However, many obstacles continue to impede their full integration DiCenso et al. The integration of advanced practice nurses APNs into healthcare systems has relied heavily on nursing leaders at the national, provincial, regional and local organizational levels. At the national level, nursing leaders in government and professional associations have supported the integration of APNs in Canada in a number of ways.
This paper will focus on the roles of nursing leaders at the organizational level in facilitating the integration of CNSs and NPs in healthcare settings. This paper is based on a scoping review of the literature and qualitative interviews completed for a decision support synthesis that was conducted to develop a better understanding of advanced practice nursing roles, their current use, and the individual, organizational and health system factors that influence their effective development and integration in the Canadian healthcare system DiCenso et al.
The synthesis methods are described in detail in an earlier paper in this issue DiCenso et al. We conducted the scoping review using established methods Anderson et al. We conducted a comprehensive appraisal of published and grey literature ever written about Canadian advanced practice nursing roles, as well as reviews of the international literature from to In keeping with the tenets of scoping reviews, we did not exclude articles based on methodological quality.
Teams of researchers extracted data from relevant papers and analyzed the data using a combination of descriptive tables, narrative syntheses and team discussions. We also conducted four focus groups with a total of 19 participants. We used purposeful sampling to identify participants with a wide range of perspectives. When our synthesis was completed, CHSRF convened a multidisciplinary roundtable to develop recommendations for policy, practice and research.
For this paper, we integrated findings from the Canadian literature that described the role of nursing leaders in facilitating the integration of APNs with interview data from those who identified leadership issues, especially the 11 Canadian nurse administrators. These administrators came from five provinces and worked in academic teaching centres, regional health authorities, community care agencies and a rehabilitation and continuing care centre.
International literature has been used to provide global context and for further discussion about key issues when relevant. We highlight the most frequently mentioned themes that emerged from the literature and that were identified by our interview participants specific to leadership.
We begin with a general description of the importance of organizational leadership in supporting advanced practice nursing roles and then focus on the leadership role specific to planning for and implementing these roles. Senior nursing administrators play an important role in linking APNs to organizational priorities to improve nursing practice Bryant-Lukosius et al.
They identified challenges related to clarifying the reallocation of tasks, managing altered working relationships within the nursing team, and continuing to manage the team as new issues emerged. Based on these results, Reay et al. These strategies place an emphasis on working with the team and managing working relationships among all team members rather than focusing solely on individual NP roles.
Consistent with this literature, the administrators we interviewed recognized the importance of their role in providing support to APNs and enabling the integration of advanced practice nursing roles in their work settings, as the following quotes illustrate: I think the number one key factor is having the administrative support, and by administrative support I mean administrative leadership in the organization to help introduce, shape and help the role evolve.
And I think that really is the number one in a hospital setting. As more organizations have moved to program management, many CNSs and NPs report to supervisors who are not nurses but are from other health or business backgrounds; some NPs also report to medical directors or other physicians.
While there is limited research about the most effective models of advanced practice nursing role supervision, reporting to a senior nurse administrator may be important for negotiating the continued implementation of the role, addressing nursing practice—related role barriers, role socialization and supporting the development of a nursing orientation to practice Bryant-Lukosius et al. Participants commented on the important role administrators can have in ensuring that different reporting relationships for APNs are clear, as this administrator did: So an administrator does well when they can work at reducing that feeling of isolation for them [APNs] and having lots and lots of infrastructure support and having a very clear reporting relationship.
What does it mean to have a dual reporting relationship? Most APNs have one. It is the responsibility of those two, to whom they report, to figure out what does that look like and what can they expect from us as a team.
So those are really important. Nursing administrative leadership is critical to help streamline the advanced practice nursing integration process and to work with APNs to smooth the way for day-to-day practice. Responsibilities for planning for and hiring APNs are usually those of the nursing administrator.
The importance of undertaking a systematic process to assess patient or community needs, develop the advanced practice nursing role to address those needs, and introduce, implement, and evaluate the role was emphasized both in the literature Bryant-Lukosius et al.
Many of our participants highlighted how poor planning for CNS and NP role implementation under tight time pressures, sometimes in response to funding availability, was a barrier to the successful integration of the roles. Furthermore, as the following quote from an administrator illustrates, participants reported that it was a crucial determinant of successful role integration to first identify the service need or practice gap and, based on that assessment, then select the most suitable role for the position.
Developing guidelines, expectations and priorities for the CNS or NP position and creating a supportive environment facilitate role implementation and integration Bryant-Lukosius et al.
Cummings and McLennan discuss the importance of individualizing advanced practice nursing positions to ensure there is a good fit between the CNS or NP role requirements and the individual filling the role. Participants suggested that CNS and NP roles need to be dynamic and continuously negotiated based on the needs of patients, organizations and the healthcare system, and on the skill set of the individual CNS or NP.
As the following quote shows, NP and CNS participants agreed a role negotiation process was desirable: There certainly has to be recognition and acceptance at the administration level.
Various participants highlighted the importance of utilizing existing advanced practice nursing implementation toolkits Advanced Practice Nursing Steering Committee, Winnipeg Regional Health Authority ; Avery et al.
The Participatory, Evidence-based, Patient-focused Process for Advanced practice nursing role development, implementation and evaluation PEPPA framework as described by Bryant-Lukosius and DiCenso is a systematic healthcare planning guide used to minimize or prevent commonly known barriers to the effective development, implementation and evaluation of advanced practice nursing roles.
A number of participants from different provinces commented on how their use of the PEPPA framework gave them a structured, systematic, thorough and organized role implementation plan, as demonstrated by a quote from a nursing administrator.
We took the PEPPA framework right from the beginning, and we used the framework to build our call for applications for funding for a nurse practitioner. We shared the research. It is with reference to the PEPPA framework where we see the clear overlap between the insights garnered from literature and from the key informant interviews. An important consideration when planning for new health practitioner roles is the engagement of key stakeholders within and outside of the organization.
Participants emphasized the importance of the early involvement of key stakeholders such as physicians, staff nurses and other healthcare providers in planning and implementing NP and CNS roles. Most participants reported that the extra time, energy and resources needed to ensure stakeholder participation was worth the effort.
In the words of one administrator participant: Administrators noted that a lack of stakeholder involvement contributed to poor role clarity. Getting more into the same programs is not an issue because they [APNs] are well received. There was a sense from participants that strategies to enlist stakeholders have had good results in gaining their support and in addressing their concerns.
Implementing the Advanced Practice Nursing Role in Healthcare Settings Nursing leaders have many responsibilities related to the implementation of advanced practice nursing roles. Our results suggest the most significant responsibilities of nursing leaders implementing advanced practice nursing roles include finding and sustaining funding, providing adequate infrastructure and resources, ensuring utilization of all role dimensions, creating awareness of the roles, and enabling network support and mentorship.
Each is described below. Finding and Sustaining Funding. Nursing leaders often have the responsibility to find funding for advanced practice nursing roles. Administrators working in acute care organizations reported being forced to choose between funding an advanced practice nursing position or other registered nurse services, as this administrator explains: There needs to be support from an administrative level in terms of support for the development of new roles and responsibilities and the implementation, and that implementation needs to involve support and evaluation.
There needs to be support from other healthcare professionals, particularly physicians in terms of the collaboration.
The multidisciplinary roundtable convened by CHSRF to formulate evidence-informed policy and practice recommendations based on the synthesis findings recommended that advanced practice nursing positions and funding support should be protected.
Providing Adequate Infrastructure and Resources. Most administrator participants commented on the insufficient infrastructure resources, as the following two quotes from an administrator and an APN demonstrate. The system needs to be prepared to support them [CNSs] in that you need an office; you need a phone; you need a pager. You know you need space. It is very hard to put six CNSs in an office the size of a closet and think they can work there.
Inattention to basic resources such as office space, clerical support, communication and technology marginalizes the purpose and legitimacy of CNS and NP roles. Participants also noted a lack of supportive policies that would allow APNs to function to their full scope. Cummings and McLennan suggest that nursing leaders in healthcare settings can influence policy change and shape the healthcare system by facilitating changes in the workplace that continually improve quality of care and meet fiscal realities.
Ensuring Utilization of Role Dimensions. CNSs and NPs value the non-clinical aspects of their role, and these activities contribute to role satisfaction Bryant Lukosius et al. However, insufficient administrative support and competing time demands associated with clinical practice are frequently reported barriers to participating in education, research and leadership activities Bryant-Lukosius et al.
This is particularly problematic for NPs in acute care, who usually report to both a nursing and a medical director. A nursing administrator stated: They are delivering excellence in clinical care, personally working well with the team, with other interdisciplinary team members as well, but they have not been making as strong a contribution to the science of nursing, or to the development of the practice of nursing and certainly not to the development of the system.
Role expectations can be enhanced and negotiated by strong leadership from healthcare managers who can communicate a clear vision for the multiple dimensions of the role to team members and support the role within the organization Reay et al. As shown in the following quote from an APN, a key strategy to protect the various dimensions of the role is administrative support. Last is the ability to manage relationships; it is concerned with development, inspiration and influencing other people in the line of duty.
This implies that effective nurse leaders should be a positive inspiration to everyone they interact with and handle conflicts justly. Such skills will determine how nurses in leadership positions carry themselves and handle other people too Goleman, Other than the above mentioned personal skills in nurse-leadership, there are still myriad of knowledge and forms of attitudes required in effective nurse leadership.
In addition, nurses should possess personal qualities which include; courage, creativity, confidence, competency and collaboration. Leaders should generally show concern for the needs and objectives of staff members and understand conditions affecting work environment as this will improve performance in health centres Moiden, For instance, nurse leaders may challenge other nurses to act by allowing their contributions in decision making and promoting collaboration.
Nurse leaders today are challenged to work within myriad of challenges constantly experienced in health care environment Jooste, Effective leadership involves ability of nurse leaders to produce extraordinary things while being faced with various challenges. This will ensure continuity in operations and enhance development in health care systems.
It may require that nurse leaders move between leading and following frequently depending on circumstances Hyett, Good leadership in health care services will meet the needs of patients and handle complaints effectively Fradd, In addition, nurses need to be well educated to meet increasing needs in health care systems Cook, Leadership in nursing requires development to achieve efficiency in health care environment Marshall, In developing leaders, it is important to analyze and understand the tactical elements in nursing profession.
This is one job that requires a lot of sacrifices and self-motivation, and these are among personal attributes needed in nurse leaders Goleman, Nurses need to be better equipped with analytical and assertiveness skills because patients have become aware of their own health needs and have knowledge on treatment practices.
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Essay on the Definition of Leadership Styles in Nursing - Developing future nurse leaders is one of the greatest challenges faced by the nursing profession.
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