Tips on Overcoming Barriers
- Remind staff that the goal is to provide person-centred care and provide them with information indicating the positive client outcomes as a result of practicing to full scope.
- Initiate team discussions among staff about each others’ roles and responsibilities, and their related knowledge and skills to support staff engagement and preparedness.
- Provide nurses with professional development, time, and access to resources for education and training will assist them refresh the knowledge and skills they may have not used in awhile.
- Support more experienced nurses and other members of the primary care team to mentor novice nurses in carrying out their roles and responsibilities. In addition, new nurses can provide new energy and an opportunity to re-examine processes and roles.
- Visionary leadership at all levels in the organization is needed to fully embrace scope of practice utilization.
- Role clarification and appropriate assignment of responsibilities based on client’s needs and provider competencies, knowledge and skills will help balance workload.
- Make time to consider roles and how they are being implemented.
- Role functions can be allocated in a way that enhances teamwork and reduces pressures on overstressed staff.
3. Providing resources for education and mentoring
- Orientation and mentor program for staff
- Develop a comprehensive orientation and mentorship program (for new and existing staff) to help team members work together.
- Include information about the primary care system, and in particular refer to the Primary Solutions for Primary Care document.
- Ensure staff have access to relevant resources and training materials
- Examples include: conduct on-site education, provide time to attend events, and offer professional development funds.
- Ensure that measures are in place for staff to have access to current knowledge. Primary care nurses are committed to being lifelong learners and will need access to education (University Health Network, 2009). This may mean securing financial support to allow for further education (Oelke et al, 2008).
- A nurse educator can support staff with knowledge acquisition and acts as a resource in the practice environment
- Available resources for training and mentoring include: the Nursing Education Initiative (RN: http://rnao.ca/education-funding/nei and RPN: http://www.rpnao.org/practice-education/nursing-education-initiative ), RNAO Primary Care Institute, RPNAO Elearning, RNAO Advanced Clinical Practice Fellowships (ACPF), RPNAO Fellowships.
4. Building organizational culture
- Strong leadership, orientation, clear lines of communication and participatory decision making are important.
- Strong leadership and mentorship is extremely beneficial in creating a trusting, positive environment (Besner, 2006; Oelke et al., 2008). Staff members can often become great mentors and coaches with some additional education and resources. Individual nurses can champion their roles, and provide examples of full scope of practice (Donald et al., 2010).
- Establish a culture where maximizing nurses’ full scope of practice utilization is the norm. For example, consider incorporating this vision into your mission statement.
- Team cohesiveness is created through a non-hierarchical approach, where shared team goals are understood and outlined (Donald et al., 2010).
- The development of collaborative inter-professional relationships increases job satisfaction and retention and creates a positive environment (Kunic & Jackson, 2013)
5. Promoting an understanding of rationale for full scope
- Anchor all transformation in a focus on improving client outcomes
- Raise awareness of client outcomes, staff/team outcomes, and personal outcomes that can result from maximizing nurses’ full scope of practice utilization in primary care settings.
- It has been widely acknowledged that enhancing the role of nurses has positive economic, personal, and team-based benefits, as well as improving patient outcomes, and represents a critical aspect of the health care system that could be ameliorated (for more information please see home page). (Canadian Nurses Association, n.d.; Fairman et al., 2011). Awareness can be built by sharing this information with individuals, team members, and the general public.
- Develop a communication strategy for the public about nursing roles as well as the impact of a strong primary care sector on the health care system as a whole (Donald et al., 2010).
6. Working within funding models
- Nurses practicing to full scope enables the clinic to operate more efficiently. The clinic is optimized in roster capacity and is able to accommodate more appointments per day. This allows patients increased access to primary care. As well, NPs and MDs can then focus their time on seeing clients with the most complex needs.
- Enabling full scope of practice supports nurses in being respected as valuable team members. Utilizing nurses to full scope creates incentive by contributing to staff satisfaction, role retention, and improved client outcomes (Oelke et al., 2008; White et al., 2008).
There have been variations on the traditional primary care model, including new payment systems which can maximize full scope of practice utilization:
- Community Health Centres (CHCs) are examples of an alternative model. All employees (including physicians) are paid through salary, rather than a fee-for-service (Glazier, Zagorski, & Rayner, 2012).
- Blended Capitation models of physician funding (FHN, FHO) provide compensation for primary care providers (physicians) based on the roster size and composition (Henry et al., 2012; Ministry of Health and Long-Term Care, 2009).
Trust in relationships between physicians and nurses, and other team members is essential to maximizing nurses’ full scope practice utilization.
- Team based care is one of the building blocks for high performing primary care, and interprofessional relationships (Bodenheimer, Ghorob, Willard-Grace, & Grumbach, 2014).
- The methodology of team training is an evidence-based technique to prepare team members for optimal teamwork, including trust building, and been has shown to be effective in complex environments such as primary care.
- Team and trust building are positively influenced by strong organisational support, regular team meetings, clear goals and objectives, and clear roles and responsibilities.
For more information on team building techniques see Salas, DiazGranados, Weaver & King, 2008; Xyrichis & Lowton, 2008.
- Roles need to be clarified and discussed, and resulting role descriptions should be circulated and widely available (Lloyd Jones, 2005; DiCenso et al., 2003).
- Teams should discuss everyone’s roles, capabilities, and proficiencies and agree to who should perform what role functions and why. (White et al., 2008).
- The team should be professionally diverse enough to attend to all necessary responsibilities, with different types of expertise complementing each other, but limited enough to avoid unnecessary role duplication.
- Examples of RN and RPN role functions.
9. Managing the change process
Change requires a holistic understanding of the organisation, and should be approached in a planned way. All change should be clear, consistent, constant, and contextualised.
- The historical development of nursing illustrates the dynamic, expanding nature of nursing roles. Acknowledging the historical and ongoing developments in nursing scope of practice can help guide the process of change, breaking down the barriers of change resistance (McPherson, 2003; Ministry of Health and Long-Term Care, 2010).
- Change is supported by three types of motivation: normative (based on values, feelings, testimonials), cognitive (evidence-based), and coercive (legislative, policy) and in many cases all three types of motivation are needed to initiate and sustain the change.
- Change can feel like a roller coaster and will include uncertainty and challenges along the way. Individuals need a supportive environment when transitioning between old and new ways.
- Open communication, documental support, regular meetings, and strong leadership and champions can help this transition.
- It is important to acknowledge that the former ways were not wrong and were appropriate at the time, and that there may be loss associated with change. It is equally as important to acknowledge, with enthusiasm, the gains of the new approaches.
- While every individual will respond differently in terms of change resilience, saturation, and internalization, every individual should feel they play a role in effecting change at the organisational level. It is important that everyone feels they play a role.
10. Enhancing team communication
- Teams need to understand what it means to practise to full scope, the importance of it, and their role (Donald et al., 2010).
- Primary Solutions for Primary Care position descriptions, developed through discussion with the team and based on templates offered in the Primary Solutions for Primary Care report should be easily accessible and discussed with each member.
- Nurses need to be able to discuss what practicing to full scope means to them and what strategies are needed to enable them to carry out full scope of practice (White et al., 2008).
- Interprofessional communication is particularly important, and team meetings that allow for open dialogue on practical issues and concerns can enable team development and a cohesive approach to change (Oelke et al., 2008).
- Allowing team members the opportunity to get to know each other and their practice styles improves role clarity (DiCenso et al., 2003).
- eHealth allows for opportunities to share information regarding client care, and can greatly improve interprofessional communication (Neuhauser & Kreps, 2010).
- All members of the team should be aware that RNs and RPNs are regulated autonomous health professionals who function as individual practitioners and therefore hold full accountability for their practice.
- Nurses are required to have professional liability protection (PLP) by the CNO, and can seek such protection through RNAO and RPNAO. PLP provides individual coverage for nurses for incidents arising both at the workplace and outside of the workplace. For example, for professional nursing services provided at another employer’s site or for helping a stranger on the street.
- Building a workplace culture of safety which facilitates supportive interprofessional relationships where staff feel comfortable openly communicating if they feel they need more knowledge, education, practice, time, or mentorship. This culture can contribute to patient safety and a reduction of potentially adverse events (Oelke et al., 2008).
- Physicians should not be professionally liable for nurses, who are carrying out their roles according to their full scope of practice, and also have the related knowledge and skills. As such, nurses have a duty of care to their patients, and should not practice beyond their scope of practice, and beyond their education, knowledge and skills levels. However, when a physician is the employer, they may be vicariously liable for the actions of nurses due to the employee-employer relationship. Employers can seek independent legal advice about how to structure their practices to support maximizing nurses' full scope of practice (Cashin et al., 2009).
For more information please see Canadian Medical Law: An introduction for Physicians, Nurses and other Health Care Professionals, 4th Edition, 2013, http://www.cnps.ca/index.php?page=29 and http://www.cnps.ca/index.php?page=40
12. Understanding the patient population
- Patient population, resulting clinic structure, and the balance of professionals looking to full scope of practice should be considered for the potential impact on best client outcomes.
- Consider how the patient needs and clinic structure may affect scope of practice. Having the knowledge and understanding of these factors and how best to address them can help turn them from a barrier into an enabler
- See gap analysis for overcoming gaps between the potential and actual full scope of practice maximization of nurses.
- Remember that the benefits of optimizing full scope of practice extend to patients
Patients can be informed of full scope of practice endeavours of the setting in order to build an aware, and supportive patient population