Integration of nurse practitioners using a change

CSIRO PUBLISHING

Australian Health Review http://dx.doi.org/10.1071/AH16068

Integration of nurse practitioners using a change management framework: the way forward Grainne Lowe1 NP, RN, PhD, FACNP, MACN, Lecturer Virginia Plummer2,3,5 RN, PhD, FACN, FCHSM, Associate Professor Leanne Boyd4 RN, PhD, Associate Professor 1

School of Nursing & Midwifery, Deakin University, Geelong, Vic. 3220, Australia. Monash University, McMahons Road, Frankston, Vic. 3199, Australia. 3 Peninsula Health, Hastings Road, Frankston, Vic. 3199, Australia. 4 Cabrini, 154 Wattletree Road, Malvern, Vic. 3144, Australia. 5 Corresponding author. Email: [email protected] 2

Abstract Objective. The aim of the present study was to investigate and describe the application of a change management theoretical framework in relation to nurse practitioner (NP) role integration. Methods. A survey formed Phase 1 of a broader mixed-methods study to explore perceptions of the change process involved with integrating NPs into Australian health care settings. The stakeholder participants were NPs, nurse managers and nurse policy advisers. Results. Key themes were identified adding information about how NPs, nurse managers and nurse policy advisers perceive the integration of NPs into Australian healthcare. The themes correlate to the components of organisational change management necessary to embed NPs into the healthcare workforce. Conclusions. Healthcare reform is a complex organisational change. Alignment of several key elements is required for the process to be successful. A change management proposal for reframing organisations provides an apt framework for use in the Australian context of reforming workforce to integrate NPs into healthcare teams. The theoretical framework proposes that multiple lenses be applied to change processes, to integrate NPs into the workforce and highlights the need for exceptional leadership throughout such endeavours. What is known about the topic? NPs provide safe and efficient care to patients, often in settings where access to health care is limited. NPs have been identified as a key strategic workforce reform initiative to address some of the known healthcare gaps. What does this paper add? This paper adds information about how NPs, nurse managers and nurse policy advisers perceive progress of the integration of NPs into healthcare settings. The findings are contextualised within an organisational change framework and highlight the complexity of healthcare reform. What are the implications for practitioners? The findings provide a novel approach for managing workforce reform and identify the components of change management necessary to embed NPs into the healthcare workforce. Received 12 March 2016, accepted 7 August 2016, published online 7 October 2016

Introduction The provision of quality health care services into the future is problematic, both nationally and internationally. Issues such as human resource shortages and increasing demands for services are recurrent in the literature.1–3 Healthcare reform has been debated and discussed intensely by governments and health organisations over many years. Workforce reform is a key strategy in these discussions as a means by which to ensure the viability of health care services.4 An adequate and accessible health workforce is crucial for an effective health system able to deliver safe, timely and appropriate services to Journal compilation Ó AHHA 2016

all, regardless of compensable status, geographic location, age, race or gender. In their work, Reframing Organisations: Artistry, Choice, and Leadership, Bolman and Deal outline several key strategies required for successful integration of organisational change.5 The authors suggest that organisations need four perspectives or lenses:, namely structural, human resource, political and cultural, to view and manage change effectively.5 Change is only possible when each of the lenses are in focus to provide a clear vision of the whole. The skill and wisdom to know how to view various situations through these lenses is paramount to www.publish.csiro.au/journals/ahr

B

Australian Health Review

successful leadership and management. Further, when the view is unclear, it is important to understand why in order to adjust the components accordingly.5 These lenses identified by Bolman and Deal5 mirror the conflicts that exist in reforming the Australian healthcare workforce in relation to integrating nurse practitioners (NPs) into the healthcare team to effect changes in health care delivery.6 Because of the complex nature of the reform agenda, together with key stakeholder positions to satisfy, Bolman and Deal’s5 framework provides a novel perspective through which to view the change management processes necessary for successful NP integration.6 Background In Australia, ongoing budgetary constraints, human resource shortages, an aging population and increasing demand for services impact on health policy decisions. Australian governments, federal and state, have commissioned committees to explore these issues and to develop strategies to assist with health care equity and access.6 One strategy is to better use existing workforce, such as nurses, through expansion of traditional scopes of practice. A proposal to develop and implement NP roles to meet some of the identified service gaps emerged in Australia in the 1990s.7 The NP role expands that of the traditional registered nurse (RN) by legitimising extensions to practice: ordering diagnostic tests, prescribing medications, discharging or referring patients and writing medical certificates as needed.8 Within the Australian context, this process mirrors that which has taken place internationally, with NPs working in the US since the 1960s, in Canada since the 1970s and in the UK since the 1980s.9–12 The NP role remains a relatively underdeveloped concept in Australia, with 1380 NPs endorsed nationally.13 Numbers across Australian healthcare settings vary between states and not all qualified NPs are employed in that role.10 Several evaluations of NP roles to date have provided positive feedback for the services delivered under this key reform agenda.14,15 However, the total number of NPs employed remains small for a national workforce strategy focused on improving health care delivery. Although established in international contexts, understanding of the role and its value, marketing of the role to the public and support of the role from government policy are required to ensure success and sustainability of this model of care in improving health to become a reality in Australia.16 Expansion of the NP role has been slow across Australian states and territories, with several barriers impeding the growth of this workforce to reach full potential on service delivery and patient outcomes.14 Given the complexity of the NP issue with regard to change management, human resource reform, the political sensitivities and the tradition of professional role demarcations, the present study was undertaken to understand the intricacy of workforce reform from key nursing stakeholder positions. The Bolman and Deal theory for successful organisational5 change is an appropriate theoretical framework to underpin the present study. The framework incorporates the traditional, rational and technical approach to analysing situations, together with the inclusion of artistry to capture the subtleties of emotion and creativity.5 Each lens has a particular and practical emphasis

G. Lowe et al.

on a component of organisational operations. In the present study, the key stakeholders were nurses directly working in NP positions, nurse managers (because of their ability to inform decisions on employment) and nurse policy advisers (because of their role in informing policy decisions on nursing workforce issues). Methods Following ethics approval from Monash University Human Ethics Research Committee, a survey was undertaken, forming Phase 1 of a broader mixed-methods study to explore perceptions of key nursing stakeholders of the change process involved with integration of NPs into Australian healthcare settings. Stakeholders invited to participate in the study were NPs, nurse managers and nurse policy advisers from Australian states and territories. The survey tool was developed specifically for the present study following a review of the literature to identify current issues of NP role development and integration (see Appendix 1). The tool was piloted on NPs, nurse managers and those with knowledge of nurse policy to test face validity. Quantitative data were analysed using SPSS version 20 (IBM Corporation) reported elsewhere17 and NVivo 9 (QSR International) was used to assist in the coding and content analysis of the qualitative responses to open-ended questions. Specifically, data from Excel (Microsoft) spreadsheets containing individual text responses for each of the open-ended questions were imported into a project created in NVivo 9 software. Both content and thematic data analyses were used for the open-ended question data, obtaining both keywords/groups of words (themes) and word frequencies. Results In all, 428 questionnaires were mailed to potential participants. The number of respondents varied across groups, with 87 of 233 NPs responding, 77 of 295 nurse managers responding and seven of 16 individuals from the nurse policy adviser group responding, giving a total of 171 responses. The overall response rate to Phase 1 of the study was 40%. Analysis of the open responses from the questionnaire is provided under headings that link to the theoretical framework lenses. Structural lens The present study identified key themes relevant to the structural lens. Participants reported NPs as having a direct impact on the delivery of healthcare services and providing a patient-centred focus. Other responses included the ability of NPs to be flexible and dynamic, responding to both organisational and patient needs. Participants also commented that increased service delivery was available through the addition of services where they had previously been absent, and increased access where service delivery was inadequate. Figure 1 highlights participants’ words and their relationship to a theme and lens. Human resource lens The benefits of NP-managed patient care were reported by participants and included service improvements through enhanced utilisation of the available workforce, improved patient outcomes, increased patient satisfaction and the significant

New framework for integration of NPs


Bolman and Deal lens5

C

Structural lens

Theme

Making a difference

Emergent concept

Example responses

Direct patient care

Direct effect on patient care

Continuity of care

Continuous service across the continuum

Fig. 1.

Improving service delivery

Improving patient outcomes, satisfaction

Benefits to patients often disadvantaged in access to care

Significant effect on community access to safe and timely care

Potential to improve the service

Patient satisfaction

Increased value of NPs to organisation

Improved quality of service coordination

Example participant comments: Organisational structure lens. NPs, nurse practitioners.

rewards associated with job satisfaction for nurses. In addition, participants perceived other staff as being more satisfied with the implementation of NP roles, with reported benefits including the existence of a senior resource for nursing staff to provide advice, direction and support. Other findings of the present study relevant to the context of the human resource lens include references to the specifics of being able to work to capacity of knowledge, experience and authorisation (Fig. 2). Political lens The key findings associated with the political lens and policy requirements are related to government policy changes, such as access to the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme, to provide for patient care. Further, the findings were critical of funding models generally. Participants indicated the current policies as inadequate to support new and existing models of NP care. The funding was highlighted by many participants, across the subgroups, and related to the set-up funds required to incorporate the NP positions within organisations, as well as the ongoing funds required for NP wages. Those in policy did not see continuing government implementation of funding for NP models in organisations as a solution. The difficulty, according to participants, was a lack of understanding of how the role could fit within existing models of care where an organisations’ funding was allocated to medical or nursing pools, leaving the NP role without a specific pool of funds to set up or maintain. Participants described this situation as one that impacted on the sustainability of NP roles, indicating that this was a political issue and that support was seen as lacking from various government-level politics, as well as from politics at an organisational level.

The other political issue of note in the present findings was associated with the process of endorsement or authorisation by the Australian Health Professionals Registration Authority. NP and nurse manager participants indicated a lengthy and burdensome application process reported as lacking transparency (Fig. 3). Cultural lens The key issues, according to participants, associated with the cultural lens are those of working together, collaborating and having support. Responses from participants indicated that this was a possibility in settings where there was shared responsibility for patient outcomes. The medical profession was generally described as creating barriers to the progress of NP role development and acceptance. The existing culture was reported as doctors protecting their control and influence over what is accepted as ‘patient’ health care. Professional barriers were cited by participants relating to both medical and nursing colleagues. Doctors were described as lacking respect for nursing generally, feeling threatened with the introduction of ‘legitimate’ autonomous nursing roles, whereas nurses were described as unaccepting of a nursing role that seemed to ‘cross’ into medical territory. There were several participants who described a locally supportive medical network (Fig. 4). Discussion The Bolman and Deal lenses form the components of the key element (change), which, in this case, involves a workforce reform strategy.5 Each lens must be transparent and provide a view of the interconnectivity of the complex whole, with the importance being in correct alignment to ensure overall clarity.

D


G. Lowe et al.

Human resource management


Recognition of nursing

Theme

Emergent concept

Autonomy

Expanded SOP

Skill utilisation

Examples responses

Ability to care for patients indepentant of other practitioner

Able to prescribe, order pathology imaging, ensuring continuity of care

Utilisation of my skills in more complete way

Autonomy to assist patients

Extended practice improves outcomes

Utilisation of advanced nursing skills

Going where other practitioners won't go

Expanded role of the nurse should fit well

Realising nurses' potential

Fig. 2. Example participant comments: Human resource lens. SOP, scope of practice.


Political lens

Politics

Theme

Emergent concept

MBS/PBS

Funding

AHPRA

Example responses

Lack of access to MBS and PBS

Strategic funding, with in budget

Lack of national approach, AHPRA not guiding process

Limited access to MBS/PBS

Funding strategies

National approach to NP issues

Simplify access to MBS/PBS

Support from health department to guide role development

AHPRA does not guide process well

Fig. 3. Example participant comments: Political lens. AHPRA, Australian Health Practitioner Regulation Agency; MBS/PBS; Medicare Benefits Schedule/Pharmaceutical Benefits Scheme; NP, nurse practitioner.



E

Cultural/symbolic lens


Teamwork

Theme

Emergent concept

Collaborative practice

Example responses

Autonomy with collaboration

Changes in the team: multidisciplinary model of care

Support from other NPs, medical and nursing

Complements the healthcare team

Multidisciplinary model of care

Support from nursing executive

Good collaborative work between nurses and doctors

Multidisciplinary approach

Support

Enhanced function of multidisciplinary team

Lack of support from doctors

Fig. 4. Example participant comments: Cultural or symbolic lens. NPs, nurse practitioners.

• Direct patient care • Improving patient outcomes • Improving patient care • Increased patient satisfaction

• Autonomy • Expanded SOP • Utilising skill • Work satisfaction, fulfillment

Structural

Human resource

Political

Cultural

• MBS/PBS • AHPRA • Funding

• Collaborative practice • Multidisciplinary approach • Support

Fig. 5. Application of fit: example comments within each lens. AHPRA, Australian Health Practitioner Regulation Agency; MBS/PBS, Medicare Benefits Schedule/Pharmaceutical Benefits Scheme; SOP, scope of practice.

A diagram of the four lenses together with the key components of each lens, as they are reflected in the findings of the present study, is shown in Fig. 5. Each of the lenses contains elements of importance to the change process, providing an overall means

by which to manage the individual components necessary for success. The components have been identified by the participants of the research, and are applied here in the context of the lenses proposed by Bolman and Deal.5 The importance is having the

F


ability to adjust each lens and to allow for subtleties of adjustment to create a precise and focused vision. Structural lens Given that the goal of healthcare is to provide for those in need of such services, outcome measures reflective of effective service provision are critical to organisational success and improvement. The findings of the present study revealed an overwhelming perception by participants that NPs assist healthcare organisations in achieving their goals. There was a sense that the quality of patient care improved with the addition of NP roles into organisations. These findings are consistent with previous literature and, in fact, with the initial impetus for the drive for NP roles (i.e. service gaps and vulnerable populations).9 Providing a workable organisational structure is paramount to the maintenance of efficiency. Through the structural frame, the division of labour within an agreeable arrangement between key stakeholders is a central consideration.5 Human resource lens Invariably participants in the present study identified a lack of clarity around NP scope of practice (SOP) as a barrier to full implementation of the role. Participants reported a lack of consistency regarding NP role definition and some confusion regarding the professional accountability of the NP role. This is described by some participants as a means of ‘controlling’ nursing work by other professional groups, such that the SOP is often related to the setting in which the NP works. Participants indicated that restrictions to SOP could be dependent on individual settings. Therefore, who decides what an NP does and where the work can be undertaken is often lacking in consistency, reducing overall effectiveness of NPs through unnecessary restrictions. A desire for professional recognition is evident in the results of the present study. Nurses are demanding recognition for the skills and experience developed over many years of managing patient care that enable advanced decision-making capabilities, coupled with masters degree preparation and professional authorisation, to make decisions about patient needs. The key to successful workforce redesign is to develop roles able to improve patient outcomes, provide increased staff satisfaction and promote efficiency within organisations.14 Although barriers were reported to the boundaries of NP SOP and professional authority over autonomous practice, there were also references to the increased satisfaction and personal rewards as a result of successful episodes of support. Bolman and Deal5 describe the merit of correct management of human resources as promoting an environment where being satisfied with work outcomes is consistent with ‘better’ work rather than just ‘more’ work. Political lens According to Sasnett and Clay,18 effective leadership is achieved through the use of political skills that enable negotiation and compromise to build coalitions through conflict management. There are several political structures involved with healthcare decision making, including local, state and federal levels of government administration of healthcare. In relation to the

G. Lowe et al.

present study, the results of interest in the political lens are those associated with the delivery (or lack thereof) of strong policy changes impacting on the smooth integration of NP roles. Application of the political lens theme is evident through the desire to challenge attempts aimed at devaluing potentially positive healthcare reforms. A key result was that a lack of access to reimbursement privileges, similar to those available to the medical profession, severely hampered the ability of NPs to work autonomously and make patient decisions in a timely manner. The results appeared to be focused on issues related to red tape restricting day-to-day practices, and evident in previous literature.16 Structure and communication between and across state- and territory-level politics were strategies proposed by participants, suggesting that this is currently lacking and described by participants as an ad hoc approach, creating duplication of disputes and struggles to adjust policies. This is consistent with the overall healthcare funding problems described by White, whereby federal and state governments are in conflict over funding of healthcare and ignore problems deemed difficult to manage, instead going through a series of blame games or passing the buck.19 Further insight into the complexities of healthcare policy are described as undergoing a series of bureaucratic filtering in government and that policy proposals are not always based on best evidence.19,20 Participants indicated a need for a focused approach to the politics of reform as a strategy required to achieve outcomes. Cultural lens Recognising and sharing the organisational vision enables change to be undertaken as a transformation rather than a revolution.18 The challenges of health workforce reform involve a shift in deeply rooted institutionalised cultures and organisational structures that result in barriers to change.18 Other literature has reported on the stark cultural differences that can exist within organisations and how improvements are realised when recognition and respect leads to associate rather than subordinate relationships.20,21 In a submission to the Productivity Commission report, the Northern Territory government states: Workplace culture underpins this delineation of roles that impedes the development of interdisciplinary education, training and practice and the development of new models of care.22 Of interest, the findings of the present study reflect a harmonious working relationship among NPs and doctors in some settings. The findings indicate that this more likely where doctors have had previous familiarity with the NP role, or an existing working relationship between nurse and doctor before the nurse assumed the role of an NP. This is a position consistent with the literature, whereby reports suggest that doctors are more likely to support NP positions if they have previously had experience of NP roles, particularly if they know the person in the role, but were more likely to have concerns over someone they did not know.23,24 It may well be that familiarity breeds acceptance of change in terms of NPs and doctors working well and collaboratively together.


Application of this framework to the Phase 1 findings led to identification of key themes, namely ‘making a difference’, ‘recognition of nursing’, ‘support’, ‘collaborative practice’ and ‘role of politics’, that could be applied to the theoretical framework lenses consistent with those proposed by Bolman and Deal.5


8 9

10

Conclusion The Bolman and Deal5 framework is fitting for underpinning integration of progressive roles in health care, such as NPs. The necessary reform strategy requires examination of the divisions of labour and allocation of work responsibilities, adequate empowerment of human resources to achieve the organisational goals and tackling sensitive issues of negotiation between competing groups while continuing to portray a good performance with meaningful rituals. The astute manager, through prudent application of the lenses and the ability to focus each lens, can lead successful change, ensuring maintenance of quality outcomes and employee satisfaction with the workplace. Competing interests

11

12

13

14

15

None declared. Acknowledgements The work reported here formed part of a doctoral dissertation submitted to Monash University.

16 17

References 1

2

3

4

5 6

7

Attree M, Flinkman M, Howley B, Lakanmaa RL, Lima-Basto M, Uhrenfeldt L. A review of nursing workforce policies in five European countries: Denmark, Finland, Ireland, Portugal and United Kingdom*/ England. J Nurs Manag 2011; 19: 786–802. doi:10.1111/j.1365-2834. 2011.01214.x Hudson P, Marshall A. Extending the nursing role in emergency departments: challenges for Australia. Australas Emerg Nurs J 2008; 11: 39–48. doi:10.1016/j.aenj.2007.11.003 Gardner G, Chang A, Duffield C. Making nursing work: breaking through the role confusion of advanced practice nursing J Adv Nurs 2007; 57: 382–91. doi:10.1111/j.1365-2648.2007.04114.x Health Workforce Australia. National health workforce innovation and reform strategic framework for action 2011–2015. Adelaide: Health Workforce Australia; 2011. Bolman L, Deal T. Reframing organizations: artistry, choice and leadership. 5th edn. San Francisco: Jossey-Bass; 2013. Lowe G. Integration of nurse practitioners into Australian healthcare settings: a mixed methods study of the structural, human resource, political and cultural implications for organisational change. PhD Thesis, Monash University, Melbourne; 2014. Available at: http://arrow.monash.edu.au/vital/access/services/Download/monash:151103/THESIS01 [verified 20 August 2016]. Lowe G. Scope of emergency nurse practitioner practice: where to beyond clinical practice guidelines? Aust J Adv Nur 2010; 28: 74–82.

18

19 20

21

22 23

24

G

Trypuc J, Hudson A. Waiting lists and nursing. Nurs Leadersh 2005; 18: 36–40. doi:10.12927/cjnl.2005.17831 DiCenso A, Auffrey L, Bryant-Lukosius D, Donald F, Martin-Misener R, Matthews S, Opsteen J. Primary health care nurse practitioners in Canada. Contemp Nurse 2007; 26: 104–15. doi:10.5172/conu.2007. 26.1.104 Gardner G, Gardner A, Middleton S, Della P, Kain V, Doubrovsky A. The work of nurse practitioners. J Adv Nurs 2010; 66: 2160–9. doi:10.1111/j.1365-2648.2010.05379.x Rodriguez KA, Goodhue CJ, Upperman JS. Pediatric nurse practitioner implementation of a pediatric trauma continuity clinic utilizing the ‘medical home’ model. J Trauma Nurs 2010; 17: 64–6. doi:10.1097/ JTN.0b013e3181e7379e Browne A, Tarlier D. Examining the potential of nurse practitioners from a critical social justice perspective Nurs Inq 2008; 15: 83–93. doi:10.1111/j.1440-1800.2008.00411.x Nursing and Midwifery Board of Australia (NMBA). Nurse and midwife registrant data: March 2016. 2016. Available at: http://www.nursingmidwiferyboard.gov.au/About/Statistics.aspx [verified 20 August 2016]. Considine J, Fielding K. Sustainable workforce reform: case study of Victorian nurse practitioner roles. Aust Health Rev 2010; 34: 297–303. doi:10.1071/AH08727 Jennings N, Lee G, Chao K, Keating S. A survey of patient satisfaction in a metropolitan emergency department: comparing nurse practitioners and emergency physicians. Int J Nurs Pract 2009; 15: 213–18. doi:10.1111/j.1440-172X.2009.01746.x Harvey C. Legislative hegemony and nurse practitioner practice in rural and remote Australia. Health Sociol Rev 2011; 20: 269–80. Lowe G, Plummer V, Boyd L. Perceptions of NP Roles in Australia: Nurse Practitioners, Managers, and Policy Advisors. J Nurse Pract 2016; 12: e303–e310. Sasnett B, Clay M. Leadership styles in interdisciplinary health science education. J Interprof Care 2008; 22: 630–8. doi:10.1080/1356182080 2293006 White L. Funding debate: who pays for nursing. Nurs Rev 2013; 4 pp 20–22. Flitcroft K, Gillespie J, Salkeld G, Carter S, Trevena L. Getting evidence into policy: the need for deliberate strategies? Soc Sci Med 2011; 72: 1039–46. doi:10.1016/j.socscimed.2011.01.034 Fitzgerald A, Teal G. Health reform, professional identity and occupational sub-cultures: the changing interprofessional relations between doctors and nurses. Contemporary Nurse 2004; 16: 9–19. Productivity Commission. Australia’s health workforce research report. Canberra: Government of Australia; 2005. Street D, Cossman J. Does familiarity breed respect? Physician attitudes toward nurse practitioners in a medically underserved state. Am Acad Nurse Practitioners 2010; 22: 431–9. doi:10.1111/j.17457599.2010.00531.x Katz A, MacDonald J. Physician perceptions of nurse practitioners: the nurse practitioner role has been met with mixed reviews. A qualitative study from Manitoba reveals the perceptions of some physicians regarding this relatively new relationship on the health care team. Can Nurse 2002; 98: 28–31.

H


G. Lowe et al.

Appendix 1. Example questions for participant groups Nurse practitioner (NP) section *

*

*

*

What is the most challenging aspect of the NP role? What is the most positive aspect of the NP role? What strategies could assist the implementation of NP roles into your healthcare organisation? Other comments:tshow

Manager section *

*

*

*

*

What is the most challenging aspect of supporting NP roles? What is the most positive aspect of supporting NP roles? What strategies could assist the implementation of NP roles into your healthcare organisation? Why did you decide to support/not support NP roles in your organisation? Other comments:

Policy adviser section *

*

*

*

*

*

What strategies could ease the implementation of NP roles into healthcare organisations? How do NP roles fit into contemporary healthcare services? How do advanced nursing roles, such as NP, gain acceptance into mainstream healthcare? What do you foresee as the major hurdles to mainstream acceptance of NP roles? What policy strategies would be useful to assist integration of NP roles into healthcare organisations? Other comments:

www.publish.csiro.au/journals/ahr