The role of nurse practitioners in hospital settings: implications for interprofessional practice

Expansion of the nurse practitioner (NP) role worldwide indicates a need to understand how the role functions in interprofessional healthcare teams. Through the adoption of a mixed methods approach that gathered on-site tracking and observation, self-recorded logs of consultations and focus group interviews of team members and NPs, we describe the extent of role activity and the nature of interprofessional practices of 46 NPs and their team members in nine hospital sites across the province of Ontario, Canada. Findings outline the nature of the NP role activities, which largely focused on providing clinical care, with the support of their team, to a range of patients across the study settings. We discuss how 'embedding' the NP in this way appears to contribute to utilization of expertise of all professions as well as enabling team members to promote evidence-based practices. We argue that the use of NPs augments interprofessional role utilization through their desire to consult with a range of professionals and the capacity to perform holistic care for patients that is not limited to traditional nursing boundaries.     

EverCare nurse practitioner practice activities: similarities and differences across five sites

PURPOSE: To examine the similarities and differences in the performance and frequency of performance of EverCare nurse practitioner (NP) practice activities at demonstration sites in five states. This study builds upon a previous study in which the development and testing of the EverCare Nurse Practitioner Role and Activity Scale (ENPRAS) was conducted. DATA SOURCES: A Background Data Sheet and the ENPRAS, a 99-item tool that encompasses six role subscales-Collaborator, Clinician, Care Manager/Coordinator, Counselor, Communicator/Cheerleader, and Coach/Educator, were completed by 127 EverCare NPs at demonstration sites in five states (Georgia, Maryland, Massachusetts, Colorado, and Florida). CONCLUSIONS: Performance of NP activities across the demonstration sites in five states was generally consistent, with significant differences only in the amount of time spent on activities associated with the Collaborator and Coach/Educator roles. Overall, EverCare NPs spent more time on Clinician and Communicator/Cheerleader role activities than on activities associated with the other roles. EverCare NP patient caseload was positively related to frequency of performance of the Clinician and Care Manager/Coordinator roles. IMPLICATIONS FOR PRACTICE: EverCare NPs provide proactive primary care to long-stay nursing home residents. The observed consistency reflects a strong centrally directed practice model. The identified roles and activities of the EverCare NP are consistent with previous studies and reports focused on the roles and activities of NPs who provide care to nursing home residents in other models of care delivery. Policy makers, healthcare providers, and the public should take these findings into account when considering a national model of care for this population. Future studies should examine the effect of variations in performance of activities on resident-specific and setting-specific outcomes.     

Complementary therapy practice: defining the role of advanced nurse practitioners

The purpose of the study was to identify the current and perceived clinical role functions of advanced nurse practitioners (ANPs) within the complementary health paradigm and their learning needs. Participants were asked to identify their referral practices to complementary practitioners, current and perceived clinical activities with respect to six most popular complementary therapies, learning needs and concerns regarding their use. A random sample of 389 ANPs registered with the College of Nurses of Ontario participated in a mailed survey using a modified Dillman approach, an established method for improving response rate through repeated mailings. An overall response rate of 55.3% (215 out of 389 eligible participants) was achieved. The results show that ANPs are currently engaged in clinical activities involving these therapies, with a trend towards more participation in assessing the need for them and counselling on the risks and benefits. ANPs are interested in validating the use of these therapies and acquiring more knowledge on the scientific principles, evidence of efficacy, pharmacology and potential interactions with conventional medicine.     

The first evaluation of the advanced practice nurse role in Finland - the perspective of nurse leaders

fagerström l. & glasberg a.-l. (2011) Journal of Nursing Management 19, 925–932 The first evaluation of the advanced practice nurse role in Finland – the perspective of nurse leaders Aims The aim of this study is to explore and describe nurse leaders’ (NLs) experiences of the role of advanced practice nurses (APNs). Background The first group of advanced practice nurses (17) in Finland graduated in 2006 and were thereafter employed by seven different organizations in more or less clearly defined advanced practice nurses roles. Methods Seven nurse leaders at the relevant organizations were interviewed a year after the introduction of the advanced practice nurses role. Content analysis was used to analyze the data. Results All of the nurse leaders emphasized the importance of the advanced practice nurses role in their organization. The advanced practice nurses’ scope of practice comprised a more autonomous and independent role than registered nurses. Advanced practice nurses are an important resource in the care of patients with chronic diseases and acute health problems. An important aspect regarding support for the advanced practice nurses role is the provision of information to all health-care personnel and patients about the role and clearly defined areas of responsibility. Conclusions Advanced practice nurses are an important resource in the development of evidence-based nursing and improve the availability of health-care services for patients. Implications for nursing management Nurse leaders are responsible for creating sustainable structures and the prerequisites needed for advanced practice nursing through the formation of supportive organizational systems.     

Tort reform: an issue for nurse practitioners

PURPOSE: To inform nurse practitioners (NPs) about the issues related to tort reform and its relationship to malpractice insurance costs. DATA SOURCES: Current journals, newspapers, professional newsletters, and Internet sites. CONCLUSIONS: NPs are paying more for their malpractice premiums, and many are losing their places of employment as clinics close due to the increased cost of premiums. One method proposed for curbing the flow of monies spent on premiums and litigation is tort law reform. California serves as an example; its Medical Injury Compensation Reform Act (MICRA) tort reform law was passed 25 years ago, and it has maintained stable malpractice premiums. Other states have proposed similar laws, but some have not had similar success. To curb litigation costs, not only should tort laws be reformed, but NPs and physicians should keep abreast of current practice standards in order to provide quality medical care. IMPLICATIONS FOR PRACTICE: Like physicians, NPs are affected directly by tort laws. These laws hold NPs accountable at the same level as physicians. In addition, many states limit NPs' practice to delegation of authority by a physician. Liability is therefore transferred from the NP to the physician and vice versa in cases of injury or wrongful act. In addition, many NPs are finding it increasingly difficult to locate insurers who will write policies for medical liability.     

Hospital‐based nurse practitioner roles and interprofessional practice: A scoping review

This scoping review provides current global understanding of the rapidly evolving nurse practitioner role within hospital settings, and considers the level of understanding of its enactment within interprofessional teamwork. Arksey and O'Malley's framework was used to explore recent primary research, reviews, and gray literature in two ways. First, hospital‐based nurse practitioner literature was mapped to country of origin, and thematically summarized. Second, clearly developed and consistently defined key interprofessional concepts were identified in the interprofessional literature then conceptually mapped to the nurse practitioner studies by their operationalization. The nurse practitioner review located 103 abstracts. Twenty‐nine, originating from four countries, met the inclusion criteria. The interprofessional concept review identified a total of 137 relevant abstracts, however, only ten met the inclusion criteria. Understanding the nurse practitioner role within hospital teams remains limited due to a small number of countries producing evidence, the lack of nurse practitioner role title standardization hindering consistent knowledgebase development, and limited application and inconsistent operationalization of concepts within nurse practitioner research. Research focused on role enactment is needed to understand the uniqueness of the hospital‐based nurse practitioner role.     

Evaluating the perceived impact of an interprofessional childhood obesity course on competencies for collaborative practice

Interprofessional education (IPE) is needed to prepare health professional students to address the complexities of childhood obesity in practice. This mixed-method study sought to evaluate the perceived impact of a childhood obesity IPE intervention on health professional students’ collaborative competency development within two domains: roles/responsibilities and teams/teamwork. Fourteen health professional students participated in this mixed-methods study. Quantitative data were collected through pre/post surveys, while qualitative data were collected through reflection assignments. Survey findings indicated that students reported significant increases in growth within both interprofessional competency domains. Qualitative data elaborated on the types of learning students experienced relative to each domain. Implications of this study for research and practice related to IPE to address complex health issues, such as childhood obesity, are shared.     

Advanced nursing practice: the case of nurse practitioners in three Australian states

This paper provides insight into the work of nurse practitioners in three Australian states. Using a case study approach, the aim of the study is to give an account of some of the types of cases/patients who consult with the nurse practitioners in the states visited and to offer insight into one of the policy changes required to support the introduction of the nurse practitioner role. A snowball sampling technique was used to obtain the sample population of both 10 nurse practitioners and other health care personnel. Semi-structured interviews were conducted with the 39 respondents in both samples. The analysis of the 10 nurse practitioner interviews reported here shows that these nurses undertook a wide range of roles. The results of the semi-structured interviews with the nurse practitioners are described using four of the 10 interviews and reporting them as case studies. The results highlighted the need to address legislation issues and to prepare nurses adequately for their clinical setting and address the difficulties of continuing education of rural nurses.     

Leading interprofessional practice: a conceptual framework to support practitioners in the field of learning disability

One of the key challenges for practitioners in present day health and social care has been responding effectively in the interprofessional teamwork setting, where collaboration is at the centre of professional activity. For whilst practitioners are expected to work interprofessionally there often remains limited attention to the actual process of interprofessional practice itself, within organizational strategy, local workforce development planning and individual continuing professional development. These concerns were a driver for this research with practitioners in the field of learning disability which resulted in the development of a conceptual framework for interprofessional practice. This paper sets out the process of conceptual framework development, underpinned by the concepts of knowledge of learning disabilities, contextual socialisation, empowerment, conflict management, transforming capability and interprofessional reflection on action. The researcher suggests that the framework may offer clinical leaders in learning disabilities and a range of other practice settings a tool to facilitate individual practitioner development, enabling as it does, the identification of a range of critical factors which impact on the outcomes of interprofessional practice intervention.     

Student engagement in interprofessional working in practice placement settings

Aim. To investigate the nature of student engagement in interprofessional interaction while on placement. Background. Due to continuing emphasis on improving interprofessional collaboration, UK educational establishments are required to offer prequalifying health and social care students interprofessional education in order that they acquire relevant competencies. However, few formal interprofessional education initiatives occur in practice settings and little is known about prequalifying students’ non‐formal learning about interprofessional issues while on placement. Design. From 2003–2005 an English Faculty of Health and Social Care conducted a qualitative study to explore opportunities for interprofessional learning and working available to students in practice placement settings. Methods. Case studies were conducted in a coronary care ward, a medical ward for older patients, a maternity unit, a paediatric unit, an integrated community learning disabilities team and a residential facility for adults with challenging behaviour. Gaining access was complex, due to variable student timetables and UK research governance requirements. Sites were therefore selected according to geographical area and timing of student placements. Details of interprofessional interaction (formal and informal) were observed and recorded. Interviews were conducted with a convenience sample of 20 practitioners and 15 students. Data were analysed thematically. Results. Student experience varied considerably. Contributing factors included the influence of doctors and differing professional cultures; mentors’ support for student engagement in interprofessional working; and individual students’ confidence levels. Most sites were managed by nurses and some senior nurses were proactive in involving students interprofessionally. However, many students lacked systematic support for interprofessional engagement. Conclusions. Students lack parity of experience concerning interprofessional activity on placement. Where they do not have systematic support, their engagement depends mainly on their own confidence. Relevance to clinical practice. Senior nurses are ideally placed to promote environments where students can develop interprofessional competencies through systematic interprofessional engagement.     

Examining the interface between interprofessional practice and education: Lessons learned from Norway for promoting teamwork

Promoting teamwork in health and social care requires an understanding of the interface between interprofessional practice (IPP) and interprofessional education (IPE). A study with two parts, one qualitative and one quantitative, examined this interface in Norway. The first used focus groups to assess IPP rewards, barriers, and facilitating factors among practitioners in clinical settings. The second utilized an online survey to measure IPE attitudes, barriers, and facilitating factors among senior administrators in the educational system. Results of Part 1 indicate that providers report many intrinsic rewards of IPP; however, the more extrinsic impacts of collaborative practice on patient care need to be emphasized to system managers. Results of Part 2 suggest strong general support by academic deans and directors for IPE, though addressing specific potential barriers to its implementation has become increasingly important. Overall, bridging the IPP–IPE gap requires educating leaders in both settings about the resources needed for teamwork, linking clinical and educational settings through continuing professional development, and generally advocating more effectively for both IPP and IPE.     

Persistent isolationist or collaborator? The nurse’s role in interprofessional collaborative practice

orchard ca . (2010) Journal of Nursing Management 18 , 248–257
Persistent isolationist or collaborator? The nurse’s role in interprofessional collaborative practice Aim The present study explores current understanding about interprofessional collaborative client-centred practice and nursing’s role in this form of care delivery. Background A profession-only focus on nursing practice has been challenged at professional, national governmental and World Health Organization levels stressing for more interprofessional patient-centred collaborative teamwork. Evaluation Moving to patient-centred collaborative practice is fraught with barriers. Enablers can result in building trust, power sharing and shared decision-making. Changing current workplace environments requires institutional commitments to support collaborative team development. Key issue(s) Nurses can become collaborative members of teams through: (1) re-socialize; (2) understanding and articulating nurses roles, knowledge and skills to others; (3) other health providers sharing the same to nurses; (4) identifying where shared roles, knowledge and skills exist; and (5) learning to work in collaborative teams. Nurses must address some fundamental issues about practice that negate collaboration and patient-centred care. Conclusions All professionals, including nurses, must move away from a service-oriented delivery to a patient-centred collaborative approach to care. Implications for nursing management The values within health organizations need to be underpinned by collaborative interprofessional patient-centred practice. To accomplish this goal, administrators and managers must support assessment of employees and visiting physicians as to their conformance with agency established expectations for such practice.     

Observation of interprofessional collaboration in primary care practice: A multiple case study

Interprofessional collaboration (IPC) is known to improve and enhance care for people with complex healthcare and social care needs and is ideally anchored in primary care. Such care is complex, challenging, and often poorly undertaken. In countries such as Canada, the United Kingdom, the Netherlands, Australia, and New Zealand, primary care is provided predominantly via general practices, where groups of general practitioners and nurses typically work. Using a case study design, direct observations were made of interprofessional activity in three diverse general practices in New Zealand to determine how collaboration is achieved and maintained. Non-participant observation of health professional interaction was undertaken and recorded using field notes and video recordings. Observational data were subject to analysis prior to collection of interview data, subsequently gathered independently at each site. Case-specific themes were developed before determining cross-case themes. Cross-case themes revealed five key elements to IPC: the built environment, practice demographics and location, practice business models, shared goals, and team structure and climate. The combination of elements at each practice site indicated that strengths in one area helped offset challenges in others. The three practices (cases) collectively demonstrated the importance of an “all of practice” commitment to collaborative practice so that shared decision-making can occur.