Michelle A. Lucatorto, DNP, RN, FNP-C
Timothy W. Thomas, BSN, RN
Terry Siek, MSN, RN, NEA-BC
Registered Nurses (RNs) influence the health of individual patients and populations. RNs provide the most value for the healthcare system when they work collaboratively with other healthcare team members, work to their full scope of practice, and when they are engaged and accountable. In 2011, the Institute of Medicine report on the future of nursing made the call to achieve the full value of nursing care. Creation of this future state requires both a vision of the “to be” as well as removal of existing barriers. In this article, we present a description of this future state in the context of a team based culture that utilizes collaboration to achieve the full scope of practice, accountability to deliver healthcare based on a discrete body of knowledge, and accountability to provide value and measure effectiveness of nursing care. This proposed future vision focuses on patient advocacy for nurses working in healthcare systems. Barriers that currently exist, such as overlaps in professional scopes of practice, organizational policy and structure, and a lack of the ability to grant privileges to nurses based upon their education and skills are discussed. We offer recommendations to remove barriers and contribute to creation of a new future state of nursing, and conclude that the removal of barriers to inhibit the fullest scope of nursing practice will continue to require focus in purpose and persistence in action.
Citation: Lucatorto, M. A., Thomas, T. W., Siek, T. (September 30, 2016) "Registered Nurses as Caregivers: Influencing the System as Patient Advocates" OJIN: The Online Journal of Issues in Nursing Vol. 21, No. 3, Manuscript 2.
Key Words: advocate, caregivers, healthcare organizational culture, influencing systems, nursing intensity, registered nurse, regulatory structure, reimbursement systems, scope of practice, self-governance
Registered Nurses (RNs) influence the health of individual patients and populations. RNs provide the most value for the healthcare system when they work collaboratively with other healthcare team members, work to their full scope of practice, and when they are engaged and accountable. The American Nurses Association (ANA) Professional Issues Panel (Panel), Barriers to RN Scope of Practice, was established to identify and clarify barriers to RN practice to represent the full extent of their education, experience, and scope of practice (as determined by the relevant state nurse practice act). The Panel Steering Committee worked to identify barriers that prevent RNs from working to the full extent of their education and training, explore the basis for these barriers, and develop recommendations to address them. Findings of the Panel were organized based on four key RN roles in the healthcare delivery system: RN as professional, RN as advocate, RN as innovator, and RN as collaborative leader.
As caregivers, all RNs are engaged as advocates on behalf of patients, families, and communities they serve to positively influence systems where care is provided. Each of these four roles is the basis of separate articles in this OJIN topic. In this article, we consider the RN as advocate role. As caregivers, all RNs are engaged as advocates on behalf of patients, families, and communities they serve to positively influence systems where care is provided. The article describes our synthesis from the ANA professional issues panel review and analysis of current literature, combined with expertise of the panel, to outline a pathway for action focusing on accountability, engagement, and collaboration.
Nursing practice is based on shared sciences (e.g., biology, psychology), and many nursing actions (e.g., assessment of respirations, dressing changes) may be performed by more than one healthcare professional. However, nursing practice is unique and definable. The American Nurses Association (ANA, 2015) defines nursing as “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and treatment of human response” (para. 1). The ANA Standards and Scope of Practice (2015), along with individual state practice acts, provide ethical guidance and a rule-based structure to operationalize the definition of nursing for nurses, healthcare systems, and the public (Russell, 2012; Snelling, 2016).
It is critical that nurses can articulate their scope of practice and own responsibility for delivery of nursing care congruent with standards of practice state practice acts. It is critical that nurses can articulate their scope of practice and own responsibility for delivery of nursing care congruent with standards of practice state practice acts. Nurses must define their practice for healthcare team members, healthcare systems, patients, and the public. This requires nurse control over the creation of national, local, and organizational policies that define nursing practice though placement in organizational decision-making positions for defining nursing. Governmental and organizational bodies must respect that nurses are accountable to define scope of practice for all levels of nursing and create processes to prevent infringement by non-nursing professional groups.
Nurses provide the services of caregiving and advocacy. The American Heritage Dictionary of the English Language (n.d.) defines a caregiver as “An individual, such as a physician, nurse, or social worker, who assists in the identification, prevention, or treatment of an illness or disability” (para. 1). The authors combined the ANA definition of nursing with the dictionary definition of caregiver to describe the caregiving role of the nurse. The term caregiving as used by the Barriers to RN Scope of Practice expert panel describes the provision of direct and indirect care focused on the achievement of optimal health. The term advocacy is used to describe the provision of caregiving in a manner that respects individual or population values that have a direct effect on care provided (Hanks, 2008).
Nurse practice acts need to use language broad enough to allow for the growth of the nursing profession and should be based on a reasoning approach rather than outlining specific actions... Caregiving and advocacy are more than simply delivering task-based care. Patients have a positive experience and quality outcomes when nurses use a scientific knowledge base and critical thinking skills, along with professional empathy, to competently provide safe care (Rchaida, et al., 2009). High quality nursing care is provided when nurses work in systems that support their skills to translate scientific evidence, use experience and critical thinking, and respect the autonomy of each human being (Donnelly & Domm, 2014). The focus of nursing practice acts to define scope of nursing in terms of “permitted” tasks undermines the use of critical thinking to decide what constitutes nursing scope of practice. Nurse practice acts need to use language broad enough to allow for the growth of the nursing profession and should be based on a reasoning approach rather than outlining specific actions (e.g., suturing, inserting catheters), which prevents utilization of new evidence (Spector & Odom, 2012). We must also be ready to recognize that as the delivery of health care changes the nurses will gain new roles that require skills that are not those we consider traditional nursing today (Robert Wood Johnson, 2012). A excellent example of an aspect of nursing practice that has evolved is the nurse as first assistant in an operating room. Practice Acts much be flexible enough to allow nursing practice to continue to grow to need the needs of the population. The growth of holistic care supported by specialized holistic nursing practice is an opportunity for nurses to provide skills that today are not considered traditional.
Specific actions that nurses as advocates take when providing care need to reflect changes in systems and growth of scientific evidence. Opportunity exists to capitalize on and manage the growth of the nursing profession through removal of barriers that limit the contribution of both individual nurses and nursing as a profession. This article calls for the removal of such barriers, a process that will require focus in purpose and persistence in action.
The systematic measurement of nursing contributions to the provision of healthcare in terms of both “work” and clinical outcomes can be one way to demonstrate respect for the value for nursing care. Measurement and analysis of work performed often results in bonus rewards or payment for physicians, advanced practice registered nurses (APRNs), physician assistants (PAs), nutritionists, and physical therapists. Work performed by these professionals is recognized as having tangible value expressed using relative value units (RVUs). Physicians, APRNs, and PAs have measurements related to the actual work they perform to conduct assessments, formulate plans, perform procedures, and even manage chronic care (Bendix, 2014).
When nursing care and healthcare outcomes directly attributed to nursing actions are measured at the systems level, the significant value of the nursing workforce will be evident. Although measurement of nursing quality has been addressed in the literature (Beck, 2013; Hoi, 2007), our consensus was that nursing care is measured differently, in hours of care, and viewed as workload rather than productivity or work performed. Absence of a system of measurement and payment for specific nursing services suggests a lack of respect for performing assessments, planning, coordination, and procedures, as well as the activity of surveillance as value added work. In addition, measurement of the contribution of nursing care to outcomes is currently limited to a hand full of inpatient nursing sensitive indicators, when much of the achievement of positive health promotion and chronic disease outcomes is due to nursing interventions. When nursing care and healthcare outcomes directly attributed to nursing actions are measured at the systems level, the significant value of the nursing workforce will be evident. The authors of this article also call for measurement and provision of tangible payment for nursing services rendered.
In 2011, the Institute of Medicine (IOM, 2011) report on the future of nursing made the call to achieve the full value of nursing care. Creation of this future state requires both a vision of the “to be” as well as removal of existing barriers. In this article, we will present a description of this future state in the context a team based culture that utilizes collaboration to achieve the full scope of practice, accountability to deliver healthcare based on a discrete body of knowledge, and accountability to provide value and measure effectiveness of nursing care.
Collaboration: Full Scope of Practice in Accordance with Nurse Practice Acts
The ability of nurses to practice to their full scope depends on individual nurses articulating the principles in the ANA Nursing: The Scope and Standards of Practice (ANA, 2015) and utilizing both the scope of practice and the specific jurisdictional nurse practice act to guide practice. This knowledge and practice discipline ensures safe and effective nursing care. Nurses are accountable for understanding what specific actions they may perform when providing care across geographic borders and within various organizational environments. Interpreting the scope of practice, relevant nurse practice acts, and organizational policies will support the work of nurses to their fullest potential.
While the first step toward achieving a full scope of practice is the ability to articulate and utilize the nursing scope of practice and nurse practice acts, collaboration with other disciplines is also essential. In this section, we will briefly discuss two concepts that support achieving optimal scope of practice at the organizational level, the appreciation for nurses as knowledge workers, and the benefit of autonomy over nursing practice.
Nurses as Knowledge Workers
Knowledge workers are respected as experts in the work they perform. For nurses to own their practice, organizational structure must reflect respect for nurses and allow them accountability to create the structure, policy, and staffing needed for nurses to work to the full scope of practice and according to nurse practice acts. This accountability begins with acknowledgment of nurses as knowledge workers. Knowledge workers are best deployed in collaborative networks free of hierarchies (Drucker et al., 2008). Knowledge workers are respected as experts in the work they perform. Operationally, a healthcare organization that recognizes nurses as knowledge workers and experts in their practice is an organization in which nurses define nursing policy and procedure and are equal decision-making partners with fellow team members.
Nurses as knowledge workers are part of a healthcare team comprised of other professions of knowledge workers deserving of the same respect. Team-based patient care recognizes both differences and similarities in practice of team members. Healthcare organizations must require ongoing team training and engagement in team-based exercises centered on the patient. These exercises should focus on identifying possible differences in the meaning of terms such as medical care, nursing care, pharmacist care, and social worker care. The goal is to identify similarities and overlap for all groups providing healthcare. Collaborative teambuilding to provide a working care-based definition for all team members is an effective method to create unity (Klein et al., 2009).
Autonomy and Nursing Practice
Because much clinical knowledge is grounded in use of shared basic sciences, many areas of practice overlap, with no single profession possessing a monopoly (Dower, Moore, & Langelier, 2013). This shared concept has been operationalized in the Canadian healthcare system through enactment of the Health Professions Act (HPA) of 2002 (Alberta Health & Wellness, 2002), which improved flexibility in the practice of healthcare by removing the ability of a single profession to lay exclusive claim to a scope of practice. As such, the Canadian healthcare system recognized that an overlap in expertise and services provided by different professions may exist. By removing the ability of any specific profession to dominate the provision of a service, Canada has increased its capacity to care for its citizens (Maxston, 2003).
Healthcare organizations that withhold participation and minimize shared governance remain as barriers to maximizing nurses as a fully engaged and effective workforce. Healthcare organizations that withhold participation and minimize shared governance remain as barriers to maximizing nurses as a fully engaged and effective workforce. Conversely, healthcare organizations that adopt the principles of self-determination and peer governance demonstrate professional astuteness by acknowledging the value in treating nurses as knowledge workers. The structural foundation of shared governance is based on the idea that the profession is autonomously responsible for its practice, the quality of services delivered, the competence of the professionals, and the continued generation of profession-specific knowledge (Porter-O’Grady, 2012).
Restructuring and flattening managerial hierarchy and transferring current financial and support resources to a shared practice environment will enhance intellectual capital of nurses as knowledge workers (Davidson, 2007). Investment in the intellectual capital and institutional acceptance of principles supporting self-governance for nurses has demonstrated tangible rewards for healthcare organizations (Davidson, 2007). For example, Ma and Park (2015) described improvements in nosocomial infection rates, nurse retention rates, and patient satisfaction when unit-level nursing management was removed and a self-governance structure for nurses at the staff level was instituted.
Accountability: Delivering Healthcare Services Based on a Discrete Body of Knowledge
Opportunities for organizations to receive the best value from nurse employees and recruit high-quality nurses are enhanced when organizational policies support nurses working to the full scope of practice within their documented level of competency. Nurses will deliver high-quality services safely when mechanisms are in place that allow nurses to perform care both within their scope of practice and as defined by their nurse practice acts, and that aligns with the skill set in which the individual nurse has documented competency. This section of the article will consider examples that demonstrate how accountability for the discrete body of nursing knowledge can be reflected from the individual perspective via individual privileges; with a team-based approach that utilizes protocols and works to incorporate potential overlap; and through advocacy supported by organizational policy.
Clinical Skills Evaluations and Individual Privileges
Formal clinical skills evaluations can provide RNs with individualized privileges based on demonstrated knowledge and skills; this process supports the goal of achieving the full scope of practice (Porter-O’Grady, 2012). Basic nursing licensure indicates a minimal professional practice standard and state practice acts define scope of practice, academic preparation, experience and certification. We assert that these criteria should be utilized to define individual clinical privileges for RNs, just as is done for our physician colleagues who have a wide basis for practice, but are only provided privileges for which they demonstrate competence. Evaluation of clinical privileges requires a peer review board of clinical nurses, or a multidisciplinary board with representation from each profession. This board grants all clinical privileges and is the appropriate administrative body, using a systematic process such as one outlined by Brassard and Thompkins (2014). Granting of privileges to individual nurses will also help organizations differentiate skills associated with various levels of academic preparation (e.g., diploma, associate, baccalaureate, master’s, or doctoral degrees). Certification can also be used to determine privileges as certification validates specialized knowledge, and provides evidence of accountability and competence (Niebuhr, 2007). During ongoing clinical review, new skills and knowledge that a nurse has attained can be assessed and privileges expanded to reflect growth or removed because of skill atrophy. Leadership, both nursing and organizational, must recognize and allow these nurses to practice at their elevated level, and also hold them accountable for this elevated practice.
Team-Based Care Utilizing Protocols
Protocols reflect respect for team-based treatment plans and do not focus on delivery of nursing care through completion of task-based orders. An organizational benefit of promotion of nursing practice that respects individual nursing skills is apparent in the operationalization of team-based care protocols. Protocols reflect respect for team-based treatment plans and do not focus on delivery of nursing care through completion of task-based orders. Several studies (Brown, Carrara, Watts, & Lucatorto, 2016; Kooienga & Wilkinson, 2016) and a systematic review (Shaw et al., 2014) have found evidence for equivalent quality of care in chronic disease management provided by RNs with appropriate training and demonstrated competency as compared to physicians. The most common nurse protocol actions were related to completion of team-based plans of care, obtaining labs for surveillance of chronic disease, and adjusting medications guided by clinical decision support algorithms.
In the United Kingdom, nurses have been prescribing using protocols and supplementary formularies since 1992 (Drennan, Grant, & Harris, 2014). Engaging nurses as active participants in a team plan of care that includes protocols has resulted in positive experiences by patients and nurses; however, this engagement must be implemented with support from all team members, especially the providers (Latter & Courtenay, 2004). A number of clinical staff professionals, such as the physician, the nurse practitioner, the pharmacist, or the nurse, can assist in transferring a plan of care into practice by adjusting medication using evidence-based tools. For example, difficult-to-treat patients with diabetes in a primary care practice have demonstrated improved glycemic control when managed by an experienced RN with additional training in diabetes management, as compared to management by the primary care provider. In these cases, the nurse follows a treatment plan for diabetic patients, including medication titration using clinical protocols and decision support (Watts & Lucatorto, 2014).
Team-Based Protocols and Overlap
Team-based protocols, like all other aspects of team-based care, begin with recognition of individual team member skills and thought as to where scope of practice may overlap among team members. Team members respect each individual as the expert for his or her defining professional scope of practice and practice act regulations. An essential requirement of team-based protocols is that each team member receive training and demonstrate competency to attain privileges to perform aspects of assigned care. The team decision to implement a nursing protocol with decision support must ultimately be in alignment with nursing interpretation of scope of practice and rules in the applicable nurse practice act.
Protocols should be developed utilizing current evidence-based data, and nurses should be part of the implementation process. Protocols should be developed utilizing current evidence-based data, and nurses should be part of the implementation process (Bahtsevani, Willman, Stoltz, & Östman, 2010). Implementation of protocols and clinical decision support must also include an outline for requirements for quality monitoring, a structure for just-in-time communication between team members, and the capacity for a decision-making tool for patients. An organization may examine resources and decide that the best use of team-based resources is to have a physician team member perform procedures, an advanced practice registered nurse (APRN) team member provide diagnosis and treatment planning, and a nurse or pharmacist team member adjust medications using a clinical decision-support protocol. In this scenario, each team member works at the top of his or her own scope of practice and professional ability.
An example related to improving access to care and safety can demonstrate how professions can unite to respect overlap in scope of practice. The Centers for Medicare & Medicaid Services (CMS) initiated regulations that prevented nurses from using protocols to initiate care for patients in the emergency department (ED) (Helpren, 2009). The American College of Emergency Physicians opposed the regulation with the support of the many EDs using approved nurse-initiated protocols to improve timeliness of care for the patient and to support team-based care. Physician and nursing groups, including the Emergency Nurses Association (ENA) joined forces to advocate for patients and attempted to convince CMS to reverse the regulation. The physician and nurse groups championed care initiated by ED nurses using evidence-based clinical decision-support tools, citing evidence that RN protocols produce equivalent quality when compared to physician-initiated care (Karpas, Hennes, & Walsh-Kelly, 2002).
These protocols assist nurses to provide quality care to patients in an expeditious manner. Unfortunately, in the reversal of the ruling for use of protocols, CMS ruled that in order for care provided by the nurse to be reimbursable, a provider must write a specific medical order for the care, even in cases in which care had already been delivered 24 hours in advance. Requiring a written order after care has been provided using a standardized, evidence based, protocol with organizational support creates fear, misperceptions, and obstacles, and does not improve patient care or safety. The intent of requiring a written order for care that has already been provided using an organizationally approved protocol is perhaps a surrogate marker for creating a method to notify the team member of the completion of nursing action. However, the notification itself, which is critical to team-based care, should be the requirement. In sum, a regulation requiring a provider order up to 24 hours after nursing action performed as an organizationally supported protocol, to achieve reimbursement, undermines the value of nurses as providers of services worthy of payment without providing any measure of potential benefit for patient care..
Advocacy and Organizational Policy
Healthcare organizations support nurses as advocates for patients when they respect nurses as equal team members and adopt policy that creates the opportunity for nurses to advocate for patients. Nurses serve as advocates for patients when they utilize their clinical knowledge to provide care rather than perform care as task-based orders to be completed. Nurses described important nursing functions of the team approach to patient care as follows: a) having an overall view of the many competing, complementing, corresponding, and overlapping actions of fellow team members; b) responding continually to changes in a patient’s clinical status; and c) giving a voice to a patient’s specific concerns and wishes (White et al., 2008). Healthcare organizations support nurses as advocates for patients when they respect nurses as equal team members and adopt policy that creates the opportunity for nurses to advocate for patients.
An example of an organizational policy change that respects and supports nurses is one in which a nurse, using critical thinking, determines that administering a medication as prescribed for a patient places the patient at risk. This risk may have arisen due to a change in status or as the result of therapy that has been reinstated, but now causes the potential for adverse reactions. The nurse has support from an organizational policy that respects the nurse’s judgment and grants him or her the authority to withhold the medication. The nurse is required to inform the prescribing team member about the decision, discuss the implications, and agree upon a joint decision for action, but the nurse is not required to get an “order” to withhold the medication. Evidence has shown that in environments such as this, nurses report an increased likelihood to advocate for patient safety regarding consultant for prescribed treatment.
Accountability: Providing Value and Measuring the Effectiveness of Nursing Care
Measurement of nursing care actions and resulting outcomes is essential to understand and harvest the intellectual capital of RNs. Measurement of nursing care actions and resulting outcomes is essential to understand and harvest the intellectual capital of RNs. While there are significant challenges in measuring the type and intensity of nursing care with resulting short, intermediate, and long term outcomes at the patient level, some early study in this area is available for review (Carlson, 2010). The Nursing Minimum Data Set (NMDS), developed in 1985, was the initial attempt to measure nursing care (Werley, Devine, Zorn, Ryon, & Westra, 1991). Schoneman (2002) used the terms found in the NMDS to examine nursing actions in a community nursing care center over a 1-year period. A total of 5,258 patient care encounters were performed and coded by nurses, with 27% of the interventions coded as surveillance; 42.9% coded as health teaching, guidance, or counseling; and 22.3% coded as case management.
In a study of nursing actions performed for a group of patients with coexisting hypertension and diabetes, Wakefield, Scherubel, Ray, and Holman (2013) were able to categorize nursing interventions into direct, indirect, and non-care-related and quantify the total number and type of interventions performed by nurses to measure amount of nursing care provided. Quantifying nursing interventions resulted in the ability to correlate the amount or intensity of nursing care directly with outcomes of improvement in patient blood pressure and glycemic management. Wakefield et al. (2013) demonstrated that measuring nursing care that is harder to quantify, such as surveillance, patient education, case management, and patient advocacy, as well as procedure-based care, was possible. In this section, we will briefly discuss current procedural terminology codes and outcome measures as these concepts relate to measuring nursing care.
Current Procedural Terminology Codes
Currently... nursing care is not recognized as a payable service by most government and private payers of healthcare. An additional opportunity for measuring nursing care is the use and expansion of Current Procedural Terminology (CPT) codes. CPT codes could be used by nurses rather than, or even in addition to, the measurement of nursing care. The use of CPT codes for providing services such as chronic care coordination would be a natural fit for outpatient-based nursing measures. Healthcare organizations measure, account for, and reward much of the outpatient work performed by their employees using the relative value units (RVUs) associated with each CPT code. Currently, RNs are prohibited from documenting care in workload measurement systems using the majority of CPT codes, as nursing care is not recognized as a payable service by most government and private payers of healthcare.
An example of a code that could be used to measure nursing care is CPT code 99490, which accounts for the provision of chronic disease management services. CPT code 99490 may be billed for payment upon the provision of 20 minutes of face-to-face chronic disease management service involving care coordination each month. This service can be billed at 100% of the payment schedule for physicians and at 85% of the payment schedule for APRNs and physician assistants, but there is no reimbursement for care coordination provided by RNs.
Recent involvement of the ANA (2013) in the development of CPT codes and RVU rules that include nursing actions indicated a willingness of the current systems to consider coding by RNs for accounting of services provided. The ANA Care Coordination Task Force (ANA-CCTF, 2015) has outlined a prioritized strategy for work to capture and reimbursement of nursing care coordination. Additionally, the ANA challenges nursing leaders to develop systematic measurement standards (ANA-CCTF, 2015).
Although the issue of parity of payment is outside the scope of this article, if pricing for the same service differs among groups, this cost information should be made available to purchasers, who may use price along with other factors (e.g., professional experience, available health grades) to decide who will provide the service. If healthcare systems can be reimbursed for care provided by nurses, patients will have more options for evaluation by providers.
... outcome measures are also required for movement to a system of measurement and reimbursement for nursing services. In addition to the measurement of nursing care, outcome measures are also required for movement to a system of measurement and reimbursement for nursing services. The measurements for nursing services are in the early development stage, but they primarily cover nursing care provided in the inpatient setting. Collectively, these inpatient measures are referred to as nursing sensitive indicators (NSIs; Heslop & Lu, 2014).
Nursing outcomes in the ambulatory setting can be constructed for care management, care coordination, triage, facilitation of self-care, and measurements of patient engagement, as well as the nurse contributions to achievement of clinical goals. In 2013, The American Academy of Ambulatory Care Nursing commissioned a task force to define NSIs in the outpatient setting (Martinez, Battaglia, Start, Mastal, & Matlock, 2015). There is evidence for measurements of the achievement of current general healthcare outcome goals, such as achievement of glycemic and lipid targets by nurses utilizing protocols (Brown et al., 2016).
Clinical and academic nurses can collaboratively begin to code general nursing interventions and assign a value of intensity. Clinical and academic nurses can collaboratively begin to code general nursing interventions and assign a value of intensity. Several structured nursing languages are available to serve as a starting point to define nursing interventions. Understanding the time and intensity associated with these interventions, and such factors as the setting in which they are provided and age of the patient, can further refine measurement of intensity. The first to be coded should be the most commonly performed activities or those having the strongest evidence for improvement in care.
Once the methodology to capture the work value of nursing services is standardized, nurses will need to be able to review and analyze data collected to develop comprehensive nursing quality indicators. Nurses in academia, nurse informaticists, and clinical nurses will need to collaborate to develop systems to easily capture data in a usable format. Once data are available for analysis, the collaboration team can develop quality indicators to analyze and trend work patterns, improve quality of care, and improve patient outcomes.
Including clinical nursing staff in development of metrics and data collection/review will assist in the articulation of value directly to nurses providing care. Measurements of work intensity, productivity, and clinical outcomes will empower clinical nursing practice councils to make decisions regarding nursing priorities for improvement and staffing patterns that include the number and type of nursing personnel associated with quality care. Nurses will also be accountable for transparent publication of nursing work intensity, productivity, and outcomes to patients, the healthcare community, and other interested parties.
Recommendations and Conclusion
Removal of identified barriers to support full scope of practice, such as lack of autonomy, team-based processes, and organizational policy, will increase the capacity for nurses to answer the call of the IOM (2011) to create the future of nursing reflecting this ideal. The Table outlines recommendations to help achieve the desired state in which all RNs are optimally engaged as advocates on behalf of patients, families, and communities and serve as a positive influence in healthcare systems.
Table. Recommendations for Systems-Level Team Based Culture to Promote Collaboration and Accountability
Nurses work collaboratively and practice to the full scope of practice in accordance with nurse practice acts.
- Healthcare organizations must formally declare, through policy and conduct, that nurses are actively engaged in decisions regarding nursing care in all aspects of the organization and have the ultimate authority to decide nursing practice. This will require many organizations to include nurses in policymaking groups that currently have no nursing representation. Organizational leadership structures may need modification to place nurses in the ultimate decision-making positions for nursing care.
- Healthcare and organizational policy needs language recognizing that healthcare professions have a shared scientific body of knowledge and that an overlap may exist between professions for some aspects of care. Where overlap exists based upon each profession’s interpretation of scope of practice, organizations will respect that there may be more than one profession with a scope of practice for a service.
- Healthcare organizations need to restructure nursing hierarchy to reflect principles of shared governance. The shift to embracing principles of shared governance may require restructuring resources or positions to provide increasing support to practicing nurses.
Nurses are accountable and engaged in delivering healthcare services based on a discrete body of knowledge.
- Healthcare organizations must develop nursing practice boards that have the ultimate authority to grant privileges or approve individual nurse skill competencies, allowing nurses to practice to the fullest extent of competency yet within their professional scope of practice and relevant nurse practice acts. Nursing practice boards must include nurses with the education and experience required to evaluate competencies.
- Healthcare organizations must create an environment to attract, recruit, and retain highly skilled nurses by developing a team-based practice and culture that uses terminology respectful to all team members. Terms such as “treatment” or “prescription,” rather than “order,” better reflect a team-based culture for provision of care. Organizational policy should support and encourage nurses to use their judgment while performing care rather than completing task-based actions.
Nurses are accountable and engaged in proving value and measuring the effectiveness of nursing care.
- The profession of nursing must develop and implement standardized coded terminology or the use of coded data that serve as a measure of intensity of the nursing service provided, the type of care provided, and who provided the care. This coding can be mandated through collaboration with meaningful-use partners and be tied to reimbursement or quality bonuses in the way that other terminology has previously been implemented.
- The nursing profession must collaborate with accrediting bodies to mandate public reporting of nursing work and outcomes related to nursing care. Ongoing organizational accreditation will require public reporting of the measures for accreditation.
Nurses must own nursing practice at the individual nurse, organizational, and legislative level. In response to the IOM (2011) future of nursing report, the ANA established an expert panel to address barriers specific to ability of the RN to practice to the full extent of their education, experience, and scope of practice. This panel reviewed the literature, engaged in lively debate, and summarized findings related to the RN roles as advocates in this article. Nurses must own nursing practice at the individual nurse, organizational, and legislative level. Healthcare professions must acknowledge and respect the overlap of scope of practice as a natural consequence of shared foundational science without infringement where there is disagreement.
The profession of nursing has the ultimate authority and accountability to define nursing practice and must do so with a focus on critical thinking and evidence. Moving away from a task or procedure based description of scope of nursing practice will create the opportunity for nursing practice to grow to meet the needs of the healthcare consumer and add to the value of nurses for organizations. Lastly, nursing services should be measured and accounted for in the manner that is congruent with healthcare industry standards. Actions to account for the measurement of nursing “work” must include creating codes to capture nursing care into the existing RVU system. Defining and measuring clinical outcomes in response to nursing care needs to be a priority focus of healthcare quality systems.
The removal of barriers for nurses to practice at their full scope will require focus in purpose and persistence in action. The recommendations outlined in this article will hopefully serve as starting points to the complex discussions and decisions that must be made to realize the vision presented in the IOM (2011) report.
Portions of the research for this article were performed by an American Nurses Association (ANA) Professional Issues Panel entitled “Barriers to RN Scope of Practice.” The panel was composed of volunteers from a variety of nursing backgrounds who contributed through participation on the Panel’s Steering Committee and Advisory Committee. While the articles were generated by authors participating in a Professional Issues Panel convened by ANA, the conclusions and recommendations articulated by any author do not necessarily reflect those of the Association.
Michelle A. Lucatorto, DNP, RN, FNP-C
Michelle Lucatorto is the Clinical Program Manager for Specialty Care Nursing and a Nurse Practitioner in Primary Care in the Veterans Health Administration with a Doctor of Nursing Practice Degree. Dr. Lucatorto has practiced in the general medical and critical care inpatient, neuroscience inpatient and outpatient, family practice and internal medicine settings where she has been recognized for excellence in practice with several honor awards. Dr. Lucatorto has been an active volunteer in providing care in Central America and rural America. Dr. Lucatorto has held multiple faculty positions and is currently a Clinical Facility Advisor at Georgetown University in the Family Health Nurse Practitioner Program. Dr. Lucatorto has published multiple peer reviewed journal articles, and written chapters in several books. Dr. Lucatorto is passionate about advancing effective team-based care that maximizes individual and population health.
Timothy W. Thomas, BSN, RN
Timothy W. Thomas has worked as a registered nurse for 15 years, and started his career in the U.S. Army at the original Walter Reed Army Medical Center (WRAMC). At WRAMC, he wrote a policy on pressure ulcer prevention and treatment that was later utilized as the framework for a hospital-wide policy. After a short tour in Iraq, he did an inter-service transfer from the U.S. Army to the U.S. Public Health Service (USPHS). In the USPHS, he has been detailed to the Federal Bureau of Prisons (BOP) and has moved up from a clinical nurse, to the Improving Organization Performance/Infectious Disease Coordinator (IOP/IDC), to his current position as Regional Nurse Consultant/Medical Asset Support Team RN for the Southeast Region. In this position, he has led a team of nurses to develop evidenced-based nursing protocols for urgent/emergent situations and for non-emergent, routine care (sick call). He has also co-led the development of the Nursing Services Program Statement for the BOP. In December 2014, he was awarded a full scholarship through the American Nurses Association to complete his masters in Nursing in Leadership and Administration at Capella University, Minneapolis, Minnesota.
Terry Siek, MSN, RN, NEA-BC
Terry Siek, Vice President of Patient Care and Chief Nursing Officer at Hays Medical Center, graduated from Fort Hays State University in 1991 with a BSN and in 2002 with an MSN. Mr. Siek is responsible for the practice of all nursing staff at the 200-bed tertiary care center in rural Kansas. He has also served as the State President of the Kansas Organization of Nurse Leaders and is currently Secretary for the Kansas State Nurses Association. He is also active in Sigma Theta Tau in various roles, most recently being named to the Board of Directors of Nursing Knowledge International. His board memberships also include United Way of Ellis County, Kansas Nursing Foundation, St. Rose Health Center and the Kansas Heart and Stroke Collaborative, a $12.5 million Centers for Medicare & Medicaid Services innovation grant. He is very passionate about his profession and advocates for nursing locally, regionally, statewide and nationally.
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© 2016 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2016
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