The brief case descriptions have provided an overview of each case and serve as a background to consider EBPI and the role of the NM in more detail. A cross-case analysis of contextual factors follows, highlighting the contrasts and comparisons between cases, building on and adding to the data already presented. It is subdivided into themes derived inductively from the data: organisational factors and the management-practice gap. These focus on contextual factors in relation to the ability of NMs to engage with EBPI. By way of an introduction, Table 4.1, highlights the main points of contrast between the cases.
Organisational factors
Each of the cases had undergone some type of organisational re-structuring in their recent history and staff recognised the impact that this had had on their ability to concentrate on EBP. This was a significant problem in Case C, where they had not only faced wholescale changes due to the substantial mergers in 1999, but also had to come to terms with three new Chief Executives in six years, each of whom had brought fresh ideas for the organisation and service redesign. As a result staff spoke of ‘…putting evidence-based practice on hold’(NM) while they came to terms with
the changes taking place under service re-design. In Case D, staff also spoke of EBP not being important for them at that time as they had new roles and responsibilities to adapt to,‘…evidence-based practice just isn’t a priority for us at the moment’. (NM) In Cases A and B, where there had been relative stability, they seemed more able to focus on EBP as part of everyday work, that is to say, it did not have to compete with large scale organisational change for staff time or energy.
However, problems with recruitment and retention of staff also had an impact on their ability to engage with EBP and this was particularly noticeable in Cases B and C where both were a problem. In both sites vacancies at senior level were filled on a temporary basis by staff ‘acting up’ in the post until it was filled. This led to vacancies further down the nursing hierarchy, most often at ward level, where staff could not be spared to be involved in EBP related activities or educational opportunities. This left staff with no capacity to take on anything that they considered an addition to the day to day work of patient care. With no time available within work to take the EBP agenda forward several staff recognised that it would fall to them personally to do so ‘…as usual it’ll all have to be done on a shoestring and on my own time’.(CNS, Acting NM). Staff in all cases who were or had been involved in EBP, mentioned the amount of time they had spent out of work hours working on this. There was a general feeling that while this was unacceptable and should not be expected of them, it was sustainable in the short term. This reliance on staff to undertake work in their own time was a means of achieving EBP in all the cases. Although Case D had seen relatively long periods of stability as an organisation and also within nursing management and did not report any difficulties with recruitment or retention of staff, they did appear to have some difficulties with succession planning in relation to EBPI. In addition, the nurse who held the position of Chair of the shared governance forum was into her third term of office, against her will, because‘…no-one else wants the job’.(CNS).
Staff changes in Case B had also had an impact on EBP: when a former practice development nurse left her post, other staff were not able to continue her previous work and this had led to a re-organisation of the entire practice development unit. In Case A stability of nursing management and a stable and well qualified nursing workforce was recognised as being an advantage. However their greatest problem in
relation to organisational factors was the geographical spread of the Trust. In Cases A, B and C there were problems of duplication of effort in all the hospitals within the Trusts, although this was not necessarily recognised by them. Some of this predated the mergers, but some was specifically related to EBP and this had become apparent after the mergers had taken place. In Case C, nurses in different hospitals were working on the same tasks, for example, updating clinical skills, but although they were all working within the same Trust, there was no connection between their work. They were unaware of the work being undertaken by their colleagues.
To some extent the isolated nature of each individual hospital, even within the same Trust, was explained by staff as due to differences in culture. Culture was also seen as important by the Director of Nursing in Case B who felt that one of the difficulties relating to the development of EBP within the Trust was that there was‘…not much of a research culture here, but we’re good at the bread and butter care’. She also admitted that she had no knowledge of, or interest in research herself. The attitude of NMs and the Director of Nursing to EBP was important and was acknowledged by staff as being positive in Case A and less so in Case D. Staff in B and D were unaware of the attitude of either their NMs or the Director of Nursing to EBP.
In each case there were organisational structures in place to progress EBPI. Some of these, such as clinical governance teams, were a requirement of NHS Quality Improvement Scotland, while others such as the shared governance forums in place in Cases C and D had been chosen by NMs as a means of progressing the EBP agenda. Cases A, B and C also had a practice development unit, although these varied considerably in size (i.e. the number of staff in the unit) and in their remits. Each case also had CNSs in post, many of whom were involved in developing evidence-based products. The links between each of these structures were rarely clear, although in Case A, the practice development unit had considerable influence and more of a co- ordinating role, and staff from the unit were also involved in, for example, the clinical governance team or would be asked to contribute to meetings of other groups that concerned their particular remit. In the other cases there appeared to be little internal communication between these structures and although all of the Trusts were able to provide or draw diagrams of how these fitted together, staff did not have a clear idea of this. The remit of the practice development unit in Case C had recently changed
considerably and it was no longer involved in EBP, instead having a much greater role in staff training and skills updating. The clinical improvement teams set up to take forward the development and implementation of EBP within directorates were very new and it was not possible to conclude how effective they would be in this task.
The management-practice gap
In all cases there was evidence of increasing specialisation of clinical areas. In the past most medical wards were general, caring for patients with a range of conditions. However more and more it appeared that this was no longer the case. For example a charge nurse in Case A described his medical ward as specialising in rheumatology and diabetes. Staff from surgical wards described the same phenomenon. At the same time NMs described how their role had changed over the years from managing quite discrete specialised areas of care to managing large areas with a wide range of specialties included, often bearing no relation to each other. While some NMs saw this as an opportunity to learn about the wider organisation, others found it daunting:
‘I now cover half the hospital, I can’t possibly be expected to know everything about 13 different specialties, none of which was my own clinical background’ .(NM)
Ward staff in all cases suggested that NMs were not in touch with clinical practice and were not able to know about day to day ward life as a result of the number of wards that they covered. In Case A one NM felt that the staff most likely to make evidence-based changes to practice would be students and newly qualified nurses. In reality they are the least empowered of all staff and this suggests that there is a knowledge gap between the realities of management and practice.
The pace at which practice is changing was also cited as a contributing factor to the gap between management and practice, or NMs and practice. Several staff spoke of the need to have additional educational qualifications in the clinical area to keep abreast of changes and suggested that many charge nurses would be more highly qualified and more knowledgeable about EBP than their managers:
‘…I sometimes feel that some of the nurse managers or higher grade staff sometimes feel quite threatened by the fact that some of the more junior members of staff are more proactive, have a good knowledge base and are keen to get on. I know a lot of staff here have done degrees and other qualifications and some of the more traditional mangers feel quite threatened’. (Charge nurse)
In Cases A, C and D some nurses felt that the lack of clinical credibility would be a barrier to them approaching their NMs for help and even staff who were experiencing difficulties in relation to EBP had not sought the help of their NM either because they did not consider this necessary or helpful.
Despite this, the NMs were often the formal link between management and practice, by dint of their position within the nursing hierarchy. This often involved activities specifically related to EBP, such as being involved in shared governance meetings, charge nurses meetings or through informal links with practice development staff.
In Cases B, C and D, staff felt that one of the biggest problems relating to the gap between management and practice was due to their differing priorities. Those of practice were described as ‘getting the job done’ and having access to education and to clinical skills development, whereas for NMs, their desire was to achieve organisational goals, survive re-organisation (i.e. still have a job at the end of it), meet financial targets and be ready for the CSBS visits. EBP was not on either agenda.
CNSs, as noted above, were the most autonomous staff and the most likely to be involved in EBP. However due to the historical development of their role, most were managed by medical consultants and were not tied into the nursing hierarchy. As a result they were considered by several managers, in all sites to be, ‘…lost to nursing’ (NM). NMs were not able to access their considerable expertise and in Cases B and C the ward staff did not have access to this either. Although no formal links existed in Cases A and D between the CNSs and ward staff, personal networks and hospital size were seen as facilitating good relationships between some CNSs and ward nurses. However these were not the only factors which impacted on these networks as Case B
was also a compact Trust with modest sized hospitals and yet no such networks existed.
The impact of the changes to the NM role which had taken place in all sites during the 1990s had affected the way in which the roles had subsequently developed. Cases A,B and C had been without NMs for a number of years, before the re-introduction of the role in Cases A and B, though not in C. In Case D, NMs had remained in post, but the number of posts had been significantly reduced and they had something of a vestigial role until the recent Trust re-organisation and increase in the number of NM posts. In Case A and to a lesser extent in B, NMs had had some flexibility in the way in which their role and responsibilities had developed. While these clearly reflected the knowledge and skills and to some extent areas of interest, of the post holders (one NM in Case A was still able to undertake work in the clinical area one day per week), this also seemed to have an impact on the extent to which they were involved in EBP related activities. For example, one NM in Case B, was particularly interested in developing evidence-based products and had done so in a previous post. She wanted to remain involved in this and although new to her post in Case B, stated that once her workload had ‘settled down’ she would seek ways of doing so. It was not a specific part of her NM remit.
Despite the difficulties surrounding the CNSs, one role seemed to bridge the gap between management and practice. In Cases A and D joint NM/CNS posts had been developed. These specialist nurses were also managers of smaller, discrete areas of nursing, such as intensive care, chemotherapy or renal services. All acknowledged that it was difficult balancing both roles:
‘It’s always a balancing act, it should really be two jobs, it’s not a happy marriage, because it’s nearly always the clinical component that gives’. (NM/CNS)
They also recognised that they were best placed to implement EBP. They had a good knowledge of their staff and the clinical area and also of the theoretical and clinical knowledge relating to their specialism. They were well respected by other staff and
had a credibility and good professional networks with medical staff that made it possible for them to introduce change successfully within their own areas.