Conceptual Framework of ACNP Role and Perceptions of Team Effectiveness
Conceptual Framework of ACNP Role and Perceptions of Team Effectiveness
A conceptual framework from Canada by Kilpatrick, Lavoie-Tremblay, Lamothe, Ritchie, and Doran (2013) was developed using cross-case analysis to describe key concepts that affect ACNP role enactment, boundary work, and perceptions of team effectiveness (Fig. 2.10). The development of the conceptual framework was influenced by the conceptual framework of Sidani and Irvine (1999) for evaluating the NP role in the acute care setting and the Donabedian (1966, 2005) model of quality care that incorporates structures, processes, and outcomes.
Presented as multiple concentric circles, this conceptual framework has three central process dimensions at its core: ACNP role enactment, boundary work, and perceptions of team effectiveness. There is a bidirectional relationship proposed between the central process dimensions. Key concepts are identified within each central process dimension and include medical and advanced practice nursing and role (ACNP role enactment process dimension); creating space, loss, trust, interpersonal dynamics, and time (Boundary Work process dimension); and decision making, communication, cohesion, care coordination, problem solving, and a focus on patient/family (Perceptions of Team Effectiveness process dimension). Although key concepts are identified, the conceptual and operational definitions of these concepts are not presented.
Moving outward from the core of the conceptual framework are five concentric rings representing different layers of the structural dimensions (Patient, ACNP, Team, Organization, and Health care System) that affect the central process dimensions. The proximity of the layers is important: the closer the structural layer is to the core, the more the direct effect is on the central process dimensions. Dotted lines between the process and structural dimension represent the bidirectional relationship between the dimensions. Outcomes indicators include quality (timely care, patient follow-up, improved discharge planning); safety (safe patient discharges); cost; and team improved staff knowledge.
Given the recent emphasis on teamwork and the enactment of highly functioning interprofessional teams to achieve improved patient outcomes, this framework is timely and novel because it focuses on the impact of ACNPs on teamwork. Future work should focus on the measurement of outcomes specific to and reflective of APRN care in light of the current scope of practice legislation, organizational support for the role, and patient and family perceptions of team effectiveness.
Model for Maximizing NP Contributions to Primary Care
Poghosyan, Boyd, and Clarke (2016) have proposed a conceptual model to optimize full scope of practice for NPs in primary care (Fig. 2.11). After completing a thorough review of the literature, the authors developed a comprehensive model describing potential factors that affect NP care and patient outcomes. Three factors were identified: scope of practice regulations, institutional policies, and practice environments. Scope of practice regulations is defined as regulations across the United States that vary from state to state (despite competency-based educational preparation and national certification examinations) that create barriers to NPs’ abilities to practice to their full education and training, thereby creating barriers to optimal NP practice (e.g., hospital admitting privileges, recognition of primary care provider status, prescribing autonomy). Institutional policies are described as idiosyncratic differences between organizations even within the same state or jurisdiction that negatively impact an NP’s ability to deliver patient care. These include restriction in NP practice beyond state legislation or regulation. Practice environments that support NP practice are defined as those that promote high-quality patient care and maximize the effectiveness and utility of primary care NPs. Positive practice environments promote favorable relationships between NPs and physicians and NPs and administration that support independent NP practice. Additionally, effective communication, similar vision and prioritization of care and teamwork support a favorable practice environment for primary care NPs. Lastly, negative issues that affect NP workforce outcomes include high workloads, complex patients, rapidly changing administrations, and organization structures. These negative issues can lead to job stress, job dissatisfaction, burnout, and turnover.
The authors are commended on their work to develop a conceptual model to optimize full scope of practice for primary care NPs. As the authors noted, additional research is needed to fully understand the impact of restricted scope of practice and institutional policies on NP care and patient outcomes. Although the relationships between and among the variables will need to be tested, the model holds the potential to inform policy, practice, and patient outcomes.
Section Summary: Implications for Advanced Practice Nursing Conceptualizations
When one considers conceptualizations of advanced practice nursing described by professional organizations and individual authors, similarities and differences emerge. Many conceptual models address competencies that APRNs must possess. All are in agreement that the direct care of patients is central to APRN practice. Most models affirm two or more competencies identified by Hamric, and some models emphasize some competencies more than others. Some models (e.g., the Calkin and Strong models) address the issue of skill mix as it relates to APRNs, an issue of concern to administrators who hire APRNs. A notable difference across models is the extent to which the concept of environment as it relates to APRN practice is addressed. Another noted difference in the models is that only the Hamric model addresses all four APRN roles (CNS, CRNA, CNM and NP). In the next section, selected models that APRNs may find useful as they develop and evaluate their own practices are described.
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