Fluid role boundaries: exploring the contribution of the advanced nurse practitioner to multi-professional palliative care.

AIMS AND OBJECTIVES: To evaluate the introduction of Advanced Nurse Practitioners in a specialist, multi-professional palliative care context. The objective is to explore the core domains and competencies of the advanced nurse practitioner role in a multi-professional palliative care context. BACKGROUND: New models of health care and service delivery are emerging alongside expanded levels of autonomy, skills and decision-making for nurses and midwives. This has resulted in some confusion in the health service community internationally about the professional role and scope of the advanced nurse practitioner. DESIGN: A qualitative evaluation study (n = 21). METHODS: Three phases of data collection were conducted over 10 months. Twenty-one participants took part from a specialist palliative care unit in one health board in a U.K. region spanning ANPs (n = 2) multi-professional staff (n = 14) and patients/carers (n = 5). Data collection methods included individual and focus group interviews with key stakeholders and observation of the advanced nurse practitioners at work and their reflexive diaries. RESULTS: The findings of this evaluation demonstrate that if the advanced nurse practitioner role can flourish it has the potential to shape 'new identities', re-construct the boundaries of nursing roles and emphasise the relationship based elements of excellent nursing work. CONCLUSIONS: The advanced nurse practitioner has the potential to enhance specialist palliative care service delivery through fluid role boundaries. The context in which advanced nurse practitioner roles are developed is important as acceptance of the role is linked to the co-construction of a different nursing identity. Our findings support the need to define, defend and name the work of advanced nursing roles. RELEVANCE TO CLINICAL PRACTICE: The advanced nurse practitioner roles were regarded as providing a unique contribution to service delivery and were characterised by fluid role boundaries which crossed the traditional disciplinary boundaries between nursing and medicine.

Is a STAS-based tool valid to triage patients at a specialist palliative care inpatient unit?

Many tools exist to assess the symptoms and needs of palliative care patients, but no tool has been validated to prioritise patients referred for specialist inpatient palliative care. The aim of this study was to produce and validate such a tool. A prospective pilot study produced a Support Team Assessment Schedule- (STAS-) based tool--the Admission Assessment Tool (AAT)--and compared this with the existing system of triage at the Marie Curie Hospice, Edinburgh. Validity of the tool was not confirmed and the tool was modified and re-evaluated. One hundred and twenty-seven consecutive patients referred to the hospice received three AAT scores: from the bed manager; the admitting doctor; and the admitting nurse. The hospice's multidisciplinary team assessed the urgency of each patient's admission. The overall correct classification rate was approximately two thirds, but false positive rates were high and there was poor inter-rate correlation. It is concluded the AAT has not been validated.

Understanding reflective practice.

The Nursing and Midwifery Council (NMC) requires that nurses and midwives use feedback as an opportunity for reflection and learning, to improve practice. The NMC revalidation process stipulates that practitioners provide examples of how they have achieved this. To reflect in a meaningful way, it is important to understand what is meant by reflection, the skills required, and how reflection can be undertaken successfully. Traditionally, reflection occurs after an event encountered in practice. The authors challenge this perception, suggesting that reflection should be undertaken before, during and after an event. This article provides practical guidance to help practitioners use reflective models to write reflective accounts. It also outlines how the reflective process can be used as a valuable learning tool in preparation for revalidation.