http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, 2014; 28(3): 260–266 ! 2014 Informa UK Ltd. DOI: 10.3109/13561820.2013.867838

ORIGINAL ARTICLE

Labour saver or building a cohesive interprofessional team? The role of the nurse practitioner within hospitals Christina Hurlock-Chorostecki1, Cheryl Forchuk1, Carole Orchard1, Mary van Soeren2, and Scott Reeves3 1

Labatt Family School of Nursing, Western University, London, Ontario, Canada, 2School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada, and 3School of Nursing, University of California, San Francisco, CA, USA

Abstract

Keywords

Nurse practitioners (NP) are employed within hospital interprofessional (IP) teams in several countries worldwide. There have been some efforts to describe the nature of the NP role within IP teams largely focussing on how the role may augment care processes. Here, using a constructivist grounded theory approach, the perceptions of NPs about their role were compared and integrated into a previously published team perspective as the second phase of a larger study. Seventeen hospital-based (HB) NPs across Ontario, Canada, participated in group and individual interviews. The NP perspective substantiated and expanded the previously reported team perspective, resulting in an IP perspective. The three practice foci illustrating role value meaning of this perspective became: evolve NP role and advance the specialty, focus on team working, and hold patient care together. The IP perspective, juxtaposed with an existing contingency approach, revealed that NPs were promoting IP work, predominantly at the collaboration and teamwork levels, and aiding IP team transitions to appropriate forms of IP work. The practice, ‘‘focus on team working’’’ was strongly related to promoting IP work. The findings were consistent with HB NPs enacting a role in building IP team cohesiveness rather than merely acting as a labour saver. This is the first study to align NP and team understanding of HB NP role value using an IP framework.

Focus groups, grounded theory, hospital, interprofessional practice, nurse practitioner, teams

Healthcare renewal includes a focus on transitioning from siloed professional practices to care by synergistic groups of healthcare professionals working to their full scope of practice across the healthcare system (Romanow, 2002). Research findings regarding interprofessional (IP) collaboration and teamwork suggest these strategies improve use of clinical resources, increase access to healthcare, reduce conflict between healthcare professionals, and improve patients’ care quality, safety and outcomes (Closson & Oandasan, 2007; Frank & Brien, 2008; Zwarenstein, Goldman, & Reeves, 2009). However, there are limited data on setting specific strategies that augment or limit team development and process; specifically how collaboration occurs within hospital teams remains unclear (O’Leary et al., 2010). The nurse practitioner (NP) role within hospital teams is of interest because of the unique dual role within traditional medical practice (such as prescribing and diagnosing), and nursing (such as physical care and psychosocial support) supports the ability to cross this professional boundary (Kleinpell, 2005; Litaker et al., 2003; Sidani & Doran, 2010). Findings from several studies indicate the NP role is pivotal in hospital IP team work (Desborough, 2012; van Soeren, Hurlock-Chorostecki, & Reeves, 2011; Williamson, Twelvetree, Thompson, & Beaver, 2012).

Correspondence: Dr. Christina Hurlock-Chorostecki, PhD, NP, Western University, London, Ontario, Canada. E-mail: [email protected]

Received 13 March 2013 Revised 18 November 2013 Accepted 18 November 2013 Published online 17 December 2013

There is no clear evidence of how the NP role enhances IP team work in spite of indication from team members and NPs that this role is effective within the team context (Kilpatrick et al., 2012; van Soeren et al., 2011). To explore this phenomena, a two-phase study was completed using team members’ and NPs’ perceptions of how the NP role was enacted within the IP team. The aim of the study was to critically explore HB NP role value. Two research questions were posed: (1) what is the hospital team members’ shared perception of the value of the NP role working within hospital teams, and how does this relate to the NP shared perception? (2) How do the shared perceptions relate to the socio-political influences and position of the NP role within hospital teams? Phase one of the study explored the team member shared perception of NP role value within hospital teams. A team perspective framework emerged from the first phase of the study and revealed that the HB NP role value meaning for team members was linked to three categories and 13 sub-categories (Hurlock-Chorostecki, Forchuk, Orchard, Reeves, & van Soeren, 2013). The most valued category was that of a ‘‘labour saver’’. The remaining two categories described expectations to evolve practice for the team, and centrality of the HB NP role in holding patient care together. This framework presented new knowledge of team member expectations and understanding of HB NP practice. Phase two explored the NP shared perception of their role value, examined how the team shared perception related to the shared NP perception, and exposed how these relate to the socio-political influences of power that position the NP role within the teams. Described in this paper are the results of the NP

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Introduction

History

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shared perspective, relating this with the existing team perspective framework, and situating these within the hospital IP team setting.

Methods Charmaz’s (2006) approach to constructivist grounded theory was used to explore data from NP interviews and integrate the findings with team member results previously reported (HurlockChorostecki et al., 2013). This approach holds values and methods that differ from the classic grounded theory. Because this approach is interpretive, explores how and why meanings and actions are constructed, values the researcher’s view, explores power influences, and positions emerging theory with current theory it was deemed most appropriate for this study (Charmaz, 2000, 2006). Western University Research Ethics Board and the Lawson Clinical Research Impact Committee provided ethical approval for this study. Data collection NPs employed within Ontario hospitals were invited to participate in group or individual interviews. Email invitations were circulated by key hospital stakeholders and the NP professional organization. NP inclusion criteria consisted of: registration with the College of Nurses of Ontario (2012) in the extended class of nursing (inclusive of all NP specialty certificates); current employment within a hospital team in the role of NP working with patients, and employed in the current NP role for greater than one year. Seventeen NPs (15 females, two males) from seven Ontario hospitals were participated. Nine were employed in academic hospitals and eight in community hospitals, three of which were employed in a northern Ontario location. Five NPs worked strictly within in-patient teams, six strictly with out-patient teams, and six worked in a team providing care for both in- and out-patients. Twelve different specialty practices were represented: geriatric consult (n ¼ 2), neurosurgery, orthopedics, diabetes, geriatric rehabilitation, renal dialysis, emergency (n ¼ 3), intensive care (n ¼ 2), trauma, oncology, cardiology (n ¼ 2), and veterans care. Ten participants held Adult NP certification, five held Primary Health Care (PHC) certification, and two held dual certification in Adult and PHC. The range of years employed as an NP was two to 26 (mean 10). Group and individual interviews were audio-taped and transcribed verbatim. The interview process first invited participants to share their perception of their role value. Once the HB NP participants concluded their discussion and had nothing further to add to their role value perception, the team perspective framework from the first phase of the research project was shared with them. This provided the opportunity to explore their perception of what was realistic, missing or understated.

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comment on what was ‘‘invisible’’ work, to whom it was invisible, and why invisible work was important in understanding HB NP practice. Once no new categories emerged, and existing categories were theoretically saturated, the analysis of the NP data was determined complete. The established NP perspective enabled a comparison of constructed meanings and actions for relationships. Theoretical sorting and diagramming were completed to compare categories of the two perceptions at an abstract level (Charmaz, 2006). Comparing category properties, contexts in which the category existed, and the importance of the category aided in identifying convergent and divergent perspectives. Integration of the two perspectives fostered substantiation and extension of the team perspective, and emergence of an IP perspective. Expert opinion was sought throughout the process and exploration of existing theory enriched comparisons (Charmaz, 2006). One key category, ‘‘focus on team working’’, triggered interest in exploring for clarity and relevance with IP teamwork theoretical literature to establish how this category held up to existing theory (Charmaz, 2006). Analysis was completed in five linear steps: (1) Constructing the NP perspective of their role value. (2) Constructing the NP response to the team perspective framework. (3) Exploring how the NP and team perspectives relate. (4) Converging the two perspectives. (5) Juxtaposing the converged IP perspective with extant IP theory. The final product of the analysis was an emerging theory of HB NP IP practice constructed from a grounded team perspective, and informed by the NP perspective, influences of power and extant theory (Charmaz, 2006).

Results The nurse practitioner perspective Three categories of actions arose from the analysis of the NPs’ perception (evolving the NP role and advancing the specialty, focusing on team care and focusing on patient care). The category expressed most intensely and frequently was evolving the NP role and advancing the specialty. The remaining two categories, focusing on team care and focusing on patient care, were less frequent expressed although equally valued. Eight related subcategories represent NP perceived approaches of enacting each category, describing how the actions were constructed. The subcategories emerged as, creating and evolving the NP role, responding to program gaps, working together, enabling team efficiency, educating team members, reducing patient/family burden, being available to patient and family, and working with legitimate authority.

Analysis

Evolving the NP role and advancing the specialty

Analysis included line-by-line coding within each interview and then between interviews. NVivo 10, computer software from QSR International, aided constant comparison. Focus was maintained on explicating action rather than describing therefore supporting category rather than theme development (Charmaz, 2006). Regular principal researcher reflection, and advanced practice nurse and IP expert reviews ensured scrutiny for personal preconceptions thus established emerging categories as credible, original and clear. Theoretical sampling was used to qualify and elaborate emerging category boundaries. For example: Questions related to ‘‘invisible’’ NP work arose through researcher memoing. In subsequent interviews HB NP participants were invited to

This category centers on identification of gaps in the healthcare system and how NPs adjust their role to address the gaps. NP discussion of this category was frequent, intense and emerged consistently across all interviews. The importance of evolving the role and advancing the specialty was to improve patient care quality and safety, and sustain the NP role. One NP described the importance of evolving the role and advancing the specialty as: To practice our role in the way we feel, within our scope of practice, is appropriate for the service that we’re working with, the population we’re working with, and the workload we’re working with. . . (NP #1)

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This category has two related sub-categories – ‘‘creating and evolving the NP role’’ and ‘‘responding to program gaps’’.

help us with this, let’s bring this group together and maybe we can develop an approach to this particular problem (NP #17)

Creating and evolving the NP role. This was daunting to many NPs. Most discussed the importance of building trust in both the NP role and themselves as key to successful role implementation. Most described support from hospital leaders, physicians and NP peers as key to success. When support was lacking, NPs felt unvalued and unable to enact an effective role. Overpowering leaders and physicians restricting the NP role were major influencers of NP role dissatisfaction and resignation:

NPs discussed trust as important for team work. More frequently, NPs described a need for appreciation and inclusion. Appreciation for the NP role and inclusion within the social team environment were expressed by as many as important to sustain what NPs felt was an interdependent, respectful atmosphere. Without appreciation and inclusion, most NPs spoke of dissatisfaction with the role and several provided this as a reason for resignation. Many NPs described not fitting ‘‘into the nursing world [nor] into the physician world’’ (NP #16) as exclusion leaving them isolated. Most NPs described the ‘‘incredible power’’ (NP #16) that team members continue to provide to physicians as negatively influencing working cohesively. One participant stated it this way:

The NP role was not empowered by the physicians at all; they hadn’t asked for it, they didn’t want it, they had no interest in it. (NP #16) NPs described negotiating, and challenging powerful roles as important when support was lacking to ensure an effective role. Leadership skills and mentoring were discussed as crucial in creating and evolving an effective NP role: Leadership [skill] is ultimate to be able to [create the role]; if you’re not a leader, if you don’t have the skills, because I think anybody can learn the clinical piece to being an NP, it’s having the skills to actually implement that role that makes you a successful NP. (NP #11) Flexibility to evolve the role was described as important by all participants. Yet there were risks associated with this need for flexibility. New NPs found it difficult to achieve when consistency and role definition were important aspects of their development, and team members who wanted role clarity could find it hindered establishing familiar practice patterns. Role flexibility and leadership skills enabled the NP to evolve in response to new and changing program gaps. Most indicated an importance of involvement in activities such as program visioning to engage leadership and research skills. These skills supported alignment of evidence with program and patient population needs. Active involvement in broad organizational and specialty knowledge augmented exposure of new and changing needs or gaps. Flexibility in role enactment enabled effective and timely NP response to address gaps. Responding to program gaps. Most participants held in-depth discussions of the importance of monitoring for gaps and evolving the NP role to address these. The ability to evolve the role thus fill gaps in a timely manner influenced safety and efficiency. Participants described frustration with ineffective ‘‘gap filling’’ suggesting this was common when NP representation was not included in strategy planning. One participant shared frustration of a lack of senior leadership vision when a decision was made to fill ‘‘physician holes’’ with temporary NP assignments suggesting leadership did this without ‘‘really knowing what kind of a gap that’s going to create’’ (NP #8). Focusing on team care This is another main category discussed by all participants. Focus on team care involved engaging multiple professionals to coordinate patient care and provide team education. An engaged team working toward quality patient care was important to the NP participants. Engaging team members was one action regularly used: . . . asking for their input in rounds, asking for their expertise, why don’t we go and get physio because they might be able to

. . . if the physicians don’t want to work well with you, then the rest of the team doesn’t either. (NP #5) Several participants described disregard of NP leadership vision and capabilities by operational leaders as limiting NP role effectiveness within the team. The category, focusing on team care, has three sub-categories that describe how the NP actions are constructed. These include ‘‘working together’’, ‘‘enabling team efficiency’’ and ‘‘educating team members’’. Working together. Most participants described working together as knowledge sharing and coordinating. Many NP participants often described the importance of respectfully bridging role boundaries of other professions as key to working well together. The NPs interpreted role overlap with multiple professions as desirable, supporting the NP role as more than physician extension: The social worker and I often spend a lot of time together in family meetings and so who would be best to lead this meeting, who would be best, here’s what we see of this family, and sometimes he’ll say well I think I should take the lead, and other times I’d like if you take the lead. (NP #17)

Enabling team efficiency. NP participants believed they enabled an efficient team through their consistent presence, knowledge of the healthcare system and their legal authority to make timely changes to patient care. Most participants shared a perception that their consistent presence was an enabler of team efficiency as it provided access to the NP and their repository of patient knowledge. Key to enabling efficiency and team member engagement was the legitimate authority to make or support patient care decisions in a timely manner: Being there as the liaison with some authority, I think [NPs] allow [other professionals] to give their maximal input in terms of where the patient should go so it actually enables them to make decisions when they’re the right person to be making that decision. (NP #2) NPs believed they acknowledged and advocated for full use of expertise of other professions as well as engaged their expertise in patient care and shared goal setting. Educating team members. Educating team members ensured quality patient care and enhanced team working. All NP

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participants mentioned this action as a formal and informal activity of ‘‘. . .being up-to-date with the latest information, and sharing best practice’’ (NP #8). Focusing on patient care Focusing on patient care is the third category. This category of actions aimed to return patients to intact meaningful lives. All participants described the focus on patient care as application of system knowledge and direct patient care approaches. Participants described activities within two important contexts: gap reduction in patient care and safety, and healthcare system improvement through patient flow and reduced recidivism. Focus on patient care contained three sub-categories: ‘‘reducing patient/family burden’’, ‘‘knowledge broker for patient and family’’ and ‘‘having legitimate authority’’. Reducing patient/family burden. All NP participants discussed descriptions of reducing patient and family burden. Actions focused on using a holistic approach, addressing social determinants of health, and maintaining a focus on patient quality of life and life style choices. These actions were employed throughout the hospital stay and in planning for transition to home. For example: The time that I spend with them which allows me to do more education, really explore with them some of the components of their disease that impacts not only themselves but it’s impact on their family . . .. of their ability to do their activities of daily living and what that means to them as what their quality of life looks like. (NP #17)

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Missing or understated information related to the category most valued by the NPs, evolving the NP role and advancing the specialty. NPs described they were not surprised that the team members did not recognize much of this work. They referred to it as unseen or invisible work. The work they did was ‘‘behind the scenes’’. Examples of invisible worked included constant vigilance to create trust, commitment to mentor others, advocacy for team member roles, relationship building to enable connections with community and other specialty areas, completing complex paperwork for patients, pushing boundaries of change and knowledge, leading quality improvements at the organization level, being active in municipal, provincial and national committees, and widely translating knowledge as an expert in their specialty. NPs were concerned with the degree of understatement of leadership within the team perspective framework. They stated when time spent in leadership activities was unrealized by team members it devalued the extent of NP contribution: No one person really knows the extent to the numbers of things that I’m involved with from patient care and its various aspects to the projects, to other activities, the phone calls that I take from community patients; no one person particularly sees the full breadth of the work that I do. (NP #17) The NP response to the team perspective framework was predominantly positive. NPs felt inclusion of identified invisible work would enhance role understanding. Relating the nurse practitioner and team perspectives

Being available to patient and family. Being available to patient and family involved consistent, knowledgeable NP role availability to patients. All participants discussed consistent knowledge of patient uniqueness and responses to illness and treatments as valuable. The NP acted as a repository of patient care and response information providing easy information access for patients as well as team members: Because of the NP being immersed in the patient care issues . . . [he/she] knows the patient here so when somebody comes up to [him/her], 99% of the time [he/she] knows the patient issues. (NP #16) Working with legitimate authority. Legitimate authority, described by many participants, related specifically to the aspects of care legally authorized to NPs through their education and nursing college registration. This included tasks that overlap the profession of medicine such as diagnosing and prescribing, and the high level of accountability for following-through and ensuring quality care. The HB NPs shared a perception constructed of three categories of practice that create a valuable role: evolving the NP role and advancing the specialty, focusing on team care, and focusing on patient care. The HB NPs described evolving the NP role and advancing the specialty as highly valuable. Actions related to this category facilitate enactment of the remaining two categories. Two antecedent conditions, trust and inclusion/appreciation, emerge as important for enabling and sustaining an effective focus on team working. The NP response to the team perspective The HB NP participants expressed the team perspective framework was a reasonably good representation of their role value.

The two perspectives and related data were explored for convergence and divergence. Both perspectives centered on three similar categories as valued NP practice. Trust, a condition to ease others’ workload identified in the team perspective, was also identified in the NP perspective. While the categories were similar in definition, they held different levels of importance. Frequency and intensity of team members’ discussion identified ‘‘easing others’ workload’’ as the most valued practice focus (Hurlock-Chorostecki et al., 2013). In contrast, the NP perception placed the greatest value on evolving the NP role and advancing the specialty, highlighting numerous invisible aspects of their practice. A condition of inclusion and appreciation emerged from the NP perspective. The multiple similarities of the two perspectives supported merging to a balanced IP perspective. Divergent perspectives and the identified invisible work were used to enhance the understanding. Converging the perspectives The similarities of the two perspectives allowed for an overlaying of the HB NP perspective of role value onto the existing team perspective framework. In doing so, the convergent and divergent views within the NP perspective provided substantiation, extension and adjustment of the team perspective framework. Construction of meanings and actions were re-explored at the team member and NP data levels explicating further the category and sub-category definitions and properties. Continued analysis raised the results to a higher level of abstraction. This converged perspective, an IP perspective, retains three categories or practice foci, and includes eight action sets (Table I). The practice foci are retitled as evolve the NP role and advance the specialty, focus on team working, and hold patient care together, to reflect advancement of category definition and enhance usefulness.

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Table I. Interprofessional perspective of HB NP practice. Practice foci

Related action sets

Evolve NP role and advance the specialty

Create and evolve NP role Gap vigilance

Focus on team working

Working together Enabling team efficiency Filter and assess knowledge Legitimate voice

Hold patient care together

Reducing patient/Family burden Knowledge broker for patient and family Legitimate voice

Two practice foci, evolve NP role and advance the specialty, and focus on team working, are positioned as highly valued and equal in the IP perspective illustrating a balance of NP and team member perceived value. The focus, evolve NP role and advance the specialty was expanded and more fully defined with the inclusion of invisible work identified by NPs. Focus on team working represents broadening and enhancing the understanding of NP actions from simply acting as a labor saver, easing the work of individuals, to actions that closely resemble IP work. Trust, a condition of this focus identified by both participant groups, remains important particularly for team members. Many NP participants emphasized an additional condition, inclusion/appreciation, as related to successful team working. The third practice focus (hold patient care together) is substantiated by NP findings, although the team perspective strongly suggests this focus extends beyond simply a focus on the patient. Further abstraction revealed the practice focus as holding patient care together for patients and team members through consistent NP presence within a team of constantly rotating members, and being a repository of information. This convergence represents an IP perspective understanding of the HB NP role value. The three practice foci form the meaning of HB NP practice and provide a balanced IP understanding of role value (Hurlock-Chorostecki, 2013). Juxtaposing with IP theory Extant IP theory provided a framework for focused exploration of the sensitizing concepts of IP collaboration and teamwork. The practice focus, focus on team working, reveals NP actions identified as key IP collaboration and teamwork concepts (Hurlock-Chorostecki, Forchuk, Orchard, van Soeren, & Reeves, in press; Reeves, Lewin, Espin, & Zwarenstein, 2010). For example, HB NPs engage team members, build trust, coordinate interdependent tasks, respectfully overlap roles, openly communicate and share goal setting. Juxtaposing with current IP theory allows intriguing comparisons and assists in situating the relevance of HB NP practice within the hospital IP context. To further explore the IP perspective of HB NP practice, Reeves et al.’s (2010) contingency framework was used as a comparator. Focus on team working was explored for consistency with Reeves’ four different forms of IP work (networking, coordination, collaboration and teamwork). The form of IP work that NPs engaged in was determined through exploring for actions illustrating elements of teamwork (shared team identity, clear roles and goal, interdependence, integration and shared accountability) and considering the level of team tasks (predictability, urgency and complexity). In comparing this model with the new findings from this study, HB NP actions within focus on team working were found to be fostering clear roles and goal,

interdependence and shared accountability. The centrality of the HB NP role positions them as leaders in promoting team transition to appropriate forms of IP work when patient situations change in complexity, urgency and predictability. The hospital context requires high level team tasks. Urgent, complex and unpredictable patient and team situations are common within hospitals, thus often necessitating IP work at the teamwork and collaboration level. Several described HB NP actions promote these two highest IP work forms. HB NPs, who are present and available on the patient care unit, hold legal authority to make care delivery changes. Availability of the NP role coupled with legal authority to make medical-based care delivery decisions promote rapid teamwork and collaborative responses to solve patient issues. Timely NP decision-making and management of urgent issues reduce fracturing of care actions and foster maintenance of interdependent tasks of professions. The day-to-day presence of the NP role ensures a repository of patient information in urgent situations within a team of constantly changing IP team members. Consistency, valued in both perspectives, facilitates quality and accurate communication of changing patient information amongst team members. HB NP roles were described as acknowledging team members’ work as important, maximizing the use of their professional skills, and ensuring frequent connection with team members. These actions support IP interdependence and common goal setting. NP knowledge of professional roles, confidence in team member professional expertise, and valuing of shared leadership facilitate IP interdependence and shared responsibility required in collaboration and teamwork. Role overlap with medicine is key to the HB NP role value although role overlap was also described with many professions. When overlap was respectful, trust was enhanced thus promoting a shared team identity and cohesive team working. In less urgent situations, HB NP role consistency promotes linkages of patient information supporting clear goals and care coordination. Open communication connects team members and provides opportunity for several elements of IP work: shared decision-making, shared goals and clarity of responsibilities. Additionally, IP coordination actions are described as organizing complicated patient transfers, completing intricate time-consuming procedures and sharing leadership. Broad healthcare system knowledge and providing formal and informal education support IP networking. NP vigilance in monitoring gaps, and the ability to adjust their role based on a situation need, suggest they enact a leadership role in transitioning to alternate forms of IP work. The overlap into medical knowledge supports timely recognition of situation complexity and urgency, thus allowing HB NPs to trigger a shift in IP work form to match the need. Availability, consistency and legitimate authority to make care changes enables the HB NP to act as a facilitator of transitioning to the appropriate form of IP work. This comparison identifies that HB NPs work in environments that require high forms of IP work and likely frequent transitions between the four forms. It also identifies NP roles as central within the team, positioning them in a leadership role of promoting IP work. NPs currently engage in IP-related activities suggesting they are actively involved in fostering IP work and building cohesive IP teams.

Discussion Phase two of this study provides knowledge of NP practice and value within IP hospital teams not previously presented. An IP perspective has emerged from this analysis and validation of HB NP IP activity provided. In describing the three practice foci (evolve NP role and advance the specialty, focus on team working,

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and hold patient care together), the meaning of NP role value is formed and everyday HB NP activities that impact and promote IP collaboration are illustrated. The first of the two key practice foci, evolve NP role and advance the specialty, is highly valued yet not consistently supported by leaders and team members. NPs with this focus valued are effective in timely practice change based in evidence, and assisting in achievement of organizational efficiency goals, thus improve care quality and safety. When support and initiative for mentoring new NP roles exists these NPs enhance their role understanding, thus improve role integration. Yet, power influences from hospital leaders, and physicians negatively impact NP integration and full utilization. Unwarranted leader constraints of NP role enactment reduce role flexibility thus inhibiting their role evolution to match changing patient and team needs. This risks stagnation of practice potentially worsening care quality in the current environment of rapid change. Hospital leader approaches that exclude NP roles from organizational system knowledge reduce their effectiveness in monitoring and responding to gaps. A lack of organization system knowledge hinders the NPs’ ability to integrate hospital goals with directions for team approaches to care delivery. It is important for hospital leaders, team members and NPs to recognize the added value of the NP role when this practice focus is supported as a significant aspect of the role. The second key practice focus, focus on team working, builds a cohesive IP team working toward quality patient care, and supports respectful and efficient use of professional roles. Identification of the NP role as central and consistent suggests it is positioned to lead promotion of IP work and assist the team in transitioning between the different forms. Crucial aspects that differentiate the NP role from others are the ease of availability and the legitimate authority to make medical decisions. NPs are using skills that promote IP work such as engaging team members in shared goal setting, valuing their knowledge and expertise, and respectfully overlapping professional boundaries. Although, a review of the literature suggests clear HB NP understanding of IP theory is lacking (Hurlock-Chorostecki et al., 2013). Physician tensions with NP roles continue to exist. These are described as a professionalism approach to maintain control of the body of the work of medicine, the type of relationships with other professions, and negotiation of ambiguous boundaries establishing who directs care (Freidson, 2001). Physician approval of the NP as an autonomous decision-maker creates acceptance of NP role legitimacy within the team, thus providing opportunity for HB NP to promote IP work. When physicians do not support NP autonomy, their role is rendered subservient and unable to facilitate IP collaboration and teamwork. This results in an inefficient use of team member time and expertise. Hospital leader restricted NP role flexibility impairs the ability to lead transitions between forms of IP work required to meet increasingly complex or urgent goals. This can result in delayed resolution of patient issues, errors, unaddressed care gaps and professionals reverting to separate rather than integrated contributions. Team member and NP tensions negatively impact IP team work resulting in a breakdown of shared team identity. Fostering IP team work is important for quality and safe patient care and efficient use of professional expertise. Physicians, hospital leaders and NPs must understand the role that IP work plays in enhancing quality and safe patient care. The final practice focus, hold patient care together, reduces gaps in care that impede patient flow through the healthcare system or result in recidivism. NPs act to monitor and solve patient issues, address social determinants of health, and promote seamless informed patient transitions. The recipient relationship of this practice focus with the two key foci above exemplifies the importance of supporting all components of NP practice.

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When their role is underutilized or only partially enacted, delivery of patient care is at high risk of remaining disjointed and mediocre, and team function fragmented and less effective. Limitations to this study are considered. The findings explored here are within the IP context although neither team members nor NPs were specifically invited to address IP actions or values. NPs were not asked to share their exposure to IP education, although there has been limited exposure to IP education for the role in the hospital setting to date. Additionally, different jurisdictions with varying regulations governing NP practice and levels of education may alter role enactment. This study is based on participants from one province within Canada and findings may not be generalizable. Finally, the findings were explored using one IP teamwork model. Exploration with another model may raise different relationships and understandings.

Concluding comments The IP perspective of the HB NP role is presented here as new knowledge that will enhance role clarity and utilization within IP hospital teams. The perspective clearly illustrates their roles are valuable beyond simply labor savers. The explicit linking of NP actions with IP theory, not previously reported in the literature, highlights their roles as central in building cohesive teams and influencing IP work. The IP perspective is constructed to support usefulness in everyday practice. It can be used by healthcare professionals, hospital leaders and NPs to explain practice, enable full role utilization, and predict outcomes. The perspective will be useful in enhancing HB NP education and indicates the benefit of including IP theory within NP education such that NPs could more effectively assert their legitimate role within these teams. Future research of power and privilege is warranted to raise this perspective to theory.

Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

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