Consensus on a Specialist Clinical Learning and Teaching Framework for Australian Nurse Practitioners

Background

The Australian nurse practitioner (NP) role is represented by over 1,400 endorsed NPs practising in over 50 different specialty areas. Generic standards have broadly supported the role’s behavioural, professional and expanded practice expectations since 2006, and have been used for the accreditation of NP Masters programmes nationally.

The need for consistent and flexible specialty clinical education for NP students has been described in the Australian literature. The clinical learning and teaching of Australian NP specialty roles has traditionally occurred in the student’s workplace, within a specified area of practice. Jurisdictional differences at state/territory and local levels have influenced how NP students develop and enact their roles once endorsed. Factors such as the student’s clinical supervisor, local legislation and policy, role ambiguity, restrictive local clinical guidelines and protocols influence what NP students learn in their clinical learning environments. These factors contribute to a highly differentiated NP workforce, with differing clinical skills, knowledge and abilities noted within the same specialty area. Similar difficulties have led to the development of broad specialty areas in the United States of America. To better complement the generic learning and teaching students receive through their academic programmes, this research aims to validate a specialist clinical learning and teaching framework for Australian nurse practitioners. This framework will not only enhance consistency in their specialty clinical learning and teaching, but create greater workforce flexibility.

A consensus-based research methodology was needed to validate the specialty clinical learning and teaching framework. Delphi Technique is a consensus-based research methodology commonly employed in nursing research to explore solutions to questions that have unclear or indeterminate answers. It aims to achieve a pre-determined level of consensus on a research question, using content experts through an anonymous and iterative process. Critical to the method’s validity is the participation of a heterogeneous group of experts with advanced knowledge of the content area, and whose feedback to other panelists is controlled to minimise social influence. Individual participant characteristics, such as experience level and confidence in decision-making, and the influence of these upon consensus are poorly described in the Delphi literature. There was little previous empirical research to inform how to best describe heterogeneity of opinion informing the specialty clinical learning and teaching framework using nurse practitioners. Aims - To validate a specialty clinical learning and teaching framework for Australian NP students.

Specific objectives that addressed this aim were: - To validate a previously developed Australian NP metaspecialty taxonomy.
- To validate supporting clinical practice standards used for the metaspecialty taxonomy.
- To contribute knowledge of how consensus is achieved when using Reactive Delphi methodology.

Specific questions that addressed this aim were: - Does Reactive Delphi methodology potentiate the negative influence of the bandwagon effect in Delphi panelists?
- What effect does panelist confidence have on decision-making in Delphi panelists?
- How can experience level be objectively demonstrated in individual Delphi panelists?
- What effect does experience level have on decision-making in Delphi panelists?
- Does confidence relate to opinion change in individual Delphi panelists?
- What effect does panel composition have on consensus outcomes?
- To demonstrate the application of web-based methods in Delphi research.

Specific objectives that addressed this aim were: - Describe the advantages of using a web-based Delphi method.
- Describe the risks of using a web-based Delphi method.
- Describe how panelist feedback was managed during six concurrent Delphi studies.
Methodology and Methods

This mixed-methods research used Delphi Technique to achieve consensus on, and therefore validate, a NP specialty clinical learning and teaching framework. Two sequential 3-round Reactive Delphi surveys were used to achieve the research aims. The first Delphi survey was designed to validate a proposed broad Australian NP specialty taxonomy previously established by the 2014 CLLEVER (CLinical LEarning goVERnance) study. The second Delphi survey was designed to validate clinical practice standards, which would support and provide definition to the specialty taxonomy. Together, the taxonomy and standards informed the proposed specialty clinical learning and teaching framework. Consensus Development Conference methodology was used to refine the proposed specialty clinical learning and teaching framework. Data collected during the conduct of the first Delphi survey achieved the second research aim. The third research aim was achieved by using metadata, paradata and embedded data in an advanced web-based survey design for both Delphi surveys. Purposive sampling and snowballing techniques were used to recruit from an eligible population of NPs, endorsed by the Nursing and Midwifery Board of Australia, with at least 12 months’ post-endorsement experience (N=966). Web-based survey technology was used to collect data. Data were analysed using content analysis, descriptive and inferential statistics. The Content Validity Index and non-parametric testing using McNemar’s Test for Change were used to determine consensus that informed the proposed framework. Results

Approximately 20% of the eligible Australian NP population contributed to both Delphi surveys. Six broad specialty areas, termed metaspecialties, were validated for the proposed specialty taxonomy. A Consensus Development Conference refined the names of two metaspecialties. The metaspecialties served as a foundation for validated clinical practice standards, which provided substance and definition to the final specialty clinical learning and framework. Heterogeneity of expert NP opinion informing the framework was demonstrated using professional activities representative of advanced practice nursing. There was no indication of negative social influence determining the manner by which panelists achieved consensus on the proposed framework. A novel method of using metadata, paradata and embedded data in web-based surveys was applied, which supported high survey response rates and identified non-response bias. A novel application of web-based surveys allowed the researcher to concurrently conduct six Delphi surveys nested within a larger research project. Conclusion

This research demonstrates a rigorous approach in validating a proposed specialty clinical learning and teaching framework for Australian NP students. It contributes new knowledge on the internal and external validity of Reactive Delphi methodology.