Cummings, Greta G. MEd, BNSc, RN; Fraser, Kim MA, BN, RN; Tarlier, Denise S. MSN, RN, FNP-C (AANP)
The past decade has seen a resurgence of interest in the advanced nurse practitioner (ANP) role in Canada, with corresponding legislative changes being enacted in several provinces to support ANP practice. Alberta enacted the final piece of legislation in 1998 to allow select remote communities to hire nurses with extended practice competencies to provide primary care services. Several regional health authorities in Alberta have also received ministerial approval to institute several primary care nurse practitioners in select urban settings. However, there is still no legislative mechanism to provide full authority for ANPs to provide extended health services. Legislative reform is underway for the regulation of all healthcare professions in Alberta. When enacted, the Health Professions Act 1 is expected to allow for full recognition and authority of ANPs in a larger variety of settings than is allowed under current legislation. Until then, healthcare organizations must continue to find creative mechanisms through institutional policy and medical guidelines to allow their advanced nurse practitioners to provide these extended health services.
While ANPs in primary care/primary healthcare are now recognized in Alberta, acute care nurse practitioners are a new phenomenon in this province. In the past 2 years, consistent with emerging trends in the United States, the United Kingdom, and Ontario, an Alberta regional health authority has implemented nurse practitioner roles in several acute care programs. The introduction of this new and potentially controversial nursing role within a major healthcare organization could provoke significant effects on multiple levels in the organization and in other organizations. Both the nurse practitioner and change management literature supported this speculation.
This article describes a project undertaken to examine the process of organizational change in relation to the implementation of the ANP role in a tertiary care teaching hospital. A modified experiential case study method was used to provide a detailed description of the change effort. Analysis of study findings was based on integration of relevant literature from nursing and organizational change literature. The change effort is discussed in light of the literature, and several key recommendations are offered.
The ANP Role
Review and analysis of the relevant literature revealed three main themes: role definition, support for the role by key players, and planning for and evaluating change.
Definition and clarification of the ANP role was widely discussed in the literature as a fundamental step toward role implementation. 2–5 A clear job description and scope of practice for the ANP must be delineated early in the implementation process, a step described as “crucial for successful integration of the role” by Magdic and Rosenzweig. 4(p211) A recent Canadian study found that the lack of a formal job description and unclear role expectations in the organizational structure negatively influenced the implementation of ANP roles in one Ontario institution. 6 The issue of shared practice boundaries presented a challenge in developing job descriptions and scope of practice documents to support ANP practice. ANPs were expected to provide certain services that traditionally had been considered the exclusive domain of medical practice (eg, writing prescriptions). Thus, provincial or state legislation related to authorized scope of practice for ANPs was one factor that drove change in organizational standards and policies. Some organizations chose to deal with these issues by developing medical directives rather than allowing clinical privileging for ANPs. 2–4,6–10 This perceived versus de facto practice autonomy and prescriptive authority for ANPs in turn influenced the practice setting, and thereby directed how the organization was able to operationalize the ANP role. 2,6
The support of key players was recognized as being critical to successful implementation of the ANP role. Support might be operationalized in concrete forms, such as job descriptions and changes to organizational policy to support ANP practice, 4,6 or by developing supportive vision/mission statements. 2,10 King et al described features of supportive administrative structures, specifically, effective administrative processes, and “organizational commitment to a model of shared governance and decision-making.”9(p153) This was congruent with other authors who suggested that input by both key stakeholders and ANPs was important to planning. 4,5 Golea 2 identified supportive organizational culture as a key factor. Acceptance of the ANP role by key players, particularly nurses, physicians, and patients, was widely identified as a supportive factor, 5 and one that could be influenced by organizational culture. 2,3,9 Conversely, nonacceptance was seen as a significant barrier to role implementation. 6,8,11
The organizational change literature speaks to the importance of considering several dimensions of change as well as organizational dimensions when implementing change. Long-term success is brought about through continually aligning strategy, structure, people, and culture through incremental change, punctuated by discontinuous or revolutionary change with a simultaneous shift in strategy, structure, people, and culture. 12 Organizational culture is a significant dimension that will embrace or resist change because it reflects the organization’s decision-making, behavioral, and social norms.
One important strategy to support ANP role implementation was to approach this change from the planned rather than emergent change perspective, therefore beginning with organizational planning. Developing job descriptions, establishing practice standards, and changing institutional policies to support ANP practice prior to implementing the role represented a basic level of planning, but some organizations went a step further, utilizing (and in some instances developing) a change model to guide the process.
A common approach to planning described in the literature was that of identifying an organizational model appropriate to the needs of a specific agency. King 9 and Magdic and Rosenzweig 4 each discussed organizational models in terms of three models: the physician practice model, wherein ANPs were responsible to and report to physicians; the nursing model, wherein ANPs worked collaboratively with physicians but were responsible to and report to nursing administration; and a joint or collaborative practice model, wherein ANPs and physicians worked as a team and “share[d] authority equally for providing care within their respective scopes of practice.”9 These authors suggested that a collaborative practice model best supported professional interdependence, vital to the delivery of quality, cost-effective health services. This model may be “foreign” to traditional hospital organizations, and thus necessitate the most profound change on the part of the organization. Despite this, Knaus 3 described how the initiation of a collaborative practice model facilitated the implementation of ANP roles in an American hospital, and provided one of the few available evaluations of the change process from the organizational perspective.
In a more proactive approach, Kohr 10 developed the Collaborative Process Model, labeling it “a framework to guide change.” Five main components of her model include (1) need identification, (2) assessing the climate for accepting change, (3) recruiting project champions, (4) developing a communication umbrella, and (5) creating the vision. This model was found to be a useful template for the implementation of ANPs in London Health Sciences Centre. Notably, this model, by means of the “communication umbrella,” incorporated a feedback loop that allowed for ongoing evaluation of the change process, albeit in an informal manner.
The investigators used a modified case study method to examine the effect of implementing the ANP role in an acute care setting within a tertiary care teaching hospital, from the perspective of managing organizational change. Data collection was limited to a small number of informants who were interviewed on one occasion only, and at one period in time. 13
Data collection consisted of interviews with key players who had been involved in implementing ANP roles on three acute care services in the study hospital. The sample consisted of 17 informants, including 2 hospital administrators, 1 nurse manager, 3 ANPs, 2 physicians, 1 clinical nurse specialist, 2 clinical supervisors, and 6 staff nurses. The informants were selected based on either their involvement in implementing the program, or their roles being affected by the implementation of the ANP role. Written job descriptions for each ANP were retained as artefacts.
The study limitations rest primarily in the design, a single post-hoc interview process with a small purposive sample, which did not include medical residents. Additionally, an analysis of the organization’s culture and subcultures was not explicitly undertaken using any formal instruments. Information regarding culture was gleaned from the interview findings.
Ethical approval was obtained from the university ethics committee. The study was explained to each informant verbally by one of the investigators and a written informed consent was obtained.
Interview data was analyzed around three themes that emerged as the interviews progressed. Three key main themes, followed by four additional subthemes, emerged from the data:
* Role definition,
* Support for the ANP role and the incumbent,
* Planning for and evaluating change,
* Relationship of incumbent “fit” with the success of role implementation,
* Nursing and “people” skills of the ANP,
* Remuneration and benefit structure, and
* Organizational culture within the facility.
These themes each describe the effect of implementing the ANP role as an organizational change within the hospital. The three key themes that emerged will be discussed further.
The six points that surfaced within the role definition theme were:
* Job description,
* Practice boundaries,
* Reporting lines,
* General inconsistencies,
* Medical model versus nursing model as an approach to the role, and
* The “fit” of individual with the role.
Although each ANP had a job description, these varied, and were at various stages of implementation, review, and revision. All informants presented varying perspectives and understandings of the role of the ANP. Some reported that it should be more of a nursing role, and that the ANP should be a support to the nursing staff; however, others saw it as a physician extender role and thought that the ANP should primarily support the physician. This discrepancy in perspectives regarding the role was apparent among participants in each of the various positions. Although staff nurses reported that they saw the role as a physician extension, they also stated that ANPs should participate as team members (eg, “answering the phone or helping with patient care”). There was a trend toward uncertainty regarding the role of the ANP. Other than the ANPs themselves, most were unsure of what to expect from the role.
Practice boundaries between staff nurses, clinical supervisors, clinical nurse specialists, residents, and physicians were seen as unclear, with the greatest degree of uncertainty occurring between the ANP and the resident. Almost all respondents except the ANPs themselves shared this perception. The ANPs were clear about their role and job duties, this clarity flowing from their specific working relationship with their primary physician and the relationships between physicians and residents. There appeared to be no commonality between units or among the practitioners on a unit where there was more than one ANP. Some ANPs thrived on the flexibility and independence their role permitted; others appeared to prefer more structure and interdependence.
In situations where practice boundaries overlapped, such as physicians and ANPs both having authority to write orders, staff nurses reported that they often verified the ANP’s orders with the physician or resident. This was carried out to a greater extent in the beginning stages of role implementation. Reasons given for checking ANPs’ orders varied from having no confidence in the skill of the ANP to uncertainty about the role and practice of the ANP. Efforts to promote role clarification were not explicit on any unit, and there seemed to be no single player responsible for guiding and directing the implementation of the ANP role. Most respondents expressed this as a frustration. Because the educational preparation of the ANP varied, as did the years of nursing experience, the staff nurses’ trust in the ANP’s knowledge and competence directly reflected their confidence in following the ANP’s orders.
The reporting lines of the ANP were different from those of most other line positions in the hospital. Where nurses on a unit would typically report to the unit manager and medical personnel would typically report through the medical academic hierarchy, the ANPs reported jointly to the primary physician and to a senior administrator. Several study participants recommended that the ANP report to the unit manager rather than a senior administrator in order to effect solutions for urgent and timely ongoing practice and performance issues. Physicians reported being satisfied with the existing joint reporting structure because it allowed them to focus exclusively on medical care issues.
Overall, knowledge and understanding of the ANP role was unclear and not well understood by most players, especially by staff nurses. There was great consistency on this point among respondents. In some cases, this lack of role clarity resulted in unclear direction and overall underutilization of the ANP by the nursing staff. There was little or no evidence of contribution to educational programming or to research activities by the ANP, although all respondents felt that this should be an important part of the ANP role. Some respondents stated that there was an obvious pull between service delivery and education/research.
Physicians and staff nurses tended to see the ANP role evolving under the medical model, whereas senior management personnel and the ANPs themselves saw the ANP role evolving under a joint medical/nursing model. Given that ANPs were nurses, this was reported as a concern. The staff nurses reported that this was not a good thing for nurses, as they believed that the ANP should enhance the organizational profile of nursing and be a support for them. One respondent stated, “the ANP was always attending medical rounds” and suggested that some effort should be made to hold nursing rounds, which would positively influence the nursing care patients received on the unit. Physicians reported that the ANPs needed to move toward the medical model by taking more calculated risks in clinical decision making.
Most informants discussed the need for appropriate “fit” of the individual ANP in terms of having the right person and personality in the position. The successful ANP should not only be a highly skilled practitioner, but also should possess a high level of maturity and experience to cope with the dynamics and challenges of such an innovative new position. Some physicians and ANPs indicated that personal characteristics (eg, flexibility, adaptability, and a willingness to learn and grow with the position) were more important attributes at the outset than formal education, as there was a strong need to adapt to varying situations on a daily basis. In the initial period of implementation, the ANP needed to utilize strong communication, relationship, and team-building skills, and access a good support system from peers, employers, and other ANPs. Many dynamics of the position could be tied to personalities, acceptance of the role, and attitude toward the selected individual in terms of their level of education and years of experience.
Support of Key Players
Senior management and physicians led the implementation of the ANP role. Staff nurses reported that they and residents were the most threatened by the ANP role. Although no residents were interviewed for the study, this was a common thread reported by both the ANPs and other respondents. One ANP reported that residents, who perceived the ANP role as a threat, would try to manage all patients on the unit so that the ANP would be involved only with stable chronic care clients.
Overall, support for the ANP role appeared to have increased over time since implementation and as players became more familiar with the role and developed trust in individual ANPs. Furthermore, staff nurses reported having better access to the ANP than to residents or physicians, and saw this as a significant advantage, along with greater continuity of care being provided by ANPs than by rotating residents. Nurses who were supportive of the ANP role saw the introduction of the ANP in acute care as an exciting time for nursing. One nurse stated, “It gives me something to aspire to.”
The ANPs interviewed reported that receiving support was an important factor contributing to their feelings of success. They stated that a good working relationship existed with the physicians who mentored them. One ANP referred to her mentor as “the most wonderful person and physician...even-keeled and so supportive of my position”; another reported, “He is a big supporter of my role.” ANPs reported feeling valued and supported when nurses sought them out for their advice and clinical expertise. The ANPs felt their role was valued and affirmed and that acceptance was increasing, as evidenced by the fact that they were now paged by unit nurses more often than in the beginning stages of ANP role implementation. Staff nurses were also now more likely to consult with the ANP about patient treatment.
The introduction of the ANP stemmed from some early discussions by hospital administration that this role would add value to the healthcare team. The change was further driven by a shortage of residents and attending physicians. Senior management was in the process of reviewing options to meet hospital staffing needs, and the time was right to “seize the opportunity” for the introduction of the ANP role. It was believed that the role would contribute to continuity of care and provide a more holistic approach to patient care. The introduction of the ANP came when Alberta was experiencing a trend toward recognizing nurse practitioner practice in a variety of healthcare settings.
No formal evaluation process had yet been reported, either in terms of ANP role implementation as a change for the unit, or the process and outcome measures of the role. Performance evaluations of the ANPs were at various stages and involved contributions from key players. Self-evaluation and continual review of goals and objectives were reported to be an ongoing process by the ANPs. Implementing the ANP role appeared to be an evolutionary process; incremental changes were regularly made to “tweak” the role and processes. This approach seemed to be working well for the ANPs and most of the physicians. However, the staff nurses reported that this lack of planning and evaluation contributed to ongoing role ambiguity. Most participants reported that the lack of planning had delayed role implementation anywhere from 2 to 8 months.
Some respondents postulated that the organizational culture of the hospital was potentially a significant barrier to the full implementation of the ANP. This was not discussed in a negative way, but in regard to the hospital being a large teaching center. The respondents reported that it might be easier to implement the change fully in a smaller community hospital with a less complex system. It was suggested that ANPs should perform more discharge planning and community liaison. This was not currently happening due to the treatment focus of their position. Overall, when questioned about goal achievement, respondents most often reported success. Many felt they were “part-way there” and that it was an evolutionary process. They were now asking questions related to how the role could be more fully developed and ways in which the ANPs might better contribute to the organization overall.
This tertiary care teaching hospital has developed an identity as an organization that embraces change and continuous quality improvement. Since the early 1990s, this organization has maintained a focus of continuous quality improvement despite a brief interruption by province-wide healthcare restructuring in the mid-1990s. A small number of advanced practice nursing roles had been implemented in isolated critical care and specialty areas over the years, yet the introduction of advanced practice nurses was never fully embraced due to the organization’s focus on resident and medical specialty teaching programs. The impetus for the role was now clearly in response to external pressures: the widely reported shortage of physicians, including residents. The organization’s decision to seize the opportunity to implement a new role for nursing while filling a medical manpower gap is consistent with notions that competent organizations are alert to early signs of external pressures and respond promptly by making internal changes to keep the organization viable. 14
Although the implementation of this ANP role was purposeful, what was missing was a clear vision and the use of a model or framework to guide the change process and to assist the individuals affected in dealing with the change and its accompanying issues. This implementation was not a pilot or trial and had not been portrayed in any way as being temporary in nature. This, along with the “seize the opportunity” approach to implementation, may explain why the senior administrative/physician team did not develop a strategic plan for the ANP role throughout the institution to ensure success. The approach began with strong support from senior administration and continued with evolutionary development of the role within each program area where it had been determined the role was needed. The use of a change model may have proved beneficial, and even at this point, may be considered for ongoing development of the role.
Despite implementation commencing nearly 2 years ago, most respondents still perceived this change as being new. The consistent reporting of lack of role definition and differing role expectations of the ANP by all staff interviewed indicates that many may still be experiencing the transition between the end of the old ways and the beginning of the new reality. Comments about ANPs not assisting unit nurses with tasks such as answering phones and lifting patients speaks to the unit staff’s need to hang onto something from the past, as well as speaking to their values that “good” nurses help each other and provide care to patients rather than write orders and go on rounds.
Despite a culture of change in the organization, a nursing subculture also exists based on assumptions, beliefs, and values about what nursing practice is, which guide nurses in their daily work. The ANP role is neither “fish nor fowl,” that is, no longer a clinical nurse but not a physician either; the ANP scope of practice lies somewhere between and overlapping the two professions. This raises identity issues for most staff nurses, as they continue to grapple with how their role interfaces with the ANP role. Open discussions among all stakeholders about their expectations of the ANP role and shared meanings of their traditions may clarify the uncertainty that some have about the role accountabilities and assist them to move beyond the neutral zone. It must be acknowledged that for those individuals who are ambiguous about nurse practitioners fulfilling this role in acute care, no amount of information may change their thinking.
No one individual has been selected to champion the implementation of this new role throughout the institution. Within each program, a senior administrator and physician have led the implementation. Job descriptions were developed based on individual ANPs and specific program needs rather than a generic template that includes expectations of contributions to nursing research and professional development. This may be a missed opportunity for nursing to provide leadership to the functioning and overall accountabilities of these positions, as no one seems to be working from the same premise or template.
By operating under the medical model, these ANPs have been mentored and socialized into their roles by physicians, with little time and support to pursue nursing research and provide nursing rounds to share knowledge and expertise with colleagues. This lack of focus on profession-specific knowledge advancement and professional development may in fact be a long-term effect of multiple transformation efforts undertaken by the organization in the past decade. All profession-specific departments had been dissolved and multidisciplinary patient care teams had been created, led by directors from a variety of disciplines. While the organizational structures have continued to evolve, the notion of integrated patient care services as a superior means of delivering services remains strongly within the organization’s culture.
If the ANP position is to evolve to its full potential, then administration, unit nurses, ANPs, and physicians must work together to reach an understanding and appreciation for the value of the role. Without clear expectations and a plan for managing the necessary cultural shift, the ANP will continue to be pulled in multiple directions, struggling between meeting the expectations of physicians/residents and nursing staff, as well as being pulled between service delivery and education/research. The “middleness” being experienced by most ANPs interviewed may lead to growing frustration and burnout. 15 The sources of power for ANPs lie in their formal authority (which will increase when regulatory reforms are complete), their relevance to the present manpower needs in healthcare, and their growing autonomy in fulfilling their roles. The reporting relationships are perceived by some ANPs to be a source of power because they report directly to a senior administrator, as do most Clinical Nurse Specialist roles, rather than a unit manager, despite working solely within the area of responsibility of the unit manager. The prevalence of respondents indicating how important it was to have individual “fit” in the position, as well as the reported lack of procedural skills on the part of some ANPs, speaks to the high need for expertise, effort, and attractiveness as personal power sources in these positions.
Recommendations and Summary
Clearly, the focus in this implementation of the ANP role in acute care has been on changing practices of how medical care of inpatients is managed within select programs rather than focusing on changing the culture or shared meanings that staff hold about how patients should be managed. Analysis of the findings of this study in conjunction with selected relevant literature has suggested 5 specific recommendations. These have been broadly discussed and supported in the foregoing section, and are further delineated here. First, employ a change model to guide the change process and integrate ongoing evaluation or feedback. Second, assign a champion: 1 or 2 individuals to support, coordinate, and market the change on both micro and macro levels within the organization. Third, articulate a vision: clarify and communicate a consistent definition and expectations of the ANP role, and anticipated outcomes of role implementation. Fourth, establish a forum to facilitate open and ongoing communication between all players that will recognize and attend to the values and beliefs of staff participating in this change, by valuing and reorienting the past and present together to shape the future. Last, attend to cultural and personal transitions.
By implementing these recommendations, there is still opportunity to fine tune the implementation process, assuring this exciting new role is institutionalized before all perspectives are “frozen” and ensuring that it remains viable long after the medical manpower issue is abated.
© 2003 Lippincott Williams & Wilkins, Inc.