Edtrina Moss, MSN, RN-BC, NE-BC
Patricia C. Seifert, MSN, RN, CNOR, FAAN
Ann O’Sullivan, MSN, RN, CNE, NE-BC, ANEF
State-specific nurse practice acts, a defined registered nurse (RN) scope of practice, and nurse-led initiatives prepare nurses to lead in a meaningful and ethical way within the professional practice setting. However, barriers still exist that challenge the full RN scope of practice. One of these barriers is insufficient interprofessional collaboration among healthcare providers from multiple disciplines. We will briefly discuss the RN scope of practice and describe several evidence-based transition to practice programs and activities that are effectively helping to minimize these barriers. The article will also consider opportunities for interprofessional collaboration for RNs to implement evidence-based programs to support transition to practice, create interprofessional collaborative environments, and care for patients in a culturally competent way to minimize healthcare disparities. We conclude by offering recommendations to enhance interprofessional collaboration.
Citation: Moss, E., Seifert, C.P., O’Sullivan, A., (September 30, 2016) "Registered Nurses as Interprofessional Collaborative Partners: Creating Value-Based Outcomes" OJIN: The Online Journal of Issues in Nursing Vol. 21, No. 3, Manuscript 4.
Key Words: interprofessional collaboratiion, value-based outcomes, transition to practice, diversity, culturally competent care, workforce data, nurse led initiatives, scope of practice
Members of the American Nurses Association (ANA) Professional Issues Panel (Panel) Steering Committee, Barriers to RN Scope of Practice, recently worked to identify barriers that prevent RNs from working to the full extent of their education and training. This Panel both explored the basis for barriers, and subsequently developed appropriate recommendations. Panel findings were divided into four key roles of RNs in the healthcare delivery system, specifically RN as professional, RN as advocate, RN as innovator, and RN as collaborative leader. This OJIN topic considers barriers to RN scope of practice from the perspective of each of these roles.
One barrier is insufficient interprofessional collaboration among healthcare providers from multiple disciplines.One barrier is insufficient interprofessional collaboration among healthcare providers from multiple disciplines. Interprofessional collaboration is the collective involvement of various professional healthcare providers working with patients, families, caregivers, and communities to consider and communicate each other’s unique perspective in delivering the highest quality of care (Sullivan et al., 2015). As leaders, all RNs are, or should be, invested as interprofessional collaborative partners in the creation of outcomes of value for the patients, families, and the community they serve. We will discuss several evidence-based transition to practice programs and activities that are effectively helping to minimize this and other barriers. The article will also consider opportunities for interprofessional collaboration for RNs to implement evidence-based programs to support transition to practice, create interprofessional collaborative environments, and care for patients in a culturally competent way to minimize healthcare disparities. We conclude by offering recommendations to enhance interprofessional collaboration.
RN Scope of Practice
Nursing has ranked number one in ethics and honesty, according to Gallup polls, for 16 of the past 17 years (Gallup, 2014). Registered nurses (RNs) advocate as they contribute to care of families, individuals, communities, and populations. Care by professional nurses helps to protect, promote, and optimize health and prevent illness and injury through the diagnosis and treatment of human response (ANA, 2016). RN practice is bound by a set of rules and regulations, known as nurse practice acts, which defines practice within the scope of the profession. These practice acts require licensed professional nurses to demonstrate a minimum requisite education and/or training and competence to provide services within the scope of practice (Russell, 2012).
The scope of nursing practice describes the “who,” “what,” “when,” “where,” “why, and “how” of nursing practice. The scope of nursing practice describes the “who,” “what,” “when,” “where,” “why, and “how” of nursing practice. All actively licensed and advanced practiced RNs describe “who” practices nursing. The definition of nursing describes a succinct characterization of the “what” of nursing. Nursing occurs “when” there is a nursing need for leadership, advocacy, caring, knowledge, or education anywhere. The “why” considers reasons why the nursing profession has ranked number one in ethics and honesty for 16 of the past 17 years. RNs respond to the changing needs of society to achieve positive healthcare outcomes in keeping with nursing’s social contract with society. The “how” is characterized as the ways, means, and methods that RNs use to practice professionally (ANA, 2015a; ANA, 2015b).
... all professional nurses should be implementing evidence-based programs to support transition to practice... Guiding documents in the profession prepare nurses to lead within the professional practice setting and the profession itself. Specific competencies establish actions required of RNs to influence policy to promote health; mentor colleagues for the advancement of nursing practice and the profession; encourage innovation in practice and role performance; and influence decision-making. Individual RNs must actively take responsibility to seek opportunities for developing leadership skills, as recommended by the Institute of Medicine (IOM; ANA, 2015b; IOM, 2015). Opportunities must exist for RNs to lead and diffuse collaborative improvement efforts and to lead changes to advance health (IOM, 2015). As the nursing profession moves forward in the 21st century, all professional nurses should be implementing evidence-based programs to support transition to practice and creating interprofessional collaborative environments. In addition, nurses should identify optimal opportunities to provide culturally competent care for patients; minimize healthcare disparities from a nursing care perspective; and develop a workforce reflecting the communities served.
Barriers to Full Scope of Practice
A common reason [for barriers] is differences among and between the states in their regulatory language for RNs... Barriers related to RN practice at the full scope stem from various sources. A common reason is differences among and between the states in their regulatory language for RNs (states individually regulate practice). These differences may be subtle or obvious. In each state, there is a unique nurse practice act (NPA) which serves as the definition of professional nursing practice. The NPA is supported by a board of nursing (BON) consisting of members appointed by an elected official (governor), a legislative body, or persons elected by the population at large (Russell, 2012).
The restriction of nursing practice by state regulation and subsequent organizational limits are highlighted in the ANA model of professional nursing practice regulation (ANA, 2015a; Fowler 2015). Nursing practice begins with a professional statement of practice and code of ethics to support decision making, but these core professional nursing tenets are then subjected to interpretation by each state, territory, and district. They become differing scopes of practice for RNs, based solely on geographic location. State-defined scopes of practice for RNs may be further restricted at the organizational level through enactment of policy and procedure.
Nurse leaders must decide on a uniform scope of practice that focuses on knowledge and is grounded in evidence. Nurse leaders must decide on a uniform scope of practice that focuses on knowledge and is grounded in evidence. The growth in participation in the Nurse Licensure Compact that has grown to include 25 states represents a movement in the direction of uniformity of practice (NCSBN, 2012), yet RNs must still adhere to individual state restrictions. Essentially, a nurse traveling a short geographic distance from one state to another may have a change in scope of practice unrelated to scientific evidence or individual skill. One agency, the Department of Veterans Affairs (VA) is an exemplar in its demonstration of uniformity of practice across states. RNs may seek employment at any VA location in one of all 50 states, the District of Columbia, and Puerto Rico and maintain only one active unrestricted state license (U.S. Department of Veterans Affairs, 2012).
One example of interprofessional collaboration is illustrated by a joint meeting of the Virginia BON and the Board of Medicine in the 1970s (Joint Committee, 1976). This enabled RNs in the operating room to serve as surgical first assistants and enhance their clinical leadership skills, thereby foreshadowing both expanded and advanced practice pathways for RNs. Whether nurses are practicing in a hospice or a hospital, it is important to recognize not only the intellectual basis of nursing, but also the importance of the technical skills that, properly managed and employed, make a significant impact on patient outcomes.
Differences in the entry level of RN practice and the related educational preparation (e.g., diploma, associate degree, or BSN) to become an RN are also relevant to any discussion of barriers concerning scope of practice. Educational curriculum and education accreditation criteria must focus on a knowledge-based scope of practice based on baccalaureate level preparation. Nursing leaders must be the ones to define professional scope of practice for those RNs graduating from an academic, knowledge-based, educational program.
RNs must be in key organizational leadership and decision-making roles to reduce restrictions to nursing practice. The nursing profession scope of practice should address RNs as team leaders and focus on nursing as a holistic clinical discipline (Folan et al., 2012). RNs must be in key organizational leadership and decision-making roles to reduce restrictions to nursing practice. Organizational leadership includes practice-based organizations (e.g., healthcare), federal entities (e.g., Centers for Medicare & Medicaid Services [CMS]), and private insurers. Organizational limits to nursing practice place unnecessary restrictions on RNs and limit availability of innovative and creative solutions to many of the problems encountered, understood, and resolved by RNs on a daily basis. However, before nurses can serve in leadership roles, they must achieve a successful transition to practice.
Transition to Practice
Socialization of nursing students is important to prepare graduates for interacting with a variety of professional and nonprofessional individuals in the healthcare setting. Socialization of nursing students is important to prepare graduates for interacting with a variety of professional and nonprofessional individuals in the healthcare setting. However, the emphasis in nursing education must alter from largely socialization among nurses to formation of professional nurses collaborating with others; specifically, from imitating or copying past practices to being a reformed process of interprofessional collaboration. Using dated approaches to nursing education and failure to adopt approaches when evidence has demonstrated significant successes is a barrier to achieving the goal of interprofessional collaboration (Benner, Sutphen, Leonard, & Day, 2010).
The majority of healthcare disciplines are educated at the baccalaureate level or higher. A 2-year curriculum, no matter how exemplary (and many are) cannot teach all components needed to prepare RNs to assume needed leadership positions. Over 50% of new RN graduates in the United States are prepared at the diploma or associate-degree level (Raines & Taglaireni, 2008) Integration into pre-practice level educational courses with other providers (e.g., social workers, medical or pharmacy students) is difficult, as students in such disciplines are not educated at community college campuses (American Association of Colleges of Nursing [AACN], 2008, n.d; Benner et al., 2010). The variety in nursing educational pathways for licensure contributes to graduates with diverse competencies. Because of this educational diversity, new graduates arrive at the workplace with widely differing abilities and skills that create additional challenges in the workplace.
There are a variety of transition to practice programs, with several basic considerations integral to all programs. One important consideration is reflected in the Dreyfus’ Model of Skill Acquisition (Dreyfus, 1982). Benner (2001) adapted and applied this model to her concept of contextual learning. According to this model, a new graduate transitions from advanced beginner to competent practitioner, which enables the nurse to acquire:
- Improved organizational ability and technical skills
- Greater focus on managing the patient condition as opposed to accomplishing “tasks”
- Ability to identify significant clinical signs and symptoms
- Movement toward involvement and responsibility
...a successful transition to practice has important benefits to patients and families. The American Organization of Nurse Executives (AONE; 2010) guiding principles address the role of preceptors, mentors, and coaches. These principles emphasize that a successful transition to practice has important benefits to patients and families. The AONE guiding principles note that commitment to transition of newly licensed nurses into practice occurs across all organizational levels, including senior leadership and nursing leadership.
New graduate transition programs have been developed in response to beliefs that new graduate nurses were ill prepared for practice in the highly acute, complex, and rapid-paced hospital environment where most nurses are employed (Culley et al., 2012; Lofmark, Smide, & Wikblad, 2006). Health systems were further motivated by costs related to high turnover rates for new graduate nurses in the first two years of employment (Hayes et al., 2012; Trepanier, Early, Ulrich, & Cherry, 2012).
Transition programs build upon traditional orientation programs, which last from three days to six weeks (Theisen & Sandau, 2013). Traditional orientation focuses on skill acquisition, information systems, and specific organizational routines and policies. Retention, organizational, and individual outcomes from these traditional programs are often compared to outcomes of more comprehensive transition programs. Three specific examples of expanded transition programs are described below.
Nurse residency. National healthcare thought leaders called for the implementation of nurse residencies to reduce new nurse stress, practice errors, and turnover (Benner et al., 2010; IOM, 2011; Joint Commission, 2002). However, existing programs vary in content, length, and other essential elements (Barnett, Minnick, & Norman, 2014; Spector et al., 2015). Adoption of residency programs by health systems has been slow, although there is evidence that the rate of uptake is increasing (AACN, 2008). According to the National Council of State Boards of Nursing (NCSBN, 2014), it is the responsibility of healthcare systems to assure new RNs have experiential learning in the specialties where they are employed. Thus, customized transition programs are required based on practice specialty.
Recent efforts by health systems and academic stakeholders have produced evidence-based, programmatic transition programs. Recent efforts by health systems and academic stakeholders have produced evidence-based, programmatic transition programs. The University Health System Consortium (UHC) and American Association of Colleges of Nursing (AACN) Nurse Residency Program, Transition to Practice (TTP), was developed collaboratively by academic medical centers and baccalaureate schools of nursing (University HealthSystem Consortium [UHC], 2008). With funding from the Robert Wood Johnson Foundation (RWJF), a comprehensive evaluation plan was implemented to identify outcomes of the first two program phases. Program outcomes demonstrated positive improvements on retention rates, nurse confidence, competence, organization, prioritization, communication, leadership, and decreased perceived stress (UHC, 2008). The UHC/AACN team also developed a set of standards for accreditation of post-BSN nursing residencies. Accreditation is a criterion for reimbursement of residency costs by CMS. Furthermore, standards and accreditation are critical mechanisms for improving residency rigor and standardization.
Both TTP and established programs resulted in new graduates having higher overall competence, less stress, more job satisfaction, and fewer turnovers (Spector et al., 2015). In the limited programs, new graduates were more likely to report higher job stress and less job satisfaction, and were twice as likely to leave their position within the first two years of practice (NCSBN, 2014).
NCSBN (2014) offers a TTP toolkit that includes the following e-learning modules: patient-centered care; communication and teamwork; evidence-based practice; quality improvement; informatics; and preceptor training. Another program with goals similar to those of the TTP of UHC/AACN was developed by the Department of Veteran Affairs, Veterans Health Administration (VHA, 2011). The VHA designed a 12-month residency program with goals similar to the UHC/AACN program. The VHA also formulated strategies to combat the high cost of new RN turnover. Teaching methodologies included classroom education, preceptor clinical experiences, monthly meetings, group clinical debriefings, one-on-one mentoring, and an evidence-based project (VHA, 2011). The VHA pilot resulted in a 100% retention rate across facilities and formed the basis for a national launch. Reviews found that programs were effective when they spanned the first year of practice. Preceptorship was highlighted as an important component of program success (Spector et al., 2015).
...barriers can exist when RNs who might serve as preceptors come from different educational backgrounds. Preceptorship. Preceptorships have been a common transition program for new RN staff. Despite frequent use of preceptors, and evidence that this model provides an important component of success (Spector et al., 2015), challenges still exist for both new staff RNs and preceptors. For example, barriers can exist when RNs who might serve as preceptors come from different educational backgrounds. Expecting clinical RNs to have the competencies of skilled educators may not be a reality (Hautala, Saylor, & O’Leary-Kelley, 2007).
Student nurse externship. Nurse externships allow nursing students an opportunity to experience real-world clinical practice over a 3 to 12-week period using a nurse preceptor-student model (Friday, Zoller, Hollerbach, Jones, & Knofczynski, 2015). The major goals are to attract student nurses for employment upon graduation, reduce costs for employee recruitment, and improve new graduate nurse performance and retention. However, outcomes have been mixed. Both retention and professional satisfaction of new graduate nurses who participated in externships were slightly improved over nonparticipants in several studies (Cantrell & Browne, 2006; Friday et al., 2015; Steen, Gould, Raingruber, & Hill, 2011), although in one study, 2-year retention was markedly less than that of new graduates who participated in residency or preceptor programs (Salt, Cummings, & Profestto-McGrath, 2008). Numerous studies have indicated minimal or no improvement in ease of transition to practice, professionalism, and job performance in new graduate nurses who completed externship programs (Cantrell & Browne, 2006; Friday et al., 2015; Steen et al., 2011).
...continued attention to program development can provide experiences to maximize opportunities for interprofessional collaboration to create strong nurse leaders at every level of care. In sum, several transition to practice programs have been in place and have demonstrated some positive outcomes. However, continued attention to program development can provide experiences to maximize opportunities for interprofessional collaboration to create strong nurse leaders at every level of care.
Healthy Work Environments for Nursing Practice
A healthy work environment is one that is safe, empowering, and satisfying. It is not merely the absence of real and perceived physical or emotional threats to health, but a place of physical, mental, and social well-being, supporting optimal health and safety. Healthcare workers have a fivefold risk of experiencing workplace violence when compared to the overall workforce (National Institute for Occupational Safety and Health, 2013). The presence of overt and covert workplace violence, bullying, and incivility significantly impacts both the individual nurse and the overall work environment, including increased time away from work, higher turnover rates among RNs and other team members, and suboptimal patient outcomes.
...all leaders, managers, healthcare workers, and ancillary staff have responsibility as part of the interprofessional team to perform with a sense of professionalism, accountability, transparency, involvement, efficiency, and effectiveness. A culture of safety is paramount and must include everyone, including those who are transitioning into practice. In such a culture, all leaders, managers, healthcare workers, and ancillary staff have responsibility as part of the interprofessional team to perform with a sense of professionalism, accountability, transparency, involvement, efficiency, and effectiveness. All must be mindful of the health and safety of both the healthcare consumer and the healthcare worker in any setting providing care, offering a sense of safety, respect, and empowerment to and for all persons (ANA, 2015a). To do this with intent, genuine interprofessional collaboration that includes all levels of nursing practice must be evident in daily interactions. In the next section, we will consider opportunities for interprofessional collaboration specifically as they might apply to barriers to full RN scope of practice.
Opportunities for Interprofessional Collaboration
The landmark report, The Future of Nursing: Leading Change, Advancing Health (IOM, 2011), focused on the rapid changes occurring in healthcare and the critical role of RNs in developing policy, implementing changes, providing and coordinating patient care, and measuring healthcare improvements.
After the release of the 2011 IOM report, the Robert Wood Johnson Foundation (RWJF), in collaboration with Campaign for Action (2015), initiated a campaign to assist in the explication and implementation of the report recommendations. The RWJF also asked the IOM to examine changes and progress made after releasing of their report. The followup report (IOM, 2015) illustrated both significant progress and additional considerations for further study.
AACN, along with five other organizations, established the Interprofessional Education Collaborative (IPEC), which is committed to advancing interprofessional learning experiences and promoting team-based care. The IPEC mission is to ensure the current and new health professionals are proficient in competencies for community-oriented and population-oriented, patient-centered, collaborative, interprofessional practice (Interprofessional Education Collaborative, 2016).
In both the 2011 and 2015 IOM reports, considerable focus was placed on the importance of interprofessional collaboration and the valuable abilities of RNs to collaborate with patients, other clinicians, educators, and researchers. Targeted areas recommended for greater attention included:
- Removing barriers to practice and care
- Transforming education
- Collaborating and leading
- Promoting diversity
- Improving data
Removing Barriers to Practice and Care
...collaborative practice models are not limited to APRNs... Although much emphasis in the IOM 2011 report focused on advanced practice registered nurses (APRNs), collaborative practice models are not limited to APRNs, and the IOM stresses that “all health professionals” (IOM, 2015, p. 2) can improve both quality and satisfaction. An associated recommendation stresses the importance of working with other colleagues and groups (e.g., policy makers, elected officials, professional organizations, and community groups). Engaging colleagues and assisting them to understand the benefits of expanding RNs’ scope of practice supports greater opportunities for RNs to initiate and lead innovative improvements in healthcare.
Encouraging lifelong learning and obtaining higher levels of education were critical recommendations of the future of nursing report (IOM, 2011). Additionally, the complexity of the evolving healthcare system necessitates learning about new systems and procedures and incorporating new information and knowledge into the practice arena. RNs seeking to expand their education can benefit from programs that support not only obtaining a BSN but also eventually pursuing masters and doctoral degrees.
Nurse residency programs are designed to build on baccalaureate education. General goals of residency programs (Barnett et al., 2014; Spector et al., 2015) include:
- Reduce medication errors
- Minimize turnover and stress-induced burnout
- Ease adjustment into clinical practice
- Improve job satisfaction
- Increase nurse confidence
- Improve critical thinking
- Develop care coordination and patient-centered care competencies and models
In this section we discuss several themes related to the IOM call (2011; 2015) for interprofessional collaboration skills for all RNs to further enhance full scope of practice.
Collaboration and Leadership
RNs provide a broad and deep knowledge and experience related to needs of healthcare systems in general, and patients in particular. RNs interact with physicians, nurse colleagues, technologists, administrators, researchers, regulators, accrediting representatives, and others who have an impact on patient and community outcomes. In addition to interacting with others within the healthcare system, RNs contribute to the development, implementation, and ongoing improvements in processes and products such as telenursing (e.g., e-ICUs) and electronic health records (EHRs). Connecting with influential leaders, expanding colleague networks (in both the work setting and national arena), being a good listener, clearly articulating idea(s), earning others’ trust (i.e., being accountable, keeping promises, and respecting confidences), and empowering others are some recommendations described by Sherman (2015) to boost individual level RN scope of influence.
Trossman (2015) described the importance of collaboration to develop an EHR. In addition to clinical colleagues, RNs work with information technologists, vendors, and nurse informaticists to develop a health record that promotes accurate documentation, and contributes significantly to greater ease and efficiency to document RN care. For example, a nurse informaticist observing RN documentation processes identified a variety of complicated and unnecessary steps: numerous mouse clicks, scrolling through multiple computer screens, a prolonged period of documentation, and documentation of information largely of use to other departments rather than patients under the nurse’s care.
Strong, collaborative interprofessional teams enable members to embrace patient care policies and protocols that are team-based and patient-centered. Strong, collaborative interprofessional teams enable members to embrace patient care policies and protocols that are team-based and patient-centered. RNs are excellent coordinators able to interact effectively with an intellectually diverse population of physicians, technologists, administrators, patients, and family members. This ability to RNs can be excellent coordinators able to interact effectively with an intellectually diverse population of physicians; technologists; administrators; patients and family members. This ability to communicate with individuals from various backgrounds, with different goals and responsibilities, is especially valuable within the complex healthcare environment.
Collaborative efforts between RNs and physicians at multiple levels... can offer additional opportunities for RNs to lead and influence process improvement and improved outcomes. Collaborative efforts between RNs and physicians at multiple levels (e.g., national, regional, local patient setting) can offer additional opportunities for RNs to lead and influence process improvement and improved outcomes. Whether professional organizational representatives from nursing (e.g., ANA) or medicine (e.g., American Medical Association) or academic partnerships between and among different schools, creators of policy initiatives can feature and incorporate contributions of RNs (AONE, 2012). The AONE (2012) and AACN (n.d.) developed guiding principles for academic/practice partnerships. Such relationships, whether illustrated by RNs serving on boards of directors, governmental committees, insurance companies, and/or advisory boards, can play an important role in effectively and successfully redesigning healthcare, revising payer systems, and reducing barriers that prevent RNs from working to the optimal level of their education (IOM, 2011, 2015).
Diversity and Culturally Competent Care
The IOM 2011 report and 2015 update noted that greater diversity among healthcare professionals (e.g., clinicians, educators, administrators, researchers) is important to reflect growing community cultural, religious, and racial diversity. Changing population demographics require reassessment and revisions to care protocols in order to meet optimal individual (and family) needs for care. These population changes necessitate diversity of ideas and illustrate the duty of caregivers to engage in lifelong learning about evolving patient care needs. Maintaining competence and professional growth is an important component of the ANA Code of Ethics for Nurses (ANA, 2015a). By virtue of direct exposure to diverse populations, RNs are suited to lead initiatives that improve care through patient-centric policies and procedures.
To ensure that nurses are well prepared for the diversity of population health, new standards of professional nursing practice and competencies were developed to reflect a dynamic profession and nursing practice. A new standard of culturally congruent practice was added to the Nursing: Scope and Standards of Practice (2015b) further delineating the role of the RN related to cultural diversity and inclusion principles and practice competencies (Marion, in press). This standard is vital both now and in future times of social change, as the number of culturally and ethnically diverse consumers increases. The new standard 8 sets the criteria for the registered nurse’s educational, legal, and societal accountability. While extensive discussion about Standard 8 is beyond the scope of this article. However, changes resulting from the revision of it will both enhance the scope of RN practice and increase opportunities for interprofessional collaboration via team leadership for all RNs in areas related to education, self-assessment, provision of care, and policy.
Data Collection and Improvement
It is difficult to initiate any proposed change in the absence of supporting evidence. According to the IOM (2015), considerable information is missing about health professionals, such as the number and type; practice roles; skill mix distribution throughout the healthcare system; optimal educational preparation; effect on patient outcomes; and impact on cost and efficiency. This creates a great need for additional research to support the operationalization of practice at the full RN scope. RNs, and their professional colleagues, are encouraged to work toward creating strong databases that can guide changes, measure RN impact, and monitor RN roles in the workforce. With the ability to access partner organizations and association databases, researchers and policy planners may have other extensive sources of information that can be employed to create new programs and initiatives.
Conclusion and Recommendations
The IOM has offered a clear and strong case for the collaborative role of RNs on interprofessional teams. The IOM (2011; 2015) has offered a clear and strong case for the collaborative role of RNs on interprofessional teams. This article has considered interprofessional collaboration as it relates to RN scope of practice, including discussion of both barriers and opportunities for interprofessional collaboration to address them. The authors, all members of the ANA Panel, Barriers to RN Scope of Practice, conclude by offering a summary of barriers to three important areas discussed (see Table): transition to practice, interprofessional environments, and culturally competent care. The recommendations will hopefully enhance collaborative efforts and highlight potential RN driven innovative and evidence-based strategies.
Table. Barriers and Recommendations for Enhancing Interprofessional Collaboration
Barriers to evidence-based programs that support transitions to practice:
- Insufficient residency programs
- Lack of employer accountability for collaborative academic-practice programs
- Insufficient research investment
- Challenges to implementation of BSN-level education
Recommendations for evidence-based programs to support transitions to practice:
- Establish a shared commitment for evidence-based programs that are sustainable and cost effective via the collaborative development, implementation, and evaluation of nurse residency programs.
- Hold employers accountable to develop and evaluate transition programs in collaboration with academic partners.
- Support employers and academic partners to invest in research about transition program designs that includes data related to return on investment (ROI).
- Encourage employers to require BSN-level education as a minimum credential for preceptors.
- Solicit funding to support BSN level education.
Barriers to culturally competent care:
- Lack of cultural diversity
- Insufficient recruitment efforts to achieve diverse workforce
- Cultural, religious, and racial preferences not respected or understood
- Desired workforce attributes no not include community diversity
Nurse-led initiatives for culturally competent care:
- RNs create an environment and practice in a manner congruent with cultural diversity and inclusion principles.
- Leaders in academia work to recruit diverse students to achieve a multicultural workforce and develop curricula to promote cultural competence.
- RNs promote policies and organizational culture that ensures that cultural, religious, and racial preferences of patients, families and RNs are respected and incorporated into the plan of care.
- Employers of nurses should invest in the development of a workforce that reflects the community they serve.
Barriers to effective interprofessional environments:
- Little or no reflection of interprofessional practice in academic and practice models
- Few nurse-designed collaborative models
- Limited access to workforce data
Recommendations for creating/enhancing interprofessional environments:
- Leaders in academia and practice should develop and test effective interprofessional practice collaborative models.
- Nurses should drive and engage in research to develop and test interprofessional practice and academic collaborative models.
- Establish a shared commitment to create infrastructures to collect and analyze data on current and future needs of the RN workforce.
- Identify useful workforce data and consider joint collection and analysis of workforce and education data.
(AONE, 2010, 2012; Marion, in press).
Recommendations listed in the Table are not an exhaustive list of the next steps. Rather, we hope to begin dialogue for the future of nursing related to nurses as interprofessional collaborative partners, especially in the context of enhancing RN scope of practice. Findings from the work of the ANA Panel suggest that three major goals for the nursing profession related to this topic should be: implementing evidence-based programs to support transition to practice; caring for patients in a culturally competent way to help minimize healthcare disparities from a nursing care perspective; and creating supportive, interprofessional collaborative environments. Achieving these goals will require a genuine, collaborative effort among academia, practice, and healthcare partner professionals from multiple disciplines who provide care for the patients they serve.
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.
Edtrina Moss, MSN, RN-BC, NE-BC
Edtrina Moss has more than 18 years of nursing experience and expertise in dialysis, transplant, critical care, ambulatory care, nursing education, care coordination, utilization management, and leadership. She has served in the roles of nurse educator, transplant coordinator, nurse manager and program director. She is a member of the Texas Nurses’ Association Policy Council and serves as content expert reviewer for the American Academy of Ambulatory Care Nursing’s Care Coordination & Transition Management curriculum and certification. She is also a student at Texas Woman’s University – Houston Campus, where she has completed all course work for a PhD in Nursing. Her research focus is exploring differences of self-reported competence of certified and non-certified registered nurses. She is Board Certified in Ambulatory Care and a Board Certified Nurse Executive. Edtrina is employed with the Veterans Health Administration in Houston, Texas.
Patricia C. Seifert, MSN, RN, CNOR, FAAN
Patricia C. Seifert has more than 25 years of experience as a perioperative nurse. She has been a clinical manager in cardiac surgical services and has developed four cardiac surgical programs. She has also functioned as an RN First Assistant on over 3,000 cardiac surgery procedures. Seifert is a past president of the Association of periOperative Registered Nurses (AORN), past Lead Coordinator of the Nursing Organizations Alliance, a member of Sigma Theta Tau International. She is a Fellow in the American Academy of Nursing. Seifert is the author of six books and numerous articles and chapters; she was a member of the writing group for the 2013 American Heart Association Scientific Statement: Patient Safety in the Cardiac Operating Room: Human Factors and Teamwork. She has presented educational programs locally, nationally, and internationally. Seifert has been the recipient of the Inova 2015 Ronald S. De Volder Memorial Award for participation in the Cardiac Surgery QI Team Project: “Patient Handoff from CVOR to CVICU and CVICU to CVSDU;” she also received the Inova Health System’s 2014 award for Service Excellence. Seifert has been recognized by her professional organization, AORN, receiving AORN's first President's Award (1991-1992), the 2003 Award of Excellence, AORN's 2007 Jerry G. Peers Distinguished Service Award, and AORN’s 2014 Award for Mentorship.
Ann O’Sullivan, MSN, RN, CNE, NE-BC, ANEF
Ann O’Sullivan has 45 years of experience in nursing, including critical care, Clinical Nurse Specialist, Director of Nursing, and associate professor, and currently serves as Assistant Dean for Support Services at Blessing-Rieman College of Nursing and Health Sciences in Quincy, IL. Ann has served in many roles in the American Nurses Association, including state Board of Directors and President, chair of Health Policy, chair of Assembly Nursing Practice, and many others. She is currently Vice-President of ANA-Illinois and chairs the Illinois Expert Panel of Scope of Practice. At the national level, Ann served as chair of the Reference Committee, member and vice-chair of the Congress of Nursing Practice and Economics. Ann chaired the workgroup that revised the 2010 ANA Scope and Standards of Practice and was co-editor of Essential Guide to Nursing Practice (2012). Ann has also served in leadership roles in Sigma Theta Tau, Pi chapter, Illinois Organization of Nurse Leaders and the steering committee for the revision of the Illinois Nurse Practice Act. She is a Certified Nurse Educator and Certified Nurse Executive. Ann was inducted as a Fellow in the Academy of Nurse Educators. She has been awarded the Nurse Educator Award and Anne Zimmerman Honorary Member Award by the Illinois Nurses Association.
American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author. Retrieved from www.aacn.nche.edu/education-resources/BaccEssentials08.pdf
American Association of Colleges of Nursing. (n.d.) What every nursing student should know when seeking employment. Washington, DC: Author. Retrieved from www.aacn.nche.edu/publications/hallmarks.pdf
American Nurses Association. (2016). What is nursing? Retrieved from www.nursingworld.org/EspeciallyForYou/What-is-Nursing
American Nurses Association. (2015a). Code of ethics for nurses with interpretive statements (2nd ed.). Silver Spring, MD: Author.
American Nurses Association. (2015b). Nursing: Scope and standards of practice (3rd ed.). Silver Spring, MD: Author.
American Organization of Nurse Executives. (2010). AONE guiding principles for the newly licensed nurse’s transition into practice. Retrieved from www.aone.org/resources/newly-licensed-nurses-transition-practice
American Organization of Nurse Executives. (2012). AONE guiding principles. Retrieved from www.aone.org/resources/academic-practice-partnerships.pdf
Barnett, J. S., Minnick, A. F., & Norman, L. D. (2014). A description of U.S. post-graduation nurse residency programs. Nursing Outlook, 62(3), 174-184. doi:10.1016/j.outlook.2013.12.008
Benner, P. (2001). From novice to expert: Excellence and power in clinical nursing practice. Upper Saddle River, NJ: Prentice Hall Health.
Benner, P., Sutphen, M., Leonard, V., Day, L. (2010). Educating nurses: A call for radical transformation. San Francisco, CA: Jossey-Bass.
Campaign for Action. (2015) retrieved from http://campaignforaction.org/issues/
Cantrell, M. A., & Browne, A. M. (2006). The impact of a nurse externship program on the transition from graduate to registered nurse: Part III. Recruitment and retention efforts. Journal of Nurses in Staff Development, 22(1), 11-14.
Culley, T., Babbie, A., Clancey, J., Clouse, K., Hines, R., Kraynec, M., . . . Wittmann, S. (2012). Nursing U: A new concept for nursing education. Nursing Management, 43(3), 45-47. doi:10.1097/01.NUMA.0000412950.80510.95
Dreyfus, S.E. (1982). Formal models vs. human situational understanding: Inherent limitations on the modelling of business expertise, Office Technology and People, 1(2/3), 133 - 165. doi:10.1108/eb022609
Folan, P., DeCain Tarraza, M., Delaney, M., Fardellone, C., Leners, C., Ross, E., & Fitzpatrick, J. J. (2012). Leadership initiatives to disseminate the Institute of Medicine’s Future of Nursing report. Policy, Politics, & Nursing Practice 13(1), 38-44. Retrieved from http://ppn.sagepub.com/content/13/1/38.full.pdf
Friday, L., Zoller, J. D., Hollerbach, A. D., Jones, K., & Knofczynski, G. (2015). The effects of a prelicensure extern program and nurse residency program on new graduate outcomes and retention. Journal for Nurses in Professional Development, 31(3), 151-157. doi:10.1097/NND.0000000000000158
Fowler, M.D.M. (2015). Guide to the Code of Ethics with Interpretive Statements (2nd ed.). Washington, D.C.: author.
Gallup. (2014). Americans rate nurses highest on honesty, ethical standards. Retrieved from www.gallup.com/poll/180260/americans-rate-nurses-highest-honesty-ethical-standards.aspx
Hautala, K. T., Saylor, C. R., & O'Leary-Kelley, C. (2007). Nurses' perceptions of stress and support in the preceptor role. Journal of Nurses in Staff Development, 23(2), 64-70.
Hayes, L. J., O’Brien-Pallas, L., Duffield, C., Shamian, J., Buchan, J., Hughes, F., . . . North, N. (2012). Nurse turnover: A literature review—An update. International Journal of Nursing Studies, 49(7), 887-905. doi:10.1016/j.ijnurstu.2011.10.001
Institute of Medicine. (2011). Future of nursing: Leading change, advancing health. Washington, DC: National Academies Press. Retrieved from http://iom.nationalacademies.org/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx
Institute of Medicine. (2015). Assessing progress on the Institute of Medicine report: The future of nursing. Washington, DC: National Academies Press. Retrieved from www.nationalacademies.org/hmd/Reports/2015/Assessing-Progress-on-the-IOM-Report-The-Future-of-Nursing.aspx
Interprofessional Education Collaborative. (2016). IPEC news and announcements. Retrieved from https://ipecollaborative.org/IPEC.html
The Joint Commission. (2002). Health care at the crossroads: Strategies for addressing the evolving nursing crisis. Retrieved from www. www.jointcommission.org/assets/1/18/health_care_at_the_crossroads.pdf
Joint Committee of the Virginia State Boards of Medicine and Nursing. (1976, June 30). Policy statement: Registered nurses as first assistants. Richmond, VA: Department of Health Professions.
Lofmark, A., Smide, B., & Wikblad, K. (2006). Competence of newly-graduated nurses—A comparison of the perceptions of qualified nurses and students. Journal of Advanced Nursing, 53(6), 721-728.
Marion, L. (in press). Implementing the new ANA standard 8: Culturally congruent practice. Online Journal of Issues in Nursing.
National Council State Boards of Nursing. (2014). NCSBN’s Transition to Practice® study: Implications for boards of nursing. Retrieved from www.ncsbn.org/TTP_ImplicationsPaper_Dec2014.pdf
National Council of State Boards of Nursing. (2012). Changes in healthcare professions’ scope of practice: Legislative considerations. Retrieved from www.ncsbn.org/ScopeofPractice_09.pdf
National Institute for Occupational Safety and Health. (2013). Workplace violence prevention for nurses. Retrieved from www.cdc.gov/niosh/topics/violence/training_nurses.html
Raines. C. F., Taglaireni, M. E., (Sept. 30, 2008) "Career Pathways in Nursing: Entry Points and Academic Progression" OJIN: The Online Journal of Issues in Nursing; Vol 13 No 3 Manuscript 1
Russell, K. (2012). Nurse practice acts guide and govern nursing practice. Journal of Nursing Regulation, 3(3), 36-40. Retrieved from www.ncsbn.org/2012_JNR_NPA_Guide.pdf
Salt, J., Cummings, G. G., & Profetto-McGrath, J. (2008). Increasing retention of new graduate nurses: A systematic review of interventions by healthcare organizations. Journal of Nursing Administration, 38(6), 287-296. Retrieved from http://journals.lww.com/jonajournal/Abstract/2008/06000/Increasing_Retention_of_New_Graduate_Nurses__A.8.aspx?trendmd-shared=0
Sherman, R. O. (2015). Boosting your influence. American Nurse Today, 10(12). Retrieved from https://americannursetoday.com/boosting-influence/
Spector, N., Blegen, M. A., Silvestre, J., Barnsteiner, J., Lynn, M. R., Ulrich, B., . . . Alexander, M. (2015). Transition to practice study in hospital settings. Journal of Nursing Regulation, 5(4), 25-38. Retrieved from www.ncsbn.org/Spector_Transition_to_Practice_Study_in_Hospital_Settings.pdf
Steen, J., Gould, E. W., Raingruber, B., & Hill, J. (2011). Effect of student nurse intern position on ease of transition from student nurse to registered nurse. Journal for Nurses in Staff Development, 27(4), 181-186. doi: 10.1097/NND.0b013e3181a68acc
Sullivan, M., Kiovsky, R. D., Mason, D. J., Hill, C. D., & Dukes, C. (2015). Interprofessional collaboration and education: working together to ensure excellence in health care. American Journal of Nursing, 115(3), 47-54. Doi: 10.1097/01.NAJ.0000461822.40440.58
Theisen, J. L., & Sandau, K. E. (2013). Competency of new graduate nurses: A review of their weaknesses and strategies for success. Journal of Continuing Education in Nursing, 44(9), 406-414. doi:10.3928/00220124-20130617-38
Trepanier, S., Early, S., Ulrich, B., & Cherry, B. (2012). New graduate nurse residency program: A cost-benefit analysis based on turnover and contract labor usage. Nursing Economic$, 30(4), 207-214.
Trossman, S. (2015). Collaboration is key: Nurse experts discuss challenges, pose solutions. The American Nurse, 47(5), 1, 8-9.
University HealthSystem Consortium. (2008). Nurse residency program executive summary. Retrieved from www.aacn.nche.edu/leading-initiatives/education-resources/NurseResidencyProgramExecSumm.pdf
U.S. Department of Veterans Affairs. (2012). Become a VA nurse. Retrieved from www.vacareers.va.gov/assets/common/print/Nursing_Brochure.pdf
Veterans Health Administration. (2011, November 23). VHA registered nurses transition-to-practice program. VHA Directive 2011-039. Washington, DC. Retrieved from www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2469
© 2016 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2016
- Registered Nurses as Caregivers: Influencing the System as Patient Advocates
Michelle A. Lucatorto, DNP, RN, FNP-C; Timothy W. Thomas, BSN, RN; Terry Siek, MSN, RN, NEA-BC (September 30, 2016)
- Registered Nurses as Professionals: Accountability for Education and Practice
Barbara Zittel, PhD, RN; Edtrina Moss, MSN, RN-BC, NE-BC; Ann O’Sullivan, MSN, RN, NE-BC, CNE, ANEF; Terry Siek, MSN, RN, NEA-BC (September 30, 2016)
- Enhancing Patient Safety: Factors Influencing Medical Error Recovery Among Medical-Surgical Nurses
Theresa A. Gaffney, PhD, MPA, RN; Barbara J. Hatcher, PhD, MPH, RN, FAAN; Renee Milligan, PhD, RN, WHNP-BC, FAAN; Amber Trickey, PhD, MS, CPH (September 30, 2016)
- Registered Nurses as Professionals, Advocates, Innovators, and Collaborative Leaders: Executive Summary
T.E. Williams; K. Baker; L. Evans; M.A. Lucatorto; E. Moss; A. O’Sullivan; P.C. Seifert; T. Siek; T.W. Thomas; B. Zittel (September 30, 2016)
- Registered Nurses Leading Innovative Changes
Timothy W. Thomas, BSN, RN; Patricia C. Seifert, MSN, RN, CNOR, FAAN; Jane Clare Joyner, JD, MSN, RN (September 30, 2016)