Edinburgh Napier University

  Over the past 30 years, Senior and Advanced Nurse Practitioners (SNPs/ANPs) have been introduced into the healthcare arena across the world. The international literature reports such roles have created tensions within healthcare systems (Smith 2000; Tye & Ross 2000; Scholes & Vaughan 2002). However, over the past three decades the root causes of such tensions remain still to be addressed. The literature reports the consistent entrenched reluctance to collaboratively engage with SNP/ANP roles (Cummings et al. 2003; Reay et al. 2003; Davies 2006). This led to the aims of my Constructivist Grounded Theory (CGT) study, which were to discover why there continues to be tensions surrounding Senior and Advanced Nurse Practitioner roles in healthcare, in addition to attempting to generate a substantive theory to provide a foundation in which a hypothesis could be tested across a wider arena. Arising from these aims were three research questions which were explored in three phases. The first research question, posed in phase 1, was ‘where are tensions created by Senior and Advanced Practitioner roles from a service user and healthcare team perspective?’ This led to in-depth interviews taking place with service users (n=12) and members of the healthcare team (n=18). Theoretical sampling consisted of medical staff (n=9), nursing staff (n=7) and Allied Health Professionals (n=2). Data were considered saturated when no new data could be identified and the main categories with focused codes were coherent.

The second research question, posed in phase 2 of my study, was ‘where do tensions remain apparent in service and what meanings and actions are attributed to them?’ The method of Grounded Theory Ethnography was employed, which gave priority to interactions rather than the setting. This method consisted of a 3 stepped approach, employing participative observation and individual interviews. In total, 13 periods of observation were undertaken, which equated to 64 hours of observation within different sites. The emergent categories from this phase built upon the categories from phase 1. In phase 3 the research question posed was ‘what are the interpretations of Senior and Advanced Nurse Practitioners on interactions with the healthcare team and service users?’
Six focus groups and one paired interview enabled the development of the core category “Status Games”. This subsumed the main categories from each phase and incorporated common themes and patterns across all data. This core category was further verified with five individual interviews and no new properties emerged. This core category reflected the data across all phases effectively. Interpretative theorising incorporated advanced memos across all 3 phases of my study and enabled the development of a substantive theory. Social psychological game theory and underpinning script theory, which is part of the Transactional Analysis Paradigm, provided the theoretical lens to interpret what was grounded in the data. This led to the development of two new concepts, the first was status games which incorporated game analysis and highlighted ulterior transactions which have not been previously reported in the literature. The second was the professional script concept, which it is theorised underpins status games. This is also new and has not been conceptualised in the Transactional Analysis or healthcare literature. This theoretical framework illustrated that status games which fulfil professional script are being played out with awareness. It is proposed that by recognising these concepts, this will reduce tensions with SNP/ANP roles and lead to improved patient-centred care.

As Vandra (2009) reports by recognising the processes and actions of communication it is possible to bring ulterior transactions into full awareness and prevent games, thus problems with communication. This led to the development of the substantive theory in this study which is: ‘The tensions generated by SNP/ANP roles stem from playing status games to fulfil professional script which requires to be recognised and acknowledged by the healthcare team in order to change the status quo and culture’. Whilst social psychological game and script theories can provide an underpinning understanding of social games and life scripts for individuals, the status game concept which emerged from my study expands our knowledge and provides a unique understanding surrounding the impact of professional script in healthcare organisations. It is hypothesised that this script has led to status games, which is central to the tensions surrounding SNP/ANP roles.