Attending Registered Nurses: Evolving Role Perceptions in Clinical Care Teams.
A CALL FOR INNOVATIVE care delivery models that improve care, enhance quality, and reduce healthcare costs is a key strategy to improve the U.S. healthcare system (Berwick, Nolan, & Whittington, 2008). Healthcare systems are implementing different approaches to achieving these interdependent goals known as the Triple Aim. New care delivery models are emerging along the fragmented continuum of care and present solutions to some aspects of the healthcare crisis.One strategy to reduce fragmentation in the hospital setting is the attending registered nurse (ARN) role, designed to support delivery of integrated, patient-centered care at Massachusetts General Hospital (MGH) in Boston, MA (Erickson, Ditomassi, & Adams, 2012). The ARN is an experienced staff nurse who, with the attending physician, is responsible for ensuring the consistent and timely progression of each patient's care from admission to discharge. The ARN maintains a constant presence on the unit 5 days per week as a resource for both patients and families and other staff. The ARN is accountable for ensuring patient care meets clinical standards (evidence-based practice) and coordinates decision making and communication, notably during transitions in care. The goal for this new role is to provide continuity of care for patients and families with optimal coordination of care, including discharge planning. It was anticipated this intervention, coupled with other simultaneous administrative changes (e.g., improved handoffs of care, earlier discharge planning, increased attention to patient and family education, enhanced preadmission evaluations, daily care coordination rounds) would reduce length of stay and readmissions, enhance patient satisfaction, and, ultimately, improve patient safety and quality of care.
According to Benner's model for knowledge and skill acquisition in nursing, skills and acquisition of nursing expertise develop within five levels: novice, advanced beginner, competent, proficient, and expert (Benner, 1984). Nurses at each level demonstrate changes in three key aspects of practice: movement from dependence on concepts to use of accumulated experiences as exemplars; a change from compiling individual situational events to appreciating more holistic views; and movement from observer to involved performer. In this framework, the ARN role leverages both the knowledge base and leadership experience of selected staff nurses to coordinate care for complex patients often across multiple teams of providers, mentorship of nursing staff, and application of hospital guidelines and other educational resources to clinical care.
The purpose of this qualitative descriptive study was to describe changes in the perception by ARNs of their role after working in the position for 2 years. Seven ARNs, who were interviewed in 2012, were re-interviewed in 2014 using the same semi-structured interview guide to assess changing role perceptions over time.
Background
The Institute of Medicine (IOM) Report, Crossing the Quality Chasm: A New Health System for the 21st Century, described a healthcare delivery system poorly organized to meet national healthcare needs. "The delivery of care often is overly complex and uncoordinated, requiring steps and patient handoffs that slow down care and decrease rather than improve safety" (IOM, 2001, p. 1). This report called for redesigned priorities for providers to fundamentally improve care. These included "reengineered care processes; effective use of information technologies; knowledge and skills management; development of effective teams; and coordination of care across patient conditions, services, and sites of care over time" (p. 2). The IOM (2001) described six aims to improve individual and community healthcare services: safe, effective, patient-centered, timely, efficient, and equitable care. The changing healthcare environment provides an opportunity to reexamine staffing roles and processes within the acute care setting.
A review of the literature was conducted using key search terms including attending registered nurse, care delivery model, collaboration, continuity of care, navigator, nursing role, patient care facilitator, and practice innovation. Search engines used to conduct the search included CINAHL, Cochrane Database of Systematic Reviews, and the National Guidelines Clearing House via interfaces including EBSCOhost, Ovid, and Nursing@ Ovid. The study focused on evaluation of evidence related to formative experiences contributing to development of skills required for the ARN role. Inclusion criteria also included evidence describing where nurses develop skills (academic preparation, specific job training, or experience in the role), innovative care delivery models describing specific nursing attributes in the role, and articles written in English.
The literature described four general categories of nursing roles focusing on patient-centered care: faculty-led attending nurse models, advanced practice RN-led models; clinical nurse leaders-led models, and RN-led models. This review focused on RN-led models.
RN-led models of care evolved from traditional models including patient-focused care and case management roles (Deutschendorf, 2003). Common programmatic components contributing to success include elevating the RN role, increasing focus on patient and family involvement in care, smoothing patient transitions and handoffs, leveraging technology to enable care model redesign, and providing results-driven care (Kimball, Joynt, Cherner, & O'Neil, 2007).
A series of inpatient models address the need for patient-focused clinical care and improved handoffs across the healthcare system to enhance nursing leadership and participation in care. Ac-cording to Clark (2004), the 12-bed hospital at the Baptist Hospital of Miami provides a care model for a cure-dominated environment. The patient care facilitator position provides clinical leadership roles for nurses within smaller areas of patient responsibility. The aim was to ensure a caring and professional practice culture for patients and clinical staff (Brown et al. 2005). Brown and colleagues conducted a qualitative and quantitative multimethod study to measure the patient care facilitator role (independent variable) on continuity of care and caregiving behaviors of the nursing staff (dependent variable). Batcheller, Burkman, Armstrong, Chappell, and Carelock (2004) studied the impact of an innovative nursing infrastructure in a sevenhospital network in which the nurse retained the primary oversight role, provided long-term mentorship for new employees, and provided the primary interface with patients. In these studies, RN-led models using experienced nurses as the team leader demonstrated positive outcomes including improvement in nurses' perceptions of the frequency of assessment by experienced RNs of patient readiness for discharge, physician perceptions of the availability of experienced RNs, reduction in RN staff turnover, reduction in medication errors (Batcheller et al., 2004), and improved patient perceptions of staff knowledge of care and discharge plans (Brown et al., 2005). The economic implications of these observations include direct healthcare benefits of nurse retention (variously estimated at 0.75-2 times the salary of each lost nurse), reduced patient length of stay, and reduced potential exposures to medication errors (Jones & Gates, 2007).
Erickson and coauthors (2012) described the Attending Registered Nurse Model at MGH. Innovation units were created on 12 inpatient units to "improve clinical outcomes, enhance patient and staff satisfaction, as well as reduce costs and lengths of stay for hospitalized patients" (p. 283). While 12 interventions were implemented simultaneously on innovation units, the ARN was considered the consistent presence on the clinical team, working 5 days per week, providing continuous relationships with patients, families, and healthcare team. The ARN developed and coordinated interprofessional teams' clinical plans for inpatient admissions. The ARNs were experienced, highly respected nurses who participated in a comprehensive curriculum including role-specific education for the innovation unit program. The program augments ARN's skills related to conflict resolution, resiliency, and communication. ARN discussion groups provided forums to share experiences, observations, and best practices. This model was designed to support the challenge of delivering integrated, patient-centered care at a large academic health center. To date, there are no published outcomes of the ARN model. Quantitative data will be evaluated in the future including culture of safety surveys, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, length of stay, quality indicators, patients' perceptions of feeling known, cost per case mix, and staff retention.
In addition to the economic benefits of nurse retention and reduction in clinical errors, the ARN has an important role in the maintenance of the nursing knowledge base and in mentorship. A key element is the identification of those skills required to evolve into the leadership role. Benner's Novice to Expert model, used to guide the study, encompasses progression from novice to expert clinician. Benner adapted Dreyfus and Dreyfus' Model of Skill Acquisition and Skill Development to clinical nursing practice (Benner, 1984). "The Dreyfus and Dreyfus model provides concepts to differentiate between what is taught by precept (i.e., teaching) and what must be learned experientially from comparison of similar and dissimilar cases" (Benner, 1984, p. 186).
Benner (1984) posited that development of knowledge in nursing is the extension of practical knowledge through research and description of experiences in clinical practice. She proposed expert nurses develop skills and understanding of patient care over time as a function of both education and experience. She suggested clinicians could gain knowledge and skills (knowing how) without learning theory (knowing that).
Benner, Hughes, and Sutphen (2008) suggested a cycle exists between experiential knowledge and scientific investigation: experiential knowledge stimulates scientific investigation and scientific investigation fuels a cycle of further experiential learning. In Benner's construct, the repository of clinical knowledge and experience is in the clinical team with responsibility for optimizing clinical care (Benner, 2001). The ARN model builds on the team concept by providing team leadership to leverage the experience of senior staff to provide mentorship and knowledge transfer within care teams. The clinician's past experience from specific clinical cases positions him or her to identify future similar cases which provides educational and research opportunities. Benner suggested nurses develop skills and understanding of patient care over time through a sound educational base and a multitude of clinical experiences. Clinical situations are more complicated and dynamic than theoretical scenarios; practice provides a valid source of knowledge evolution. Through experiences and study of clinical practice, nurses discover new knowledge.
Methods
This study used a qualitative descriptive design (Sandelowski, 2000). Data were collected using a semi-structured interview template developed in 2012 and applied to the same subjects. Initial interview data from 2012 were collected as part of a larger project in which ARNs were interviewed to assess adoption of 12 interventions from innovation units at MGH and ARN perceptions of that role. For this study, the same interview guide was used to reinterview ARNs remaining in the position 2 years later. Key elements of the interview are described below. Study subjects included all nurses in the ARN role for at least 2 years at the selected time points.
Setting and sample. The MGH is an academic medical center within Partners Healthcare, the largest healthcare system in Massachusetts. The author conducted the interviews in 2012 and 2014. All ARNs from the 2012 study were invited to participate. Eligibility criteria included participating ARNs who had been interviewed in June 2012 and were identified by the department of nursing as remaining active in the role. All ARNs meeting eligibility criteria agreed to participate in the study. Interviews were conducted with 16 subjects in 2012 and all of the 7 remaining ARNs in 2014.
Data collection. Interview data were collected by the author using a semi-structured interview guide. Key elements of the interview included subject's perceptions of relationship-based care and ARN role; the adequacy of training and resources provided for subjects and clinical staff; barriers to successful job performance; role-specific changes in interactions with patients, families, and staff; and the role of technology in job performance. Participants were interviewed individually in a private hospital conference room. The interviewer took notes during the meeting. Following each interview, the author's typed summary of responses was emailed to subjects within 24 hours. Each participant was invited to edit or comment on the written summary until satisfied with his or her answers. This editing and refinement process was done via email to ensure process validation. Some participants provided detailed changes, which were incorporated into a final document. All participants provided final email confirmation their responses for each perception were described accurately. Following email confirmation, data were de-identified, replacing participants' names with numbers.
Ethical considerations. The MGH Institutional Review Board and the Spaulding Rehabilitation Hospital Institutional Review Board approved the 2014 study. Informed consent and authorization were implied by voluntary participation in the interview. The author had no conflicts of interest related to the study.
Data analysis. Data generated from each interview were organized in a matrix to allow direct comparison between individuals and over time. The author and Ruth Palan Lopez, PhD, GNP-BC, a researcher with expertise in qualitative analysis, analyzed written notes from both interview periods using an iterative process of description, analysis, and interpretation (Wolcott, 1994). The process included three levels of coding: coded concepts for major themes; assess similarities and create higher-level categories; and identify relationships between categories across individuals and over time. During first-level coding, interview reports were read jointly line-by-line, highlighting key words and assigning a code to each concept. During second-level coding, similarities in concepts were identified that were collapsed into higher-level categories. In third-level coding, categories were analyzed to identify relationships and differences over time. Themes were compared between individuals over time (see Table 1).
Strategies were employed to enhance the trustworthiness and credibility of study processes and findings. An audit trail was maintained of research methods, sampling processes, data collection, respondent validation, content management, data analysis, and data re-presentation (Mays & Pope; 2000; Patton, 1990; Sandelowski, 2000). An audit trail was maintained for participant response confirmation. Performing joint data analysis targeted increased reflexivity, diminished bias, and enhanced internal consistency. Discussions ensured consensus around each theme. Data analysis was refined until higher levels of categories accounted for all questions included in the study.
Results
Available subjects were interviewed at both time points. Participants were all RNs, female, 30-56 years of age (mean 45.6; SD 10.6). All participants were Caucasian and had at least 6 years nursing experience on their units. Five nurses had a bachelor of science degree in nursing and two had masters in nursing degrees. All nurses had at least 4 years experience in leadership roles on the unit (charge or resource roles) prior to assuming the ARN role in 2012. All participants had been an ARN for 2 years.
Findings
Analysis of interview data from 2012 and 2014 revealed participants demonstrated greater insight into their roles after 2 years. Changes in perception included two major themes at the highest level: (a) ARNs demonstrated increased awareness of roles related to team-based functions (2014) as compared with narrower task-oriented roles (2012) (from tasks to teams); and (b) reduced staff pushback to the role (2012) with greater buy-in or acceptance (2014) (from pushback to buy-in). All ARNs demonstrated increased clarity in understanding of the ARN role and confidence in that role over the study period (see Table 1).
From tasks to teams. When asked about role perception in year 1, ARN responses centered on specific tasks including developing care plans, planning for discharge, and conducting patient education. In contrast, when asked about the role in year 2, they described responsibilities including communication, team builder, continuity, and individualized plans of care (see Table 1). In 2012, ARNs used terms such as ensure continuity of the plan of care, being present daily, support the patient's discharge planning needs, helper, and extra pair of hands. By contrast, in 2014, all ARNs described the role with terms including communication, collaboration, team builder, and knowing patient and family. One ARN described her role as "collaborative --like part of a braided ponytail" using strong communication skills to help bring together all members of the nursing team. She felt the role was to ensure the team was in agreement regarding care plans for patient and family. She believed this to be supportive of relationship-based care. All ARNs described a focus on team building through collaboration and facilitating communication. Each ARN told patients nurses were to care for them "for the day" and the ARN would manage the care "for the stay." Communication, teamwork, presence, knowing the patient, and individualizing plans for care were terms used to describe the ARN role in 2014. This suggests an increased awareness of the potential value of the role and the ability to look at the bigger picture. This understanding allowed ARNs to be more active in support of staff nurses and in discharge planning.
From pushback to buy-in. In 2012, in response to the new role, all ARNs described pushback from the staff nurses on their units. In contrast, interview data from year 2 revealed ARNs reported buy-in and acceptance by the staff. Pushback was described by ARNs as role confusion, ambiguity, and negative responses by staff nurses. ARNs experienced a major challenge in describing the new role to the staff. Unit staff nurses were concerned ARNs were not assigned patients, especially when there were absences. One ARN noted, "The staff exhibited some strong reactions and some bitterness to my role change." Another ARN said, "The biggest challenge comes from the staff pushing back when working with them, patients, and families."
In 2014, evidence of buy-in included various subthemes including increased understanding of the ARN role by staff nurses (role clarification) as well as collaboration and positive responses from staff nurses (see Table 1). In the 2014 interviews, all of the ARNs described buy-in from nursing peers with a supportive team environment on each unit. Each of the ARNs said leadership of the unit nursing director was key to successful transition into the effective ARN role. The ARNs said nursing directors held regular staff meetings when the role was initiated to manage negative perceptions and allow staff to voice concerns and address issues. Another factor in successful transition into the role was weekly ARN peer support groups, called "brown bag lunches." These lunches provided a forum for ARNs to share individual challenges, experiences, and successes in a safe environment. One ARN learned to provide support to the staff by helping with some functional nursing tasks such as medications or bathroom requests. She believed such assistance accelerated role acceptance. All of the ARNs noted contributions of the nursing director, brown bag lunches, and provision of added support enhanced understanding and acceptance by staff of the ARN position over 2 years. These shifts resulted in greater acceptance of ARNs, enhancing their function and the quality of the experience.
Discussion
This study was designed to examine how ARNs perceived changes in their role after 2 years of experience. The data demonstrate that with experience, ARNs' perceptions of the role changed from a task focus to a team focus, and from staff pushback to acceptance. They described greater understanding of the purpose of their role within the totality of patient care.
While research supports the benefits of an RN-led model of care (Batcheller et al., 2004; Brown et al., 2005; Clark, 2004), less is known about experience of nurses in these roles. The findings of this study related to the task to team theme are consistent with Benner's concept of movement between novice, advanced practitioner, and competent nurse. The novice demonstrates rule-governed behavior that is rigid and limited while with experience, the nurse demonstrates the increased ability to recognize patterns and gain perspective and greater efficiency in decision making (Benner, 1984). In 2014 in this study, movement was demonstrated toward looking beyond narrow tasks and evaluating the entire clinical scenario including patients, families, and care teams. While the new role was initially challenging from both purpose and peer-acceptance perspectives, ARNs described staff as increasingly accepting of the position over time as ARNs improved communication skills, supported unit staff, and led the care team in managing patient care plans and discharges. The key element for success in both areas was a supportive environment created by peers and by unit and hospital leadership.
Benner (1984) suggested practitioners could gain knowledge and skills without learning theory. She noted clinical situations are more complicated and dynamic than theoretical scenarios, so clinical practice provides a valid source of knowledge evolution. Through both experience and studying of clinical practice, nurses discover new knowledge. This study demonstrates ARNs' role perceptions evolved over time from task-oriented (care plans, discharge plans, and patient education) to viewing the whole care delivery process (communication, teamwork, presence and knowing the patient, and individualizing the plan of care). In 2014, ARNs described a focus on the "patient's stay, not just the day." This growth in awareness allows ARNs to provide more substantive support to staff nurses in patient care and ensure patients experienced smoother clinical care and discharge planning processes. Increased role clarity and confidence appeared to enhance job performance, satisfaction, communication skills, and acceptance by staff.
The lack of acceptance of the ARN role by staff nurses has not been addressed in previous studies of new nursing leadership roles. It is notable that of the 16 nurses in the initial ARN group interviewed, only 7 remained at 2 years into the program. The basis for this observation is unknown. The available data indicate the need for institutional and local support as well as the importance of specific training for ARNs and staff nurses that anticipates adverse responses to the new leadership roles. In a more general framework, introduction of new leadership roles will require clear articulation of goals and expectations of such positions and metrics to assess acceptance and impact of such innovations. The observation that resistance to the role dissipated over time suggests adaptation of ARNs to their new roles alleviates resistance by care teams.
Despite growth in individual and group skills related to the ARN role, although asked, none of the interviewees provided specific evidence of the ARN role on patient safety, quality assurance, or patient satisfaction--major elements of modern clinical care. This may reflect the questionnaire used or the training received by these individuals. Future studies should assess the contribution of ARNs to such important nurse-sensitive indicators including staff turnover, job satisfaction, and patient safety (Batcheller et al., 2004), and cost per case mix (Erickson et al., 2012). Prior studies suggest institutionalization of care teams, including unit-based utilization of knowledgeable nursing leadership, would have a beneficial impact on patient satisfaction, reduction in medication errors, retention of experienced nurses, and job satisfaction as well as reduced patient length of stay and readmissions (Batcheller et al., 2004; Jones & Gates, 2007). Preliminary data (unpublished) at MGH demonstrate an overall 5% reduction in length of stay and improved patient satisfaction (HCHAPS) on the innovation units compared with the same units at baseline which incorporated multiple administrative changes at the time of introduction of the ARN role. Data on staff nurse retention are not yet available from the ARN-based innovation units. An assessment of quality and safety data, readmissions, and other financial indicators is ongoing.
Limitations
Small heterogeneous sample, derived from one hospital on seven inpatient units, limits generalizability. However, findings illustrate the importance of a development process for nurse leaders. As nurses assume new roles in the healthcare delivery system, including major leadership roles, they will require training and support specific to those new positions. When the ARN role was introduced in 2012, multiple care interventions at the same time were propelled by rising costs of healthcare delivery. This environment may have influenced perceptions of the ARN role. In addition, data collection was restricted to interviews that did not include observations of practice of ARNs on their units. ARNs who participated in this study were those who remained in their role for 2 years. This provided insight into those who implemented the role successfully. Conclusions cannot be drawn about those who left the role during that period.
Conclusion
Multiple newer leadership roles in nursing have been described for which impact on the quality and safety of care delivery and on costs of care delivery remain to be defined. Further, appropriateness of training and optimal deployment of personnel have not been investigated. In this study, in one such care model, ARNs' perceptions of their role evolved from functional thinking to "looking at the big picture," underscoring an increased level of insight over time. Data highlight the importance of ensuring buy-in from peers to ensure success in leadership roles. These observations are mutually reinforcing; improved leadership and communication skills produce greater acceptance by peers. These findings should influence design of training and support programs for nursing leadership positions in the future. Structured orientation for other staff to introduce new clinical leadership positions will be essential. Such roles will be pivotal in the evolution of interprofessional clinical care and to improve transitions of care. However, to be successful, they require significant investment in training and support by local leadership. Each new intervention will require parallel evaluation of the sustainability of clinical and financial benefits for the healthcare system.
REFERENCES
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GAYLE A. FISHMAN, DNP, MBA, RN, NEA-BC, is Nursing Director, Endoscopy Units, Massachusetts General Hospital, MA.
Table 1.
Themes and Subthemes
Theme 1: From Tasks to Teams
Subthemes Subthemes
2012 2014
Care plans Communication
Discharge planning Team builder
Patient education Continuity
Individualized plan of care
Theme 2: From Pushback to Buy-In
Subthemes Subthemes
2012 2014
Role confusion Role clarification
Ambiguity Collaboration
Negative response Positive response
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| Author: | Fishman, Gayle A. |
|---|---|
| Publication: | Nursing Economics |
| Article Type: | Report |
| Date: | Jan 1, 2018 |
| Words: | 4523 |
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