Reframing professional boundaries in healthcare: A systematic review of facilitators and barriers to task reallocation from the domain of medicine to the nursing domain

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Tilburg University

Reframing professional boundaries in healthcare

Niezen, M.G.H.; Mathijssen, J.J.P.

Published in:

Health Policy

DOI:

10.1016/j.healthpol.2014.04.016

Publication date:

2014

Document Version

Publisher's PDF, also known as Version of record

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Citation for published version (APA):

Niezen, M. G. H., & Mathijssen, J. J. P. (2014). Reframing professional boundaries in healthcare: A systematic

review of facilitators and barriers to task reallocation from the domain of medicine to the nursing domain. Health

Policy, 117(2), 151-169. https://doi.org/10.1016/j.healthpol.2014.04.016

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HealthPolicy117(2014)151–169

ContentslistsavailableatScienceDirect

Health

Policy

j o u r n al ho me p ag e :w w w . e l s e v i e r . c o m / l o c a t e / h e a l t h p o l

Review

Reframing

professional

boundaries

in

healthcare:

A

systematic

review

of

facilitators

and

barriers

to

task

reallocation

from

the

domain

of

medicine

to

the

nursing

domain

Maartje

G.H.

Niezen

∗

,

Jolanda

J.P.

Mathijssen

TilburgUniversity,DepartmentTranzo,Netherlands

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received20August2013

Receivedinrevisedform24March2014

Accepted22April2014

Keywords:

Professionaldelegation

AdvancedPracticeNursing

Nursepractitioners

Organisationalinnovation

Physician–nurserelations

Systematicreview

a

b

s

t

r

a

c

t

Aim:Toexplorethemainfacilitatorsandbarrierstotaskreallocation.

Background:Oneoftheinnovativeapproachestodealingwiththeanticipatedshortageof physiciansistoreallocatetasksfromtheprofessionaldomainofmedicinetothe nurs-ingdomain.Various(cost-)effectivenessstudiesdemonstratethatnursepractitionerscan deliverashighqualitycareasphysiciansandcanachieveasgoodoutcomes.However,these studiesdonotexaminewhatfactorsmayfacilitateorhindersuchtaskreallocation. Method:AsystematicliteraturereviewofPubMedandWebofKnowledgesupplemented withasnowballresearchmethod.Theprinciplesofthematicanalysiswerefollowed. Results:The13identiﬁedrelevantpapersaddressabroadspectrumoftaskreallocation (del-egation,substitutionandcomplementarycare).Thematicanalysisrevealedfourcategories offacilitatorsandbarriers:(1)knowledgeandcapabilities,(2)professionalboundaries,(3) organisationalenvironment,and(4)institutionalenvironment.

Conclusion:Introducingnursepractitionersinhealthcarerequiresorganisationalredesign andthereframingofprofessionalboundaries.Especiallythefacilitatorsandbarriersin theanalyticalthemesof‘professionalboundaries’and‘organisationalenvironment’should be considered when reallocating tasks.If not, these factors mighthamper the cost-effectivenessoftaskreallocationinpractice.

1. Introduction

Varioushealthcaresettings(e.g.withinprimarycare,

child healthcare and hospitals) are facing shortages of

medicalstaffandspeciﬁcallyphysicians.Simultaneously,

∗ Correspondingauthor.Currentaddress:TilburgUniversity,

Depart-mentTILT,TilburgInstituteforTechnology,Law&Society,Netherlands.

Tel.:+31134662407.

E-mailaddresses:m.g.h.niezen@tilburguniversity.edu

(M.G.H.Niezen),j.j.p.mathijssen@tilburguniversity.edu(J.J.P.Mathijssen).

thereisanincreaseddemandforhealthcareingeneraland

formorespeciﬁcandmoreintensivepatienttreatments

[1–3],whiletheexplosivegrowthofhealthcare

expendi-turecontinuestodominatemanypolicyagendas[4].Oneof

theinnovativeapproachestodealingwiththeanticipated

shortageofphysiciansand/orattemptingtocontrol

health-careexpenditureistointroducenewnursingroles,suchas

thenursepractitioner(NP)[5].NPsareregisterednurses

speciallyeducatedtotakeontaskspreviouslyperformed

byprofessionalsofthemedicaldomain.Thisimpliesthat

tasksareshiftedfromthetraditionalprofessionaldomain

ofmedicine(cure)tothedomainofnursing(care).

http://dx.doi.org/10.1016/j.healthpol.2014.04.016

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152 M.G.H.Niezen,J.J.P.Mathijssen/HealthPolicy117(2014)151–169

Severalstudieshavedemonstratedthatappropriately

trainednursescandeliverashighqualitycareasphysicians

and achieve equallygood outcomesin terms ofpatient

health,careprocesses,useofresourcesandeconomic

vari-ables[6–10].ReviewsbyHorrocksetal.andLaurantetal.

onNPsinprimarycaresettingsyieldnumerousindications

thatNPscandeliverequivalentqualityofcareas

physi-cians,handinhandwithpatientsatisfaction,althoughthe

cost-effectivenessofNPdeliveredcareremainssomewhat

unclear[7,9].Similarly,Bissingeretal.andSakretal.show

thatNPscanprovidesafeandhighqualitycarein

neona-tologyandemergencycaresettings,respectively[6,8].

Nevertheless,debates onworkforcechanges

demon-stratethatintroducingnewrolesinhealthcarepractices

isnotastraightforwardprocess[6,11,12].Forone,

work-forcechangesoftenputpressureonworkforceboundaries.

Traditional workforceboundaries become dynamic due

tothe identiﬁcationof newwork areas or byadopting

new roles normally fulﬁlled by other professionals [6].

Inresponse,however,establishedprofessionalsmayseek

toprotect and maintain boundaries or to expand their

areasofcontrolviainstitutionalwork(e.g.thecreationof

rulesthatfacilitate,supplementandsupportinstitutions)

[11]. Consequently, the newly introduced roles,against

thebackgroundof(anticipated)physicianshortagesand/or

thereductionofhealthcare costs,generatefundamental

questions concerningprofessionalismand theprovision

ofpublicservicessuchashealthcare.Inotherwords,the

changingpositionofprofessionalsnotonlyraisespower

andprivilegeissuesattheindividuallevelofprofessionals,

butalsoinvolvescontextandsocialtransformationsatthe

professional,organisationalandinstitutionallevels[13].

Introducing new nursing roles in healthcare

prac-ticesthusoftenimpliesredesigningtheorganisationand

raisesdiscussionsonworkforcechangeand

professional-ism.Thisappliesespecially whentheserolesoperatein

between,andintheoverlapof,thetraditionalprofessional

domainsofmedicineandnursing.Thispaperfocuseson

theintroductionofnewnursingrolesthatcauseor

war-rantinterdisciplinaryworkforcechange.Thedisciplinary

boundariesofnursingareexpandedbytakingonworkthat

istraditionallyperformedbyotherdisciplines,particularly

physicians[6].Beforeredesigninghealthorganisationsto

enabletheintroductionofNPs,itisimportantto

under-standwhat facilitatorsand barriersmaybeexpectedin

taskreallocation.Ifthesefactorsarenottakenintoaccount

theymighthamperthe(cost-)effectiveexecutionoftask

reallocationinactualpractice[14].

Thisreviewexploreswhatfacilitatorsandbarriershave

beenfoundinearlierevaluationsandstudiesoftask

real-locationfromtheprofessionaldomainofmedicinetothe

domainofnursing.Thequestionsaddressedinthisreview

are:(a)Whatformsoftaskreallocationcanbeobservedin

healthcare?(b)Whatbarriersandfacilitatorsareperceived

whentaskreallocationoccurs–speciﬁcallyinrelationto

theabilityofNPstoperformtheirrole?and(c)Howarethe

differenttypesoftaskreallocationandperceived

facilita-tors/barriersrelated?

Themulti-layeredconceptofprofessionalismby

Brand-senet al.is used toexplore taskreallocation fromone

professional to another professional domain [13]. The

professional is ﬁrst deconstructed in terms of essential

components:(a)relyingonspeciﬁcknowledgeand

exper-tise;(b)belongingtoaclosedcommunityofpeoplewith

similarknowledgeandexpertisecharacterisedbyshared

normsandvalues,institutionsforsocialisationand

regula-tion;(c)thisclosednatureofthecommunityisconsidered

legitimate by society at large; and (d) discretionary or

professionalautonomyareallowedatbothanindividual

andcommunitylevel.Taskreallocationandthespecially

trainedNPschallengetheboundariesofthespeciﬁc

knowl-edge and expertise these closed communities rely on.

AccordingtoBrandsenetal.,professionalismshould

there-fore be consideredmulti-layered, with theprofessional

challengedatdifferentlevelsofanalysis:(1)atthe

indi-viduallevel, (2) withinhis/her professionalcommunity,

(3)withinhis/herorganisationalcommunityand(4)atthe

levelofthegeneralpublicorsociety[13].

Using the multi-layered concept of professionalism

enabled the emergence of a networked model. This

networkedmodeldescribestheinternalandexternal

struc-turespositioningtheNPinrelationtothefacilitatorsand

barriersintaskreallocation.Thismodelmightcontributeto

theorganisationalredesignprocessesandsuccessful

adop-tionbystakeholders(e.g.hospitalmanagers,NPs)tomeet

futurerequirementsofaccesstoandqualityofcare[15].

Thenextsectiondescribesourresearchmethods.The

Resultssectionpresentsthedifferentcategoriesof

facil-itators and barriers in task reallocation, followed by a

Discussionofhowthenetworkedmodel,positioningthe

NPinrelationtothefacilitatorsandbarriersintask

reallo-cationatdifferentanalyticallevels,answersourresearch

questions,andoftherestrictionsofthepresentedreview.

2. Materialsandmethods

2.1. Design

Weconductedasystematicliteraturereviewto

iden-tifyfacilitatorsandbarrierstoreallocatingtasksfromthe

traditionaldomainsofmedicinetonursing.This“vertical

substitutioninvolvesthedelegationoradoptionoftasks

acrossdisciplinaryboundarieswherethelevelsoftraining

orexpertise(andgenerallypowerandautonomy)arenot

equivalentbetweenworkers”[5,p.909]”.

Inclusion criteria for literature consisted of:

popu-lation, intervention/topic of interest, study design and

outcomes. We includedarticles thatdiscuss the role of

specially trained nursesadopting new tasksthat

previ-ouslybelongedtothemedicinedomain.Thesenursesare

referred to as either nurse practitioner (NP), advanced

practice nurse (APN), nurse specialist (NS), or general

nursesspeciallytrainedforanewtask.APNisanumbrella

termcontainingboththeNPandNS,althoughtheyhave

varyinglevelsofauthority.APNcanbedeﬁnedin

differ-entways,yetmoststudiesseemtousethedeﬁnitionused

bytheInternationalCouncilofNursesoradeﬁnitionwith

similarcontent.

A Nurse Practitioner/Advanced Practice Nurse is

a registered nurse who has acquired the expert

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M.G.H.Niezen,J.J.P.Mathijssen/HealthPolicy117(2014)151–169 153

clinicalcompetenciesforexpandedpractice,the

char-acteristics of which are shaped by the context

and/or country in which s/he is credentialed to

practice.Amaster’sdegreeisrecommendedforentry

level (see: http://www.icn-apnetwork.org, accessed

December2012,emphasisadded).

Fromhereon,thispaperonlyusesthetermNPforclarity

reasons.

Includedarepapersonthetopicof ‘taskreallocation

frommedicinetonursing’.Taskreallocationconcernsa

broadspectrumofshiftingtasksandresponsibilitiesfrom

medicinetonursing,rangingfromminimaldelegationto

completesubstitutionand alsotheintroductionof

com-plementarycare.Withdelegationthecareprovisionshifts

fromahighergrade(physician)toalowergradeperson

(NP),yetmedicalresponsibilityremainswiththehigher

gradeprofessional[1,16].Substitutionentailsthatonetype

ofprofessionalisexchangedforanother.Thesesubstitutes

manageawidevarietyofpatientproblems,without

refer-encetoaphysician[9,16].TheNPasacomplementaryrole,

i.e.supplementation,meansthatanNPextendsthecareof

thephysicianbyprovidinganewcareservice[9].

Thestudieseligibleforthereview arenotlimitedto

RCTsandquasi-experimentalresearch,butcanreporton

eitherqualitative,quantitativeorbothtypesofevidence

andarepublishedinpeer-reviewedjournals.Moreover,the

scopeoftheliteraturereviewisnotlimitedtoone

partic-ulartypeofhealthcaresettingorcountry.Theoutcomes

ofinterestarefacilitatorsandbarriersintaskreallocation.

Thepapersmustthereforediscussatleastonefacilitatoror

barrier.Afacilitatorisdeﬁnedasanyfactorthatstimulates

orexpandstaskreallocationfromthemedicaltothe

nurs-ingdomain.Abarrierisdeﬁnedasanyfactorthatlimitsor

restrictstaskreallocationfromthemedicaltothenursing

domain.

2.2. Searchmethods

WesearchedEnglish-languagearticlesonlythatwere

published between 1950 and February 2012, using the

PubMedandWebofKnowledgedatabases.

Weconductedtwosearches:(1)usingMeSHtermsonly,

and(2)usingrelevantkeywords,sincetheMeSHterms

likely do not incorporateall relevant papers. Using the

searchstrategyasshowninBox1,weidentiﬁed519papers.

Theexclusionof‘jurisprudence’wasnotpartoftheoriginal

searchstrategy,buttheresultofourprogressive

under-standing. Afteridentifyingduplicatepapers viaEndNote

X3,358paperswereincludedforfurtherreview.

2.3. Searchoutcome

Box2isaﬂowchartoftheselectionprocess.The

selec-tion ofpapers wasvalidated byusingtwo independent

reviewers (MN & JM). Differences were discussed until

consensuswasreached.Intheﬁrstselectionphase,titles

of all358papers werescreenedbased ontheinclusion

criteria:(1)focus ontaskreallocationfrommedicineto

nursing,(2)newnursingroleswerethesubjectofthestudy

and(3)facilitatorsandbarrierstotasksubstitutionwere

considered.First, a 10% sample of the papers (36) was

reviewedandcomparedbybothreviewers(94%agreement

betweenthetworeviewers).Basedonthiscomparison,MN

individuallyconductedfurtherreviews.Anyarticlethat

ful-ﬁlledtwooftheinclusioncriteria,orthatthereviewerwas

uncertainabout,proceededtothenextselectionphase.The

secondselectionphasecomprisedindependentjudgement

ofthe abstracts,and if notavailable thefulltext paper

wasscannedbybothreviewers. Thethirdreviewround

involvedacriticalreadingofeachstudy’sfullpapertosee

whetherinclusioncriteriatrulyweremet(MN).Any

uncer-taintiesintheselection ofthearticleswereresolvedby

consultingthesecondreviewer(JM).Basedonthis

assess-ment,fourmorepaperswereexcluded.Twopaperswere

excludedbasedoncontentandtwopapersbecausethey

wereliteraturereviews.Thesnowballmethodresultedin

theadditionofthreepapers.Thepreviouslyexcluded

liter-aturereviews[17,18]werescannedforadditionaloriginal

studiesrelevantforthisreview[19–21].Theﬁnalselection

thereforeinvolved13papers.

2.4. Qualityappraisal

The quality of the qualitative/behavioural studies

was assessed through a combination of appraisal tools

derived fromHarden [31] andDixon-Woods et al.[32].

The one outcomes-based trial in the ﬁnal selection

was assessed using the CASP assessment tool for RCTs

(http://www.sph.nhs.uk/sph-ﬁles/casp-appraisal-tools/) (see Tables 1 and 2). All studies were independently

assessedbyMN&JM,overallagreementof73%,remaining

uncertainties or disagreements were resolved through

discussion.

Thequalityappraisalwasusedtoassignweighttoeach

ofthestudies;eitherbeingofgoodquality(A)orbeingof

lesserquality(B).Thepapersdenotedaslesserqualityhad

atleasttwonegativeassessments[19,23,25,26,33].Taking

intoaccountthelimitednumberofavailablestudiesand

thepossibilityofrobustﬁndingsinthelessvaluedpapers,

noneofthepapers wereexcludedbased onthequality

assessment.However,intheidentiﬁcationand

interpre-tationofrelevantthemeswecheckedwhetherthethemes

werenotbasedonﬁndingsonlypresentedinoneoftheless

valuedpapers,butwereconﬁrmedbyatleastoneother

study.

2.5. Dataabstractionandsynthesis

Inordertosynthesisebothqualitativeandquantitative

evidencewemadeuseofthematicanalysis[34].The

fol-lowinginformationwasabstractedfromeacharticle:the

typeoftaskreallocation,descriptionoffacilitatorand/or

barrier, and studycharacteristics(e.g. type of evidence,

health setting and sample size). We used an inductive

approach toidentifyall recurrentfacilitators and

barri-ers byreading and opencoding allthetext labelled as

‘results’or‘ﬁndings’intheincludedstudies,allowingfor

thedeterminationofkeyconcepts,themesandpatterns.

Thequantitativeevidenceintheoutcomes-basedtrialwas

converted into a description of the key ﬁndings,

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Box1:Searchstrategy

MeSH term search

a. Nurse clinicians OR nurse practitioners OR advanced practice nursing b. Capacity building OR personnel delegation OR delegation, professional c. jurisprudence

Search: a AND b NOT c Key words search

a. Nurse practitionersOR nurse specialists OR specialistnurses ORadvanced practice nurses OR nurse clinicians OR practice nurses

b. Delegation OR substitution OR diversification OR task allocation OR skill mix OR interprofessional workforce OR service transfer OR interdisciplinary healthcare teams c. Boundaries OR barriers OR facilitators OR organisational change

d. Jurisprudence Search: a AND b AND c NOT d

PubMed WOK

Mesh Terms 101 195 Key words 62 161

Box2:Selectionprocess

WOK N = 356

Search results combined N = 519

Duplicates N = 161

First review round: articles screened based on title (and abstract)

N = 358

Second review round: reading abstracts by two independent reviewers

N = 76

Excluded N = 282 (79%)

Not original research or review N = 12 (4%) No task rearrangement N = 248 (88%) No delegation / substitution N = 5 (2%)

Delegation/ substitution is not from cure to care N = 16 (6%) Language is not English N = 1 (0%)

Final selection N = 13

Excluded by both independent reviewers N = 51 Not original research or review N = 18 (35%) No focus on facilitators and barriers N = 15 (29%) No delegation / substitution N = 6 (12%)

Delegation/ substitution is not from cure to care N = 5 (10%) Focus is on nurse-prescribing, evidence-based nursing, nurse-led care and/or education models N = 5 (10%) No full text available within the Netherlands N = 2 (4%) Discussion between two

reviewers

N = 25 (19 inclusion with doubt, 6 direct inclusion)

Third review round: reading full text

N = 14

Excluded after consensus discussion between two independent reviewers N = 11

PubMed N 163

Excluded N = 2

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M.G.H. Niezen, J.J.P. Mathijssen / Health Policy 117 (2014) 151–169 155 Table1

Qualityofnon-experimentalandqualitativeresearch.a

Study Theoretical frame-work/literature review described? Aims, objectives, research questions clearly described? Context clearly described? Sampleand recruitment described? Sample appropriate toresearch question? Methodof data collection andanalysis clearly described? Methodofdata collectionand analysis appropriateto research question? Attemptsmade toestablish reliabilityor validityofdata analysis? Aredata, interpretations andconclusions clearly integrated? Pilotwork con-ducted and described? Participation respondents (pro-cess/consent)? Useful contribution? Bonneletal.,2000 [19],B Y Y Y Y Y Y Y N Y N.A. N Y

BrodskyandVan Dijk,2008[22],A Y Y Y Y Y Y Y ? Y Y N.A. Y Fletcheretal.2007 [22],B Y Y Y N Y Y N N N N.A. N.A. N Kaasalainenetal. 2010[24],A N Y Y Y Y Y Y Y Y ? Y Y Lindbladetal.2010 [25],B N Y Y Y Y Y Y ? Y ? N Y Middletonetal. 2011[26],B

N N Y Y Y Y Y N.A. Y N.A. N.A. Y

Offredyetal.,2007

[20],A

Y Y Y Y Y Y Y Y Y N.A. Y Y

Pearson,2009[21],A N Y Y Y Y Y Y Y Y Y N.A. Y

TyeandRoss,2000

[27],A

Y Y Y Y Y Y Y Y Y N.A. Y Y

VanOffenbeeketal. 2009[28],A Y Y Y Y Y Y Y Y Y N Y Y Wilsonetal.2002 [29],A Y Y Y Y Y Y Y Y Y N Y Y Zwijnenbergand Bours,2012[1],A Y Y Y Y Y Y Y Y Y Y N.A. Y A,goodquality. B,lesserquality. Y,yes. N,no. ?,Can’ttell. N.A.,notapplicable.

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156 M.G.H.Niezen,J.J.P.Mathijssen/HealthPolicy117(2014)151–169 Table 2 Quality of RCT. Study Did the study ask a clearly focused question? Was this an RCT, and was it appropriately so? Were participants appropriately allocated

to

intervention and

control

groups?

Were participants, staff

and study personnel ‘blind’ to participants’ study group? Were all of the participants who entered the trial accounted for at its conclusion? Were the participants in all groups followed up and was data collected in the same way? Did the study have enough participants to minimise the play of chance? How are the results presented and what is the main result? How precise are these results? Were all

important outcomes considered

so the results can be applied? Pioro et al., 2001 [33] , B Y Y Y N Y Y N Y Y Y A, good quality. B, lesser quality. Y, yes. N, no. ?, Can’t tell. N.A., not applicable.

descriptionswereopencoded.Subsequently,theresults

of the open coding of the primary studies were

orga-nisedtoformdescriptivethemes.Thedescriptivethemes

wererevisedandmergedbydiscussingthethemes,

sub-themesandtherelationsbetweenthe(sub)themes.New

codeswerecreatedtocapturethemeaningofgroupsof

initial codes (see Appendix A for the Coding tree). The

coding and construction of thematic themes was peer

reviewedbythreeindependentreviewers(RZ,JHandEG).

Last,we generated analytical themes bysubsumingthe

descriptivethemesidentiﬁedintheprimarystudiesintoa

higher-ordertheoreticalstructure.Thegoalofthe

analyti-calthemeswastoobtainanswerstoourreviewquestions,

speciﬁcallywhatfacilitatorsandbarrierstotask

realloca-tioncanbeidentiﬁed,andhowdotheyrelate?Wemade

useoftheinductiveanalysisofstudyﬁndingsin

combi-nationwithadeductiveapproach,thatis,thetheoretical

structureofferedbyBrandsenetal.onthemulti-layered

natureofprofessionalism[13].

3. Results

3.1. Studycharacteristics

Thethirteenstudiesincludedinthereviewwere

pub-lishedbetween2000and2011.Studycharacteristicsare

depictedinTable3.

3.2. Barriersandfacilitators

Ouranalysisledtofouranalyticalthemesoffacilitators

or barriers: (1) knowledge and capabilities, (2)

profes-sionalboundaries,(3)organisationalenvironment,and(4)

institutional environment. In Table4 we structuredthe

information aboutthe articles reviewed. The ‘plus’ and

‘minussymbolsaddedtothetablecontentsrefertohowthe

identiﬁedfactorswerecategorisedinthesearticles.

How-ever,factorsconsidered‘plus’sometimescan,forexample

atotherpointsintime,be‘minus’aswellandviceversa.

Each identiﬁedanalytical themecomprises a setof

fac-torsinﬂuencingtheNProleatadifferentlevelofanalysis

(Fig.1).Thesedifferentlevelsofanalysisprovideinsight

intothetypeofchangesinattitudestowardstask

realloca-tionthatcanbeidentiﬁedineachlayer,eitherproactively

byindividualNPsorthroughgoverningmechanisms(e.g.

law).

3.2.1. Knowledgeandcapabilities

Fourstudiesdescribedfacilitatorsandbarriersrelated

toNPs’knowledgeand capabilities.TheNPs’knowledge

and capabilities theme is dividedin two subcategories:

(1) self-knowledge, and (2) interpersonal skills. NPs’

self-knowledge, speciﬁcallyNPs’ insight into their own

limitations and conﬁdence in their capabilities is

con-sidered important since it mayencourage NPsto make

decisions.LackthereoflikelycausesNPstoreferpatients

tophysicians,whichhampersthetaskreallocationprocess

[1,20,23,27].NPs’effectiveinterpersonalskillsareseenas

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M.G.H. Niezen, J.J.P. Mathijssen / Health Policy 117 (2014) 151–169 157 Table3 Studycharacteristics.

Author(s) Study Typeofevidence Country Healthsetting Typeof

nurse

Sample Bonneletal.,

2000[19]

DescriptivestudyofNPs’challengesandstrategiesin initiatinganeffectiveroleinanursingfacility.

Qualitativeresearchanalysingwrittenjournalsof5 NPsand2groupdiscussions.

U.S.A. Long-termcare; geriatrics

NP 5NPs

BrodskyandVan Dijk,2008[22]

Evaluateattitudesofnursesandphysicianstothe introductionofnewnursingrolesandtoexpandingthe scopeofnursingpractice.

Quantitative:questionnairesdistributedaccording toaconveniencesamplemethod.

Israel 3hospitalsand15 communityclinics

ANP 325nurses/physicians

Fletcheretal., 2007[23]

DescriptivestudyonNPs’andMDs’perceptionsoftheroleof NPs,thedegreeofcollegialitybetweenprofessions,andNPs’ feelingsofacceptance.

Qualitativeandquantitative:adescriptivestudy includingbothclosedandopen-endedquestions, andLikert-typequestions.

U.S.A. Primarycarein7 VeteransHealth Administration facilities NP 153physiciansandNPS, with109responsesto4 open-endedsurvey questions Kaasalainen etal.,2010[24]

Descriptivestudyontheperceptionsoflong-termcareteam membersandnursemanagersaboutbarriersandfacilitators tooptimaluseofNPstomanageresidents’pain.

Qualitative:anexploratorydescriptivedesign makinguseoffocusgroupsandindividual interviews.

Canada 2long-termcare settings

NP 5focusgroupswith nurses(N=between6and 10/focusgroup),and14 individualinterviews withotherhealthcare teammembersandnurse managers.

Lindbladetal., 2010[25]

DescriptivestudyontheexperiencesofAPNsandtheir supervisingGPsregardingthenewroleandscopeofpractice ofAPNs.

Qualitative:fourindividualinterviewswithNPs followedbyonefocusgroupwithsupervisingGPs.

Sweden Generalpractice APN 9(APNs/physicians)

Middletonetal., 2011[26]

StudytoproﬁleNPsandtheirpracticeinAustraliain2009 andtodescriptivelycomparethesetothedatafrom2007.

Quantitative:Self-administeredquestionnaire Australia Allsettingswhere NPsareallowedto practiceinAustralia

NP 293NPs

Offredyetal., 2007[20]

Explorativestudyoftwoprimarycaretrusts(UK)onnurse prescribers’pharmacologicalknowledgeand

decision-makingandfactorsenablingpractitioners’ willingnesstobenurseprescribers.

Qualitative:Interviewsandcasescenarios,making useofpurposivesampling.

United Kingdom

Primarycaretrusts Qualiﬁed nurse prescribers 25qualiﬁednurse prescribers(7intraining) Pearson,2009 [21]

Studyprovidinganoverviewofnursepractitionerlegislation andreimbursementissues.

Quantitative:Compilationsofthenumbersof accumulatedoccurrencesintheNational PractitionerDataBank(NPDB)andtheHealthcare IntegrityandProtectionDataBank(HIPDB)for nursepractitioners(NPs),doctorsofosteopathy (DOs)andmedicaldoctors(MDs).

U.S.A Allsettingswhere NPsareallowedto practiceintheU.S.A.

NP 147,295NPs56,754 doctorsofosteopathy 961,473medicaldoctors

Pioroetal.,2001

[33]

Explorativestudyontheapplicabilityandlimitationsof NP-basedcareinacademicteachinghospitals.

Quantitative:outcomes-basedtrialofaninpatient NPserviceforgeneralmedicalpatients.

U.S.A Hospitalcare, heterogeneous patientpopulation

NP 381patients(193 NP-basedcare/188house staffcare)

TyeandRoss, 2000[26]

CasestudyoftheNProleinanAccident&Emergency department.

Qualitative:Casestudywithnineface-to-face semi-structuredinterviews

United Kingdom

Accident& EmergencyCare

NP 9keystakeholders(e.g. NPs,A&Econsultantsand DirectorofNursing Service) VanOffenbeek

etal.,2009[28]

Comparativestudytoexplorewhich(combinationof) theory/theoriesbestexplainsredesignincareorganisations

Qualitative:Casestudiesoffoursubunitsthat introducedNPs,usinginterviewsandobservations.

Netherlands Pre-and post-operativecare; extramural rheumatologycare; post-operative neurosurgicalcare; minortraumatology atemergencycare NP 64(NPs,medical specialists,nurse managers,nurses,interns, etc.)

Wilsonetal., 2002[29]

ExplorativestudyontheviewsofGPsonbarriersin developinganadvancednursingroleinGP.

Qualitative;afocusgroupstudyofGPsinfour generalpractices United Kingdom Generalpractice NP 25GPs Zwijnenbergand Bours,2012[1]

StudyexploringtheroleofNPsandPAs,theextentof substitutionandthebarriersandfacilitatorsexperiencedby NPsandPAsasaconsequenceofsubstitutioninpublic hospitals.

Qualitativeandquantitative:Interviewsand questionnaires.

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158 M.G.H. Niezen, J.J.P. Mathijssen / Health Policy 117 (2014) 151–169 Table4

Facilitatorsandbarriers.

Author(s) Facilitatorsandbarriers +=reportedfacilitator,−=reportedbarrier,+/−,reportedbarrierandfacilitator

Individualcharacteristics Professionalboundaries Organisationalenvironment Institutionalenvironment Bonneletal.,

2000[19]

NPsproactivecommunication approachesandefﬁcient informationmanagementwere identiﬁedasabasisforgood practice(+).Levelof knowledge/skilllikelyimpacts transitiontoNProle(+/−).

Blurringboundariesbetweeneachprofessional’sroles. Thetypeofphysiciandelegationoftaskscanbea barrierinanursingfacility(−).Aclosecollaboration betweendoctorandNPcanpositivelyaffecttheNP’s role(+).Also,therolenegotiation,abouttaskstobe performedisimportant(+).EducatestaffaboutNP role(+).

Familiaritywiththeenvironmentisanearlyneedto makesenseoftheregulatoryenvironment, understandtheroleandfunctionsofvariousmembers oftheinterdisciplinaryteam,andﬁgureouthowto gettheworkdone(+).Formalprocedurestocredential orgrantprivilegestoNPorphysiciansimplemented differentlyinthedifferentsettings(−).Settingupa physicalenvironment(acorner,closet)facilitatesthe initiationofnursingfacilitypractices(+).Lackofgood resources,people,computers,referenceshampersNPs ﬁrstyearsettling(−).

Learningandunderstandingthe spectrumofresponsibilitiesunderfederal regulationscomplicatedpractice(−). Regulatoryandﬁnancialissuesare barriers(−).Examplesreportedare reimbursementissuesandMedicareand Medicaidthatonlyallowforpartial substitutionforsomephysicianservices.

Brodskyand VanDijk,2008

[22]

FeelingstowardsexpandingNPs’scopeofpractice wereaffectedbytheamountofmedicalresponsibility delegatedtotheNPs(+/−).

TheperceivedaddedvalueofNPswasinﬂuencedby theeducationofphysicians(country)(+/−)andthe amountofexperience(seniority)ofthephysicians (+/−).Moreseniorityhadanegativeinﬂuence.In Israeleducatedphysiciansweremoresupportivethan overseaseducatedcolleaguestoNPs.

Thetypeofhealthsettingappearedtoinﬂuence physicians’attitudestowardsNPs.Communityclinics tendedtobelesssupportivetoNPsthanhospitals (+/−).

Thetypeofcare,especiallythecomplexityofcare, inﬂuencestheattitudetowardsNPs.Thelescomplex thecare,themorepositivetheattitude(+/−).

Fletcher,Baker etal.,2007

[23]

NPsinsightintheirown limitationsisanimportantfactor intheacceptanceofNPsas providersofprimarycare(+/−).

ThepossiblerolesoftheNPincludevariouslevelsof medicalresponsibilityandindependence.Theamount of(in)dependenceisrelatedtothetypeof

collaborationbetweentheNPandphysician(+/−). Thereisatensionbetweenpracticingwithout adequatesupervisionandnotbeingabletopractice independentlywithinscopeoftrainingand experience(+/−).

Thecomplexityofcareprovidedisanimportantfactor intheacceptanceofNPsasprovidersofprimarycare (+/−).

Kaasalainen etal.,2010

[24]

RoleNPisnursewithaddedskillsthatcanbeusedasa conduitbetweennursingstaffandphysicians(+).The extentoftheNP/physiciancollaborationisinﬂuenced bytheleveloftrustbetweenthetwoofthem(+/−). Theamountoftrust,infact,ismentionedasthekey aspectininﬂuencingtheperceptionsofthedifferent healthprofessionals.

Thescopeofpracticeregardinge.g.(restrictionsin) prescribingaffectsthedifferentperceptions(−).

Employmentarrangementscanlimitorenhancethe fullintegrationofNPintotheteam.Animportant factoristhe(lackof)clarityoftheNProle(−). TheavailabilityoftheNP,onsite(+)oroffsiteposition (−),affectstheperceptionofhealthcareteam membersandnursemanagersregardingtheNProlein painmanagementinlongtermcare.

Legislativeboundariesareenvironmental factorsinﬂuencingtheperceptionsonthe NProle(−).

Lindbladetal., 2010[25]

TheNPispositionedonthecontinuumbetween nurseswithextendedlevelofcompetencyanda mini-doctor,orevenasacompletenewvocation. Dependingonwhattypeofdeﬁnitionisgivenforthe NPandwhatamountofteamworkiscommon,the experiencewiththeNPchanges(+/−).

Thescopeofpracticedependsontheauthorityto prescribeandordertreatments.Alackofexpanded rightsnegativelyinﬂuencestheNPsexperiencesin Sweden.Havingauthorityisfundamentalfor independentwork(−).

MutualconﬁdenceandtrustbetweenNPandGPis necessary.Conﬁdencecanbegainedthrough supervision(+/−).

ThefamiliaritywithNPsskills(NPasa

matured/graduallydevelopednewfunction)versus NPasanewlyintroducedfunctioninﬂuencesthe experienceoftheﬁrstadvancedpracticenursesin Swedishhealthcare(+/−).

The(lackof)clearconceptionofNPsrolechangesthe GP’sroletoconsultantoftheNP(−).

Also,the(lackof)demarcationoftheNPallowsfor (no)fulltimeNP’s(−).Thestudyarguesforaclear deﬁnitionofroles,rightsandresponsibilitiesneeded (+).

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M.G.H. Niezen, J.J.P. Mathijssen / Health Policy 117 (2014) 151–169 159 Table4(Continued)

Individualcharacteristics Professionalboundaries Organisationalenvironment Institutionalenvironment Middletonetal.,

2011[26]

Barriersofauthorityarerelatedtothelackof admissionprivileges(−),noprescriptionauthority(−) andnoauthoritytoissueworkerscompensation certiﬁcatesorsickcertiﬁcates(−).

Itistheaccessibilityanduniformityofqualiﬁcation andauthorisationoftheNPworkforcethatisan importantlimitingorfacilitatingfactorregardingthe statusoftheNP(−).

Oftenreportedbarriersintheinstitutionalsettingare relatedtothelackoforganisationalsupport.NPsare often(still)waitingforapprovalforclinicalprotocols (−).

Theinter-professionalcollegialityoftenislow,NPs reporttheyexperiencealackofsupportfromwithin thenursingprofession(−).

Reportedfinancialbarriersarethe non-availabilityofMedicareprovider numbersforNPs(−)aswellasthelackof authorisationtoprescribemedications throughthePharmaceuticalBenefits Scheme(−).Thesefinancialbarriersare closelyrelatedtolegislativeboundaries. Anotherreportedbarrieristhe professionalindemnityofNPs.Thereare nolimitssetbyprofessionalindemnity insurance(−).

Offredyetal., 2007[20]

Lackofappropriate

pharmacologicalknowledgeand conﬁdenceinhibitsnurses’ abilitytomakeprescribing decisions(−).

SupportbyGP’scanpositivelyaffectthenurse prescribers’role(+).

Pearson,2009

[21]

ProfessionaltensionsreportedarecredentialingNPs onlyincaseofphysicianshortage(−).NPsshouldbe heldaccountablefortheircontributionstoprimary care(+).Thetensionbetweenresponsibilityand independencebecomesvisibleinthecollaboration requirementsforprescriptiveauthority(−).However, thereisnorationaleforsupervisionofNPsby physiciansbasedonthedescribedmalpracticeand malfeasanceratiosandﬁgures(−).

Paymentpolicies,inwhichNPsare reimbursedonlyaproportionof physicians’reimbursementforthesame work,enclosethewayprimarycare servicesarevaluedingeneral(−). Equitablecredentialingand reimbursementforNPprimarycare providerswillremainelusiveaslongas lawsdonotenforcesuchcredentialing (−).

Pioroetal.,2001

[33]

Ultimateresponsibilityforpatientcarerestedwith patients’attendingdoctors,andnottheNPs(−).The typeoftaskrearrangementinﬂuencedtheoutcomes oftheinpatientNPservicetrial(−).

Also,therequestsforcross-oversreﬂectedconcerns onNPscapabilitiesandvalueforpatientcare(−). DoctorsshouldbeeducatedonthevalueofNPsfor generalmedicalpatientsinhospitals(+).

Thetypeofcaredelivered,especiallythecomplexity ofprovidedcare,affectedthecross-overofpatients fromtheNPwardtothehousestaffward. Moreovertheavailabilityofnursingbasedprotocols waslesscriticalthantheavailabilityofhousestafffor thesuccessfulimplementationofNP-basedcareinthe hospital.

TheavailabilityandﬂexibilityofNPsonthewardare factorsinﬂuencingtheoutcomeofaninpatientNP serviceforgeneralmedicalpatients.

TyeandRoss, 2000[27]

Thevaryinglevelsofconﬁdence bytheNPsaffecttheNPs’rolein practice.Also,effective interpersonalskillsvarybetween theindividualNPs(+/−).

ThepositionoftheNPvariesfromcomplementaryto medicine(moreholisticthanmedicine)–to– replacementofmedicine(doctorsubstitute). DependingonthepositionoftheNPonthisscale,the roleboundariesbecomemoreblurred(+/−).Especially regardingtheprofessionalde-skillingofphysicians andthemedicalisationoftheNP,physicianshold somereservations(−).

MedicalopinionwasconservativetoexpansionofNPs role–therewereespeciallyconcernsregarding trainingrequirements.The(absenceof)educational standardisationaffectsthemanagementof uncertaintyregardingNPs’role(−).

The(lackof)cleardeﬁnitionofNPsrole,forexample throughlocalprotocolizationfacilitatesorhindersthe NPs’role(−).

Inaddition,generalandtechnicalsupportaffectsthe implementationoftheNPsroleinthehealthsetting. Forexample,the(amountof)isolationfromthe nursingteam–e.g.uniform/shifts/etc.–can facilitate/hindertheNPsrole(−).Theoperational conﬁgurationoftheNProle–stafﬁngshortagesforces ENPstorelinquishduties.Inconsistencyofservice provisioncreatedconfusionamongstmedicalstaff(−).

Functionalpressuressuchasproviding careeropportunitiesandenhancing professionalstatusofnursinghave facilitatedtheNP’srole(+).

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160 M.G.H. Niezen, J.J.P. Mathijssen / Health Policy 117 (2014) 151–169 Table4(Continued)

Individualcharacteristics Professionalboundaries Organisationalenvironment Institutionalenvironment VanOffenbeek

etal.,2009

[28]

Thepotentialoverlapintasksaddstoblurring professionalboundariesaswellasthediscussionof theownershipofmedicalresponsibilityandneedfor supervision(−).Theﬂexibilityofroledivisioncanbe limitedbyprofessionaldemarcationsand identiﬁcations(−).

Yet,doctorsdoperceiveNPstobemoreawareoftheir ownlimitationsthanjuniordoctors(+).

Thetypeofcareandcure(routineversusnon-routine) provideopportunitiesforformalisationandtherefore delegation/substitution(+/−).

Taskenvironmentalinﬂuencesaffectworkstructure (re)design(+/−).

TheavailabilityoftheNPinthehealthsettingrelates totheamountofcontinuityincareprovided(+).

FunctionalpressuresforNPsuggesta changedworkloadforphysicians(+).In practicetheamountofdecreased workloadvaries(−).

Wilsonetal., 2002[29]

Theperceivedthreatstothedoctor’srole;joband ﬁnancialsecurityaffectprofessionalboundaries(−). TheperceivedthreatsrelatetoassociationoftheNP withde-skillization.And,theamountoflossofstatus andself-esteem(−).

Theamountofpersonalexperiencedevelopsthe conﬁdenceinNP’sroleinpractice(+).Yet,thereare GPsconcernsregardingtheoverconﬁdenceofNPsand (limited)insightintheirowncompetencies(−). Also,thescopeofpracticeisdeterminedbythe availabilityofauthorisationtoprescribe(−). NPs(donot)havethenecessarytraining,skillsand intellecttoadequatelyassesspatientanddiagnose disease(−).

Thereisa(lackof)conﬁdenceintheabilityofnurses totakeontheNProle.TheadequacyofNPtrainingis doubted(−).

Theroleofpatients/patientsatisfaction canhinderorfacilitatetheNProle.For example,patientsdo(not)wanttosee NPs.Moreover,patients’feelingstowards legitimisingtheirillnessbyseeinga doctorplayarole(−).

Financialboundariesareforexamplethe (ﬁnancial)meansforadequatetraining andtheﬁnancialstructureofUKgeneral practice(−).

Lastly,legislativeissuescanplayarole. Thereisa(lackof)claritywithregardto thelegalresponsibilitiesoftheGPs, shouldaNPmakeamistakeresultingin harmtothepatient(−).

Zwijnenberg andBours, 2012[1]

NPsownsuccess,personality, owninitiativeandyearsofwork experiencefacilitatetask reallocation(+).

Extentofsubstitution/typeofdelegationdependson NPsresponsibility(+/−).

NPsauthoritytoprescribemedicationandordertests andtreatmentsisoftenrestricted(−).

ThecollaborationbetweenNPanddoctorisvisiblein themotivationofspecialiststoprovideguidance duringNPs’training(+).

Facilities-relatedproblemsrefertonothavingone’s ownofﬁceortreatmentspaceandowncomputer,as wellastheacceptanceofofﬁcehoursbypatients(−). MoreoverNPsexperiencethatoftenaprotocol,policy plan,orverbalarrangementembeddingtheNPsroleis notavailable.Theseplans(should)containaclear visionofjobresponsibilitiesbeforehand.(−) Theinter-professionalcollegialityisalsoanimportant factorinsupportingtheNPsrole:support,effortand trustfrommanagementaswellasotherhealthcare professionalsandenthusiasmfrompeopleinvolved (+).

Lastly,aninstitutionalsettingprovidessupporttothe NPwhenthereisfreedomtodeveloptheNP’srole, trainingopportunitiesareprovidedaswellas challengeandopportunitiesforpersonaldevelopment (+).

AlegalframeworkgivingNPsauthorityto prescribemedicationandordertestsand treatmentsislacking(−).

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Fig.1.Anetworkedmodeloftheidentiﬁedfacilitatorsandbarrierstotaskreallocation.

qualityofcareandspeciﬁcallytopatientsatisfaction,and

thereforemaystimulatetaskrearrangement[27].

3.2.2. Professionalboundaries

The consequences of theintroductionof theNP are,

amongstothers,shiftingprofessionalboundariesbetween

thedomainsofmedicineandnursing.Allstudiesreport

ontheseshiftingboundariesasanimportantbarrierand

potential facilitator in task reallocation. We identiﬁed

sixsubcategories:(1)typeoftaskreallocation,(2) trust,

(3)Physician-NPcollaboration,(4) NPs’qualiﬁcation,(5)

physicians’education,and(6)physicians’jobsecurity.

Allstudiesdescribedtaskdelegation,althoughthe

stud-iesoftenreferred tocasesinwhichbothdelegation and

partialsubstitutionoccurred.ThepositionoftheNPwithin

these different types of task reallocation ranged from

super-nursetomini-doctor,orwasdepictedasanentirely

newvocation[23–25,27].Thesuper-nurseisanursewith

a higher level of competency, whereas the mini-doctor

is a nurse performing tasks formerly locatedin,

subse-quentlyreplacing,themedicaldomain.Forexample,Tye

andRossdescribehow NPsputmore emphasisontheir

holisticratherthanmedicalapproach tounderlinetheir

complementaryrole(supplementation)tophysicians[27].

Theiremphasisonnotreplacingorsubstitutingfor

physi-cians increasedtheiracceptance by otherprofessionals,

asprofessionalboundarieswerenotcrossed.Incontrast,

Lindbladetal.describehowthestructuralreallocationof

physiciantaskstoNPs,likeprescribingmedications,didnot

materialise.Thistypeoftaskreallocation,thatis

substitu-tion,explicitlyinvolvedcrossingthetraditionalboundaries

betweenmedicine and nursing,creating boundary

ten-sions[25].Thetypeoftaskreallocationthusinteractswith

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substitutionislinkedtotheownershipofmedical

respon-sibility,NPs’levelof(in)dependence,therequired

supervi-sion,andthe(restrictionsin)authorisation[1,22–29].For

example,theownershipofmedicalresponsibilityaffects

theauthority ofNPstoperformtheirtasks.Asreported

inthesurveybyZwijnenbergandBours“70.8%(n=17)of

theNPsindicatedthattaskswerereallocatedona

perma-nentbasis(substitution).Inaddition,87%oftheNPs(n=20)

reportedthattaskswerereallocated,butthattheywere

notpredominantlyresponsibleforthesetasks(delegation),

56.5%(n=13)reporteda combinationofstructural

real-locationanddelegationoftasks”[1,p.6].VanOffenbeek,

SorgeandKnipconﬁrmthatultimateresponsibilityoften

remains with the (attending) physician. Subsequently,

supervision did not decrease despite increased

experi-enceand even causedNPstoleave ahealthcare setting

onaccountof insufﬁcientprofessionalgrowth potential

[28].Physiciansespeciallyhavereservationstowardsthe

medicalisationofNPsandoftenstillholdorclaimultimate

responsibilityforpatientcare[1,28,33].Inotherwords,the

organisedoppositiontoNPs’independenceishighwhen

taskallocationentailsgivinguptaskspreviously‘owned’by

thedomainofmedicineandpartofmedicalresponsibility.

Consequently,thelevelofindependenceexperiencedby

NPswasoftenlowanddelegationoftaskslimited.

TheleveloftrustinNPs’abilitytoprovidegoodpatient

care,thecollaborationbetweenphysiciansandNPs,and

the qualiﬁcation of NPs are three factors affecting the

professionalboundariesbetween medicineand nursing.

Twostudies report how trust is related tothe amount

ofsupervision,NPs’perceivedcompetenciesandthetype

of collaborationbetween theNP and physician [20,21].

Fivestudiesdemonstratehowthecollaborationbetween

physicianandNPnotonlycanbuildtrustbygaining

expe-riencewithaNPinpractice,butcanfacilitateindependent

practicebyNPsandcanpositivelyaffecttheNPs’roleas

well[1,19,23,24,29].AlsothedebateonNPs’qualiﬁcation

affectstaskreallocation,oftendiscussedinrelationtothe

standardisation,qualityandadequacyoftheireducation.

Itistheaccessibilityanduniformityofqualiﬁcationand

authorisationoftheNPworkforcethatformanimportant

factorregardingtheNP’sstatus[21,26–29].Wilson,

Pear-sonandHassey describe“abeliefthatnurse trainingat

presentwasgenerallyinadequateforanadvancedrole.”

[29,p.643].Subsequently,theystate,thesefeelings“may

impedethedevelopmentofadvancednursingrolesin

gen-eralpractice”[29,p.644].However,asurveybyMiddleton

etal.showsthatamoreclearlydeﬁnedpathwayto

becom-inganNPinAustraliahasstimulatedthesustainabilityof

theNPworkforceintermsofaccessibilityanduniformity

ofqualiﬁcationandauthorisation[26].Nevertheless,itis

theperceivedabsenceofeducationalstandardisationthat

negativelyaffectstaskreallocation[26,27].

Physicians’education and job security are described

asbothbarriersandpotentialfacilitators[19,22,27,29,33].

Physicians’educationcaneitherbeabarrierorafacilitator

intheacceptanceofNPs[22,33],sincetheperceivedadded

valueofNPsis inﬂuenced bythephysicians’ education.

Themoretraditional theeducation,themore

hierarchi-calanddeﬁnedtheworkstructureisorganisedand the

morethenurses’autonomylevel is restricted.The NPs’

(perceived)threattophysicians’jobandﬁnancialsecurity

wasdescribedasabarriertodevelopingtheNProlesinceit

resultedinlessdelegationandmoreresistanceto

expand-ingtheNPs’scopeofpractice[29].Therearereportsofsome

ambivalenceonthepartofprofessionalregulatorybodies

regardingNPdevelopment.Ontheonehandthepotential

ofNProlesisacknowledged,ontheotherhandmedicalstaff

havereservationsaboutwherefutureboundariesshouldbe

drawn,astransferringmedicalknowledgeinvolvesgiving

upanexclusiveclaimtothisknowledge[27].

3.2.3. Organisationalenvironment

Elevenstudiesreportedontheimpactofthe

organisa-tionalenvironment ontaskreallocation[1,19,21–28,33].

Theorganisationalenvironmentimposesasetoffactors,

locatedoutsidetheprofessionalcommunitiesofphysicians

and NPs, which inﬂuences the successful

implementa-tion ofNPsin a healthcare setting. Intotal, we deﬁned

eightsubcategories:(1)organisationalpolicysupport,(2)

complexityofcureandcareprovided,(3)facility

arrange-ments, (4) employment arrangements, (5) institution’s

familiaritywiththe(regulatory)environment(6)typeof

healthsetting,(7)experienceinworkingwithNPs,and(8)

(inter)professionalcollegiality.

The ﬁrst factor, organisational policy support, was

addressedineightstudies,andencompassesademarcation

oftheNP’srole,thatprofessionaltensionsareaddressed,

that protocols or formal procedures are available and

thatunwarrantedrestrictions,suchaslimitedprescription

authority,areremoved[1,19,23–27,33].Alackof

demarca-tion–acleardeﬁnitionofroles,rightsandresponsibilities

–canmakeitdifﬁcultforNPstopracticetotheir

poten-tial.Furthermore,theavailabilityof(clinical)protocolsand

formalprocedurescanfacilitatethetaskreallocationfrom

physicianstoNPs[1,19,23,26].

Fourstudiesindicatethatthecomplexityofthecure

andcareprovidedisanimportantfactorintheacceptance

ofNPsascureproviders.Thelesscomplexthecure

com-ponent(medicine),themorepositivetheattitudetowards

NPsfulﬁllingthesetasks[22,23,28,33].VanOffenbeeketal.

reﬂect ontheroutineversusnon-routinenatureofboth

cure and care-orientedtasks [28]. NPscontribute most

intaskenvironmentswherepatientsrequirenon-routine

careandroutinecure.Itisassumedthatlesscomplex,more

routine,cure-orientedtasksofferscopeforformalisation

andthereforetaskreallocationtothenursingdomain[28].

Bothfacilityandemploymentarrangementsinﬂuence

theabilityofNPstoperformtheirrole.Thelackofproper

facility arrangements, such as not having one’s own

ofﬁce/treatment space and computer, was experienced

as a barrier to task reallocation [1,19,27]. Like facility

arrangements, employment arrangements can limit or

enhancethefullintegrationofNPsintoateamorclinical

practice [24,27,28,33].The availability ofthe NPonthe

workﬂooraffectshealthcareteammembers’and(nurse)

managers’perceptionregardingtheNProle.NPsrotating

on different sites, and therefore seen as working in a

consultativeor‘offsite’position,wereconsideredto

con-tributelesstoprovidedcareandsubsequentlywereless

(14)

upaphysicalenvironmentwasoneofthestrategiesused

byNPstoinitiatenursingfacilitypractices[19].

Other factors withinthe organisationalenvironment

that can facilitate/hinder task substitution are: the

health setting’s familiarity with(governmental)

regula-tions and rules [21], the type of health setting [28],

theamountof (previous)experiencewithNPs[25],and

(inter)professionalcollegiality[1,26].Institutionsneedto

knowhow(theinteractionbetween)regulationsandrules

caneitherfacilitateorhindertherolesandfunctionsofNPs

[21].Thetypeofhealthsettingfocusesonthedifference

between,forexample,acommunityclinicandahospital;

theformerbeinglesssupportiveofexpandingthescopeof

nursingpracticerolestothedomainofmedicinethanthe

latter,asithasdifferentexpectationsandoftenless

experi-encewithNPs[28].(Inter)professionalcollegialityrefersto

theperceivedsupportfromwithinthenursingprofessions

[26],thesupport,effortandtrustfrommanagementand

theenthusiasmfromotherpeopleinvolved[1].

3.2.4. Institutionalenvironment

Theinstitutionalenvironmentcomprisesasetoffactors

thathasthestrongestexternalinﬂuenceontask

realloca-tionfromthedomainofmedicinetothenursingdomain.

Institutionalenvironmententailstheinﬂuencesoflegal,

politicalandsocietalinstitutionsinshapingthehealthcare

system.Theseexternalfactorscanhavea strongimpact

since they involve: (1) legislation, (2) socio-economic

forces,(3)governmental(research)policy,and(4)patients’

perceptions.

Legislation is referred to as a barrier by six studies

[1,21,24,26,27,29].StatelawsdeﬁnetheNPs’roles,

artic-ulatesupervisoryrequirementsandgovernpracticeand

prescriptiveauthorities[21].However,suchlegal

frame-worksareoftenlackingorinadequate[1].Thelegislative

boundariesareintertwinedwiththeissueofprofessional

indemnity.Thereisalackofclaritywithregardtothelegal

responsibilitiesofphysicians,shouldanNPmakeamistake

thatresultsinharmtothepatient[26,29].Mistakesmade

byNPsarejudgedmoreseverelythanmistakesmadeby

physicians,sincetheNPsareanewprofessionwithnoprior

testcase.ThisincreasesthepressureonNPstobecareful

andtoavoidmistakes,whichmighthindertaskreallocation

[27].

Thesocio-economicforcesshapingNPcarearereported

insevenstudies[1,21,25–29].Innovation,intheformof

taskreallocation,isseenasanimportantstimulating

fac-torfor NP-deliveredhealthcare [25,27,28].For example,

therisingdemandforhealthcare,requiringmoreand

spe-cialisednurses,enhancestheprofessionalstatusofnursing

andhasfacilitatedtheNP’srole.Also,copingwith

physi-cianshortagesandthepromiseofachangedworkloadfor

physiciansincreasestheneedforNPs,therebystimulating

taskreallocation.Fourstudiesreporthowﬁnancial

barri-ers,suchasuncertaintyaboutfundingNPs’employment

[1,29],theﬁnancialresourcesforadequatetraining[29],or

reimbursementissues[21,26],cannegativelyaffect

inter-disciplinarytaskreallocation.

Otherandmoreobstructivefactorsdescribedare:

gov-ernmental(research)policy,andpatients’perceptionson

NPcare.Twostudiespointtothelackofpolicyregarding

thefundingfortheNPworkforceexpansionandforthe

con-tinuedprofessionaleducationofNPsasabarrier[20,21].

Patients’perceptionsonNPcarerelatetotheneedof

legit-imisingone’sdisease.Thewishtobeseenbyadoctorsince

thislegitimisesapatient’sillnessisasocietal

countermove-mentthatshouldnotbeignored[29].

4. Discussion

Ouranalysisoftheliteraturesoughttodeterminethe

barriers and facilitators encountered when reallocating

tasksfromthedomainofcuretothedomainofcareby

implementing a new professional role in practice. The

implementationof theNP served totackle issues such

asexpectedshortagesinworkforceandvalueformoney.

Researchconﬁrmedthatthequalityofcareprovided by

NPsoffersatleastequivalenthealthoutcomestocare

pro-vided by physicians [6–10]. However, theeffectiveness

of NP delivered care is greatly affected by its

imple-mentation,therequiredorganisationalredesign,andthe

reframingofprofessionalism.Transferringtasksfromthe

medicaltothenursingdomainalsocreatesuncertainty,for

instancebecausetraditionalprofessionalidentitiesare

bro-kendown.Thisuncertaintyorotherbarriersmightinfact

hindereffectivetaskreallocation.Therefore,weaimedto

understandthedifferentfacilitatorsandbarriersatplay

bycategorisingthose reportedin earlierstudies.

Impor-tantly,oneshouldbearinmindthatalthoughanidentiﬁed

factormaybeviewedasafacilitatorinthearticles(see

alsoTable4),theymightbeperceivedasbarriersinother

contexts,andviceversa.

4.1. Differenttypesoftaskreallocationandtheir

facilitatorsandbarriers

First,wewantedtolearnmoreaboutwhatformsoftask

reallocationcanbeobservedindifferenthealthsettings.

Thetypesoftaskreallocationidentiﬁedaredelegation,

sub-stitution,andsupplementation.Themostcommonformof

taskreallocationistaskdelegation,oftenincombination

withpartialsubstitution.Delegationinsteadofcomplete

substitution is more likely to occur, as withdelegation

themedicalresponsibilityremainsinthemedicaldomain.

However,itislikelythatNPs’legalandregulatory

inde-pendence will grow in due time and that substitution

andsupplementationwillincrease.Thisappliesespecially

sincelegalframeworksregardingprescriptionauthority,

responsibilityandindemnityarestillintheirinfancy.The

increasedgovernmentalconcernfor physicianshortages

and efﬁcient healthcare delivery will stimulate further

regulatory support for substitution [e.g. 25,27,28]. The

modernisationprocesses in,for example,theUK(NHS),

theNetherlands(youthhealthcare/GPcare)andtheUSA

(responsetodecreased accessibilitytocare)willfurther

stimulate and modify the position of professionals in

healthcare[16,35–37].

Second,weexploredtheperceivedbarriersand

facil-itators when task reallocation occurred, resulting in a

frameworkconsistingoffourcategories thatrangefrom

internal to external factors: (1) knowledge and

(15)

environment and (4) institutional environment. Our

frameworkincludestheperspective“thattheconstruction

andmaintenanceofboundariesiscrucialtoprofessional

development,anddemandsconstant‘boundarywork’to

preserveorexpandthem”[5,p.903].TheNPs’knowledge

andcapabilitiesarethemostinternalfactorsinﬂuencing

theabilityoftheNPtoperformhis/herroleinpractice.The

professionalboundariesclosely reﬂectthedailypractice

ofNPs,yetarelessinternalinnature.Basedonthetypeof

taskreallocationandtheNP’srole,professionalboundaries

becomeblurredtolesserorgreaterextent.Withdelegation

physiciansmaintainmedicalresponsibility,whereas

sub-stitutionrequiresthetransferofresponsibilitytoNPsand

entailsshrinkingthephysicians’professionaldomain.NPs

arepartofthisrenegotiationofprofessionalboundaries.

However,inpractice,thereallocationoftasksoftenentails

a combination ofsubstitution, complementarycare and

delegation,makingthesenegotiationsevenmorecomplex.

Theorganisationalenvironmentimposesasetofexternal

factorsontheprofessionaldomainswhichinﬂuencesthe

successfulimplementationof NPsinthehealthcare

set-ting,forexamplethroughfacilityarrangementsorhealth

settingcharacteristics.Thisorganisationalenvironmentis

moredifﬁcultforNPstoinﬂuence,yethasastrong

inﬂu-enceonNPs’abilitytoperformtheirtasks.Forexample,

whilethetype ofcomplexity ofcureand careprovided

isunlikelytochangetoﬁttheNPs’workproﬁle,facility

arrangementscan be adjusted. Finally, the institutional

environmentrepresentsthemost externalfactors. They

oftencannotbetargetedorchangedlocally,butneedto

beaddressedthroughprofessionalorganisations.

Last,wefocussedonhowthedifferentforms oftask

reallocationandperceivedfacilitatorsand barrierswere

related.Akeyﬁnding,interwoveninthefourcategories,

wastheinteractionbetweenthetypeoftaskreallocation

andthe NPs’position,sincethe extentofdelegation or

substitutionislinkedtotheownershipofmedical

responsi-bility,NPs’levelofindependence,therequiredsupervision,

andthe(restrictionsin)levelofauthority. Delegationof

tasksismorelikelytotakeplacesincemedical

responsi-bilityremainsinthemedicaldomain,withNPspositioned

assuper-nurseswithoutultimatemedicalresponsibility,

but with additional and specialised nursing

competen-cies.However,fullsubstitutioninthesensethatmedical

responsibilityisentirelytransferredtothenursingdomain,

ismoredifﬁcult.Completesubstitutionisnotonlyhindered

byprofessionalboundaries,inthesensethatphysiciansare

reluctanttograntNPstheiracquiredauthorityinpractice,

butalsobytheorganisational(e.g.availabilityofprotocols)

andinstitutionalenvironment(e.g.legislationandﬁnancial

support).Anotherexternalfactoristhecomplexityofthe

cureandcare-orientedtasksprovided inthehealth

set-ting.Thecomplexityofcureandcaregreatlydetermines

what tasksare reallocated toNPsand whether

delega-tionorsubstitutionoccurs.EspeciallyVanOffenbeeketal.

showhowthecomplexityofthecureandthepossibility

toformalisecureinprotocolsortoselectspeciﬁcpatient

groupsaffectsthetypeandamountoftasksallocatedand

entrustedtotheNPs[28].Thepossibilitytostandardise

cure-orientedtasksthenlegitimisesthedelegationor

sub-stitutionoftasks.Thelegalframeworkalsoinﬂuencesthe

type oftaskreallocationthat cantakeplace.Aslongas

prescriptionauthority,responsibilityandindemnity

regu-lationsarenotfullyestablishedand/ornottranslatedinto

localprotocolsandregulations,NPsface(in)dependence

andresponsibilityissueswhensubstitutingforphysicians.

Thetypeoftaskreallocationthusgreatlydetermineswhat

facilitatorsandbarriersareexperienced,whileviceversa,

theexistingfacilitatorsandbarriersmaydeterminewhat

typeoftaskreallocationcanoccur.

4.2. Interactionsbetweendifferentprofessionallayers

andinnovation

Although the networked model (Fig. 1) depicts the

analytical themes separately, the arrows indicate the

importance of the interactions between the different

professionallayers.Forinstance,theorganisational

envi-ronmentaffectstheprofessionalautonomyofphysicians

andNPs(atthelevelofprofessionalboundaries)sinceit

developsitsownsetofcontrolsandhierarchies.Inother

words, the driving and restraining forces of workforce

changearelocatedespeciallyattheintersectionofthese

different analytical levels.For example, even if NPsare

acceptedascomplementarycareprofessionals,thelackof

acleardeﬁnitionoftherolewasidentiﬁedasamajor

prob-lem[27].Similarly,physiciansmightbewillingtoallocate

taskstoNPs,yetlegalproblemssuchasthelackof

author-itytoprescribemedicationcanstillcomplicatetheactual

allocationofthesetasks[1].

Acomparisonbetweenthewell-knownmodelfor

inno-vationsinhealthserviceorganisationsbyGreenhalghetal.

[14]andournetworkedmodelmightprovidemoreinsight

in the interrelationship between the different

analyti-calthemesandtheintroductionofnewnursingrolesin

healthcare.Especiallysinceournetworkedmodeldoesnot

explicitlydemonstratethedifferentstagesofdiffusion,

dis-semination and implementation [14]. Greenhalgh et al.

conductedameta-narrativereviewofRogers’overviewof

the diffusionof innovation[38] and otherkey research

studiesoninnovationsinservicedeliveryand

organisa-tion[see39].Theyexaminethefollowingdeterminants:

(a)theinnovation,(b)adoptionbyindividuals,(c)

assim-ilationoftheinnovationbythesystem,(d)diffusionand

dissemination,(e)systemantecedentsforinnovation,(f)

systemreadinessforinnovation,(g)theoutercontext,(h)

implementationandroutinisationand(i)linkageamong

thedifferentcomponents(a–h).Astheyarecloselylinked

tothedifferentlayersofprofessionalism,ineachanalytical

themewemayexpecttoﬁndseveralofthesedeterminants.

First,theNP’sknowledgeandexpertiserepresentsthe

NP’sroledesign(thecontent)morethantheprocessofNP

implementation.InlinewithGreenhalghetal.,ourmodel

arguesforindividualantecedentsforinnovation(b).NPsdo

nothaveapassiverolein‘theinnovation’,rathertheyare

(thestimulusorforcingfactorin)theinnovation(a).

Subse-quently,inexpandingtheirprofessionalskillsNPsneedto

demonstratetheirrelativeadvantageinpractice.For

exam-ple,interpersonalskillsareneededtoensurethatother

professions affected by the NPs’introduction recognise

how theirownvalues andperceivedneedsare

(16)

ifNPslacksuchinterpersonalskillsorlackconﬁdencein

theirabilitytoperformtheirroleasNP,theantecedents

(a,b)oftheinnovationarenotstronglyrepresentedanda

successfuladoptionislesslikely.

Second,theanalyticalthemeofprofessionalboundaries

reﬂects the facilitatorsand barriersto taskreallocation

withintheprofessionalcommunity.Theseare,forexample,

inﬂuencesthathelpspread NPscaresuchasthe

profes-sionalnetworksinwhichtheNPsneedtooperate(d).Since

NPsandphysiciansoftentendtohavedifferenttypesof

networks,thecollaborationbetweenthetwoprofessionsis

essentialforthediffusionofNPcare.However,ourmodel

focusesmoreonthedrivingandrestrainingfactorsinthe

requiredreframingofprofessionalismtosupportthe

intro-ductionofanewnursingprofession,whereasGreenhalgh

etal.focusonhowexistingprofessionalboundariescanbe

addressed[14].Subsequently,wehighlightthetensionsfor

changeasdescribedinthesystemreadinessforinnovation

(f).

Thethirdanalyticaltheme,organisationalenvironment,

encompassesmanyelementsofGreenhalgh’smodel[14].

Withrespecttotheassimilation(c),thefocusisonthe

envi-ronmentinwhichchangesarerequired.Similarly,wehave

identiﬁedseveralaspectssuchasorganisationalpolicy

sup-port,facilityandemploymentarrangements,requiredto

even facilitate NP care. Especially organisational policy

supportiscalledforifNPcarerequiresactivedissemination

(d).However,themainoverlapbetweenthetwomodels

canbefoundinthedeterminantsoforganisational

innova-tiveness(e),forexamplethedeterminantsofcomplexity

andtypeofhealthsetting.Thesystemreadinessfor

inno-vation(f)isreﬂectedintheorganisationalpolicysupport

factor.

Fourth, as described in our review, the institutional

environmentmainlycoincideswiththeoutercontext(g),

speciﬁcallythepoliticaldirectives.Apolicypushisrequired

to boost the chances of success of workforce change.

Research policies,however, aredepictedby Greenhalgh

etal.asanelementofanorganisation’ssystemreadiness

forinnovation[14].Theyfocusoninnovationsinservice

deliveryandorganisationﬁttingwithincurrentlawsand

regulations.However,theintroductionofanewprofession

doesnotnecessarilyﬁtcurrentlawsandregulations.

For-mulatingresearchpolicy,inthiscase,shouldbeperceived

asaneededstimulusorincentivebygovernmentandnot

bytheorganisationalcommunitysolely.

Bothmodelsthushaveapparentsimilaritiesand

there-forewecanarguethatthenetworkedmodelcanprovide

insightintheinnovationprocessofintroducingnew

nurs-ingrolesinhealthcare.Nevertheless,ournetworkedmodel

offersadifferent,approachtotheintroductionofNPsin

healthcare,comparedtoGreenhalghetal.’ssomewhat

lin-earmodelforinnovationsinhealthserviceorganisations.

Thenetworkedmodelemphasizesthedynamicinterplay

between the different facilitators and barriers to task

reallocationthataffectthepositioningof(theprofession

of)NPsinhealthcare. Theintroductionofanew

profes-sionnot onlyaddresseschanges inservice deliveryand

organisation, butimplies areframingofprofessionalism

in multiple layers of the healthcare system. The

net-workedmodeldemonstrateshowdifferentdeterminants

playaroleineachlayerofprofessionalismwhichshould

betakenintoaccountpriortoandduringthe

implemen-tation of NPs in healthcare. In other words,each layer

of professionalism hasits own set of rules, values and

social contextinﬂuencing the introductionofthe NPin

healthcare.We believe thata successfulintroductionof

effectiveNPcaremuststartbyaddressingthesefactorsin

eachlayerandseekingtheinteractionbetweenthese

dif-ferentlayers.Understandinghowthedifferentfactorsin

thesedifferentlayerscanfacilitateorhinderthe

introduc-tionofNPswillprovidepolicyandpracticewithhands-on

informationas towhat determinantstoaddressto

pro-motethe adoption of NP care. Thisespecially concerns

thefacilitators and barriersof the‘professional

bound-aries’and‘organisationalenvironment’categoriesreported

in (almost) allstudies. Negotiating theNPs’ positionin

theoverlap betweenthecureand care domainin

rela-tiontoresponsibilityshouldbeanimportantspearheadin

theorganisationalredesign.ClearlydemarcatingtheNPs’

positionwithintheorganisationalenvironmentthrough

protocols,butalsoinfacilityarrangementssuchas

techno-logicalsupport,canfurtherfacilitatetheimplementation

ofNPdeliveredcareinpractice.Thenetworkedmodel,we

believe,isbettersuitedtoresearchand/orstimulatethe

introductionofnewnursingrolesandsubsequenttask

real-locationinhealthcare,thanGreenhalghetal.’smodelfor

innovationsinhealthserviceorganisations.

Animplicationofthisapproachcouldbethatthe

para-doxoftheneedforNPcaredue to(expected)physician

shortagesandtheperceivedthreatofNPsexpandingtheir

professionaldomainattheexpenseofthemedicinedomain

canbediscussedmoreopenlyatthedifferentprofessional

layers.Forone,abetterdescriptionoftheNProleinthe

organisationalenvironmentcanbefollowedbya

descrip-tionofopportunitiesforphysiciansasaresultofthistask

reallocation.However,theabsenceoftheformer,asoften

describedinourreviewedstudies,sofarprohibitsthe

lat-ter.

Moreover, the insights of the networked model

approachmightbegeneralisedandusedinothersimilar

situations of task reallocations between other

health-careprofessions. For example, taskreallocationhasnot

only taken place betweenphysicians and NPs, but also

betweenphysiciansand physicianassistants(hospitals),

between physicians and practice nurses (primary care)

andalsobetweenNPsandgeneralnurses(youth

health-care/hospital).Ournetworkedmodel hasintegratedand

abstractedﬁndingsfromthecontextoftaskreallocation

fromthemedicaltothenursingdomaininsuchwaythat

the results might be transferable to other situations if

deemedcomparable.

4.3. Methodologicalstrengthsandweaknesses

Importantly,weunderstandtheremightbeserious

con-cernswithgeneralisingtheresultsofvariousqualitative

researchstudies(i.e.studiesthatrelyonqualitativedata

collectionandanalysis).“Qualitativeresearch,it isoften

proposed,isnotgeneralisableandisspeciﬁctoa

partic-ularcontext,timeandgroupofparticipants”[40,p.46].