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Gayle A.

Fishman

Attending Registered Nurses:


Evolving Role Perceptions in
Clinical Care Teams
EXECUTIVE SUMMARY
Multiple new leadership roles in
A CALL FOR INNOVATIVE care
delivery models that im -
accountable for ensuring patient
care meets clinical standards (evi-
nursing have been described for prove care, enhance quali- dence-based practice) and coordi-
which the impact on the quality ty, and reduce healthcare nates decision making and commu-
and safety of care deliv-ery and costs is a key strategy to improve nication, notably during transitions in
on the costs of care delivery the U.S. healthcare system care. The goal for this new role is to
remain to be defined. Further, the (Berwick, Nolan, & Whittington, provide continuity of care for
appropriateness of training and 2008). Health care systems are patients and families with optimal
the optimal deploy-ment of implement-ing different approaches coordination of care, including dis-
personnel have not been to achiev-ing these interdependent charge planning. It was anticipated
investigated. goals known as the Triple Aim. New this intervention, coupled with other
In this study, in one such care care delivery models are emerging simultaneous administrative
model, attending registered along the fragmented continuum of changes (e.g., improved handoffs of
nurses’ perceptions of their role care and present solutions to some care, earlier discharge planning,
evolves from functional thinking aspects of the healthcare crisis. increased attention to patient and
to “looking at the big picture,” One strategy to reduce frag- family education, enhanced pre-
underscoring an increased level of admission evaluations, daily care
mentation in the hospital setting is
insight over time. coordination rounds) would reduce
the attending registered nurse (ARN)
The data highlight the impor- length of stay and readmissions,
role, designed to support delivery of
tance of ensuring “buy-in” from enhance patient satisfaction, and,
integrated, patient-cen-tered care at
peers to ensure success in ultimately, improve patient safety
Massachusetts General Hospital
leadership roles. and quality of care.
(MGH) in Boston, MA (Erickson,
These observations are mutual-ly According to Benner’s model for
Ditomassi, & Adams, 2012). The
reinforcing; improved leader-ship ARN is an experienced staff nurse knowledge and skill acquisition in
and communication skills who, with the attending physician, is nursing, skills and acquisition of
responsible for ensur-ing the nursing expertise develop within five
produces greater acceptance by consistent and timely pro-gression levels: novice, advanced begin-ner,
peers. of each patient’s care from competent, proficient, and expert
admission to discharge. The ARN (Benner, 1984). Nurses at each
maintains a constant presence on level demonstrate changes in three
GAYLE A. FISHMAN, DNP, MBA, RN, NEA- key aspects of practice: move-ment
BC, is Nursing Director, Endoscopy Units,
the unit 5 days per week as a
Massachusetts General Hospital, MA. resource for both patients and fam- from dependence on con-cepts to
ilies and other staff. The ARN is use of accumulated experi-

12 NURSING ECONOMIC$/January-February 2018/Vol. 36/No. 1


ences as exemplars; a change from A review of the literature was patient care facilitator position pro-
compiling individual situational conducted using key search terms vides clinical leadership roles for
events to appreciating more holis-tic including attending registered nurse, nurses within smaller areas of
views; and movement from observer care delivery model, collabo-ration, patient responsibility. The aim was
to involved performer. In this continuity of care, navigator, nursing to ensure a caring and professional
framework, the ARN role lever-ages role, patient care facilitator, and practice culture for patients and
both the knowledge base and practice innovation. Search engines clinical staff (Brown et al. 2005).
leadership experience of selected used to conduct the search included Brown and colleagues conducted a
staff nurses to coordinate care for CINAHL, Cochrane Data-base of qualitative and quantitative multi-
complex patients often across mul- Systematic Reviews, and the Na method study to measure the
tiple teams of providers, mentor-ship tional Guidelines Clear ing House patient care facilitator role (inde-
of nursing staff, and applica-tion of via interfaces including EBSCOhost, pendent variable) on continuity of
hospital guidelines and other Ovid, and Nursing@ Ovid. The care and caregiving behaviors of the
educational resources to clin-ical study focused on evalua-tion of nursing staff (dependent variable).
care. evidence related to forma-tive Batcheller, Burkman, Armstrong,
The purpose of this qualitative experiences contributing to Chappell, and Carelock (2004) stud-
descriptive study was to describe development of skills required for ied the impact of an innovative
changes in the perception by ARNs the ARN role. Inclusion criteria also nursing infrastructure in a seven-
of their role after working in the included evidence describing where hospital network in which the nurse
position for 2 years. Seven ARNs, nurses develop skills (acade-mic retained the primary over-sight role,
who were interviewed in 2012, were preparation, specific job train-ing, or provided long-term men-torship for
re-interviewed in 2014 using the experience in the role), inno-vative new employees, and provided the
same semi-structured interview care delivery models de-scribing primary interface with patients. In
guide to assess changing role specific nursing attributes in the these studies, RN-led models using
perceptions over time. role, and articles written in English. experienced nurses as the team
leader demonstrated positive
Background The literature described four outcomes including im-provement in
The Institute of Medicine (IOM) general categories of nursing roles nurses’ perceptions of the frequency
Report, Crossing the Quality Chasm: A focusing on patient-centered care: of assessment by experienced RNs
New Health System for the 21st faculty-led attending nurse of patient readi-ness for discharge,
Century, described a healthcare models, advanced practice RN-led physician per-ceptions of the
delivery system poorly organized to models; clinical nurse leaders-led availability of expe-rienced RNs,
meet national health-care needs. models, and RN-led models. This reduction in RN staff turnover,
“The delivery of care often is overly review focused on RN-led models. reduction in medication errors
complex and un-coor dinated, RN-led models of care evolved (Batcheller et al., 2004), and
requiring steps and patient handoffs from traditional models including improved patient perceptions of staff
that slow down care and decrease patient-focused care and case knowledge of care and dis-charge
rather than improve safety” (IOM, management roles (Deutschendorf, plans (Brown et al., 2005). The
2001, p. 1). This report called for 2003). Common programmatic com- economic implications of these
redesigned priorities for providers to ponents contributing to success in- observations include direct health-
funda-mentally improve care. These clude elevating the RN role, in- care benefits of nurse retention (var-
in-cluded “reengineered care pro- creasing focus on patient and fami- iously estimated at 0.75-2 times the
cesses; effective use of information ly involvement in care, smoothing salary of each lost nurse), reduced
technologies; knowledge and skills patient transitions and handoffs, patient length of stay, and reduced
management; development of effec- leveraging technology to enable potential exposures to medication
tive teams; and coordination of care care model redesign, and providing errors (Jones & Gates, 2007).
across patient conditions, services, results-driven care (Kimball, Joynt, Erickson and coauthors (2012)
and sites of care over time” (p. 2). Cherner, & O’Neil, 2007). described the Attending Registered
The IOM (2001) described six aims A series of inpatient models Nurse Model at MGH. Innovation
to improve individual and commu- address the need for patient-fo- units were created on 12 inpatient
nity healthcare services: safe, effec- cused clinical care and improved units to “improve clinical out-comes,
tive, patient-centered, timely, effi- handoffs across the healthcare sys- enhance patient and staff
cient, and equitable care. The tem to enhance nursing leadership satisfaction, as well as reduce costs
changing healthcare environment and participation in care. Ac-cord- and lengths of stay for hospitalized
provides an opportunity to reexam- ing to Clark (2004), the 12-bed hos- patients” (p. 283). While 12 inter-
ine staffing roles and processes pital at the Baptist Hospital of Miami ventions were implemented simul-
within the acute care setting. provides a care model for a cure- taneously on innovation units, the
dominated environment. The ARN was considered the consistent

NURSING ECONOMIC$/January-February 2018/Vol. 36/No. 1 13


presence on the clinical team, working ing is the extension of practical at MGH and ARN perceptions of
5 days per week, providing continuous knowledge through research and that role. For this study, the same
relationships with patients, families, description of experiences in clini- interview guide was used to re-
and healthcare team. The ARN cal practice. She proposed expert interview ARNs remaining in the
developed and coor-dinated nurses develop skills and under- position 2 years later. Key elements
interprofessional teams’ clinical plans standing of patient care over time of the interview are described
for inpatient admis-sions. The ARNs as a function of both education below. Study subjects included all
were experienced, highly respected and experience. She suggested nurses in the ARN role for at least 2
nurses who partic-ipated in a clini-cians could gain knowledge years at the selected time points.
comprehensive curricu-lum including and skills (knowing how) without Setting and sample. The MGH is
role-specific educa-tion for the learn-ing theory (knowing that). an academic medical center within
innovation unit pro-gram. The program Benner, Hughes, and Sutphen Partners Healthcare, the largest
augments ARN’s skills related to (2008) suggested a cycle exists healthcare system in
conflict reso-lution, resiliency, and between experiential knowledge and Massachusetts. The author con-
communica-tion. ARN discussion scientific investigation: experi-ential ducted the interviews in 2012 and
groups pro-vided forums to share knowledge stimulates scien-tific 2014. All ARNs from the 2012
experiences, observations, and best investigation and scientific study were invited to participate.
practices. This model was designed to investigation fuels a cycle of further Eligibility criteria included partic-
sup-port the challenge of delivering experiential learning. In Benner’s ipating ARNs who had been inter-
integrated, patient-centered care at a construct, the repository of clinical viewed in June 2012 and were
large academic health center. To date, knowledge and experience is in the identified by the department of
there are no published out-comes of clinical team with responsibility for nursing as remaining active in the
the ARN model. Quan-titative data will optimizing clinical care (Benner, role. All ARNs meeting eligibility
be evaluated in the future including 2001). The ARN model builds on the criteria agreed to participate in the
culture of safety surveys, Hospital team concept by providing team study. Interviews were conducted
Consumer As-sess ment of leadership to leverage the experi- with 16 subjects in 2012 and all of
Healthcare Provi ders and Systems ence of senior staff to provide men- the 7 remaining ARNs in 2014.
(HCAHPS) survey, length of stay, torship and knowledge transfer Data collection. Interview data
quality indicators, patients’ within care teams. The clinician’s were collected by the author using
perceptions of feeling known, cost per past experience from specific clini- a semi-structured interview guide.
case mix, and staff retention. cal cases positions him or her to Key elements of the interview
identify future similar cases which included subject’s perceptions of
provides educational and research relationship-based care and ARN
In addition to the economic opportunities. Benner suggested role; the adequacy of training and
benefits of nurse retention and nurses develop skills and under- resources provided for subjects
reduction in clinical errors, the ARN standing of patient care over time and clinical staff; barriers to suc-
has an important role in the through a sound educational base cessful job performance; role-spe-
maintenance of the nursing knowl- and a multitude of clinical experi- cific changes in interactions with
edge base and in mentorship. A key ences. Clinical situations are more patients, families, and staff; and
element is the identification of those complicated and dynamic than the- the role of technology in job per-
skills required to evolve into the oretical scenarios; practice provides formance. Participants were inter-
leadership role. Benner’s Novice to a valid source of knowledge evolu- viewed individually in a private
Expert model, used to guide the tion. Through experiences and study hospital conference room. The
study, encompasses pro-gression of clinical practice, nurses discover interviewer took notes during the
from novice to expert cli-nician. new knowledge. meeting. Following each inter-
Benner adapted Dreyfus and view, the author’s typed summary
Dreyfus’ Model of Skill Acquisition Methods of responses was emailed to sub-
and Skill Development to clinical This study used a qualitative jects within 24 hours. Each partic-
nursing practice (Benner, 1984). descriptive design (Sandelowski, ipant was invited to edit or com-
“The Dreyfus and Dreyfus model 2000). Data were collected using a ment on the written summary until
provides concepts to differ-entiate semi-structured interview tem- satisfied with his or her answers.
between what is taught by precept plate developed in 2012 and This editing and refine-ment
(i.e., teaching) and what must be applied to the same subjects. process was done via email to
learned experientially from Initial interview data from 2012 ensure process validation. Some
comparison of similar and dissimi-lar were collected as part of a larger participants provided detailed
cases” (Benner, 1984, p. 186). project in which ARNs were inter- changes, which were incorporated
Benner (1984) posited that viewed to assess adoption of 12 into a final document. All partici-
development of knowledge in nurs- interventions from innovation units pants provided final email confir-

14 NURSING ECONOMIC$/January-February 2018/Vol. 36/No. 1


mation their responses for each Table 1.
perception were described accu- Themes and Subthemes
rately. Following email confirma-
tion, data were de-identified, Theme 1: From Tasks to Teams
replacing participants’ names with Subthemes Subthemes
numbers. 2012 2014
Ethical considerations. The
Care plans Communication
MGH Institutional Review Board Discharge planning Team builder
and the Spaulding Rehabilitation Patient education Continuity
Hospital Institutional Review Individualized plan of care
Board approved the 2014 study.
Informed consent and authoriza- Theme 2: From Pushback to Buy-In
tion were implied by voluntary Subthemes Subthemes
participation in the interview. The 2012 2014
author had no conflicts of interest
Role confusion Role clarification
related to the study. Ambiguity Collaboration
Data analysis. Data generated
from each interview were organ- Negative response Positive response
ized in a matrix to allow direct
comparison between individuals
and over time. The author and 2000). An audit trail was main- roles related to team-based func-
Ruth Palan Lopez, PhD, GNP-BC, tained for participant response tions (2014) as compared with
a researcher with expertise in confirmation. Performing joint data nar-rower task-oriented roles
qualitative analysis, analyzed analysis targeted increased (2012) (from tasks to teams); and
written notes from both interview reflexivity, diminished bias, and (b) reduced staff pushback to the
periods using an iterative process enhanced internal consistency. role (2012) with greater buy-in or
of description, analysis, and inter- Discussions ensured consensus acceptance (2014) (from pushback
pretation (Wolcott, 1994). The around each theme. Data analysis to buy-in). All ARNs demonstrat-ed
process included three levels of was refined until higher levels of increased clarity in under-standing
coding: coded concepts for major categories accounted for all ques- of the ARN role and con-fidence in
themes; assess similarities and tions included in the study. that role over the study period
create higher-level categories; and (see Table 1).
identify relationships between Results From tasks to teams. When asked
categories across individuals and Available subjects were inter- about role perception in year 1, ARN
over time. During first-level cod- viewed at both time points. Parti- responses centered on spe-cific
ing, interview reports were read cipants were all RNs, female, 30-56 tasks including developing care
jointly line-by-line, highlighting key years of age (mean 45.6; SD 10.6). plans, planning for discharge, and
words and assigning a code to All participants were Caucasian and conducting patient education. In
each concept. During second-level had at least 6 years nursing contrast, when asked about the role
coding, similarities in concepts experience on their units. Five in year 2, they described
were identified that were col- nurses had a bachelor of science responsibilities including commu-
lapsed into higher-level cate- degree in nursing and two had mas- nication, team builder, continuity,
gories. In third-level coding, cate- ters in nursing degrees. All nurses and individualized plans of care (see
gories were analyzed to identify had at least 4 years experience in Table 1). In 2012, ARNs used terms
relationships and differences over leadership roles on the unit (charge such as ensure continuity of the plan
time. Themes were compared or resource roles) prior to assuming of care, being present daily, support the
between individuals over time (see the ARN role in 2012. All partici- patient’s discharge planning needs,
Table 1). pants had been an ARN for 2 years. helper, and extra pair of hands. By
Strategies were employed to contrast, in 2014, all ARNs
enhance the trustworthiness and Findings described the role with terms
credibility of study processes and Analysis of interview data from including communication,
findings. An audit trail was main- 2012 and 2014 revealed par- collaboration, team builder, and
tained of research methods, sam- ticipants demonstrated greater knowing patient and family. One ARN
pling processes, data collection, insight into their roles after 2 described her role as “collabo-rative
respondent validation, content years. Changes in perception – like part of a braided pony-tail”
management, data analysis, and included two major themes at the using strong communication skills to
data re-presentation (Mays & Pope; highest level: (a) ARNs demon- help bring together all members of
2000; Patton, 1990; Sandelowski, strated increased awareness of the nursing team. She

NURSING ECONOMIC$/January-February 2018/Vol. 36/No. 1 15


felt the role was to ensure the nursing director was key to suc- with experience, the nurse demon-
team was in agreement regarding cessful transition into the effective strates the increased ability to rec-
care plans for patient and family. ARN role. The ARNs said nursing ognize patterns and gain perspec-tive
She believed this to be supportive directors held regular staff meet- and greater efficiency in deci-sion
of relationship-based care. All ings when the role was initiated to making (Benner, 1984). In 2014 in this
ARNs described a focus on team manage negative perceptions and study, movement was demonstrated
building through collaboration and allow staff to voice concerns and toward looking beyond narrow tasks
facili-tating communication. Each address issues. Another factor in and evaluating the entire clinical
ARN told patients nurses were to successful transition into the role scenario includ-ing patients, families,
care for them “for the day” and the was weekly ARN peer support and care teams. While the new role
ARN would manage the care “for groups, called “brown bag lunch- was ini-tially challenging from both
the stay.” Communication, team- es.” These lunches provided a pur-pose and peer-acceptance
work, presence, knowing the patient, forum for ARNs to share individ- perspec-tives, ARNs described staff
and individualizing plans for care ual challenges, experiences, and as increasingly accepting of the posi-
were terms used to describe the successes in a safe environment. tion over time as ARNs improved
ARN role in 2014. This suggests One ARN learned to provide sup- communication skills, supported unit
an increased aware-ness of the port to the staff by helping with staff, and led the care team in
potential value of the role and the some functional nursing tasks managing patient care plans and
ability to look at the bigger picture. such as medications or bathroom discharges. The key element for suc-
This understanding allowed ARNs requests. She believed such cess in both areas was a supportive
to be more active in support of assis-tance accelerated role environment created by peers and by
staff nurses and in dis-charge acceptance. All of the ARNs noted unit and hospital leadership.
planning. contribu-tions of the nursing
From pushback to buy-in. In director, brown bag lunches, and Benner (1984) suggested
2012, in response to the new role, provision of added support practi-tioners could gain knowledge
all ARNs described pushback from enhanced under-standing and and skills without learning theory.
the staff nurses on their units. In acceptance by staff of the ARN She noted clinical situations are
contrast, interview data from year 2 position over 2 years. These shifts more complicated and dynamic than
revealed ARNs report-ed buy-in resulted in greater acceptance of the-oretical scenarios, so clinical
and acceptance by the staff. ARNs, enhancing their function prac-tice provides a valid source of
Pushback was described by ARNs and the quality of the experience. knowledge evolution. Through both
as role confusion, ambigui-ty, and experience and studying of clinical
negative responses by staff nurses. Discussion practice, nurses discover new
ARNs experienced a major This study was designed to knowledge. This study
challenge in describing the new examine how ARNs perceived demonstrates ARNs’ role percep-
role to the staff. Unit staff nurses changes in their role after 2 years tions evolved over time from task-
were concerned ARNs were not of experience. The data demon- oriented (care plans, discharge
assigned patients, especially when strate that with experience, ARNs’ plans, and patient education) to
there were absences. One ARN perceptions of the role changed viewing the whole care delivery
noted, “The staff exhibited some from a task focus to a team focus, process (communication, team-
strong reactions and some bitter- and from staff pushback to accept- work, presence and knowing the
ness to my role change.” Another ance. They described greater patient, and individualizing the plan
ARN said, “The biggest challenge understanding of the purpose of of care). In 2014, ARNs described a
comes from the staff pushing back their role within the totality of focus on the “patient’s stay, not just
when working with them, pa - patient care. the day.” This growth in awareness
tients, and families.” While research supports the allows ARNs to pro-vide more
In 2014, evidence of buy-in benefits of an RN-led model of care substantive support to staff nurses
included various subthemes includ- (Batcheller et al., 2004; Brown et al., in patient care and ensure patients
ing increased understanding of the 2005; Clark, 2004), less is known experienced smooth-er clinical care
ARN role by staff nurses (role clari- about experience of nurses in these and discharge plan-ning processes.
fication) as well as collaboration and roles. The findings of this study In creased role clari-ty and
positive responses from staff nurses related to the task to team theme are confidence appeared to enhance job
(see Table 1). In the 2014 consistent with Benner’s concept of performance, satisfac-tion,
interviews, all of the ARNs movement between novice, advanced communication skills, and
described buy-in from nursing peers practitioner, and competent nurse. acceptance by staff.
with a supportive team environ-ment The novice demonstrates rule- The lack of acceptance of the
on each unit. Each of the ARNs said governed behav-ior that is rigid and ARN role by staff nurses has not
leadership of the unit limited while been addressed in previous stud-

16 NURSING ECONOMIC$/January-February 2018/Vol. 36/No. 1


ies of new nursing leadership porated multiple administrative from peers to ensure success in
roles. It is notable that of the 16 changes at the time of introduction leadership roles. These observa-
nurses in the initial ARN group of the ARN role. Data on staff nurse tions are mutually reinforcing;
interviewed, only 7 remained at 2 retention are not yet available from improved leadership and commu-
years into the program. The basis the ARN-based innovation units. An nication skills produce greater
for this observation is unknown. assessment of quality and safe-ty acceptance by peers. These find-
The available data indicate the data, readmissions, and other ings should influence design of
need for institutional and local financial indicators is ongoing. training and support programs for
support as well as the importance nursing leadership positions in the
of specific training for ARNs and Limitations future. Structured orientation for
staff nurses that anticipates Small heterogeneous sample, other staff to introduce new clinical
adverse responses to the new derived from one hospital on leadership positions will be
lead-ership roles. In a more seven inpatient units, limits gen- essential. Such roles will be
general framework, introduction of eralizability. However, findings pivotal in the evolution of inter-
new leadership roles will require illustrate the importance of a professional clinical care and to
clear articulation of goals and development process for nurse improve transitions of care.
expecta-tions of such positions leaders. As nurses assume new However, to be successful, they
and met-rics to assess acceptance roles in the healthcare delivery require significant investment in
and impact of such innovations. system, including major leader- training and support by local lead-
The observation that resistance to ship roles, they will require train- ership. Each new intervention will
the role dissipated over time ing and support specific to those require parallel evaluation of the
suggests adaptation of ARNs to new positions. When the ARN role sustainability of clinical and
their new roles alleviates was introduced in 2012, mul-tiple financial benefits for the health-
resistance by care teams. care system. $
care interventions at the same
Despite growth in individual and
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