Evolving Role Perceptions in Clinical Care Teams EXECUTIVE SUMMARY Multiple new leadership roles in A CALL FOR INNOVATIVE care delivery models that im - accountable for ensuring patient care meets clinical standards (evi- nursing have been described for prove care, enhance quali- dence-based practice) and coordi- which the impact on the quality ty, and reduce healthcare nates decision making and commu- and safety of care deliv-ery and costs is a key strategy to improve nication, notably during transitions in on the costs of care delivery the U.S. healthcare system care. The goal for this new role is to remain to be defined. Further, the (Berwick, Nolan, & Whittington, provide continuity of care for appropriateness of training and 2008). Health care systems are patients and families with optimal the optimal deploy-ment of implement-ing different approaches coordination of care, including dis- personnel have not been to achiev-ing these interdependent charge planning. It was anticipated investigated. goals known as the Triple Aim. New this intervention, coupled with other In this study, in one such care care delivery models are emerging simultaneous administrative model, attending registered along the fragmented continuum of changes (e.g., improved handoffs of nurses’ perceptions of their role care and present solutions to some care, earlier discharge planning, evolves from functional thinking aspects of the healthcare crisis. increased attention to patient and to “looking at the big picture,” One strategy to reduce frag- family education, enhanced pre- underscoring an increased level of admission evaluations, daily care mentation in the hospital setting is insight over time. coordination rounds) would reduce the attending registered nurse (ARN) The data highlight the impor- length of stay and readmissions, role, designed to support delivery of tance of ensuring “buy-in” from enhance patient satisfaction, and, integrated, patient-cen-tered care at peers to ensure success in ultimately, improve patient safety Massachusetts General Hospital leadership roles. and quality of care. (MGH) in Boston, MA (Erickson, These observations are mutual-ly According to Benner’s model for Ditomassi, & Adams, 2012). The reinforcing; improved leader-ship ARN is an experienced staff nurse knowledge and skill acquisition in and communication skills who, with the attending physician, is nursing, skills and acquisition of responsible for ensur-ing the nursing expertise develop within five produces greater acceptance by consistent and timely pro-gression levels: novice, advanced begin-ner, peers. of each patient’s care from competent, proficient, and expert admission to discharge. The ARN (Benner, 1984). Nurses at each maintains a constant presence on level demonstrate changes in three GAYLE A. FISHMAN, DNP, MBA, RN, NEA- key aspects of practice: move-ment BC, is Nursing Director, Endoscopy Units, the unit 5 days per week as a Massachusetts General Hospital, MA. resource for both patients and fam- from dependence on con-cepts to ilies and other staff. The ARN is use of accumulated experi-
ences as exemplars; a change from A review of the literature was patient care facilitator position pro- compiling individual situational conducted using key search terms vides clinical leadership roles for events to appreciating more holis-tic including attending registered nurse, nurses within smaller areas of views; and movement from observer care delivery model, collabo-ration, patient responsibility. The aim was to involved performer. In this continuity of care, navigator, nursing to ensure a caring and professional framework, the ARN role lever-ages role, patient care facilitator, and practice culture for patients and both the knowledge base and practice innovation. Search engines clinical staff (Brown et al. 2005). leadership experience of selected used to conduct the search included Brown and colleagues conducted a staff nurses to coordinate care for CINAHL, Cochrane Data-base of qualitative and quantitative multi- complex patients often across mul- Systematic Reviews, and the Na method study to measure the tiple teams of providers, mentor-ship tional Guidelines Clear ing House patient care facilitator role (inde- of nursing staff, and applica-tion of via interfaces including EBSCOhost, pendent variable) on continuity of hospital guidelines and other Ovid, and Nursing@ Ovid. The care and caregiving behaviors of the educational resources to clin-ical study focused on evalua-tion of nursing staff (dependent variable). care. evidence related to forma-tive Batcheller, Burkman, Armstrong, The purpose of this qualitative experiences contributing to Chappell, and Carelock (2004) stud- descriptive study was to describe development of skills required for ied the impact of an innovative changes in the perception by ARNs the ARN role. Inclusion criteria also nursing infrastructure in a seven- of their role after working in the included evidence describing where hospital network in which the nurse position for 2 years. Seven ARNs, nurses develop skills (acade-mic retained the primary over-sight role, who were interviewed in 2012, were preparation, specific job train-ing, or provided long-term men-torship for re-interviewed in 2014 using the experience in the role), inno-vative new employees, and provided the same semi-structured interview care delivery models de-scribing primary interface with patients. In guide to assess changing role specific nursing attributes in the these studies, RN-led models using perceptions over time. role, and articles written in English. experienced nurses as the team leader demonstrated positive Background The literature described four outcomes including im-provement in The Institute of Medicine (IOM) general categories of nursing roles nurses’ perceptions of the frequency Report, Crossing the Quality Chasm: A focusing on patient-centered care: of assessment by experienced RNs New Health System for the 21st faculty-led attending nurse of patient readi-ness for discharge, Century, described a healthcare models, advanced practice RN-led physician per-ceptions of the delivery system poorly organized to models; clinical nurse leaders-led availability of expe-rienced RNs, meet national health-care needs. models, and RN-led models. This reduction in RN staff turnover, “The delivery of care often is overly review focused on RN-led models. reduction in medication errors complex and un-coor dinated, RN-led models of care evolved (Batcheller et al., 2004), and requiring steps and patient handoffs from traditional models including improved patient perceptions of staff that slow down care and decrease patient-focused care and case knowledge of care and dis-charge rather than improve safety” (IOM, management roles (Deutschendorf, plans (Brown et al., 2005). The 2001, p. 1). This report called for 2003). Common programmatic com- economic implications of these redesigned priorities for providers to ponents contributing to success in- observations include direct health- funda-mentally improve care. These clude elevating the RN role, in- care benefits of nurse retention (var- in-cluded “reengineered care pro- creasing focus on patient and fami- iously estimated at 0.75-2 times the cesses; effective use of information ly involvement in care, smoothing salary of each lost nurse), reduced technologies; knowledge and skills patient transitions and handoffs, patient length of stay, and reduced management; development of effec- leveraging technology to enable potential exposures to medication tive teams; and coordination of care care model redesign, and providing errors (Jones & Gates, 2007). across patient conditions, services, results-driven care (Kimball, Joynt, Erickson and coauthors (2012) and sites of care over time” (p. 2). Cherner, & O’Neil, 2007). described the Attending Registered The IOM (2001) described six aims A series of inpatient models Nurse Model at MGH. Innovation to improve individual and commu- address the need for patient-fo- units were created on 12 inpatient nity healthcare services: safe, effec- cused clinical care and improved units to “improve clinical out-comes, tive, patient-centered, timely, effi- handoffs across the healthcare sys- enhance patient and staff cient, and equitable care. The tem to enhance nursing leadership satisfaction, as well as reduce costs changing healthcare environment and participation in care. Ac-cord- and lengths of stay for hospitalized provides an opportunity to reexam- ing to Clark (2004), the 12-bed hos- patients” (p. 283). While 12 inter- ine staffing roles and processes pital at the Baptist Hospital of Miami ventions were implemented simul- within the acute care setting. provides a care model for a cure- taneously on innovation units, the dominated environment. The ARN was considered the consistent
presence on the clinical team, working ing is the extension of practical at MGH and ARN perceptions of 5 days per week, providing continuous knowledge through research and that role. For this study, the same relationships with patients, families, description of experiences in clini- interview guide was used to re- and healthcare team. The ARN cal practice. She proposed expert interview ARNs remaining in the developed and coor-dinated nurses develop skills and under- position 2 years later. Key elements interprofessional teams’ clinical plans standing of patient care over time of the interview are described for inpatient admis-sions. The ARNs as a function of both education below. Study subjects included all were experienced, highly respected and experience. She suggested nurses in the ARN role for at least 2 nurses who partic-ipated in a clini-cians could gain knowledge years at the selected time points. comprehensive curricu-lum including and skills (knowing how) without Setting and sample. The MGH is role-specific educa-tion for the learn-ing theory (knowing that). an academic medical center within innovation unit pro-gram. The program Benner, Hughes, and Sutphen Partners Healthcare, the largest augments ARN’s skills related to (2008) suggested a cycle exists healthcare system in conflict reso-lution, resiliency, and between experiential knowledge and Massachusetts. The author con- communica-tion. ARN discussion scientific investigation: experi-ential ducted the interviews in 2012 and groups pro-vided forums to share knowledge stimulates scien-tific 2014. All ARNs from the 2012 experiences, observations, and best investigation and scientific study were invited to participate. practices. This model was designed to investigation fuels a cycle of further Eligibility criteria included partic- sup-port the challenge of delivering experiential learning. In Benner’s ipating ARNs who had been inter- integrated, patient-centered care at a construct, the repository of clinical viewed in June 2012 and were large academic health center. To date, knowledge and experience is in the identified by the department of there are no published out-comes of clinical team with responsibility for nursing as remaining active in the the ARN model. Quan-titative data will optimizing clinical care (Benner, role. All ARNs meeting eligibility be evaluated in the future including 2001). The ARN model builds on the criteria agreed to participate in the culture of safety surveys, Hospital team concept by providing team study. Interviews were conducted Consumer As-sess ment of leadership to leverage the experi- with 16 subjects in 2012 and all of Healthcare Provi ders and Systems ence of senior staff to provide men- the 7 remaining ARNs in 2014. (HCAHPS) survey, length of stay, torship and knowledge transfer Data collection. Interview data quality indicators, patients’ within care teams. The clinician’s were collected by the author using perceptions of feeling known, cost per past experience from specific clini- a semi-structured interview guide. case mix, and staff retention. cal cases positions him or her to Key elements of the interview identify future similar cases which included subject’s perceptions of provides educational and research relationship-based care and ARN In addition to the economic opportunities. Benner suggested role; the adequacy of training and benefits of nurse retention and nurses develop skills and under- resources provided for subjects reduction in clinical errors, the ARN standing of patient care over time and clinical staff; barriers to suc- has an important role in the through a sound educational base cessful job performance; role-spe- maintenance of the nursing knowl- and a multitude of clinical experi- cific changes in interactions with edge base and in mentorship. A key ences. Clinical situations are more patients, families, and staff; and element is the identification of those complicated and dynamic than the- the role of technology in job per- skills required to evolve into the oretical scenarios; practice provides formance. Participants were inter- leadership role. Benner’s Novice to a valid source of knowledge evolu- viewed individually in a private Expert model, used to guide the tion. Through experiences and study hospital conference room. The study, encompasses pro-gression of clinical practice, nurses discover interviewer took notes during the from novice to expert cli-nician. new knowledge. meeting. Following each inter- Benner adapted Dreyfus and view, the author’s typed summary Dreyfus’ Model of Skill Acquisition Methods of responses was emailed to sub- and Skill Development to clinical This study used a qualitative jects within 24 hours. Each partic- nursing practice (Benner, 1984). descriptive design (Sandelowski, ipant was invited to edit or com- “The Dreyfus and Dreyfus model 2000). Data were collected using a ment on the written summary until provides concepts to differ-entiate semi-structured interview tem- satisfied with his or her answers. between what is taught by precept plate developed in 2012 and This editing and refine-ment (i.e., teaching) and what must be applied to the same subjects. process was done via email to learned experientially from Initial interview data from 2012 ensure process validation. Some comparison of similar and dissimi-lar were collected as part of a larger participants provided detailed cases” (Benner, 1984, p. 186). project in which ARNs were inter- changes, which were incorporated Benner (1984) posited that viewed to assess adoption of 12 into a final document. All partici- development of knowledge in nurs- interventions from innovation units pants provided final email confir-
mation their responses for each Table 1. perception were described accu- Themes and Subthemes rately. Following email confirma- tion, data were de-identified, Theme 1: From Tasks to Teams replacing participants’ names with Subthemes Subthemes numbers. 2012 2014 Ethical considerations. The Care plans Communication MGH Institutional Review Board Discharge planning Team builder and the Spaulding Rehabilitation Patient education Continuity Hospital Institutional Review Individualized plan of care Board approved the 2014 study. Informed consent and authoriza- Theme 2: From Pushback to Buy-In tion were implied by voluntary Subthemes Subthemes participation in the interview. The 2012 2014 author had no conflicts of interest Role confusion Role clarification related to the study. Ambiguity Collaboration Data analysis. Data generated from each interview were organ- Negative response Positive response ized in a matrix to allow direct comparison between individuals and over time. The author and 2000). An audit trail was main- roles related to team-based func- Ruth Palan Lopez, PhD, GNP-BC, tained for participant response tions (2014) as compared with a researcher with expertise in confirmation. Performing joint data nar-rower task-oriented roles qualitative analysis, analyzed analysis targeted increased (2012) (from tasks to teams); and written notes from both interview reflexivity, diminished bias, and (b) reduced staff pushback to the periods using an iterative process enhanced internal consistency. role (2012) with greater buy-in or of description, analysis, and inter- Discussions ensured consensus acceptance (2014) (from pushback pretation (Wolcott, 1994). The around each theme. Data analysis to buy-in). All ARNs demonstrat-ed process included three levels of was refined until higher levels of increased clarity in under-standing coding: coded concepts for major categories accounted for all ques- of the ARN role and con-fidence in themes; assess similarities and tions included in the study. that role over the study period create higher-level categories; and (see Table 1). identify relationships between Results From tasks to teams. When asked categories across individuals and Available subjects were inter- about role perception in year 1, ARN over time. During first-level cod- viewed at both time points. Parti- responses centered on spe-cific ing, interview reports were read cipants were all RNs, female, 30-56 tasks including developing care jointly line-by-line, highlighting key years of age (mean 45.6; SD 10.6). plans, planning for discharge, and words and assigning a code to All participants were Caucasian and conducting patient education. In each concept. During second-level had at least 6 years nursing contrast, when asked about the role coding, similarities in concepts experience on their units. Five in year 2, they described were identified that were col- nurses had a bachelor of science responsibilities including commu- lapsed into higher-level cate- degree in nursing and two had mas- nication, team builder, continuity, gories. In third-level coding, cate- ters in nursing degrees. All nurses and individualized plans of care (see gories were analyzed to identify had at least 4 years experience in Table 1). In 2012, ARNs used terms relationships and differences over leadership roles on the unit (charge such as ensure continuity of the plan time. Themes were compared or resource roles) prior to assuming of care, being present daily, support the between individuals over time (see the ARN role in 2012. All partici- patient’s discharge planning needs, Table 1). pants had been an ARN for 2 years. helper, and extra pair of hands. By Strategies were employed to contrast, in 2014, all ARNs enhance the trustworthiness and Findings described the role with terms credibility of study processes and Analysis of interview data from including communication, findings. An audit trail was main- 2012 and 2014 revealed par- collaboration, team builder, and tained of research methods, sam- ticipants demonstrated greater knowing patient and family. One ARN pling processes, data collection, insight into their roles after 2 described her role as “collabo-rative respondent validation, content years. Changes in perception – like part of a braided pony-tail” management, data analysis, and included two major themes at the using strong communication skills to data re-presentation (Mays & Pope; highest level: (a) ARNs demon- help bring together all members of 2000; Patton, 1990; Sandelowski, strated increased awareness of the nursing team. She
felt the role was to ensure the nursing director was key to suc- with experience, the nurse demon- team was in agreement regarding cessful transition into the effective strates the increased ability to rec- care plans for patient and family. ARN role. The ARNs said nursing ognize patterns and gain perspec-tive She believed this to be supportive directors held regular staff meet- and greater efficiency in deci-sion of relationship-based care. All ings when the role was initiated to making (Benner, 1984). In 2014 in this ARNs described a focus on team manage negative perceptions and study, movement was demonstrated building through collaboration and allow staff to voice concerns and toward looking beyond narrow tasks facili-tating communication. Each address issues. Another factor in and evaluating the entire clinical ARN told patients nurses were to successful transition into the role scenario includ-ing patients, families, care for them “for the day” and the was weekly ARN peer support and care teams. While the new role ARN would manage the care “for groups, called “brown bag lunch- was ini-tially challenging from both the stay.” Communication, team- es.” These lunches provided a pur-pose and peer-acceptance work, presence, knowing the patient, forum for ARNs to share individ- perspec-tives, ARNs described staff and individualizing plans for care ual challenges, experiences, and as increasingly accepting of the posi- were terms used to describe the successes in a safe environment. tion over time as ARNs improved ARN role in 2014. This suggests One ARN learned to provide sup- communication skills, supported unit an increased aware-ness of the port to the staff by helping with staff, and led the care team in potential value of the role and the some functional nursing tasks managing patient care plans and ability to look at the bigger picture. such as medications or bathroom discharges. The key element for suc- This understanding allowed ARNs requests. She believed such cess in both areas was a supportive to be more active in support of assis-tance accelerated role environment created by peers and by staff nurses and in dis-charge acceptance. All of the ARNs noted unit and hospital leadership. planning. contribu-tions of the nursing From pushback to buy-in. In director, brown bag lunches, and Benner (1984) suggested 2012, in response to the new role, provision of added support practi-tioners could gain knowledge all ARNs described pushback from enhanced under-standing and and skills without learning theory. the staff nurses on their units. In acceptance by staff of the ARN She noted clinical situations are contrast, interview data from year 2 position over 2 years. These shifts more complicated and dynamic than revealed ARNs report-ed buy-in resulted in greater acceptance of the-oretical scenarios, so clinical and acceptance by the staff. ARNs, enhancing their function prac-tice provides a valid source of Pushback was described by ARNs and the quality of the experience. knowledge evolution. Through both as role confusion, ambigui-ty, and experience and studying of clinical negative responses by staff nurses. Discussion practice, nurses discover new ARNs experienced a major This study was designed to knowledge. This study challenge in describing the new examine how ARNs perceived demonstrates ARNs’ role percep- role to the staff. Unit staff nurses changes in their role after 2 years tions evolved over time from task- were concerned ARNs were not of experience. The data demon- oriented (care plans, discharge assigned patients, especially when strate that with experience, ARNs’ plans, and patient education) to there were absences. One ARN perceptions of the role changed viewing the whole care delivery noted, “The staff exhibited some from a task focus to a team focus, process (communication, team- strong reactions and some bitter- and from staff pushback to accept- work, presence and knowing the ness to my role change.” Another ance. They described greater patient, and individualizing the plan ARN said, “The biggest challenge understanding of the purpose of of care). In 2014, ARNs described a comes from the staff pushing back their role within the totality of focus on the “patient’s stay, not just when working with them, pa - patient care. the day.” This growth in awareness tients, and families.” While research supports the allows ARNs to pro-vide more In 2014, evidence of buy-in benefits of an RN-led model of care substantive support to staff nurses included various subthemes includ- (Batcheller et al., 2004; Brown et al., in patient care and ensure patients ing increased understanding of the 2005; Clark, 2004), less is known experienced smooth-er clinical care ARN role by staff nurses (role clari- about experience of nurses in these and discharge plan-ning processes. fication) as well as collaboration and roles. The findings of this study In creased role clari-ty and positive responses from staff nurses related to the task to team theme are confidence appeared to enhance job (see Table 1). In the 2014 consistent with Benner’s concept of performance, satisfac-tion, interviews, all of the ARNs movement between novice, advanced communication skills, and described buy-in from nursing peers practitioner, and competent nurse. acceptance by staff. with a supportive team environ-ment The novice demonstrates rule- The lack of acceptance of the on each unit. Each of the ARNs said governed behav-ior that is rigid and ARN role by staff nurses has not leadership of the unit limited while been addressed in previous stud-
ies of new nursing leadership porated multiple administrative from peers to ensure success in roles. It is notable that of the 16 changes at the time of introduction leadership roles. These observa- nurses in the initial ARN group of the ARN role. Data on staff nurse tions are mutually reinforcing; interviewed, only 7 remained at 2 retention are not yet available from improved leadership and commu- years into the program. The basis the ARN-based innovation units. An nication skills produce greater for this observation is unknown. assessment of quality and safe-ty acceptance by peers. These find- The available data indicate the data, readmissions, and other ings should influence design of need for institutional and local financial indicators is ongoing. training and support programs for support as well as the importance nursing leadership positions in the of specific training for ARNs and Limitations future. Structured orientation for staff nurses that anticipates Small heterogeneous sample, other staff to introduce new clinical adverse responses to the new derived from one hospital on leadership positions will be lead-ership roles. In a more seven inpatient units, limits gen- essential. Such roles will be general framework, introduction of eralizability. However, findings pivotal in the evolution of inter- new leadership roles will require illustrate the importance of a professional clinical care and to clear articulation of goals and development process for nurse improve transitions of care. expecta-tions of such positions leaders. As nurses assume new However, to be successful, they and met-rics to assess acceptance roles in the healthcare delivery require significant investment in and impact of such innovations. system, including major leader- training and support by local lead- The observation that resistance to ship roles, they will require train- ership. Each new intervention will the role dissipated over time ing and support specific to those require parallel evaluation of the suggests adaptation of ARNs to new positions. When the ARN role sustainability of clinical and their new roles alleviates was introduced in 2012, mul-tiple financial benefits for the health- resistance by care teams. care system. $ care interventions at the same Despite growth in individual and time were propelled by ris-ing REFERENCES group skills related to the ARN role, costs of healthcare delivery. This Batcheller, J., Burkman, K., Armstrong, D., although asked, none of the interviewees provided specific evi- environment may have influ-enced Chappell, C., & Carelock, J. (2004). A perceptions of the ARN role. In practice model for patient safety: The dence of the ARN role on patient value of the experienced registered safety, quality assurance, or patient addition, data collection was nurse. 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