Barriers and Enablers
There were several factors identified in the literature that may impact the maximization of nurses’ full scope of practice. Some of the key barriers included staff not feeling ready or willing to maximize their scope of practicei, a perceived lack of time, heavy patient workloads, staff shortages, inappropriate nurse to patient ratio, and high patient acuityii. In addition, nurses are regularly involved in performing administrative or secretarial tasks, such as booking appointments and preparing clinic exam rooms, which should be delegated to non-nursing personneliii. Lack of time was also noted to result in safety and quality of care concernsiv. Ineffective communication and teamwork was found to lead to workplace tension, which was underpinned by a lack of understanding of each other's competencies, skills, and rolesv. In addition, a lack of public awarenessvi, the local context and patient population of the practicevii, and a lack of clarity in role boundariesviii can act as barriers. Role ambiguity creates tension among providers, a lack of professional identity, stress, unproductive behaviour and ineffective communication. Role ambiguity should be addressed through a focus on developing role clarity and a mutual understanding of rolesix. Akeroyd et al., (2009) found that RNs in family practice were unsure of what their scope of practice actually consisted of. While some nurses felt that they were currently practicing at too narrow an aspect of scope of practice, other nurses felt that they were practicing too broadly. Donald et al (2005) found that a lack of professional awareness leads to ambiguous expectations, turf protection, and concern about whether members are practising outside their scope of practice. There may also be worry that as nurses expand their scope of practice and role functions, in the case of an accident, liability will fall to the employer or physicianx.
In addition to identifying factors that were perceived to act as barriers, factors perceived to act as enablers were also identified. These enablers included team work, collaborative practice, leadership, a non-hierarchical workplace, sharing common goals, orientation for new hires, having managerial and educational support (attending conferences was seen as beneficial), and role clarification. i . Staff who felt valued and who trusted and respected each other were more likely to be accepting of the idea of full scope of practice maximisation and more likely to practice interprofessional collaborationii.
From this literature, and in consultation with experts in primary care, a list of 12 barrier and enabler categories were developed that were included on the RNAO/RPNAO Primary Care Toolkit survey administered to primary care employers and teams in Ontario (see below). The findings from the survey results confirmed that the following factors were perceived as relevant in the maximization of nurses’ full scope of practice.
- Staff readiness
- Time available
- Resources for education and mentoring
- Organizational culture
- Understanding rationale for full scope
- Funding models
- Team trust
- Role clarity
- Change management
- Team communication
- Liability considerations
- Patient population