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Original Articles

Leveraging Advanced Practice Nursing in Complex Health Care Systems

Younger, Samuel J. PhD, MHA, MSN, AGPCNP, FACHE

Author Information
Nursing Administration Quarterly: April/June 2020 - Volume 44 - Issue 2 - p 127-135
doi: 10.1097/NAQ.0000000000000408
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Abstract

THE HEALTH CARE INDUSTRY has been devoted to improving the delivery of health care over the past 20 years with mixed results. Yet, the US spending on health care services in 2016 was nearly twice as much as any other nation (17.8% of gross domestic product) and quality outcomes lag behind other developed countries.1 Capitalizing on the expertise of advanced practice providers, such as nurse practitioners, has been touted as one solution to improving the quality of patient care.2 Nurse practitioners have been providing care to patients since 19653 and patient safety has long been an area of professional focus. According to the American Association of Nurse Practitioners, there are more than 270 000 licensed nurse practitioners in the United States.4 Clinical practice is only one dimension of a nurse practitioner's role in complex health care systems. As leaders of health care teams, nurse practitioners must also balance evidence-based standards with the need for new and creative solutions to realize continued improvement in quality and patient safety outcomes.

The literature on the role of nurse practitioners as leaders of quality improvement in complex health care systems is limited, and mainly focuses on managerial positions of authority. Many health care systems are utilizing archaic, top-down, leadership models based on bureaucratic control and structure with limited success related to leading for improved patient care. These outdated models of leading quality improvement inevitably lead to the creation of processes that will ultimately fail due to the lack of flexibility and inability to adapt to constantly changing patient conditions and accounting for internal and external environmental factors. This ambiguous environment requires an understanding of the complex and interconnected nature of patient care delivery. High-quality patient care is not the responsibility of a single team member but rather is the product of complex interactions among many individuals working toward the same goal of safe patient care. This article seeks to bridge concepts of rapid cycle improvement and the PDSA (plan-do-study-act)5 with complexity leadership theory and offers a nurse practitioner-led model of transformational change.

NEED FOR INNOVATION IN QUALITY IMPROVEMENT

The health care quality improvement paradigm began to shift in response to the 1999 Institute of Medicine report To Err is Human, when an intergovernmental task force was created to address patient safety concerns over high rates of hospital mortality from preventable medical errors.6 In 2001, Crossing the Quality Chasm: A New Health System for the 21st Century continued to call for major change in health care delivery and improved patient outcomes.7 This began an evolution in how we think about medical error, as historical notions of punishment for errors have proven to be ineffective and unsafe for patients.8 Policy makers, patients, and clinicians now demand health care transformation that has resulted in an era of quality improvement that has focused on care pathways and standardization. However, the potential value of creativity and innovation may often be overlooked in clinical practices that are inflexible and rigid.

Patient harm in US hospitals remains high despite significant progress to improve the quality of care in our health systems. For example, the most recent data available from the Agency for Healthcare Research and Quality are from 2014 to 2016, and note a national reduction in hospital-acquired conditions (HAC) of 90 HACs per 1000 discharges.9 However, the rate of improvement has slowed (145 HACs per 1000 discharges in 2010 and 98 HACs in 20149), indicating that a new approach to quality improvement is necessary. The problem is that many quality improvement efforts have continued to focus on clinical standardization rather than incorporating creative and adaptable solutions. As health care systems have become more complex and interconnected, new approaches to quality improvement are necessary to realize true gains in patient safety.

COMPLEXITY LEADERSHIP

Today, more than any time in the past, health care is provided in a complex ecosystem of interconnected professionals and teams who are working in symphony toward providing high-quality patient care. Complexity leadership theory seeks to extend our understanding of how leadership for the 21st century is able to utilize concepts of complex adaptive systems by exploring the behaviors and strategies that foster creativity, learning, and adaptability within the context of bureaucracy.10 Uhl-Bien et al10 describe complexity leadership theory as focusing on 3 types of leadership: administrative, enabling, and adaptive. Administrative leadership is grounded in traditional alignment and control structures that govern traditional health care systems. Administrative leadership is composed of individuals who are in positions of authority and whose main activities consist of planning, organizing, and coordinating. Within the nursing infrastructure this is illustrated as traditional positions of authority, including the frontline nurse manager (often referred to as the “charge nurse”), unit manager, and executive nurse leaders (Chief Nursing Officer and/or Vice President of Nursing).

Adaptive leadership is the underlying emergent dynamic that generates change. Adaptive leadership is not a person or position, but social patterns of interactions between individuals and that produce creative outcomes and new knowledge development. The condition of adaptability is one that is pertinent to creating new and improved systems of care in the face of unforeseen patient clinical conditions. Enabling leadership seeks to catalyze the conditions of complex adaptive systems to address creative problem-solving, adaptability, and learning. The main role of enabling leadership is to mediate the balance between administrative leadership (bureaucracy) and the adaptive leadership necessary for change.10 A stronger relationship between formal leaders (managers) and nurse practitioners in quality initiatives is one model that could strengthen the foundation needed for new adaptive leadership models.

Complexity leadership and quality improvement

It is essential to characterize the context in which the quality improvement process takes place in a complex acute care medical center.11 Nurse practitioners now practice within an interdisciplinary model of care delivery where interconnections are essential to providing effective and safe patient care. The nurse practitioner may direct the plan of care in conjunction with an interdisciplinary team of health care professionals that includes physicians, pharmacists, physical and occupational therapists, social workers, nurses, and nurse managers. These rich interconnections across diverse disciplines create new challenges for organizations and their leaders on how to best harness the power of relationships to produce new innovations, knowledge, learning, and adaptability. When quality improvement is viewed through a traditional lens (structure and control), the outcome may be one that is linear (ie, clinical pathway). When the quality improvement narrative is shifted to include concepts of complexity science, which values autonomy and decentralization, adaptive outcomes may emerge as information is exchanged across networks of providers.

Complexity leadership in acute care health care systems often occurs in the face of adaptive challenges defined by interconnected patient care plans that span multiple teams (consult, primary team); settings (medical/surgical unit, intensive care unit); and time frames (preoperative, postoperative) that are representative of a complex health care system. Adaptive challenges would be characteristic of today's complex acute care environment, with nurse practitioners leading teams that must adapt to rapidly changing environmental conditions or patient circumstances to provide effective patient care. Adaptive challenges require new learning, innovation, and new ways of thinking and providing care. Ultimately, 21st-century health care challenges require a new framework for quality improvement that enables solutions to emerge as problems arise. In contrast, the typical quality improvement process has taken place under technical conditions characteristic of the industrial era, with planned linear solutions. These are problems that can be solved with current knowledge and procedures already in hand. In order to improve patient safety in the 21st century, nurse practitioners must be able to lead collaboratively among multiple health care team members and exploit the powerful networks present in complex health care systems.

INNOVATIVE NURSE PRACTITIONER MODEL FOR QUALITY IMPROVEMENT

Within the acute care setting, care is often provided by an interdisciplinary team of nurse practitioners and physicians.12 Nurse practitioners perform clinical examinations and procedures, order and interpret diagnostic studies, direct pharmacotherapy, and coordinate care of patients to the next level of care. As leaders of these care teams, nurse practitioners are strategically positioned in health care systems to collaboratively lead quality improvement efforts and improve patient care.13 The success of many quality improvement initiatives may depend on the engagement of health care providers, particularly the nurse practitioner, given his or her proximity to direct patient care while individuals are hospitalized.13 Another stakeholder in quality improvement at the point is the frontline nurse manager. Nurse managers are intentionally positioned at the point of care to influence patient safety as key conduits to frontline nurses' daily work.14

Nurse managers and nurse practitioners should synergistically create an environment whereby their interactions can cultivate new and shared solutions to adapt to the current clinical environment. Within this clinical engagement model of innovation, nurse managers (administrative) are expected to lead for adaptability and change rather than control.10 This model of clinical innovation in quality improvement should be understood as an integrated strategy within the bureaucratic health care system. It must incorporate the informal networks of providers led by nurse practitioners, acting within the formal organizational structure. This is due to the nature of the complex social systems that comprise care delivery networks within health care systems. These interdisciplinary networks of care providers change over time, in both predictable and unpredictable ways, based on internal (patient condition) and external forces (policy).15 Delivery of improvement in these complex networks of care may best be understood through the use of the most common quality improvement model: The Model for Improvement (MFI), popularized by the Institute for Healthcare Improvement, and based on the work of Edwards Deming.

The foundation of the MFI is based on 3 questions outlined in the Table. These 3 fundamental questions, combined with the PDSA cycle, are the basic framework for change.5 Within the PDSA method, the first stage (plan) refers to the identification and description of the problem. The second stage (do) is to carry out the intervention. The third stage (study) is aimed at understanding if the intervention produced an improvement. The fourth stage (act) seeks to guide future improvements.16 The PDSA cycle uses small tests of change that enables rapid deployment and assessment of changes according to feedback to ensure improvements fit the context of care provided.

Table. - Complexity Model for Leading Quality Improvement Based on PDSA
Model for Improvement5,16 Complexity Leadership Approach to PDSA
What are we trying to accomplish?

How will we know that a change is an improvement?

What changes can we make that will result in improvement?
Aim: Determine which specific outcomes you are trying to change.
Measures: Identify appropriate measure to track your success.
Changes: Identify key changes that you will test.
Nurse manager (NM):
Plan: AL is key in developing roles, responsibilities, accountabilities, baseline data. Keep creativity in mind.
Do: EL should create space/time for new ideas to be brought forward in real time. Interdisciplinary patient care rounds group to test change, discuss barriers, and implement solutions in real time.
Study: EL provides constant information flow in real time
Act: EL focuses dissemination of new and creative processes that have emerged.
Nurse practitioner (NP):
Plan: EL seeks to balance clinical and financial goals.
NP should develop “sphere of influence” to engage their network in change.
Do: EL may incorporate new pattern interaction, clinical interdependency, and tension to produce innovative solutions.
Study: EL promotes constant evaluation of change based on evidence.
Act: EL fosters conditions that is consistent with improved patient care (mission) and discourages nonuseful adaptations.
ADL can be seen throughout the PDSA cycle as new ideas are exchanged through patient rounds. NM can foster ADL by creating asymmetry and constantly reframing the problem based on the interactive dynamic. NP can impact ADL through encouraging other team member to debate new care processes and contrast with existing assumptions.
Abbreviations: ADL, adaptive leadership; AL, administrative leadership; EL, enabling leadership; PDSA, plan-do-study-act.

The PDSA method is a practical approach to health care quality improvement that allows for the iterative development of scientific interventions that are able to adapt to unforeseen clinical circumstances.16 If the PDSA method is viewed through the lens of complexity, then the steps in the cycle itself should be considered symbiotic, and thus adaptive to changing context. In this view, the steps in the cycle may run parallel or simultaneously to each other. The principles of complexity leadership may best inform this method for quality improvement through processes of learning and adaptability, ultimately leading to innovation in patient care.

Adaptive outcomes through PDSA

Uhl-Bien and Marion17 state that adaptive leadership is an informal process that occurs intentionally through the independent interaction among agents when they work to generate unique solutions central to the needs of the organization. Adaptive leadership is very much intertwined with the PDSA method in creating the conditions that allow for emergence of innovative solutions. Adaptive leadership is not position specific, and can occur at any level of the organization. Adaptation is a fundamental principle of the PDSA method, as clinical teams have ability to enact change in response to new problems. In this context, adaptive leadership recognizes that the organization is being confronted by a problem. The nurse manager and nurse practitioner must work in combination toward a solution through debate and learning, which ultimately leads to creative solutions. Within the PDSA method, the nurse practitioner and the nurse manager have a shared responsibility to enable creative interaction among team members that leads to innovation. The interaction between the nurse manager and the nurse practitioner may seed the adaptive leadership capacity of the PDSA cycle, as various solutions to the problem are deliberated.

Enabling leadership and emergence of solutions

Traditionally, the first step in the PDSA method is considered the planning phase. However, a complexity-informed approach would mean that the “plan” is adaptive. The initial “plan” requires an initial deep, analytical understanding of the problem identified. Without a thorough, evidence-based understanding of the problem identified, the analysis and interpreting hypothesis will be imprecise and may lead to unsustainable results. Administrative leadership from nurse managers is critical to acquiring resources, identifying and managing data, and structuring the quality improvement within the confines of larger system strategy. Nurse practitioners in the planning stage should be considered key sources of data and knowledge about current practice because of their role as leaders of patient care teams. Nurse practitioners should take inventory of their sphere of influence and foster relationships to enhance the power of their broad networks.

The reality of implementation (do) is that learning is constantly taking place, as the clinical team is reformulating solutions based on feedback (study). Furthermore, quality improvement is an ongoing process, as is the process of evaluation. The implementation of the improvement should take place in the normal course of patient care (ie, patient rounds) so that the interdisciplinary care team can debate the comparative value of the change. When viewed through a complexity leadership lens, the “do” stage has significant overlap with the “study” component of the PDSA cycle. Many of the small tests of change will be applied in the normal course of patient care provided by the health care team, which requires real-time modification for safe patient care. In the solving complex problems, the nurse practitioner, frontline nurse, and nurse manager may concurrently act in an enabling leadership capacity and as catalysts for adaptive solutions.

Nurse managers play a key role in fostering the emergent behaviors among frontline nurses so that they have the capacity to change or adapt to new clinical conditions. Quality improvement projects often face systemic barriers to change that nurse managers should anticipate and are best equipped to overcome. Important to the quality improvement process is the ability of formal administrative leaders (nurse managers) to create networks of clinical engagement and drive collaboration. As a formal leader who is closest to the patient care, the nurse manager is best positioned to provide necessary resources and knowledge dissemination, while fostering interactions and interdependency and navigating the formal bureaucratic structure of the organization. The nurse manager can enable the adaptive capacity of the clinical team through dissemination of data about the improvement in real time (during patient care rounds). In the complexity leadership point of view, nursing leaders must foster clinical collaboration that has the potential to unlock new and creative solutions to rapidly changing clinical demands.

The nurse practitioner should work closely with the nurse manager who can provide real-time data on the progress of the quality improvement project (study). Patient care that is provided in interdisciplinary teams seeks to promote the enabling conditions of interaction, interdependency, and tension.10 It is through the diverse interaction among team members that information is exchanged about the status of the quality improvement. These interactions may produce tension based on opposing sentiments, which are shared among the group and debated. Tension in this team environment may lead to adaptive problem-solving and improved care. Allowing for practice autonomy of the nurse practitioner can also foster the interdependency necessary for adaptive solutions to emerge. In practice, this may mean that the standard of care (protocol) is circumvented, as clinical teams adapt to new clinical information. Enabling leaders would encourage risk-taking behavior, which balances standard operating protocols in high-risk areas and the need for continued innovation to produce the best patient outcomes.18 Nurse managers can co-create enabling leadership through articulating clear standards, coordinating complex tasks, and recognizing the achievement of goals.

The advantage of a complexity-informed approach to quality improvement is that learning is compounded through the small test of change. Therefore, the “act” stage of the PDSA method, when informed by complexity leadership, is one of ongoing evaluation of the evidence. The action in a complexity view is a fluid reframing of assumptions based on previous PDSA cycles. The nurse practitioner, acting in an enabling leadership capacity, will evaluate the evidence for improvement in real time and foster the conditions that improve patient care. Nurse practitioners must act as a champion of these new ideas within interdisciplinary teams. They are seen as clinical experts in patient care and are able to encourage adoption of new solutions while discouraging nonuseful solutions.10 This is a reframing typical of current project champions who are commonly executive leaders. While executive leaders are essential to providing the necessary resources and strategic influence (administrative leadership), it is the nurse practitioner who should be empowered to inform those administrative decisions. Nurse practitioners are best suited to bridge the gap between the administrative (bureaucratic) requirements of the organization (ie, financial metrics) and the mission of providing high-quality patient care. This allows for enabling leadership by the nurse practitioner to reframe the clinical question within the interdisciplinary team and determine the most appropriate solutions to move forward. The nurse manager can utilize enabling leadership practices to objectively evaluate the current state (data management) and disseminate the creative solutions that have emerged. Evaluation or “act” should be seen as a fluid exchange of information across multiple stages of the PDSA cycle, as teams seek improvement.

IMPLICATIONS FOR PRACTICE

Key to understanding this narrative is acknowledging that rapid cycle quality improvement is not an isolated activity, but a process that is already taking place within interdisciplinary teams. Traditionally, organizations have focused on top-down embedded routines and outcomes through cause-and-effect relationships to develop standard processes and care pathways. While not specifically addressed in this narrative, the frontline nurse is a key member of the care team who is crucial to attaining quality improvement at the bedside. When frontline nurses are engaged in quality improvement, the innovation is more likely to be successful and sustained.13 It is not solely the role of the nurse manager to engage frontline nurses through administrative means. In practice, the PDSA method offers a unique opportunity for nurse practitioners to promote adaptability to new patient care innovations through communication and feedback from frontline nurses. It is through this constant qualitative feedback and analysis of quantitative data about the innovation that a nonlinear roadmap for innovation in patient care can be paved.

To take advantage of a complexity-informed approach to quality improvement, nurse practitioners, frontline nurses, and nurse managers must have the appropriate knowledge of the science of quality improvement. Use of DNP (Doctor of Nursing Practice) and PhD (Doctor of Philosophy)-prepared nurse practitioners as leaders of quality improvement has been a successful strategy to drive positive change and improve health outcomes.19 These doctoral-prepared nurses are well educated in the science of improvement, and are currently positioned to translate current evidence into opportunities for creative change. Enabling these doctoral-prepared nurses within interdisciplinary teams is central to encouraging constant learning and the emergence of creative solutions through ongoing reformulation of clinical practice. Utilizing doctoral-prepared nurses to train team members in the science of quality improvement may be a framework for sustainable quality improvement on nursing units.

Finally, this complexity-informed model for quality improvement requires that nurse practitioners, frontline nurses, and nurse managers collaborate to establish clinical priorities that are most pressing. While nurse managers are part of the bureaucratic leadership structure responsible for establishing system quality goals, nurse practitioners are often left to attain patient care goals as uninformed and passive members of the care team. Development of quality goals that are co-created with nurse practitioners and nurse managers may be the best approach to the development of flexible care models that achieve sustainable quality improvement. The complexity-informed PDSA method could then be adapted with a focus on continuous quality improvement within interdisciplinary teams.

SUMMARY

Leading quality improvement has never been more difficult. The problem with many current quality improvement initiatives is the lack of flexibility provided through linear approaches to solving complex multidimensional, nonlinear problems. When executing quality improvement in complex health care systems, many projects will fail due to unforeseen circumstances. The beauty of approaching quality improvement through the use of a complexity-informed PDSA cycle is the inherent learning and adaptability produced.

Health care transformation is underway, as health care systems seek to provide care that is team-based, personalized, affordable, and coordinated across multiple settings. If clinical team leaders, such as nurse practitioners, are going to get the most out of the quality improvement process, it will require a sustained commitment and an understanding of the complexity of managing change in the patient care environment that is continuously creating new knowledge. To address these changes, health care systems must empower nurse practitioners to drive change in partnership with their nurse management colleagues. As leaders in health care teams, nurse practitioners consistently provide high-quality and cost-effective patient care in nearly every sector of the health care system.20 This narrative offers a nurse practitioner-led framework for quality improvement that promotes a new way to think about how to address complex quality challenges in interdisciplinary care teams. In conclusion, by proposing the inclusion of complexity leadership principles within current PDSA methods, I hope to stimulate nurse practitioner-led quality improvement through rapid cycle improvement. This new model of change considers adaptability as a key construct of quality improvement. It could be better enabled by nurse practitioners practicing leadership at the intersection of clinical care and management.

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Keywords:

advanced practice nursing; complexity leadership; nurse practitioner; nursing leadership; PDSA; quality improvement

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