
based learning programmes. They acknowledge that work-based learning means
different things to different people and that this results in confusion. Equally their
research established that whilst the relationship between HEI and employer was
important, it also had its difficulties, with different concepts of what actually
constitutes knowledge and learning. Accreditation of the courses where still HEI led
with an agenda for academic bias. Philips (2012) considers her thoughts on work-
based learning. She purports that they are attractive to employers as the learners
are not excluded from the work place. She agrees with previous claims that there is
a lack of clarity surrounding definition, but concludes that the usual model reflects a
tripartite relationship between the student, employer and HEI. This leads to learning
that can be directly applied to practice and personalised to the individual learner.
Work-based learning theoryRaelin (2008) discusses the concept of work based learning theory. His initial
thoughts on traditional learning echoes much of the literature available he
advocates “…unfortunately, we have become conditioned to separate the classroom
model that separates theory from practice…” (p.1-2). As previously acknowledged
work-based learning is intended to bridge the theory/ practice gap and views the
workplace as a positive environment for learning where by practice uses theory in
harmony and vice versa. He visualises three key elements as integral to the work
based learning process:
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1. It views learning as acquired in the midst of action and dedicated to the task
in hand.
2. It seeks knowledge creation and utilization as collective activities where
learning becomes everyone’s job.
3. Its users demonstrate a learning to learn aptitude, which frees them to
question underlying assumptions in practice. (p.2)
He discusses how work-based learning differs from conventional learning as it is
engaged with real life experience. He advocates that the concept of metacognitivism
is fundamental to the process whereby it is insufficient to merely look at what we
learnt but views it in a much wider context, ensuring that we fully understand the
ramifications of the learning, thus assisting us to analyse out current knowledge
base and rethink what we know. In doing so provide a framework to develop and
synthesise new knowledge.
Raelin relays that for many individuals the concept of work-based learning has
become synonymous with vocational study, which in turn has become tantamount to
saying that it is most suited for individuals who dislike classroom or academic study.
He reiterates that this should not be the case “…work-based learning is not
antagonistic to theory it respects and uses theory” (p.69). He recognises that all too
often practice and theory are developed devoid of each other’s contribution whereby
theory is determined as the thinking and practice the action, with both parties
holding somewhat derogatory ideas about the other. “Theory is often constructed as
impractical or as ‘academic’ or ‘ivory towerish’. Meanwhile, practice is viewed by
academics as banal and a theoretical” (p.64).
Raelin although reflecting on Kolb’s experiential learning model (1984), concludes
that work-based learning is much more, it is multi-layered with practice well capable
of producing theory. Raelin’s model of work-based learning initially incorporated two
dimensions’ theory and practice and explicit and tacit knowledge. He suggests that
theory offers a framework to challenge assumptions that when combined with action
creates a model of learning. Practice is viewed as the process by which
practitioners develop their skills and experience. Raelin highlights that positivism,
whereby knowledge is produced under scientific paradigms, is more credible due to
its objectivity and unbiased nature. It was deduced therefore, that theory be
developed outside of the influences of practice. As a result, theory was developed in
isolation and outside of context, leaving the learners to make sense of theory back
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in practice. Some schools of thought feel that this approach has produced a
framework even further removed from practice. He speculates that teaching became
disjointed from learning, teaching imparting knowledge and learning being the
storage, retrieval and recapitulation of the subject matter, leading to theory based
teaching with little regard to context. Once again the learner has to make sense of
this on their own out in the field. He argues that we now know that our
understanding is changes, we construct our knowledge and it is influenced by many
factors, knowledge that is abstract is of limited use in the real world. He concludes
“Theory makes sense only through practice, and practice makes sense only through
reflection as enhanced by theory” (Raelin, 2008 p.67). Work based learning relies
on a blend of both.
Raelin (2008) consequently explores the role of both explicit and tacit knowledge.
Work-based learning is more than just the knowledge and procedures passed on
from one individual to another. It also involves tacit knowledge not typically taught
but gained through experience and constitutes deep-rooted understanding
expressed through contextualised action often difficult to put into words. He
describes this as the difference between ‘knowing how’ and ‘knowing that’ (p.67)
Raelin argues that tacit knowledge can be transferred by observation and modelling
of others. He reiterates that conventional theory based learning can leave the
practitioner ill prepared in the workplace, unable to think independently and problem
solve. Tacit knowledge is what aids us in difficult situations or to engage in complex
problem solving. This can be built on by the collective knowhow of the environment
as a whole by the proximity of others and sharing of experiences. Theory may well
be developed as a living experience than that which is preordained. Work based
learning requires both explicit and tacit learning to have true impact. (Raelin, 2008;
Philips, 2012) Therefore, by utilising theory and practice, coupled with explicit and
tacit learning, Raelin advocates a conceptual model of work-based learning can be
constructed. In addition, he also considers a third dimension that of learner activity,
each individual learns at their own pace and from the people around them. (Raelin,
2008)
Impact Evaluation Process The aim of the project engaged in for this study was to develop a tool that could
measure the impact of new roles introduced into service. There have been many
evaluations of the AP role as previously stated.
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Wilson (2008) project managed and developed the East Midlands AP tool kit. She
considered how the role might be measured and how the role must be identified in
the business plan which should “…identify all the benefits expected from developing
and implementing the AP role and how they will be measured” (p.14) She
recommended that outcomes in the workplace should look at value, costs and
savings. They considered the impact of the role from a number of perspectives:
1. The service: Have strategic targets been met? Had the patient experience
improved? What affect had there been on key performance indicators?
2. Care Team: Had it allowed practitioners to work differently? Had it affected
capacity within the team?
NHS Wirral (2011) developed a number of fact sheets. including evaluating a project
or service. They identify three types of evaluation:
1. Formative: Carried out prior to the project commencing
2. Process: Begins at the start of the project can be used to look at delivery
and implementation of the project and whether it delivered to the original
plan?
3. Impact/Outcome: Did it meet its aims and objectives?
They cover a number of important issues; considering the purpose for evaluation
and who is the audience posing the question “Is the main impetus one of
demonstrating the benefits of the service to other potential users? “(NHS Wirral
2011) A key aspect of the impact evaluation project the researcher was engaged in,
was to provide tangible information that both the participant and others could use.
NHS Employers (2012) discussed their rationale for ‘evaluating an AP project’ and
how this helps establish the effectiveness of the intervention. They believe that a
project’s impact and success must be measured in relation to the original objectives
to assess its validity. They employed a number of methods in their process,
including interviews, surveys, staged assessments and the use of feedback forms.
Stern, et al. (2012) discussed the design of impact evaluation tools and states,
“Impact evaluation (IE) aims to demonstrate that development programmes lead to
development results” (p.i). They consider three elements to be essential in IE
design, the evaluation questions, appropriate design and method and programme
attributes. Stern et al. advocates five different types of impact evaluation
experimental, situational, theory based, case based and participatory.
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The Organisation for economic co-operation and development (OECD) claim that
impact evaluation is an assessment of how interventions have affected outcomes,
“… the proper analysis of impact evaluation requires a counterfactual of what those
outcomes would have been in the absence of the intervention” (OECD, n.d., p.1).
Counterfactual is not necessarily a before verses after, however this can be seen as
a valid method of impact evaluation. Robust impact evaluation will highlight both
successful and unsuccessful aspects, where there is potential for redesign by
establishing which objectives have been met and what lessons can be learnt along
the way. In turn this can influence decisions on whether future investment is
worthwhile. OECD discuss the importance of base line assessments and how this
will develop programme theory. They recommend a mixed method approach
declaring “Good evaluations are almost invariably mixed method evaluations”
(OECD, n.d., p.5). They conclude that impact evaluation surrounds specific
interventions and set in a specific context.
Rogers (2012) considers impact evaluation and echoes OECDs perspective;
“Impact evaluation investigates the changes brought about by an intervention” (p.2).
She suggests that expected results are an important aspect of impact evaluation,
whilst exploring unexpected results as part of the process. She discusses some
common reasons why impact evaluations are conducted:
1. Decisions around continuing to fund the intervention.
2. Whether to continue or expand the intervention.
3. Whether to replicate the intervention in other areas.
4. Whether it can be successfully adapted to suit other areas.
5. Reassurance to stakeholders that it is a valid use of funds.
The rationale is readily transferred to the AP role and its impact on services.
Rogers discusses the importance of establishing a theory with which to measure the
impact. Programme theory or change theory as she refers to, develops a hypothesis
of the expected outcomes that the interventions should achieve. She articulates “It
is often helpful to base an impact on a theory or model of how the intervention is
understood to produce its intended outcomes” (2012, p.6). She continues by noting
that credible evidence is needed. Equally how well the programme has been
implemented, to distinguish between implementation failures and theory failures.
Productive impact evaluation helps make sense of the intervention, “…it does not
just gather evidence that impacts have occurred but tries to understand the
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interventions role in producing them” (2012, p.9). Perrin (2012) discusses change
theory identifying it as referred to as programme theory, result chain, programme
logic model or attribution logic and the series of assumptions. He examines the link
between inputs, activities, intermediate outcomes and the intended impact. There
needs to be a logically constructed counterfactual, as in there is no other logical
reason for the identified impact other than the intervention itself. Quality impact
evaluation according to Rogers (2012), must be utilised, be accurate paying
attention to both intended impacts and unintended impacts, positive and negative
and have propriety, that is ethically sound recognising any potential harmful effects.
Rogers highlights that impact evaluation can be influenced by the characteristics of
participants and the environment. She claims impacts can take many years to fully
emerge, on some occasions results are needed before enough time has elapsed to
gain the true picture (2012).
Bamberger (2012) assesses the benefits of mixed methods and impact evaluation
advocating this as the preferred model. He suggests that quantitative results give
breadth of the impact whist qualitative inquiry adds depth to the evaluation. He
claims that no single method on its own can fully explain the impact of an
intervention in the real world and that a mixed method is a truer reflection. He notes
that whilst quantitative evaluation can provide information such as how many, how
much, significant differences, qualitative evaluation can provide evidence on how
the changes were experienced. He recommends that a multi-level, mixed method is
the most robust.
Evaluating training Programmes for the AP role Equally important in assessing the role of the AP in practice is evaluating the
training programme itself. Work-based learning and in particular the foundation
degree, has both academic aspects to evaluate and those in the work place.
Seminal work by Kirkpatrick originally in 1959, defines his four levels of evaluation
model. Now in its third edition, and written in collaboration with his son he discusses
the four levels:
1. Reaction of the student
2. Learning
3. Behaviour
4. Results
(Kirkpatrick and Kirkpatrick, 2010)
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At the first level the programme is evaluated in relation to the learner’s experience
of the programme. Did they enjoy it? Was it at a suitable pace? Could they see
application of the training back in practice? The second level looks at the learning
that took place as part of programme. This examines whether knowledge or
capacity to learn has increased for participants. Did participants have more
understanding as a result of the programme than they did before? Did the students
learn what was intended to be taught and experience what was intended in the
programme? Level three concerns itself with the behaviours of the participants and
their ability to interpret what they have learnt back in the workplace. Have they been
able to apply their learning? Has it resulted in a change of behaviour and practice?
Are the confident to pass on skills to others? The fourth level looks at the results of
the training on the organisation itself. Has the programme delivered on the
expectations of the business? Are there measurable impacts within the
organisation? Does the performance of the participant live up to the expectations
within the business case? (Kirkpatrick and Kirkpatrick, 2012).
Kirkpatrick emphasised that training needs to reflect the demands of the market
place and that it is not enough for educator to only concern themselves with the first
two levels of his model. He discusses the need for training to be practical,
interesting, enjoyable and relevant to the job in hand. He advocates that all four
levels must be explored to truly evaluate how effective a training programme has
been, claiming much of the learning is embedded through work once the training
programme is over (Kirkpatrick and Kirkpatrick, 2010). Kirkpatrick and Kayser
Kirkpatrick (2009) reflected on the model, suggesting that in many instances the
model had been misinterpreted and viewed too simplistically, creating an inability in
to understand the inter-relationship of the four levels.
A fifth level has been suggested by Phillips (2003) looking at return on investments
(ROI), he argues that in many circumstances ROI is intrinsically linked to
accountability and justification for time and money spent on training and
development. Phillips debates that whilst executives majorly agree that training is
needed for organisations who are developing and expanding and can result in
greater productivity or customer satisfaction, there is a lack of robust method to
evaluate an accurate ROI for many training programmes. Phillips claims that
attention to ROI has resulted in a paradigm shift within training from that of an
activity model to one of results. (Phillips, 2003)
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Kirkpatrick’s model can be applied in the most part to the development of the AP
and training programme. For the vast majority of APs, the foundation degree
qualification has proved to be the programme of choice. Students are requested to
evaluate their experience of learning at an individual level through local evaluation
procedures and the national student survey. Level two is evidenced in many
evaluations of the foundation degree programme by the students who prudentially
comment on the improvements they have seen in both their academic ability,
learning capacity and confidence levels. (Bungay et al., 2015) Level three of the
evaluation model can be measured by the students’ performance in practice.
Foundation degrees are characterised by their work based learning content;
students are expected to show competence in practice as well as academic rigour.
Level four it might be argued is somewhat compromised with managers reporting
that some APs lacked the desired skills in the workplace and that often the content
of the foundation degree had been too generic. Investigation into the fifth level
suggested by Philips reflects the spirit of this research investigation. The
development of an impact evaluation tool would consider return on investment as
one of its primary domains.
SummaryThis chapter has examined the literature from a broad base to support the different
phases of the action research project. It has looked at the current evaluation of the
AP role nationally and considered the methodologies deployed to conclude said
evaluations. It has evaluated whether any tangible tool had been developed to
assist the research claims. It has investigated the merits of work force planning in
implementing the role successfully. The education and training of APs has been
interrogated including the use of work-based learning as a model for programme
delivery. Consideration to the use of foundation degrees had been assessed and
the move towards generecism verses specialism has been discussed. The theory of
work-based learning g has been explored, along with identified characteristics of
work-based learning programmes. As this research study involves the creation of an
impact evaluation tool for the AP role, the process of impact evaluation has been
analysed. Finally, Kirkpatrick’s model of evaluation training programme has been
examined in relation to the underpinning process in developing the AP role.
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Chapter Three: Methodology
This dissertation discusses an action research approach, taken to develop an
impact evaluation tool that would provide resources for stakeholders to make
informed decisions supporting role development. The research is carried out in
three phases, ultimately leading to the development of the tool itself. A mixed
methodology was considered as the most appropriate way of conducting the
research study. Triangulation of both quantitative and qualitative methods were
employed within the study, to reap the benefits from both approaches. Research is
considered within two broad paradigms, quantitative methods, aligned to a
positivist /post positivist tradition and qualitative methods aligned to a naturalistic
tradition (Bowling, 1997; Bell,2006; Gray,2009; Ross, 2012). Silverman (2010)
identifies that traditionally quantitative methods have dominated proclaiming,
outside of the social sciences their prevalence still exists. Ross (2012) identifies that
quantitative research is prevalent in health care and is “considered more scientific
and trustworthy” (p.43). This has led to greater influence in shaping policy and
interventions. Ross (2012) continues by examining the contribution of qualitative
investigation in the field of health care, considering the impact and feelings that
research may have on its participants. Ross considers the mixed method approach
and argues that this is now defined by many as the third paradigm. She suggests,
“There are very strong arguments for combining approaches in order to capitalize
on the strengths and produce a more holistic view of the phenomena being
investigated” (p.133). Cohen et al. (2013) argues that robust research relies on the
ability of the researcher to used mixed methods where appropriate and not remain
steadfast to one method or another. He advocates that mixed methodology offers a
new paradigm in the field of research. Johnson and Onwuegbuzie (2004), discuss
mixed methods and declare that it is a “paradigm whose time has come” (p.1).
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Ethics The need for ethical approval was considered throughout the process and sought.
Ethical principle such as voluntary participation, informed consent, risk of harm and
confidentiality was maintained (Trochim,2006). The health research authority
decision tool was used in the first context, concluding that it was not designated as
research in line with their principles (Health research authority, n.d.). Proposal for
the research was made via the University and the researchers employing
organisation. It was deemed not necessary from both quarters. The employing
organisation considered the study to constitute a service review and as such did not
require ethical approval (see appendices 6,7). Information from the initial survey
provided an anonymous return and participants agreed approval for use in this
dissertation by providing an affirmative answer at the commencement of the study.
Equally, on the pilot documentation the stakeholder is explicitly asked to sign to give
permission for use of their information.
Why an action research approach?Action research is considered a very flexible approach that can be adapted and
applicable to many situations and for many different purposes. It is a very powerful
approach that requires both action and reflection to improve practice and decision
making (Cohen et al., 2013). Bell (2006) proclaims that it can be used in any context
where specific knowledge is required for specific problems. Bowling (2009)
highlights action research as a means of developing knowledge whilst
simultaneously changing it, and identifies two distinct features of improvement and
involvement, sentiment which is echoed by Gray (2009). Stringer (1996) proposes a
simple three stage model of action research of looking, thinking and acting. Ross
(2012) comments on the cyclical nature of action research and reports on the
discourse that surrounds it. She suggests a five stage model: identifying the
problem, fact finding, planning, action, evaluation. She argues that action research
has gained popularity with in health care as it is able to respond more readily in an
environment of rapid change. Bowling (2009) concludes, “Action research is a
popular technique for attempting to achieve improvements by auditing processes
and critically analysing events” (p.367). Bowling continues by suggesting that action
research often uses many different methods and may often use evidence generated
from both qualitative and quantitative methods, considering a variety of data
collection tools to inform the process. There are many different models of action
research. Gray (2009) comments that although there may be different approaches
they share three common characteristics:
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1. Research subjects are themselves researchers or involved in a democratic
partnership with researchers.
2. Research is seen as an agent of change.
3. Data are generated from the direct experience of research participants.
(p.313)
This study can be argued is aligned itself, to many of the different models of action
research. Cooperative inquiry model which focuses on research with people, as
opposed to on people, underpins the approach of the project undertaken. Although
cooperative inquiry is identified as a particular type of participatory research it
acknowledges its overlap with action research in general. (Herron, 1996). This study
is characterised by a small core group of two researchers with input from a variety
of individuals when and where appropriate.
Identifying the problemInitially, a problem was highlighted through employers concerning resources
available to support them in developing their bands 1-4, in particular the role of the
AP. Stakeholders were increasingly requesting more statistical evidence in relation
to the impact of the AP role to compliment the qualitative data available. Although
some evidence relating to cost effectiveness and direct effects on patient put
through and experiences were available, it remained limited. The action research
team believed that a possible solution to the problem was to create an information
gathering tool that could evaluate the impact of new roles within organisations. The
action research team consisted of two core members from the WBEF network with a
mission to produce a more holistic impact evaluation tool that would yield both
qualitative evidence and statistical data. Contributions from a number of sources
culminated in the final design of the impact evaluation tool.
The search cycles The research was carried out in phases utilising a variety of methods to produce the
information gathering tool, otherwise referred to as an impact evaluation tool. With
respect to this particular study the main focus was consideration of the AP role. The
first aspect was to look at the problem at hand. The research team identified the
projects objectives and considered how these would be addressed. A PEST
analysis was carried out by the team to help identify the areas that might be
important to managers when considering the investment and development of the AP
role. The aim was to create a tool that could be used by stakeholders to evaluate
the impact that introducing the AP (or any new role) would have in practice, whilst
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also considering the training and qualifications that might underpin role
development. The project was identified as having two objectives:
1. To develop a tool to determine the impact of a new role within a service
area.
2. Conduct research to determine the impact of a new role with a service area
– analysing results obtained from research.
Phase One of the research processThe first phase concentrated on two aspects. Initially desk top research was
conducted in line with the literature review, to investigate what evaluations had
already been conducted, methods used and what evaluation tools if any, had been
developed for said evaluations and measuring consequent impacts. Secondly,
running concurrently, a market research questionnaire via survey monkey. The
questionnaire was designed in conjunction with the PEST analysis, to establish
what were the highest priorities for stakeholders concerning the development and
introduction of AP roles within their organisation. This took a predominately
quantitative approach to gathering information but did include some qualitative
aspects providing opportunity for stakeholder comment.
Desk top research, also referred to as secondary research was conducted to scope
out the current situation with regards to the AP role and also ascertain what tools
had been used to gather the evidence. Utilizing the research finding of others in the
field would help identify areas that were successful and also problematic with the
AP role. Equally it would inform the research project at an early stage what methods
and resources might already exist and whether these could be adapted to meet the
needs of the project. Gray (2009) acknowledges that whilst some scepticism must
be deployed when using secondary sources, arguing some data cannot be
effectively replicated, this method can be efficient in both time and cost. It was
considered by the research team that analysis of secondary data would in this
instance help benchmark current knowledge and the findings would influence the
direction of the design for the impact evaluation tool.
Concurrently a questionnaire was designed to identify what managers and
stakeholders felt would be the most important information to have and what were
their greatest priorities were when considering the development of new roles within
their service(see appendix 4). The use of a questionnaire was identified as an
appropriate method of data collection at this point in the life of the research project.
The questionnaire was designed so that answers needed to be ranked in order of
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importance to help establish which domains should be captured in the design of the
impact evaluation tool whilst disregarding areas of least interest. This would
produce quantitative data identifying numerically which statements on the
questionnaire where of highest importance. A final section offered free text for
respondents to add comments they felt were significant to the topic.
Bell (2006) offers a reminder that attention needs to be paid to the design of the
questionnaire and the questions asked. The design should match up to the
objectives, the researcher must avoid ambiguity, provide a tidy questionnaire (which
receives a better response) and asks “…what do I really need to know” (p.140). She
advocates “It requires discipline in the selection of question writing, in the design,
piloting, distribution and return of the questionnaire” (p.136). Ross (2012) adds that
to some extent a questionnaire needs to be targeted at participants who have some
knowledge of the subject matter, seeing no advantage in targeting those who have
no understanding of the topic. She discusses that unless participants are selected it
can compromise the validity and reliability of the study, as respondents may well be
just guessing rather than providing a considered response. Bowling (2009) states
advantages of structured questionnaires to be useful in that they can remain
anonymous, economical and have the potential to access a relatively large
audience. Disadvantages may arise if participants are obliged to choose options
that do not reflect their true opinion or may not understand the instruction or
questions themselves. Equally response rates may prove disappointing. Ross
(2012) echoes the concerns raised by Bowling, whilst supporting the advantages
highlighted.
The researchers were aware of both arguments but as this would not be the sole
way of data collection felt that for market research purposes, this would be a valid
method. Participants were selected on the basis of their current interest in the AP
role and their positions within organisations to influence workforce development.
Gray (2009), offers a reminder that successful completion of questionnaires often
relies on the participants having a vested interest in completing them and cautions
that they should not be too lengthy. Piloting questionnaires is deemed good practice
(Bell, 2006; Ross 2012), therefore a small pilot was conducted prior to full
distribution to ascertain user friendliness, appropriate questioning and clarity of
accompanying instructions. The use of survey monkey was employed and the
questionnaire distributed using contacts held on a data base within the WBEF
network and resent four weeks later to encourage greater response, Consent to use
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data was embedded within the questionnaire itself and returns remained
anonymous maintaining confidentiality.
Phase Two Piloting the tool Data produced from the results of the survey and combined with secondary
research were reflected on by the action research team. The questionnaire
identified the priorities managers had indicated as the most pertinent in influencing
their decisions around role development. This was used in the design and content of
a draft impact evaluation tool. An appraisal of secondary research highlighted that
the majority of evidence surrounding AP evaluation was indeed qualitative in nature
with repeated use of questionnaires and semi-structured interviews as the dominate
data collection tools. Research into impact evaluation processes and work based
learning theory were also considered in the construction of the design of the impact
evaluation tool (see appendix 8).
The tool offered opportunity for stakeholders to consider the impact from both a
qualitative and quantitative perspective and produce data that had both anecdotal
and statistical qualities. Its design aimed to focus the stakeholders experience of the
role within the service area and consider whether the training and development
programme underpinning the role had resulted in individuals fit for practice. Equally,
it offered opportunity to consider the original vision for the role and assess the
actual role against the original concept. This is seen as a fundamental principle of
impact evaluation. Any deficits could be identified and an action plan established. A
meeting was held with the WBEF who would conduct the follow up interview to go
through the tool itself and also the guidance notes. A discussion also took place
around the process map provided to help the identified WBEF choose the area they
felt would be suitable for conducting the study with (see appendices 9,10).
The tool was then piloted with a service manager and guidance notes disseminated
(see appendix 11). An opportunity prior to the semi-structured interview stage was
offered to the manager to consider the evidence requested and allow time to
consider how they might best gather the evidence and prepare for the follow up
interview two weeks later. The follow up semi-structured interview conducted face to
face by a member of the WBEF network would then interrogate and consolidate the
information provided. Bowling (2009) highlights the advantages of face to face
contact and the ability to probe, clarify ambiguities, check out any inconsistencies
and gain a greater depth of knowledge. She continues by suggesting that with a
skilled interviewer the use of open ended questions can result in richer texts,
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especially useful in the pilot stage of any study. However, she also acknowledges
that they can be time consuming and expensive.
Bell (2009) cautions the need to consider bias when interviewing, therefore a WBEF
was identified to engage with the pilot phase who had not been involved in the
design of the impact evaluation tool, therefore minimising opportunity for bias when
conducting the follow up interview. Although the impact evaluation tool would guide
the interview there was opportunity for free discussion in the different domains of
the documentation and for open discussion around additional comments and
experiences. Ross (2012) comments that semi- structured interviews are often seen
as the most democratic method of interviewing as it offers the prospect for both
interviewer and interviewee to have some degree of free exchange during the
process. Issues of informed consent were also considered, Bell (2006), maintains
that during interviewing this is extremely important. Therefore, participants were
asked to consent by signing that they were happy for the information to be shared
and with whom, equally offering the opportunity for participants to give consent to
share one aspect but decline consent for its use in another context.
Phase Three: Tool review and redesignAfter completion of the pilot phase data was analysed to see if it had produced the
quality of information anticipated. The WBEF who carried out the interview were
contacted by the researcher. This was to ascertain the user friendliness of the tool,
highlight areas they felt were difficult to complete and what changes they would
recommend in the final design of the tool. This will be discussed in more fully in
chapter four.
Future phases of the research. Making the Impact evaluation tool a resource for practiceDue to the logistical restrictions of timescale the final production of the impact
evaluation tool is the point of conclusion for the purposes of this study. Further
recommendations for further use will be discussed in chapter six when
recommendations for further investigation are discussed.
SummaryThis chapter has discussed the methodology of the research study. It has examined
the rationale for why an action research model was chosen as an appropriate
approach for guiding the research process. The use of mixed methods has been
discussed in relation to data collection and a justification offered for the use of a
variety of data collection methods employed at each of the three phases of the
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study. It has explained how each phase of the research process has been used to
develop an impact evaluation tool to be used in practice and so contribute to the
resources available to stakeholders when considering the development of AP roles
within their service. It has offered the opportunity to discuss the importance of
piloting the initial market research questionnaire and the draft impact evaluation tool
that was developed.
Chapter 4: Findings and data analysis
Findings of the research are discussed with regards to the three phases of the
study. It is appropriate to refer back to the overall aims and objectives of the project
to rationalise the approach and finding
Aims: -
1. To provide managers with evidence based resources that can inform their
decision making when contemplating the training and development of non-
registered staff into the role of AP.
2. To develop a tool that will evaluate the impact of the AP role within a service
area.
Objectives: -
1. To scope out the current literature in relation to impact evaluations of new
roles within service areas.
2. Design an initial market research questionnaire to ascertain stakeholder’s
priorities when considering the development and introduction of new roles
within their service.
3. Utilise the findings of the initial survey to construct an impact evaluation tool
to gather both qualitative and quantitative evidence of the impact of the role.
4. Assist managers to make informed decisions with regards to the future
training and development of their non-registered staff within their service
area.
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The initial stage was threefold: -
Firstly, to scope out current evidence and conduct market research to illicit the
priorities of managers in relation to the design and content of the impact evaluation
tool itself.
Secondly, conduct research to analyse the current evidence and formulate a picture
of the main themes surrounding the AP role, equally establish what methods or
tools if any, had been developed when collecting the data.
Finally, to test the initial hypothesis of the action research team that the majority of
available evidence was qualitative in nature and lacked quantifiable data, which
stakeholders were now demanding. This lack of evidence justified the need to
develop an impact evaluation tool, that would enable the gathering of qualitative and
quantitative data regarding the AP role, to illustrate the extent of patient, service and
economic outcomes
Phase one part one: Secondary research and Scoping the AP role and evaluation methods. (Objective 1)Gray, (2009) discusses the role of secondary research of both qualitative and
quantitative evidence. He notes that in quantitative terms this might be the reference
to official statistics or documents where as in qualitative terms this would concern
itself with research done by others and often analysed by others. He advocates that
the purpose of secondary research in both methods is “…to perform additional, in-
depth analysis of a sub-set of the original data; or to apply a new perspective or
conceptual focus to the data” (p.497). He proclaims secondary research does come
under criticism, arguing that the context of the original research may be
compromised. Duffy (2009) contributes discussing the analysis of documentary
evidence and acknowledges this as a valid contribution when evaluated with other
forms of evidence. Clifford (1997) discusses how written text can be subject to
content analysis and is a useful method to gain perspective of the current evidence
base. The results of secondary research combined with the results of the
questionnaire would be incorporated into the content and design of the impact
evaluation tool. Duffy (2009) identifies two approaches to scrutinising documents a
‘source-orientated approach’ and a ‘problem-orientated approach’ (p.123). The latter
is deemed appropriate in this circumstance. Also the credentials of the documents
need to be considered, including the authors and content. The sources for this
particular analysis were subject to peer review and published in reputable journals,
or carried out in connection to professionally established organisations. In relation
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to the stated purpose for this phase of the research project, which was
fundamentally a scoping exercise it is deemed an appropriate method.
A content analysis approach was taken allowing the researcher to determine
themes that would influence the focus of the study and impact evaluation tool. In the
first instance the approach of role evaluations was considered. An appraisal by the
researcher of the vast majority of the research projects analysed in an extended
literature review, provided a qualitative profile of the AP role. Ross, (2012) confirms
that although not considered as scientific as quantitative methods, qualitative
investigation should not be “less vigorous” (p.114) in its approach. However, when
considering the evidence, a mixed method approach was often identified in the
methodology. Questionnaires featured heavily in the research and more often than
not this was followed up with semi-structured interviews. In some circumstances
there had been some investigation into statistical analysis most regularly around the
numbers of APs and organisations in which they were deployed. In most instances
there was no evidence of direct impact of the role on patient throughputs or the
economic benefits the role had brought about. Equally, there was no evidence of
any specific tool developed for capturing the impact of the role in practice.
The validity and reliability of the literature analysed from this section was considered
in relation to where it was published and by whom. The research papers were from
reputable journals and professional bodies. The credentials of the authors provided
reassurance to the vigour of the investigation. In depth interrogation of the literature
enabled recurrent themes to be established which would also be reflected in the
finalised impact evaluation tool. In the second instance the national distribution of
APs was interrogated. It emerged that in most instances evaluation of the role had
been conducted in NHS organisations and within the acute setting. However, there
was acknowledgment that the role should be extended to community settings and
the non NHS. This was taken into account when designing the impact evaluation
tool, ensuring that its design could be adapted to a number of different settings.
Equally, the evidence supported the view that the AP role had great potential and
was likely to become more widespread across NHS and non NHS organisations.
The evidence from several investigations in the literature review suggested:
1. Increased numbers of Assistant Practitioners in the future.
2. The extension of the AP role across different clinical settings.
3. The expansion of the AP role in response to new initiatives.
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4. Future investment in the role in addressing increasing demographic
challenges in service provision.
These observations reinforced the concept that developing an impact evaluation
tool and offer opportunity to fully evaluate the impact of the AP role, was a
worthwhile venture.
Barriers to the role were also highlighted in several of the studies as areas for
concern. A thematic approach identified the following concerns:
1. Confusion surrounding the role: - lack of clarity in what the AP could and
could not do and what tasks could be delegated appropriately to the post
holders.
2. Lack of opportunity for the skills of the AP to be fully utilised: - instances
whereby qualified APs were not allowed to carry out the skills and
competencies they were trained to do.
3. Inconsistencies in the level of qualification and course content: - There was
no singularly recognised qualification for the AP role. The title is not
protected and as such there is a wide variance in the level of training
received. Although the foundation degree was recognised as by far the most
popular route for qualification and AP status there was no standardisation of
content across these programmes.
4. Lack of registration and regulation: - This was envisaged as an obstacle to
confidently delegating tasks by the registered professionals and gave rise to
concerns with regards to accountability of the AP for their acts and
omissions
5. APs deemed not fit for practice: - There was evidence from some managers
that the AP could not carry out the tasks the manager required on
completion of the programme leading in some instances to managers having
little confidence in the role.
6. Limitations of the role and level of responsibility: - Managers reported that
delegation to an AP was limited worrying it exceed their remit and scope of
practice.
It was important that these concerns were incorporated into the design of the impact
evaluation tool to identify whether they had been addressed in other services and if
so, how? When constructing the impact evaluation tool, sections where therefore
included as to the type of service and area of practice. An opportunity to consider
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the tasks and responsibilities of the role, including the scope of practice,
competencies achieved, what training programme or qualification had been used to
underpin the role development were included in the body of the impact evaluation
tool. Equally, how well the role measured up to the original vision, along with
anticipated benefits, were incorporated into the text of the tool.
Phase one part two: Developing an initial market research questionnaire to establish stakeholder’s priorities (Objective 2)In conjunction with the secondary research of the literature an initial market
research questionnaire was also constructed and launched. Ross (2012) confirms
that surveys are a popular method of collecting data and the structured
questionnaire a preferred instrument to investigate opinion. It was agreed that
survey monkey would be deployed to distribute the questionnaire. Survey monkey
ensures that the questionnaire looks professional which Bowling (2009) highlights
as being important. Survey monkey also permits participants to engage
anonymously protecting individual’s identity and assuring confidentiality, which is
considered the basis of good practice (Bowling 2009). The results are automatically
calculated for the researcher ensuring that data analysis is more straightforward.
Choosing the right sample is considered fundamental to the success of a
questionnaire. A non-randomised sampling strategy described as purposive
sampling was employed as it was deemed necessary for those selected to have
similar characteristics, knowledge of the subject and have an insight into the issues
of role development (Bowling 2009; Gray, 2009; Ross, 2012). The sample group
would therefore be in one context from a homogenous group who all had an interest
in the AP role, however, heterogeneous in that within the sample group there would
be stakeholders from a number of different service areas, both clinical and non-
clinical, different professional backgrounds, holding different posts and from NHS
and non NHS organisations.
Determining the right questions to ask was an important factor in considering the
validity of the questionnaire in ascertaining the information that was of most
significant importance to stakeholders, therefore the results in each section with the
highest value could be incorporated into the impact evaluation tool. This also was
factored into the design of the questionnaire and format. Stakeholders where
presented with a range of statements that they were asked to rank in accordance
with the most important and least important information they would require when
considerations the implementation of new roles. This could be likened to a semantic
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differential scale with numerical options representing the participant’s opinions
around priority areas (Ross, 2012).
The questionnaire was piloted with three people prior to full distribution to ascertain
whether if it was too complicated, targeted the right information and how long to
complete. Ross (2012) indicates that this enhances the validity of the tool.
Feedback confirmed that the questionnaire was use friendly, asked the right
questions and that it took approximately ten minutes to complete. These three
returns were removed from the final results. For efficacy and economy, it was
agreed that the contacts already held by the WBEF network would be an
appropriate sample for this survey and would become the population for this survey.
Population refers to any grouping that has been chosen for the purposes of the
research (Ross, 2012). This would give the potential of accessing 292 participants.
The campaign function of 10Fulcrm was utilised as this allows one e mail to be sent
to multiple recipients at the same time.
Analyses of the questionnaire results The questionnaire was initially distributed to 292 individuals on the 11th December
2015, (n=292), with a covering e mail which is considered important (Bowling, 2009)
(see appendix 3). 28 e mails were subject to delivery failure from the original
distribution due to inaccurate details being recorded in the system. This meant a
9.52% reduction in the original population of the study. This resulted in 264
participants successfully receiving the e mail and questionnaire link (n=264).
Response rate was low in the first instance and by the 22nd December 2015, 33
individuals had responded this represented a 12.5% participation rate. There had
also been communication from a small number of individuals who had not been able
to open the link or had reported that the questionnaire had not worked. The survey
was resent on the 22nd December with a second accompanying e mail (see
appendix 5). A further 22 individuals responded. As responses are anonymous it
was impossible to know if any of the individuals experiencing problems had now
completed the questionnaire. This totalled 55 individuals who had responded,
representing a 20.8% engagement (when n=264).
Question one requested consent from participants to use the data produced in
relation to this dissertation,100% of participants agreed to this. Throughout the
survey the results are calculated to two decimal points.
10 Fulcrm is a data management system utilised by the WBEF network. It contains contact data as part of the functions.
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Question two asked the person to identify their role. This would enable the
researcher to gain an understanding of the breadth and diversity of the sample
group. The researcher was able to code the respondents into categories therefore
identifying what positions were held by those participating. There were ten
categories identified. The greatest response rate was from first line managers,
equally other managerial roles also featured heavily. It was thought that this was an
appropriate group as they often were the individuals with decision making
responsibilities in relation to new staff. Significantly ten of the participants were
categorised as ‘Specialist Practitioners’, these tended to be lead nurses or specialist
practitioners. The researcher’s knowledge of the AP role acknowledged that there
were significant numbers of APs in specialist services (see table 1).
Your Role (55 Respondents: n=55)
Role Number % Rate
Director of Services 2 3.36%
Educational leads 6 10.90%
Managers 19 34.54%
Matrons 3 5.45%
Practice Managers 3 5.45%
Service managers 8 14.54%
Specialist Practitioners 10 18.18%
Practitioners 3 5.45%
Other 1 1.82%
(Table 1 Roles of Respondents)
Question three related to the types of organisations employing the participants. This
would assist the researcher in quantifying different types of organisations to
establish a broad range of responses. It was acknowledged that the impending
impact evaluation tool would capture the interests of both NHS and non NHS
organisations. The researcher coded this section into five distinct categories. The
majority of respondents were from NHS Trusts; however, a quarter of respondents
were from organisations outside the of NHS Trusts. This enabled consideration to
be given to the needs of individuals across services, acknowledging that the trend
for AP roles to be developed outside of the NHS (see table 2).
Types of Organisation (55 Respondents: n=55)
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Organisation Type Number %Rate
NHS Trust 41 74.54%
GP Practices 3 5.54%
PIVO 7 12.72%
Social Services 3 5.54%
Other 1 1.82%
(Table 2 Types of Organisations)
Question four related to the service areas that the participants practiced. This would
allow the researcher to examine whether there was representation from the different
bases to identify whether practitioners in different circumstances, who may have
different priorities were represented in the survey. Once again this would offer
intelligence with regards to developing the AP role across a divergence of services.
The researcher coded this section into eight distinct categories. This data indicated
that there was participation across many different settings. The development of the
AP role in community is envisaged as a growth area for the new role (see table 3).
Service Area (55 Participants: n=55)
Area Number %Rate
Acute 15 27.27%
Community 24 43.63%
Primary Care 4 7.27%
Integrated Care 5 9.09%
Education 1 1.81%
Secure Services 1 1.81%
Other 5 9.09%
(Table 3 Service Area)
The results of questions two to four enabled the questionnaire to be placed into
context. It had established the designation held by the participants and so their
positions within organisations and as such, the influence they would have in
developing staff within their organisation. The types of organisations and
environments, said individuals worked in, helped understand the needs of those
organisations where APs might be developed. Therefore, input was provided from a
divergence of roles, employment cultures and circumstances for service delivery.
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Questions five to twelve would establish the priority individuals had given to a
variety of statements which would be embodied into the structure and text of the
impact evaluation tool. The statements receiving the highest responses would be
represented in the tool itself enabling the researcher to concentrate on priority areas
and eliminate areas that participants had indicated were less influential factors.
Participants were asked to rank in order of importance for each statement
dependant on the number of options available. The highest priorities have been
summarised in the tables below and ‘n’ defined in relation to the number of
participants completing each question. The top two statements in each instance are
identified (For full results see appendix 4).
Q5 When considering the financial benefits of the development of a new role, I want
information on: - (45 participants: n=55 participation rate 81.81%)
Highest identified priority statements out of 5 options
The impact on patient’s /service users.
Cost effectiveness (value for money).
Table 4 (Financial considerations of developing the AP role)
Q6 When considering the impact the new role might have on patient care, I want
information on: - (38 participants: n=55 participation rate 69.09%)
Highest identified priority statements out of 6 options
Patient / service user satisfaction.
Number of patient / service user interventions.
Table 5 (impact on patient care)
Q7 When considering the training/ education of the staff in the new role, I would want information on: - (38 participants: n=55 participation rate 69.09%) Highest identified priority statements out of 4 options
What skills could be acquired/developed by the training /education provider.If there is opportunity to develop the staff after their initial training/education programme was complete.
Table 6 (Training and education of the role)
Q8 When considering the training/ education programme itself, I feel it would be
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important that:- (36 participants; n=55 participation rate 65.45%)Highest identified priority statements out of 5 optionsIt had work based competencies included in the programme.It was work based.
Table 7 (Type of training /education programme)
Q9 When considering the impact of the role on the functioning of the team/service, I would want information on: - (36 participants: n=55 participation rate 65.45%)Highest identified priority statements out of 5 optionsThe potential to maximise skills mix.Where the role could support service development and overall performance.
Table 8 (Impact on teams/service)
Q10 When considering staffing the new role, I would want information on (36 participants n =55 participation rate 65.45%)Highest identified priority statements out of 4 optionsGrowing your own? (Recognising talent in your own staff and developing them).Examples of how similar roles had been successfully integrated in other organisations.
Table 9 (Staffing of the roles)
Q11 When considering developing the new role, I would find it useful to have: - (35 participants: n=55 participation rate 63.63%)Highest identified priority statements out of 6 optionsCompetencies and competency frameworks used in other organisations for similar roles. Examples of job descriptions and person specifications from other organisations.
Table 10 (Useful resources on the AP role)
Q12 When considering developing the new role, I would want information on how: - (35 participants: n=55 participation rate 63.63%)Highest identified priority statements out of 5 optionsFits in with national and local health and social care priorities.Offers career opportunities for my staff.
Table 11 (Compatibility with national priorities and workforce opportunities)
Questions thirteen to fifteen considered wider human resource issues in relation to
roles within the organisation (see appendix 4 p.16-18). Question sixteen thanked
the participants for their time and offered free text to add comments they felt were
important (see appendix 4 p.19). Five participants made comment representing
9.09% of respondents from the original 55.
It was noted that a number of participants had ‘skipped’ questions as they had
progressed through the survey, totalling 35 of the respondents fully completing the
entire questionnaire This gave a 13.25% response rate when n=264. Ross (2012)
highlights that response rates from questionnaires can be low. However, in this
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instance the results would be triangulated and used in connection with the
secondary research conducted. Triangulation is deemed an effective way of
demonstrating validity in research studies (Polit and Beck, 2006; Gray, 2009; Ross,
2012). Analysing the responses to the questionnaire and the themes identified by
secondary research, would allow content and design of the draft impact evaluation
tool and so reflect the types of information that stakeholders would want.
Phase Two: Developing and pilot of the draft impact evaluation toolThe action research team considered the results of the research carried out in
phase one and incorporated the findings into the design and content of the draft
impact evaluation tool. This was piloted with a service manager who had introduced
APs into end of life services. An individual from the WBEF network, was identified to
carry out the process with the service manager. Guidance notes to both parties
were distributed.
Analysis of the results of the draft impact evaluation tool and processInitial feedback indicated that the impact evaluation tool and the process itself had
the potential to be time consuming. Feedback from the interviewer indicated that the
tool was very useful in the semi-structured interview as it gave focus to the meeting.
The interviewer also noted that the wording of some of the questions could be seen
as ambiguous and needed rethinking. It was also highlighted that in section three of
the tool, examples would be useful to guide the participant in completing this
section. The interview also commented that the manager had filled out parts of the
questionnaire prior to the semi-structured interview as was envisaged in the original
process map and participant’s guidance. However, this resulted in a reluctance to
change any responses previously noted. The interviewer did highlight that she felt
the follow up interview was a vital part of the process as she had been able to use
this opportunity to clarify certain points and help refocus some of the content. She
concluded that the tool had the potential to work well and was comprehensive in its
approach, however the results may have been more useful if the interviewee had
held a more vested interest in the outcome of the process.
The results from the impact tool and process were inconclusive. The actual tool is
not included in this dissertation to ensure confidentiality of the participant but the
findings are discussed. In the first instance the individual originally highlighted as
the most appropriate to engage in the process and gather the evidence, was
unavailable and so a second individual agreed to complete the process. The tool
had gathered valuable information in relation to the profile of the service and its
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intentions. It was noted that in the first instance the manager had discussed the
service as a whole and this would prove too large a team to evaluate. During the
semi-structured interview, the WBEF was able to narrow this down to the end of life
section of the service. Gray (2009) highlights that semi-structured interviews allows
the interviewer to probe more deeply and gain greater clarity. The evidence
provided was predominantly qualitative in nature, with the service manager offering
comment on the impact of the role and outcomes for service users. She indicated
that the service had improved patient choice, reduced hospital admissions and
brought together closer working with the district nursing teams. The service
manager refers to the skills mix of the team and extended skill set of the staff.
Section three of the Impact evaluation tool was specifically designed to illicit
quantitative data from the participant. It asks the individual to consider evidence
available to support claims of cost efficiencies and service improvements. In this
section the service manager indicated all activities of the support worker role as
opposed to those specific to the end of life service. This might have been as a result
of misinterpretation of the section. The section did not produce usable quantitative
data as expected. Equally the manager had used generic data compiled from the
internet as opposed to utilising the data available within the service itself. Therefore,
it was difficult to evaluate effectively the direct impact of the role within that service
in relation to cost efficiencies and patient throughput. The service manager did
indicate that there was data gathering tools available to quantify impacts such as
spreadsheets and district nursing time lines but did not investigate this data for the
completion of the impact evaluation tool. They also indicate that with increased skills
mix amongst the staff, handover times were reduced and number of visits reduced
but does not indicate by how much. The WBEF who carried out the interview
discussed these areas, however the service manager felt that to interrogate the
evidence fully would be too time consuming. Overall the impact evaluation tool had
gathered a great deal of valuable data around the service itself but had not
produced the quantifiable evidence that could calculate savings or efficiencies
specific to that service or be attributed to the introduction of the role itself. This was
considered in the redesign of the impact evaluation tool.
The rationale of piloting the impact evaluation tool and the process was to learn
lessons, gain feedback and make adjustments to the final version of the tool.
Piloting is deemed a vital process when researching as it gives opportunity to
examine all aspects of the project (Gray 2009). The researcher conducted an open
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interview with the WBEF who had piloted the tool within service and results of the
completed tool were discussed. Each section was examined for relevance and
appropriateness. The WBEF indicated that the service manager was reluctant to
revisit many of the answers. Also it was noted that originally a different individual
who had greater involvement in the service, and was identified to engage in the
process, was likely to be unavailable for a considerable time which would have
delayed the piloting of the tool. Having a vested interest in the process is important
especially if the process does have the potential to be time consuming (Ross 2012).
Discussion also took place around the appropriateness of the service for piloting the
impact tool, concluding that retrospectively it might not have been the best choice.
This indicated that the effective use of the tool would be enhanced by a request
from services themselves to identify their need and provide motivation in fully
evaluating the introduction of new roles thus completing the impact evaluation tool
fully. The researcher also discussed whether the use of examples within the
document would be useful, especially in relation to section three. It was agreed this
would be a great benefit. Discussion took place as to whether the tool was a useful
guide to conduct the semi-structured interview? The WBEF confirmed that it gave
focus to the interview, allowed them to interrogate answers and seek clarification.
She felt that this was an essential part of the process and had the potential to
produce quality, holistic data surrounding the impact of the role.
Phase Three: Redesigning the impact evaluation tool and final version Initial changes were made in line with this first set of feedback and taken back to the
action research group for further reflection and readjustment. It was noted in the
action research group that once completed it was also difficult to distinguish who
had made what comments, which was the original text and what was the
participants responses? These considerations were also taken into account, the use
of italics to identify the pre-set text of the tool was introduced into the design.
Although the guidance notes issued to stakeholders prior to completing the tool
request them to consider how they would produce the evidence for section three it
was felt that this might be reiterated in the body of the tool itself. The researcher
also discussed the usefulness of an example of how cost savings could be
calculated would also be added to the agreed template. Additional notes on
completion were also added.
Amendments were made to the tool in line with the feedback and discussion. The
redesigned impact evaluation tool was then presented to a small focus group for an
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objective analysis of the final template. The membership consisted of three
members of the WBEF network who have an understanding of the topic under
consideration. Bell (2009) feels that having knowledge in the area can have an
advantage when considering the usefulness of a focus group. The group was asked
to read through the impact evaluation tool and were asked questions on its format,
the relevance of questions, topics covered, any sections they felt were misleading or
confusing and whether it would produce both qualitative and quantitative data that
would be useful. They were asked if the examples were helpful and whether the
way in which cost savings were calculated was accessible and straightforward to
use.
The response was very positive with the group making only small recommendations
to wording and lay out of the tool. It was identified that the notes contained within
the template were useful but should appear at the top of the tool as opposed to the
end. This final adjustment was made to the impact evaluation tool. The design of the
tool was updated in line with the findings of the focus group and final process map
devised (see appendices 12,13).
Input from the management team suggested that comprehensive completion of the
tool would be more likely if the individual engaged in the process had a high desire
to evaluate the role. It was therefore suggested a flyer be produced so that
stakeholders interested in evaluating the impact of a new role, had some indication
of time commitment and expectation on their part and the support that the WBEF
network as a whole could offer in the process (see Appendix 14).
Validity and Reliability Gray (2009) discusses validity identifying “…a research instrument must measure
what it was intended to measure” (p.55). This sentiment is echoed by multiple
authors (Bowling, 2009; Ross, 2012). Gray identifies seven different types of validity
internal, external, criterion, construction, content, predictive and statistically valid.
Internal validity is identified as correlation, cause and effect, are the findings of the
study a reflection of the overall objective. Whereas external validity refers to the
extent to which the findings can be generalised to a larger population. External
validity can often be determined by what particular characteristics the population
group of the study have in relation to other groups of individuals (Bell,2006; Cohen,
2007; Gray, 2009; Ross, 2012). Reliability refers to the dependability or repeatability
of the research method. Ross (2012) identifies three levels of reliability, stability
measuring, how often a tool consistently produces the same results, equivalence,
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whereby data produced by different researchers is compared and internal
consistency, whereby different sub divides of the tool point to the same conclusion
(Ross, 2012).
The mixed method approach can be argued as both valid and reliable. Secondary
research conducted, considered evidence from different studies, across different
disciplines and at different intervals. The themes identified from this research were a
recurrent throughout and characterised by their investigation into evaluation of the
AP role. The market research questionnaire was piloted with three individuals who
had experience of AP roles, prior to its launch, who concluded that the research
questions were appropriate to the study and so offer assurances of reliability and
internal validity. The sample who completed the questionnaire shared similar
characteristics to the wider target population and so could confirm external validity
to the method. With reference to objective one and two of the project, the methods
did offer an opportunity to scope out the current situation and enable the design of a
market research questionnaire, which justify the methods in this circumstance as
valid. The findings were reflected on by the action research team in the construction
of the draft impact evaluation tool.
The draft impact evaluation tool was then piloted and did produce qualitative and
some quantitative evidence. The semi-structured interview did assist in to clarify the
information obtained. However, the motivation of the participant did compromise
some of the findings. Although the WBEF who conducted the interview probed the
service manager to justify their claims, the service manager was reluctant to revisit
sections and investigate the evidence available within their specific service. The
WBEF was clear about the information that should have been produced but did feel
that there might be some ambiguity.
Feedback from the WBEF along with the consideration of the action research team
did lead to a content review, redesign and reformatting of the actual finalised tool.
Input from the focus group on the finished product indicated that the final version of
the impact evaluation tool, if used and filled out correctly, would produce the holistic
results that were anticipated. The final development of a flyer to ensure that the
participants were motivated to complete the impact evaluation tool and had a vested
interest in engaging with the process, was considered an appropriate method of
future selection of service areas and participants. It could be argued that the impact
evaluation tool is valid in that the final version would collate the anticipated
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information if completed by a highly motivated participant. The final version is
complete and ready for use but had not been completed in other service areas at
this stage of the research project.
SummaryThis chapter has examined the results and findings of the research project and the
phases which were carried out to date. It has considered how both secondary
research and a market research questionnaire were utilised to develop a draft
impact evaluation tool. The results of this first phase have been analysed and
incorporated into the draft design of the tool. Phase two of the project has been
discussed. Piloting the tool and process within a service manager from end of life
services and the experiences of the WBEF who conducted a follow up semi-
structured interview, focusing on the impact evaluation tool have been evaluated.
Feedback from the WBEF along with recommendations from a focus group and the
thoughts of the action research group itself have been discussed and how they
influenced the final action research tool ready for use. Phase three considered how
the finalised tool has now been produced, supported by an information flyer to
provide a resource for managers to both evaluate the impact of a new role in
practice and for managers who were considering the development of roles within
their service.
Chapter 5: Discussion and Analysis
The researcher had a particular interest in the AP role. From a personal perspective
the researcher had been involved with the development of APs since 2002 and
employed in one of the first fourteen pilot sites engaged with “Delivering the
Workforce”. The researcher had first-hand experience of the emerging role, he had
been a participant in the Benson and Smith research project in 2007. Over fourteen
years the researcher had directly supported TAPs, been involved as an operational
team manager and lectured on the foundation degree. Equally, the researcher on
many occasions presented locally, regionally (North West) and nationally,
establishing a sound knowledge and understanding of the type of information
stakeholders were requesting. The original concept of the research study was: ‘The
training and development of APs: An action research project to develop a tool to
evaluate the impact of the role in practice and inform service development within
NHS and Non -NHS organisations.’ The hypothesis formulated by the action
research team and utilisation of personal experience of the author, concluded
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although there was a plethora of qualitative evidence evaluating the AP role, there
was a lack of quantitative evidence available. Equally, a tool to collate evidence and
measure impact was not apparent. The project aims in summary were to enhance
the evidence base with more comprehensive data and therefore assist stakeholders
make informed decisions about the development of their non-registered staff. As a
member of the WBEF network, the author has a prime focus on the development
and promotion of APs, particularly in the North West. Discussion and analysis will
be conducted under the following headings.
The AP roleThe literature supports the view that the AP role has gathered momentum since it’s
conceptualisation in 2002. Benson and Smith (2007) had evaluated the role and
concluded mixed results. They comment on the impact of the role however, report
from a predominately qualitative paradigm. They convey confusion around the role,
lack of trust, reluctance by registered staff to delegate and uncertainty of the
potential the role might have. Allen et al. (2012) had noted that ambiguity of the AP
had influenced the effective integration of the role in critical care. Miller et al. (2015)
subsequently echoed many of the concerns that Benson and Smith had raised.
Lack of clarity and vision were still dominating concerns and lack of consistency in
the deployment of AP nationally was still evident. The literature in almost every case
had positive examples of how the AP role could be utilised but equally had the
commonality that there were still barriers to optimising their use. Stewart-Lord et al
(2011) examined the role specifically in radiography, where the AP role had been
introduced as part of a national strategy, however they reported that despite a SoP
being established for the role written by the SoR, there were still discrepancies in
what the APs were doing. Confusion is a recurrent trend (Benson and Smith, 2007;
Spilsbury et al, 2009; Stewart-Lord et al. 2011; Allen,2012; Miller, 2013; Miller et al.
2015).
The results from the market research questionnaire confirmed that participants
viewed economic impact and effects on patients to be of great importance when
introducing new roles into their service. These priorities needed to be addressed in
the impact evaluation tool. Indeed, at stakeholder briefings this type of information
was commonly requested. Wilson (2008) supports the notion that this needs to be
taken into account. She developed a comprehensive tool kit focusing on the
implementation of the AP role in the East Midlands. This offers guidance around on
what stakeholders can do. She suggests that managers need to “…identify all
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benefits expected from developing and implementing the AP role and how these will
be measured” (p.14). She continues by emphasising the importance of
“Assessments of outcomes in the workplace” (p.15), and reiterating this sentiment
identifying that the impact of the AP role must evaluate their effectiveness in
service. Skills for Health (2015) identify staff costs as the largest expenditure in the
NHS, value for money is high on the agenda, concluding “Making better use of
support workers can also make a significant contribution to saving money and
helping improve patient care” (p.14). The impact evaluation tool developed offers
one document that enables stakeholders to consider this and engage in cost benefit
analysis of the role.
Stakeholders identified that the contribution to skills mix and effects the role would
have on meeting national targets, were factors in their decisions around developing
the AP role. Miller et al. (2015) supports this view by recognising the great
contribution the AP role has to service delivery. They acknowledge that APs are
generally a stable workforce. Equally stakeholders also reported how engagement
with other organisations who had developed APs would be extremely helpful. Miller
et al. (2015) clearly identify that: “Several employers commented that they were
keen to learn from the experience of others” (p. 98), which echoes these findings.
Participants in the questionnaire highlighted that the sharing of job descriptions and
competency frameworks would be beneficial in developing new roles. The impact
evaluation tool developed in conjunction with the findings of the market research
questionnaire, offers the opportunity for intelligence sharing amongst stakeholders.
Results of the market research questionnaire indicated 40% of participants, always
looked at skills analysis when recruiting to vacancies, and although 77.43%
indicating workforce planning did play a part when recruiting future staff, this still
indicated that over a fifth did not. The researcher also acknowledges that workforce
planning can mean different things to different people. A definition of what is
considered workforce planning may have been helpful in establishing how many
had considered this as part of a formal process. Miller et al. (2015) also consider the
use of workforce planning and highlight in their findings that this was lacking in
many cases although seen as important to the successful implementation of the AP
role.
The action research group did take the view that gathering market research
intelligence was a vital part of this process. Justifiably, the areas that people
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developing the roles deemed important would need to be reflected in the finalised
impact evaluation tool. On reflection there are limitations to the use of the
questionnaire and the sample chosen, with a final response rate of 13.25%. As
participants had to prioritise their responses, there could have been the potential for
some aspects to be seen as all having importance, some of the scores were indeed
close. The action research team where however, very keen to encourage
stakeholders to think about their priorities, as they realised that there was potential
for the document to become too unwieldly. Also the population of the research
questionnaire where from the North West and were familiar with the AP role being
developed through commissioned foundation degrees, therefore funding may not
have been highlighted as a major issue, as funding of the programme already
existed for their particular trainees. Miller et al. (2015) highlight that funding is an
issue for managers they had interviewed and highlight the availability of funding to
be influential in the decision to develop the role. This was not evident in the findings
of this particular study. The majority of respondents to the questionnaire did come
from NHS trusts which is the trend nationally (Miller et al., 2015), however there is a
recognition that the AP role can be utilised in many different settings and whilst
PIVOs and non NHS are represented their contribution could have been
investigated further.
Sustainability and expansion of the role The market research questionnaire elicited responses from different roles and
across different service areas. The AP role can be adapted to meet the needs of a
variety of disciplines. The Royal College of Nursing (2010) reported the growth of
APs across the country and acknowledged the experience of the North West, who
had developed the greatest number with sustained interest. Miller (2013) concluded
that there would be a likely rise in the number of APs nationally. Miller et al. (2014)
identified that the AP role was being deployed in a number of settings with growing
interest. Miller et al. (2015) project the increased demand for the AP role concluding
the role can continue to be embedded in the future. Skills for Health (2016; 2016a)
supports the development at utilisation of the support worker role including APs,
they advocate that the use of band 4 roles can work with minimal supervision and
continued development of the role will assist in meeting demographic change and
service demand. The evidence strongly indicates that the AP role has great
potential for the future. The impact evaluation tool will support the continued
development of the role by producing more holistic evidence to inform managers in
developing their bands 1-4.
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It is recognised by the author that one of the limitations of the tool is that it can be
time consuming and has the potential to become a lengthy document. The action
research group concluded that there is need for such a tool and to be robust, this
would have to be a process that takes time and consideration on behalf of the
stakeholder and the WBEF conducting the follow up interview. Equally, the pilot
highlighted that motivation of the stakeholder to generate meaningful data from that
service area, is vital to ensure that the impact of the role can be evaluated
effectively. It is acknowledged that the area highlighted for piloting may not have
been the most appropriate and so test the tool most thoroughly. As the tool is
disseminated more widely and used more extensively, the action research group will
continue to review its use and gain more depth of understanding of its effectiveness.
It is anticipated that future developments will produce a shorted version of the tool
that can be utilised solely to examine cost effectiveness and patient impact.
Education and training Participants in the market research questionnaire confirmed that their preferred
model of training was through work based learning, they indicated that work based
competencies were key in this. The involvement of employers is fundamental to
work-based learning as Raelin (2008) discusses. Philips (2012) also discussed the
relationship between learner, employer and HEI in her discussion on work-based
learning. Participants confirmed they were less concerned whether the programme
lead to a nationally recognised qualification or at what academic level it would be
delivered at. This suggests that fitness for practice and meaningful competencies
were of far greater importance.
When piloting the impact evaluation tool the stakeholder indicated that their staff
had followed a foundation degree programme but that there had been a need for
additional competencies to be achieved, which had resulted in their APs not being fit
for practice. Miller et al. (2015) also commented that they too had found managers
indicating that their APs were not fit for practice and that in some areas the
qualification had become too generic, resulting in some managers losing confidence
in the programme. The impact evaluation tool asks managers to consider deficits of
the role and invites them to action plan to address these potential problematic
areas.
Employer feedback on the training programme was deemed important to the action
research group. Therefore, the impact evaluation tool developed offers opportunity
for stakeholders to comment on the training programme they had utilised in
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developing the AP role. Equally it invites stakeholders to examine ROI both from an
economic perspective and patient experience. Considering the work of Kirkpatrick
and Kirkpatrick (2012) evaluation of training programmes must capture the opinions
and observations of employers. With Philips (2003) also considering ROI being
argued as critical in establishing the true worth of development programmes This
information should be shared with programme provides to influence the curriculum
content and design of their courses.
Impact evaluation The impact evaluation tool is envisaged to provide a resource for stakeholders in
their decision making process as was the aim of the study undertaken. It was
deemed important that the tool offered a mixed method approach to impact
evaluation of the role in services. This approach is supported by Bamberger (2012)
who advocates that mixed methods approach to impact evaluation produces the
most reliable results. The literature surrounding impact evaluation identifies it as a
process. Robust impact evaluation relies on establishing a counterfactual and
measuring the end product with original vision. This will help identify programme or
change theory and develop a hypothesis to measure against (OECD, nd; Rogers,
2012). Findings from piloting the impact evaluation tool helped identify areas that
needed adjustment and whether the questions were appropriate to the intended
use. Rogers (2012) highlights that asking the right questions is imperative to good
impact evaluation. The action research group considered feedback from different
sources when construction the finalised tool.
The impact evaluation tool reflects these positions in both content and design.
However, it is limited in that its deployment is to examine a before and after
comparison. The researcher is aware that a comprehensive study would provide a
more robust evaluation, however rationalises that logistically this would be a difficult
and time consuming process for all participants. Feedback from the service
manager who engaged in the pilot study indicated that she felt it could be very time
consuming and therefore dissuade them from engaging in the process. The
researcher acknowledges that the finalised tool does have limitations in this respect.
There is scope to look at conducting a more extensive impact evaluation with
organisations willing to participate over a period of time, which would produce a
more comprehensive appraisal of the impact new roles have had in that service.
Currently, the finalised tool has been agreed by the management team of the WBEF
network and is available for future use. Continuous evaluation by the action
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research group will monitor the effectiveness of the tool and reflect on its usefulness
within the practice area.
SummaryThis chapter has discussed the findings of the research study and how the literature
supports or compromised the results. It has examined the data extrapolated from a
market research questionnaire and compared its findings with those of others
researching in the field. The findings of each phase of the study has been evaluated
in relation to current evidence. The development of an impact evaluation tool has
been debated and how the tool will be used to add to the evidence base
surrounding the development of the AP role. A justification for a mixed method
approach has been offered and the intention for the tool to be available for use by
stakeholders. It has explored the research methodology and acknowledged any
limitations that exist.
Chapter 6: Conclusions and Recommendations
In conclusion this research study came from the initial position of how an action
research approach could develop an impact evaluation tool to support managers in
developing their bands 1-4 staff. It was carried out in line with a project identified by
the WBEF network to enable both qualitative and quantitative evidence to be
gathered to meet the demands for information requested by stakeholders. It also
offers the opportunity for managers who have introduced new roles, evaluate the
holistic effectiveness and influence of that role in their own service. Considering
evidence from research articles reviewed regarding the evaluation of APs, it was
found that the findings were predominantly qualitative in nature. This confirmed the
hypothesis of the action research group that there was a lack of quantifiable data in
relation to the cost benefits of the AP role and its direct effects on patient
throughput. Information received from an initial market research questionnaire also
provided an indication of what priorities stakeholders had when considering the
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development of new roles in their service. There was very little evidence when
considering the literature review that any tangible tool had been developed. The
action research team concluded that the development of a tool that would
holistically evaluate the impact of the AP role, would be a useful resource for
stakeholder to use in their service. Furthermore, it was anticipated with permission,
their information could be incorporated into information sheets and shared with
others.
The research was carried out in phases and anticipated future phases identified.
Each phase was evaluated by the action research team to assist in the design of the
final tool. The initial market research questionnaire did return results however these
were limited and the population of the survey could have been more wide-reaching.
It did provide a baseline to work from and assisted in identifying what needed to be
incorporated into the impact evaluation tool.
The draft tool was piloted with a service manager and the results and methodology
analysed. It was evident from the pilot that there were limitations to the tool. The
pilot indicated that the tool needed redesigning, reformatting and be more explicit if
it was to produce the data deemed most useful to stakeholders and potential future
stakeholders. The results from the pilot had mostly captured qualitative data and not
a mix as expected. Some of the data gathered was unusable as the service
manager had used the internet as a source of evidence which meant it did not relate
to her service. Time restraints was also highlighted as an issue and whether it would
be realistic to expect busy managers to give the attention the tool needed. An
interview with the WBEF who carried out the follow up interview with the service
manager, also raised issues around motivation of the participants and highlighted
that the service area completing the impact evaluation tool, must have an intrinsic
interest in the process and results. Comments on terminology were also considered
as was the necessity to conduct an interview with the participant. The action
research group also considered further adaptation to the impact evaluation tool. The
redesigned tool was then scrutinised by a small expert focus group with vast
experience of supporting APs before it was finalised. The issue of ensuring high
motivation of the participants was addressed by the creation of a flyer which
highlighted the expected time scale for completion and the benefits of conducting
the impact evaluation itself. The flyer will ensure that only managers who wished to
participate in the process would come forward in the first instance. For logistical
reasons the impact evaluation tool has to date only been piloted with one
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stakeholder. It is now necessary to work with other organisations, using the newly
designed tool to compare results. The finalised tool has been developed and is now
ready to be used not only to evaluate the AP role but any new role that has been
developed.
The Aims of the project were twofold:
1. To provide managers with evidence based resources that can inform
their decision making when contemplating the training and development
of non-registered staff into the role of AP.
2. To develop a tool that will evaluate the impact of the AP role within a
service area.
The impact evaluation tool will add a different dimension to the information available
and so add to the resources that stakeholders will have access to. As the impact
evaluation tool requires participants to consider what evidence they have to support
their claims, it will offer real life data that can then be used to consider future
decision making. Equally, stakeholders will be able to objectively evaluate the
effectiveness of new roles they have introduced themselves, including potential cost
efficiencies, effects on patients and impact on key performance indicators by using
the tool. Although it is acknowledged that the tool has limitations and may not have
wide appeal, it is concluded the aims of the research study have been achieved.
The true potential of the finalised impact evaluation tool will only become evident
with future use.
Recommendations The researcher makes the following recommendations in the future use of the
finalised impact evaluation tool: -
1. That the WBEF network identifies suitable areas that might be appropriate
and are motivated to carry out an impact evaluation of new roles they have
introduced into service. These should include both NHS and non NHS
organisations and cover a variety of service setting, to establish the flexibility
of the tool and its adaptability.
2. The members of the WBEF network are trained in the use of the impact
evaluation tool and the purpose of the follow up semi-structured interview.
3. Stakeholders who currently have AP positions are encouraged to fully
evaluate the impact these roles have had in service.
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4. The tool is used to evaluate new roles other than that of the AP.
5. The evidence gathered from carrying out the impact evaluation are
converted into case studies that highlight both qualitative and quantitative
data which can be shared to a wider audience. The evidence can be used to
evaluate whether the initiative has had a direct impact on services and so
can be used to justify future investment into the roles.
6. The impact evaluation tool is used as a method of showcasing excellence
and sharing good practice.
7. Data collected around the education or training programme is fed back to the
education/training provider to influence the curriculum content
8. An abridged version of the impact evaluation tool is developed as an on line
resource that stakeholders can fill out themselves in the future.
9. The action research continues to monitor the use and usefulness of the
impact evaluation tool and reviews its effectiveness at regular intervals.
10. The impact evaluation tool evolves to continue to capture the evidence that
is useful to all stakeholders both current and potential.
Final thoughts The aim of this dissertation was ‘An action research project to develop a tool to
evaluate the impact of the AP role in practice and inform service development within
NHS and non NHS organisations. To this extent the aim has been recognised. The
action research model has provided an effective way to investigate the research
question and ultimately produced an impact evaluation tool that can be used by
current service areas and potential service areas. It encourages services to focus
on the evidence base and share good practice with other practitioners, whilst
offering stakeholders an additional resource to evaluate their service.
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Bibliography
Accredited qualifications. (2012). Qualifications and Credit Framework. [Online]
Available from: http://www.accreditedqualifications.org.uk/qualifications-and-credit-
framework-qcf.html. [Last accessed 30th April 2016].
Allen, K. McAleavy, J.M. and Wright, S. (2012). An evaluation of the role of the
Assistant Practitioner in critical care. British Association of Critical Care Nurses. 18
(1), pp.14-23.
Bamberger, M. (2012). Introduction to mixed methods of impact evaluation. [Online]
Available from: https://www.interaction.org/sites/default/files/Mixed%20Methods
%20in%20Impact%20Evaluation%20(English).pdf. [Last accessed 14th March
2016].
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Student number: -0207586
Basit, T. N., Eardley, A. Borup, R., Shah, A. and Hughes, A. (2015). Higher
education institutions and work-based learning in the UK: employer engagement
within a tripartite relationship. Higher Education. 70 (6), pp.1003-1015.
Bell, J. (2006). Doing your research project. A guide for first-time researchers in
education, health and social care. 4th ed. Berkshire: Open University Press.
Benson, L. and Smith, L (2006) Delivering The Workforce. Evaluation of the
introduction of Assistant Practitioners in seven sites in Greater Manchester second
report May 2006.Manchester: Centre for Public Policy and Management University
of Manchester.
Bonbright, D. (2012). Use of impact evaluation results. [Online] Available from:
https://www.interaction.org/sites/default/files/Use%20of%20Impact%20Evaluation
%20Results%20-%20ENGLISH.pdf. [Last accessed 14th March 2016].
Boud, D., Solomon, N. and Symes, C. (2001). New Practices for New Times. In:
Boud, D. and Solomon, N.(eds.) (2003) Work-based learning: a new higher
education? Buckinghamshire: Open University Press. 3-17.
Bowling, A. (2009). Research methods in health: Investigating health and health
services. Maidenhead: Open University Press.
Brown, L., Hedgecock, L., Simm, C. and Swift, J. (2011). Advanced Paramedics
deliver on the front line. Health Service Journal. 25 (None available). pp. 24 - 26.
Bungay, H., Jackson, J. and Lord, S. (2015). Exploring assistant practitioners’
views of their role and training. Nursing standards. 30 (30), pp.46-52.
Burke Johnson, R. and Onwuegbuzie, J. (2004) Mixed method research: A research
paradigm whose time has come. Educational researcher, [Online] 33 (7), pp. 14-26.
Available from: http://www.jstor.org/stable/3700093. [Last accessed 6th February
2016]
Cavendish, C. (2013). The Cavendish Review an independent review into
Healthcare Assistants and Support Workers in the NHS and social care settings.
[Online] Available from:
63
Student number: -0207586
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/
236212/Cavendish_Review.pdf .[ Last accessed 5th April 2016].
Chapman, A. (n.d.). Pest market analysis tool [Online] Available from:
http://www.businessballs.com/pestanalysisfreetemplate.htm. Last accessed 30th
November 2015.
Chivite-Matthews, N. and Thornton, P. (2011). Guidance on evaluating the impact
of interventions on business. [Online] Available from:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/
212318/11-1085-guidance-evaluating-interventions-on-business.pdf. [Last accessed
3rd April 2016].
CIPD. (2015). PEST analysis: Resource summary. [Online] Available from:
http://www.cipd.co.uk/hr-resources/factsheets/pestle-analysis.aspx . [Last accessed
15th March 2016].
Clifford, C. (1997). Qualitative research methodology in nursing and health care.
London: Churchill Livingstone.
Cohen, L., Manion, L., and Morrison, K. (2013). Research Methods in Education.
7th ed. Oxon: Routledge.
Creswell, J.W. (2007). Qualitative inquiry and research design: Choosing among
five approaches. 2nd ed. London: Sage.
Department of Health. (2010). Equity and excellence: Liberating the NHS.
[Online] Available from:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/
213823/dh_117794.pdf. [Last accessed 11th March 2015].
Department of Health. (2013). Patients first and foremost the initial government
response to the report of the Mid Staffordshire NHS Foundation Trust public inquiry.
[Online] Available from:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/
170701/Patients_First_and_Foremost.pdf. [Last accessed 18th April 2016].
Duffy, B. (2006). The analysis of documentary evidence. In: Bell, J.(ed.) Doing your
research project: A guide for first-time researchers in education, health and social
sciences. 4th ed. Berkshire: Open University Press. 123-133.
64
Student number: -0207586
Francis, R. (2013) Report of the Mid Staffordshire NHS Foundation Trust Public
Inquiry: Executive Summary. London: The Stationery office
Garbarino, S. and Holland, J. (2009). Quantitative and qualitative methods in
impact evaluation and measuring results. [Online] Available from:
http://www.gsdrc.org/docs/open/eirs4.pdf. [Last accessed 11th March 2016].
Gray, D. E. (2009). Doing research in the real world. London: Sage.
Health Education England. (2014). Widening participation, it matters: Our strategy
and initial action plan. [Online] Available from:
https://www.hee.nhs.uk/sites/default/files/documents/WES_Widening-Participation-
Strategy_Booklet.pdf. [Last accessed 2nd April 2016].
Health Education England. (2016). Building capacity to care and capability to treat a
new team member for health and social care in England. [Online] Available from:
https://hee.nhs.uk/sites/default/files/documents/Response%20to%20Nursing
%20Associate%20consultation%2026%20May%202016.pdf. [Last accessed 5th
July 2016].
Health research authority. (n.d.). Determine whether your study is research. [Online]
Available from:
http://www.hra.nhs.uk/research-community/before-you-apply/determine-whether-
your-study-is-research/. [Last accessed November 2015].
Health research authority. (n.d.). Is my study research? [Online] Available from:
http://www.hra-decisiontools.org.uk/research/. [Last accessed 15th November
2015].
Heron, J. (1996). Co-operative inquiry: Research into the human condition. London:
Sage
Hickson, M. (2008). Research handbook for health care professionals. Singapore:
Blackwell Publishing.
Howat, C. and Lawrie, M. (2015). Sector insights: skills and performance challenges
in the health and social care sector. [Online] Available from:
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/
430164/
65
Student number: -0207586
Executive_Summary_Skills_and_performance_challenges_in_health_and_social_c
are.pdf. [Last accessed 6th April2016].
Kessler, I., Heron, P., Dopson, S., Magee, H, Swain, D. and Askem, J. (2010). The
Nature and consequences of support workers in a hospital setting.
[Online] Available from: http://www.netscc.ac.uk/hsdr/files/project/SDO_FR_08-
1619-155_V01.pdf. [Last accessed 5th January 2016].
Killgannon, H. and Mullens, C. (2008). What are assistant practitioners? British
Journal of Healthcare Assistants 2 (10), pp.513-515.
Kirkpatrick, J. and Kayser Kirkpatrick, W. (2009). The Kirkpatrick four level: A fresh
look after 50 years. [Online] Available from:
http://www.kirkpatrickpartners.com/Portals/0/Resources/Kirkpatrick%20Four
%20Levels%20white%20paper.pdf. [Last accessed 16th May 2016].
Kirkpatrick, D.L. and Kirkpatrick, J.D. (2012). Evaluating training programs: the four
levels. 3rd ed. San Francisco: Berrett-Koehler.
Kolb, D.A. (1984). Experiential learning: Experience as a source of learning and
development. Jersey: Prentice Hall.
Leach, C. and Wilton, E. (2008). Evaluation of Assistant/Associate Practitioner roles
across NHS South Central. [Online] Available from:
http://www.workforce.southcentral.nhs.uk/pdf/NESC_Evaluation_Report_Final_2009
0212.pdf. [Last accessed 9th April 2016].
Mackey H. and Nancarrow, S. (2005) The introduction and evaluation of an
occupational therapy assistant practitioner. Australian Occupational Therapy
Journal;52: (4), pp. 293-301.
Miller, L., Williams, J., Marvell, R., and Tassinari, A. (2015). Assistant Practitioners
in the NHS in England. [Online] Available from:
http://www.skillsforhealth.org.uk/index.php?
option=com_mtree&task=att_download&link_id=175&cf_id=24. [Last accessed 11th
March 2016].
Miller, L. (2011) The Role of Assistant Practitioners in the NHS. Factors affecting
evolution and development of the role. Bristol: Skills for Health
66
Student number: -0207586
Miller, L. (2013) Assistant Practitioners in the NHS: drivers, deployment,
development. Bristol: Skills for Health
Miller, L., Williams, J. and Edwards, H. (2014). Assistant Practitioner roles in the
Welsh Health Sector enhancing the potential for future development. [Online]
Available from: https://www.myhealthskills.com/uploads/articles/files/Assistant
%20Practitioners%20in%20Wales%202014(1)-1393511549.pdf. [Last accessed
12th April 2016].
Mortimer, D. (2016). Building capacity to care and capability to treat – a new team
member for health and social care: Consultation - NHS Employers response. Leeds:
NHS Employers
National Institute for Health Care and excellence. (2014). Safe staffing for nursing in
adult inpatient wards in acute hospitals. [Online] Available from:
https://www.nice.org.uk/guidance/sg1/resources/safe-staffing-for-nursing-in-adult-
inpatient-wards-in-acute-hospitals-61918998469. [Last accessed 13th April 2016].
NHS Education for Scotland. (2010). Healthcare Support Workers. [Online]
Available from:
http://www.hcswtoolkit.nes.scot.nhs.uk/media/3752/hcsw_literaturereview.pdf. [Last
accessed 1st April 2016].
NHS Employers. (2012). Evaluating an assistant practitioner project. [Online]
Available from:
http://www.nhsemployers.org/your-workforce/retain-and-improve/standards-and-
assurance/developing-your-support-workforce/assistant-practitioners/evaluating-an-
assistant-practitioner-project#1. [Last accessed 11 May 2016].
NHS employers. (2012). Evaluating an assistant practitioner project. [Online]
Available from:
http://www.nhsemployers.org/your-workforce/retain-and-improve/standards-and-
assurance/developing-your-support-workforce/assistant-practitioners/evaluating-an-
assistant-practitioner-project. [Last accessed 31st January 2016].
NHS employers. (2015). Assistant practitioners. [Online] Available from:
http://www.nhsemployers.org/your-workforce/retain-and-improve/standards-and-
assurance/developing-your-support-workforce/assistant-practitioners. [Last
accessed 31st January 2016].
67
Student number: -0207586
NHS employers. (2015a). Talent for care and widening participation resources.
[Online] Available from: http://www.nhsemployers.org/news/2015/09/update-on-
talent-for-care-and-widening-participation. [Last accessed 4th July 2016].
NHS employers. (2016). Our response to the nursing associate role
consultation. [Online] Available from:
http://www.nhsemployers.org/news/2016/03/our-response-to-the-nursing-associate-
role-consultation. [Last accessed 5th May 2016].
NHS England. (2014). Five year forward view. [Online] Available from:
https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf. [Last
accessed 30th March 2016].
NHS Wirral Research & Development Team. (2011). Fact sheet 6: How do I
evaluate my project or service? [Online] Available from:
http://info.wirral.nhs.uk/document_uploads/evidence-factsheets/6Howevaluateprojec
tservice.pdf. [Last accessed 31st January 2016].
Organisation for Economic Co-operation and Development. (n.d.). Outline of
Principles of impact evaluation: Part 1 key concepts. [Online] Available from:
http://www.oecd.org/dac/evaluation/dcdndep/37671602.pdf. [Last accessed 11th
March 2016].
Perrin, B. (2012). Use of impact evaluation results. [Online] Available from:
https://www.interaction.org/sites/default/files/Use%20of%20Impact%20Evaluation
%20Results%20-%20ENGLISH.pdf. [Last accessed 14th March 2016].
Philips, S. (2012). Work-based learning in health and social care. British Journal of
Nursing. 21 (5), pp.918-922.
Phillips, J.J. (2003). Return on investment in training and performance programs
(Improving human performance). 2nd ed. London and New York: Routledge, Taylor
and Francis group.
Polit, D.F. and Beck, C.T. (2006). Essentials of Nursing research: Methods,
appraisal and utilization. 6th ed. Philadelphia: Lippincott, Williams and Wilkins.
Powell, M., Brown, T. and Smith, J. (2016). Skill mix: Using the assistant practitioner
to drive efficiency. Practice Nursing. 27 (1), pp.40-43.
68
Student number: -0207586
Raelin, J. A. (2008). Work-Based Learning. [Online]. Jossey-Bass. Available
from:<http://www.myilibrary.com?ID=121745> [Accessed 29 April 2016].
Richard, W. (2002) Work-based Learning in Health: Evaluating the experience of
learners, community agencies and teachers, Teaching in Higher Education, 7 (1),
47-63
Rogers, P. J. (2012) Introduction to impact evaluation. [Online] Available from:
https://www.interaction.org/document/introduction-impact-evaluation. [Last
accessed 11th March 2016].
Royal College of Nursing. (2009) Policy Unit, Policy Briefing 06/2009. The Assistant
Practitioner Role. A Policy Discussion Paper, Policy Briefing 06/2009. London: RCN
Policy Unit.
Royal college of Nursing. (2010). Assistant practitioner scoping project. [Online]
Available from:
https://www2.rcn.org.uk/__data/assets/pdf_file/0003/379155/003880.pdf. [Last
accessed 12th May 2016].
Royal College of Nursing. (2016). Royal College of Nursing response to Health
Education England’s consultation: Building capacity to care and capability to treat –
a new team member for health and social care. [Online] Available from:
https://www.rcn.org.uk/professional-development/publications/pub-005567. [Last
accessed 5th April 2016].
Seagraves, L., Osborne, M., Neal, P., Dockrell, R., Hartshorn, C., and Boyd,
A. (1996) Learning in Smaller Companies: Final Report: Stirling. Educational Policy
and Development University of Stirling.
Shaw, A. (2012). Scope of Practice of Assistant Practitioners. [Online] Available
from: http://www.sor.org/learning/document-library/scope-practice-assistant-
practitioners. [Last accessed 14th April 2016].
Sheehan, J. (1986). Aspects of research methodologies. Nursing education today. 6
(5), pp.193-203.
Skills for Health (2009). Nationally Transferable Skills. Bristol: Skills for Health.
Skills for Health (2009a). Core Standards for Assistant Practitioners. Bristol: Skills
for Health
69
Student number: -0207586
Skills for Health. (2010). Key Elements of the Career Framework. [Online] Available
from: http://www.skillsforhealth.org.uk/index.php?
option=com_mtree&task=att_download&link_id=163&cf_id=24. [Last accessed 20th
April 2016].
Skills for Health. (2015) The Healthcare Support Workforce A case for ongoing
development and investment. Working paper 1 [Online] Available from:
http://www.skillsforhealth.org.uk/index.php?
option=com_mtree&task=att_download&link_id=179&cf_id=24. [Last accessed 5th
April 2016].
Skills for health. (2015a) New apprenticeship standards for healthcare support
workers and assistant practitioners – Approved by BIS. [Online] Available from:
http://www.skillsforhealth.org.uk/news/latest-news/item/209-new-apprenticeship-
standards-for-healthcare-support-workers-and-assistant-practitioners-approved-by-
bis. [Last accessed 5th July 16].
Skills for Health. (2016) How can we act now to create a high-quality support
workforce in the UK's health sector? Pt 1/2. British Journal of Health Care
Assistants. [Online] 10 (3). pp. 44-47. Available from:
http://www.magonlinelibrary.com/doi/10.12968/bjha.2016.10.3.134 [Last accessed
5th April 2016].
Skills for Health. (2016a). How we can act now to create a high quality support
workforce in the UK’s health sector? Working paper 2. [Online] Available from :
http://www.skillsforhealth.org.uk/index.php?
option=com_mtree&task=att_download&link_id=179&cf_id=24. [Last accessed 5th
April 2016].
Smith, J. and Brown, T. (2012). The Assistant Practitioner in Palliative and End of
Life Care. Journal of Community Nursing. 26 (3), pp. 4-6.
Smith, W. (2014). The Talent for Care: A national strategic framework to develop
the healthcare support workforce Part of Framework 15, the Health Education
England guide to action. [Online] Available from:
https://www.hee.nhs.uk/sites/default/files/documents/WES_TfC-National-Strategic-
Framework.pdf. [Last accessed 2nd April 2016].
70
Student number: -0207586
Spilsbury, K., Stuttard, L., Adamson, J., Atkin, K. Borgin, G., McCaughan, D.,
McKenna, H. Wakefield, A. and Carr-Hill, R. (2009a). Mapping the introduction of
assistant practitioner roles in Acute NHS (Hospitals) Trust in England. Journal of
nursing Management. 17 (5), pp.615 - 626.
Spilsbury, K. and Aitkin, K. (2009). The impact of Assistant Practitioners on Acute
NHS Trusts. British Journal of Health Care Assistants 3 (10) pp.508-509
Stern, E., Stame, N., Mayne, J., Forss, K., Davies, R. and Bafani, B. (2012)
Broadening the range of design and methods of impact evaluations: London:
Department for International development
Stewart-Lord, A., McLaren, S. and Ballinger, C. (2011). Assistant practitioners (APs)
perceptions of their developing role and practice in radiography: Results from a
national survey. Radiography: An International Journal of diagnostic imaging and
radiation therapy. 17 (3), pp.193–200.
Stringer, E.T. (1996). Action Research: A handbook for practitioners. London: Sage.
Trochim, W.M.K. (2006) Research Methods Knowledge Base. [Online] Available
from: http://www.socialresearchmethods.net/kb/index.php. [Last accessed 21st
February 2016].
Vaughan, S., Melling, K., O’Reilly, L. and Cooper, D. (2014). Understanding the
debate around regulation of support workers. British Journal of Nursing. 23 (5),
pp.260-263.
Wakefield, A., Spilsbury, K., Aitkin, K. McKenna, H. Borglin, G. and Stuttart, L.
(2009) Assistant or substitute: exploring the fit between national policy vision and
local practice realities of assistant practitioner job descriptions. Health Policy; 90: 2,
pp.286–295.
Wakefield, A. Spilsbury, K. Aitkin, K and McKenna, H. (2010). What work do
assistant practitioners do and where do they fit in the nursing workforce? Nursing
Time. 106 (12), pp.14-17.
Willis, P.G. (2015). Raising the bar shape of caring: A review of the future education
and training of registered nurses and care assistants. [Online] Available from:
https://www.hee.nhs.uk/sites/default/files/documents/2348-Shape-of-caring-review-
FINAL_0.pdf. [Last accessed 4th April 2016].
71
Student number: -0207586
Wilson, M. (2008). East Midlands Assistant Practitioner Project: Assistant
Practitioner Tool Kit. [Online] Available from:
http://www.nhsemployers.org/~/media/Employers/Publications/Assistant-
Practitioner-Toolkit.pdf. [Last accessed 30th January 2016].
Winter, R. and Munn-Giddings, C. (2002) A handbook for action learning in Health
and Social care. London, Routledge, eBook Collection [EBSCOhost, viewed 8th April
2016].
Wright, W., McDowell, R. S. Leese, G. and McHardy, K.C. (2010). A scoping
exercise of work-based learning and assessment in multidisciplinary health care in
Scotland. Journal of Practice Teaching and Learning. 10 (2), pp.28-42.
List of Appendices
Appendix 1: RIAT project plan
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Appendix 2: PEST analysis
Appendix 3: Covering e mail for Survey Monkey
Appendix 4: Survey monkey results
Appendix 5: Follow up e mail
Appendix 6: RE1 Ethics Form from the University
Appendix 7: Ethics permission from the Trust
Appendix 8: Impact evaluation tool draft
Appendix 9: Guidance notes for filling out the impact evaluation tool (WBEF)
Appendix 10: WBEF process map for pilot phase
Appendix 11: Guidance notes for stakeholder filling out the impact evaluation tool
Appendix 12: Impact evaluation tool final version
Appendix 13: WBEF process map final document
Appendix 14: Flyer for stakeholders
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