Facilitating Advanced Practice Nurses’ Collaboration

Blog post by Optimal Utilization of Advanced Practice Nursing Roles Action Team Co-Leaders, Linda Sawchenko and Maureen Shaw

Gettin’ good players is easy – Getting’ em to play together is the hard part
(Casey Stengel, former Manager, New York Yankees)

Advanced Practice Nurses (APNs) provide a key role in the health care system and efforts are underway to promote optimal utilization of these providers. Advanced Nursing Practice is an umbrella term that describes an advanced level of nursing practice that maximizes in-depth nursing knowledge and skill in meeting the health care needs of all Canadians (CNA 2008). Clinical nurse specialists (CNSs) provide expert nursing care and promote the use of evidence; provide expert support and consultation; and facilitate system change. Nurse practitioners (NPs) provide direct care, focusing on health promotion and the treatment and management of health conditions through diagnostic and prescriptive competencies. These two advanced practice roles share many common goals and competencies and are complementary; however, they generally fulfill different functions.

Evidence is mounting related to the "value added" of these roles. However, we believe that, in BC, the roles are still not well understood by many key stakeholders. A recent systematic review of published literature between 1990 - 2008 of APN roles in the US found that patient outcomes of care provided by NPs and CNSs in collaboration with physicians are similar to, and in some ways better than, care provided by physicians alone for the populations and settings included. In addition, utilization of CNSs in acute care settings showed reduced length of stay (LOS) and cost of care for hospitalized patients. The results of this systematic review indicate that APNs can have an expanded role and should be incorporated to the fullest extent possible in health care systems. Finally, the authors conclude that ideal health care comprises multiple providers who are accountable to each other to deliver coordinated care.

So, it appears the evidence is clear about the value of these advanced practice nursing roles. Now, how do we ensure that APNs are working collaboratively to achieve optimal outcomes? Studies have found NPs and CNSs sometimes work in parallel or even in competition with one another. Several issues have contributed to this divergence including organizational and reporting structures, suboptimal role implementation, role overlap and confusion, and academic preparation for the CNS role. The CNA Advanced Nursing Practice National Framework identifies consultation and collaboration as key competencies, noting that effective collaboration and communication with clients and others on the health care team represent important aspects of any nurses’ practice. The ability to consult and collaborate with colleagues across sectors and at the organizational, provincial, national and international level is characteristic of nurses in advanced practice.

Recently, Dr. Alba DiCenso, CHSRF/CIHR chair in Advanced Practice Nursing, and colleagues published a decision support synthesis that aimed to (1) describe the distinguishing characteristics of CNS and NP role definitions and competencies relevant to Canadian contexts, (2) identify the key barriers and facilitators for the effective development and utilization of CNS and NP roles, and (3) inform the development of evidence-based recommendations required to better integrate CNS and NP roles and advance the delivery of health care and nursing services.

They conclude that a number of key factors are essential to the successful integration of APNs. These include the need to establish mechanisms to support a full scope of practice, raise awareness of the function of APNs, clearly define roles, and sustain strong administrative leadership to support the implementation of those roles. One outcome from earlier research is the use of the Participatory Evidence-Based, Patient Focused Process for APN role development, implementation and evaluation (PEPPA) framework in Interior Health to identify the most appropriate provider to meet the unmet population health needs and gaps in health care services. Utilization of the PEPPA framework with current teams supported appropriate and optimal utilization of the APN role once implemented.

APN roles in Canada have a history which dates back to the late 1960s - with what has been described as a long and winding, sometimes rocky road. The roots of advanced practice nursing can actually be traced back to the early efforts of outpost nurses who have worked in remote and isolated areas to provide health services when no one else was available for decades.

In the past decade a number of activities, including the Canadian Nurse Practitioner Initiative as well as the 2005 legislation in BC to introduce NPs led to a significant focus on the NP role - some would suggest to the detriment of the CNS role. Recent Canadian statistics do perhaps tell the story. The NP workforce doubled from 800 in 2004 to 1,626 in 2008 while the opposite occurred in the numbers of CNSs which a 2010 CIHI report indicates dropped from 2,624 to 2,222 between 2000 and 2008. It appears NPs are now well integrated into most BC heath authorities and we suggest the time has come to shift the focus of health care system leaders from one particular APN role to focus more broadly on APNs roles working collaboratively with one another and other health care professionals to meet the health care needs.

One such strategy is the newly established APN Community of Practice (CoP) at Kelowna General Hospital in Interior Health (IH) where the NPs and CNSs are coming together to promote "One Voice" for advanced practice nursing in hopes of creating clarity for all stakeholders. The concept of a CoP seems to fit well in this situation. Wenger and others describe CoPs as groups of people who share a concern, a set of problems, or a passion about a topic, and who deepen their understanding and knowledge of this area by interacting on an ongoing basis. Cultivating a successful COP can be challenging. Strong leadership is required to nurture new CoPs, to support their early development and then release them and allow them to flourish!

The following five characteristics uncovered in a recent study of the successful IH NP CoP may be helpful to others supporting new APN communities of practice:
1. CoP as a "sanctioned social structure"
2. CoP as a "knowledge exchange network"
3. CoP as a "venue for generating discovery and innovation"
4. CoP as a "forum to engender participant meaning and value"
5. CoP as a "stewardship tool for strategic improvement".

A recent publication by McNamara, Lepage & Boileau focused on NP & CNS collaboration within the Cardiac Surgery population at Jewish General Hospital in Montreal. Sharing encouraging examples of successful APN collaboration is important.

The role of nursing leadership to ensure optimal utilization of advance practice nursing roles and to work with these nurses to create and promote collaboration practice environments cannot be overstated. In addition to nursing leadership, organizational and physician support in integrating the APN role, enacting policies that support and legitimize the role, and providing strong management support is essential in achieving optimal client, nursing and health system outcomes.

As members of InspireNet we wonder how we can do more to promote APN Collaboration in British Columbia?

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Maureen Shaw
Clinical Nurse Specialist
Vancouver Coastal Health

Linda Sawchenko
Regional Practice Leader
Interior Health

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InspireNet members:

Interested in learning more about the APN Action Team? By joining this team you'll be able to connect with other APN members, and have access to resources including a reference list of journal articles.

To Join an Action Team and to Access your Electronic Community of Practice (eCoP): Login to the website (blue button, top right hand side) and click My Teams. The list of eCoPs you're subscribed to as well as teams you can join will appear. Select the eCoP you want to visit, or request to be added to a new one as listed.

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