REVIEW ARTICLE

doi: 10.1111/scs.12120

The tortuous journey of introducing the Nurse Practitioner as a new member of the healthcare team: a meta-synthesis Anna-Carin Andreg
ard RN, CNS, MSc (Nurse Practitioner)1 and Eva Jangland RN, CNS, PhD (Senior Lecturer)2 1

Department of Medical and Health Sciences, Division of Nursing Science, Link€ oping University, Link€ oping, Sweden and 2Department of Surgical Sciences, Uppsala University, Uppsala, Sweden

Scand J Caring Sci; 2015; 29; 3–14 The tortuous journey of introducing the Nurse Practitioner as a new member of the healthcare team: a meta-synthesis The aim of this study was to explore the obstacles to and the opportunities for achieving optimal interprofessional team collaboration with the introduction of the nurse practitioner (NP). A team approach can contribute importantly to sustainable and safe patient care, and NPs have been added to the healthcare team in many countries. Following the international trend towards the development of the acute care NP, the role has recently been initiated in surgical care in Sweden. The introduction of an advanced nursing role into existing organisations raises questions about how the role will be developed and what its effects will be on collaboration between the different professions. We conducted a systematic review of qualitative studies using the meta-ethnographic approach developed by Noblit and Hare. Literature in the field of nursing was searched on PubMed and CINAHL, and empirical qualitative studies from outpatient and inpatient care in seven countries were included. The studies

Introduction Advanced roles in nursing practice have been developed and implemented in many countries over the last few decades with a main focus on improving patient care. This has expanded the scope of practice for nurses globally; through higher skills in nursing and medicine, advanced nurses now have the expertise to perform duties previously beyond most nurses’ normal areas of competence. In many countries, advanced nurses now working in interprofessional teams have expanded responsibility for the patient throughout the healthcare system (1–4). Correspondence to: Dr Eva Jangland, Department of Surgical Sciences, Uppsala University, Entrance 70, Uppsala University Hospital, SE-751 85 Uppsala, Sweden. E-mail: [email protected] © 2014 Nordic College of Caring Science

were appraised according to national guidelines and templates and were analysed and synthesised according to the meta-ethnographic approach. A total of 26 studies were included in the synthesis. The analysis revealed four themes: (i) a threat to professional boundaries, (ii) a resource for the team, (iii) the quest for autonomy and control, and (iv) necessary properties of a developing interprofessional collaboration. Based on these themes, the synthesis was created and presented as a metaphorical journey. The implementation of a new nursing role in a traditional healthcare team is a complex process influenced by many factors and can be described as “a tortuous journey towards a partially unknown destination”. The synthesised obstacles and opportunities drawn from international studies may help healthcare organisations and new NPs prepare for, and optimise, the implementation of a new nursing role. Keywords: advanced nursing practice, professional development, Nurse Practitioners, nurse–physician relationships, teamwork. Submitted 29 December 2013, Accepted 27 January 2014

During the implementation of advanced nursing roles, different role titles, legal requirements and scopes of practice have been developed in many countries. The most frequently used titles are nurse practitioner (NP) and advanced practice nurse (APN), and several studies point out the need to clarify and define the scope of practice for this emerging role (4–6). The International Council of Nursing (ICN) emphasises the need to develop this role in every country, taking into account the different needs of national healthcare systems and their different contexts. They defined the role as follows: ‘A Nurse Practitioner/Advanced Practice Nurse is a Registered Nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. A master’s degree is recommended for entry level’ (7). 3

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ard, E. Jangland

Nurse practitioners were introduced into acute care services in the USA in the 1990s to rectify identified shortcomings in the chain of care, lack of continuity of care from physicians, and less-than-optimal care interventions (3, 8). The introduction of NPs has been reported to shorten hospital stays and reduce cost of care (2, 3), while organisations that include NPs on the team have been shown to maintain or improve their quality of care (3, 9). It has been reported that the flow of patients through acute care departments could be improved with an advanced nursing role in the team structure, allowing medical resources to be concentrated on higher priority presentations (10, 11). According to both the World Health Organization (WHO) and prior research, a team approach is one of the most important factors in both achieving sustainable and safe care and decreasing the costs of health care (12–16). The Institute of Medicine (17) emphasises that nonfunctional teamwork can lead to patient safety risks. The Department of Health in England emphasises that the hierarchical approach needs to be replaced with flexible teamwork between different professions (18). A Cochrane review concluded that interprofessional collaboration can lead to positive changes in health care, but that further studies are needed to obtain evidence for the importance of interprofessional teamwork (19). On the other hand, studies also report that status differentials between professions on the healthcare team remain as barriers to effective collaboration (20–22). The relationship between the professions is not always optimal, because different professions are deeply rooted within their own paradigms and cultures. The traditional hierarchy that ranks nurses below physicians has been reported to hinder the nurse’s ability to convey relevant information (23). Effective cooperation requires that this ranking be challenged and that the team focus on cooperation instead of competition (24, 25). The organisation’s leadership is important both to the team’s functioning and to the challenge against traditional hierarchies (21). Studies have reported that when an NP is successfully introduced into a team, the NP can act as a clinical leader who inspires and supports nurses in the clinical routine, improves cooperation and supports more evidence-based health care (11, 26). A successful NP acts as a support for nurses and physicians and is also more available on the ward than physicians (11, 26, 27). Nurse practitioners have been added to the healthcare team in many countries, although sometimes with initial problems in the collaboration, usually attributable to unclear role definition (28–30). Following the international trend towards the development of the acute care NP, the role has recently been initiated in surgical care in Sweden, with the first students set to graduate in 2014 (31). The introduction of a new nursing role into

existing organisations raises questions about how the role will be developed and what its effects will be on collaboration between the different professions (30). Many studies examining the impact of NPs take a quantitative approach measuring quality of care, waiting times, and health economics, and several systematic reviews of those types of studies have been identified (2, 3, 10, 11). There seem to be fewer qualitative studies focused on the development of the NP role and its effect on team collaboration, and no systematic review of this topic has been identified. In health care, many phenomena cannot be captured in a quantitative study; therefore, in addition to systematic reviews of quantitative studies, it is necessary that qualitative studies also be evaluated and synthesised. Quantitative and qualitative studies can each support decisions in clinical practice, but both approaches—not just one—are needed to give us a deeper insight into the phenomenon in question (32, 33). This article reports findings of a systematic review of published qualitative research on the incorporation of the NP into the healthcare team. This review synthesises the experiences reported in international studies and may be helpful for creating strategies for the implementation process in other countries. We undertook this review to explore the obstacles to, and the opportunities for, achieving optimal interprofessional team collaboration with the introduction of NP.

Method We undertook a systematic literature review of qualitative studies (32) and conducted an interpretative and descriptive meta-synthesis using Noblit and Hare’s metaethnographic approach. The method included seven phases that repeated and overlapped as the meta-synthesis progressed (33, 34). The phenomenon of interest in this study was the healthcare team’s collaboration when introducing an NP as a new member. Meta-synthesis has been defined as a method for “bringing together and breaking down findings, examining them, discovering the essential features and combining phenomena into a transformed whole” (35, p. 314). The aim of a meta-synthesis is not merely to summarise previous research, but to provide knowledge and insights that develop and increase the understanding of a phenomenon within a particular discipline (32, 36, 37). Meta-ethnography may be an effective method for systematically drawing together and synthesising qualitative research. If applied rigorously, the reciprocal process of translating the findings from several studies into a common language or format allows qualitative data to be combined and can produce significant new insights that can contribute to clinical practice (38). © 2014 Nordic College of Caring Science

The tortuous journey of introducing the NP

Data collection The aim was to include all relevant qualitative studies from different countries that include views of NPs, nurses and physicians about team collaboration. Search strategy, keyword, inclusion and exclusion criteria are presented in Fig. 1. We decided to go back to studies from 1995 because the acute care NP role was first implemented in the beginning of 1990 (1). The search was done with help from a professional librarian. The quality review of the studies (n = 34) was performed using national guidelines and quality templates developed by the Swedish Council on Health Technology Assessment (SBU), which is the highest institute of evidence-based research in Sweden. Articles were ranked from “low quality” to “high quality” according to the national guidelines (39). The majority of the studies were of medium or high quality. Two were critically appraised as low quality. All included studies were read and reread.

The methods of these studies were diverse, comprising grounded theory, content analysis, phenomenology, ethnography and mixed methods. An overview of the included studies (n = 26) was created by summarising them in a table, an example of which, with five studies, is shown in Table 1.

Analyses The included studies were analysed and synthesised in seven phases according to the method developed by Noblit and Hare. Noblit and Hare’s phases of metasynthesis (33, 34) are presented in Table 2. The results of the studies were read and reread, and relevant themes (n = 12) were extracted and listed to analyse their relations to each other. The originally identified themes were interpreted and translated into four new themes, which led to the main metaphor, presented as a story. The two authors performed the data abstraction and analyses in

• • • • •

•

Identified items by database search n = 607

Deleted by title n = 401

Read abstract n = 206

Deleted after reading abstracts n = 132

Read abstract n = 206

Deleted after reading article n = 49

Studies initially included n = 34

Identified articles using manual search of reference lists n = 15 Selected for review n = 9

Deleted after analysis n=8

Included studies n = 26

Figure 1 Inclusion–exclusion criteria and search strategy. © 2014 Nordic College of Caring Science

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Total (n = 25) NPs (n = 9) Supervisors (n = 5) Nurse specialists (n = 3) Nurse managers (n = 4) Interns (n = 3) Department manager (n = 1)

Total (n = 59) Interviews (n = 16) Focus groups (n = 12) NPs, doctors, nurses and other team members Two different hospitals, cardiac care departments

In-depth interviews Content analysis

Grounded theory Interviews Content analysis according to Glaser

Interviews and focus groups Content analysis

To describe the first year of Nurse Practitioner (NP) development from a collaborative perspective

To explore the experience of going from nurse to NP in anintensive care department

To study the role of professional boundaries in the healthcare team 3 years after the introduction of NPs

Chang, Mu, Tsay (58) Taiwan

Fleming, Carberry (40) UK

Kilpatrick, Lavoie-Tremblay, Ritchie, Lamothe, Doran (41) Canada

NPs (n = 10) Hospitals (surgical and gynaecological wards)

Method/design

Participants Type of healthcare facility

Aim

Author, publication date, country

Table 1 A summary of five articles about the role of the Nurse Practitioner and teamwork

Role development during the first year consists of three phases: (i) role ambiguity; (ii) ‘conquering’ the role; (iii) implementing the role. NPs support new nurses. Cooperation and trust between physicians and NPs increase. NPs initially lack of confidence and feeling of alienation due to lack of commitment and support from a mentor Four categories: (i) finding a niche; (ii) being able to handle the pressure; (iii) feeling capable of the work; (iv) growing into the role. NPs ensure that skills remain in the team and close to the patient. Young doctors felt a threat to their ability to learn. After the first time working together, both interns and NPs experienced that they helped each other and their communication improved. NPs had an initial lack of confidence and were worried they might not be ready for the responsibility. In the beginning, the mentor was valuable for the development of knowledge and role identity. Nurses felt that the NP was always available and could provide support and prescriptions. They could ask the NP about anything. Nurse managers felt that NPs supported and contributed to nurses’ increased knowledge and patient safety. Obstacles: bad information. Shifting professional boundaries takes time and includes (i) creating space for the NP on the team; (ii) some loss of functionality of some team members; (iii) building confidence; and (iv) new dynamics between various people on the team. All professionals must have a clear understanding of each team member’s role and function for the team to be effective Lack of role definition can lead to poor confidence in the NP. Different role expectations may be obstacles. Doctors believe that NPs should be more medically oriented and nurses think they should be care oriented.

Main findings/conclusions

Cannot distinguish the views of the NPs, nurses, and doctors

NP role brand new in Scotland when the study was done

Cites Benner’s theory of caring in nursing. Many citations.

Strengths and weaknesses

High

High

Average to high

Quality

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ard, E. Jangland

© 2014 Nordic College of Caring Science

The tortuous journey of introducing the NP 10 Wilson A, Shifaza F. An evaluation of the effectiveness and acceptability of nurse practitioner in an adult emergency department. Int J Nurs Pract 2008; 14: 149–56. 11 Searle J. Nurse practitioner candidates: shifting professional boundaries. Australas Emerg Nurs J 2008; 11: 20–27. 12 WHO. Human Factors in Patient Safety: Review of Topics and Tools. Report for Methods and Measures Working Group of WHO Patient Safety 2009, http:// www.who.int (last accessed 10 February 2013) 13 Salas E, Burke S, Cannon-Bower J. Teamwork: emerging principles. Indian J Med Res 2000; 2: 339–56. 14 Poole M, Real K. Groups and teams in health care. In Handbook of Health Communication, (Thompson T, Dorsey A, Miller K, Parrott R eds), 2003, Sage, Thousand Oaks, CA, 369–402. 15 Salas E, Sims D, Burke S. Is there a “big five” in team work? Small Group Res 2005; 36: 555–99. 16 Begley C. Developing inter-professional learning: tactics, teamwork and talk. Nurse Educ Today 2009; 29: 276–83. 17 Institute of Medicine (IOM). Keeping Patients Safe. 2004, National Academy Press, Washington, DC, USA, http:// www.nap.edu/openbook.php?record_id=10851&page=R1 (last accessed 21 October 2013) 18 Department of Health. The NHS Plan. A Plan for Investment. A Plan for reform. 2000, Department of Health, London, http://webarchive.nationa larchives.gov.uk/20130107105354/ http://www.dh.gov.uk/prod_consum_ dh/groups/dh_digitalassets/@dh/@en/ @ps/documents/digitalasset/dh_118522. pdf (last accessed 18 August 2013). 19 Reeves S, Zwarenstein M, Goldman J, Barr H, Freeth D, Hammick M, Koppel I. Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2008, http://ipls.dk/pdffiler/ip_collaboration_cochrane.pdf (last accessed 23 September 2013). 20 Cott C. We decide, you carry it out: a social network analysis of multidisciplinary long-term care teams. Soc Sci Med 1997; 45: 1411–21.

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21 Kvarnstr€ om S. Difficulties in collaboration: a critical incident study of interprofessional healthcare teamwork. J Interprof Care 2008; 22: 191–203. 22 O‘Leary K, Ritter C, Wheeler H, Szekendi M, Brinton T, Williams M. Teamwork on inpatient medical units: assessing attitudes and barriers. BMJ Qual Saf 2010; 19: 117–21. 23 Propp K, Apker J, Zabava-Ford W, Wallace N, Serbenski M, Hofmeister N. Meeting the complex needs of the health care team: identification of nurse-team communication practices perceived to enhance patient outcomes. Qual Health Res 2010; 20: 15– 28. 24 D’Amour D, Ferrada-Videla M, San Martin Rodriguez L, Beaulieu M-D. The conceptual basis for interprofessional collaboration: core concepts and theoretical frameworks. J Interprof Care 2005; 19: 116–31. 25 Robinson F, Gorman G, Slimmer L, Yudkowsky R. Perceptions of effective and ineffective nurse-physician communication in hospitals. Nurs Forum 2010; 45: 206–16. 26 Gerrish K, Guillaume L, Kirshbaum M, McDonell A, Tod A, Nolan M. Factors influencing the contribution of advanced practice nurses to promoting evidence-based practice among front-line nurses: findings from cross-sectional survey. J Adv Nurs 2010; 67: 1079–90. 27 McMullen M, Alexander M, Bourgeois A, Goodman L. Evaluating a nurse practitioner service. Dimens Crit Care Nurs 2001; 20: 30–34. 28 Soeren M, Micevski V. Success indicators and barriers to acute nurse practitioner role implementation in four Ontario hospitals. AACN Clin Issues 2001; 12: 424–37. 29 Lloyd-Jones M. Role development and effective practice in specialist and advanced practice roles in acute hospital setting: systematic review and meta-synthesis. J Adv Nurs 2003; 49: 191–209. 30 Sangster-Gormley E, Martin-Misener R, Downe-Wamboldt B, Dicenso A. Factor affecting nurse practitioner role implementation in Canadian practice settings: an integrative review. J Adv Nurs 2011; 67: 1178–90.

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31 Jangland E, Becker D, B€ orjeson S, Doherty C, Gimm O, Griffith P, Johansson A-K, Juhlin C, Pawlow P, Sicoutris C, Yngman-Uhlin P. The development of a Swedish Nurse Practitioner program – a request from clinicians and a process supported by US experience. J Nurs Educ Pract 2014; 4: 38–48. 32 Webb C, Roe B. Reviewing Research Evidence for Nursing Practice. 2008, Blackwell Publishing, Singapore. 33 Noblit G, Hare D. Meta-ethnography: Synthesizing Qualitative Studies. 1988. Sage Publications, Inc. Beverly Hills, CA. 34 Polit D, Beck C. Nursing Research: Generating Assessing Evidence for Nursing Practice, 9th edn. 2012, Wolters Kluwer Health/Lippinicott Williams & Wilkins, Philadelphia, PA. 35 Schreiber R, Crooks D, Stern PN. Qualitative meta-analysis. In Completing a Qualitative Project. Details and Dialogue (Morse JM ed.), 1997, Sage, London, 311–26. 36 Finfgeld D. Metasynthesis: The state of art-so far. Qual Health Res 2003; 13: 893–904. 37 Bondas T, Hall P. Challenges in approaching meta-synthesis research. Qual Health Res 2007; 17: 113–21. 38 Campbell R, Pound P, Morgan M, Daker-White G, Britten N, Pill R, Yardley L, Pope C, Donovan J. Evaluating meta-ethnography: systematic analysis and synthesis of qualitative research. Health Technol Assess 2011; 15: 43. 39 SBU (Swedish Council on Health Technology Assessment). Utv€ardering av Metoder i H€also- och Sjukv
arden – En Handbok. (Evaluation of Methods in Health Care – A Handbook). 2011, http://www.sbu.se (last accessed 23 March 2013). 40 Fleming E, Carberry M. Steering course towards advanced nurse practitioner: a critical care perspective. Nurs Crit Care 2011; 16: 67–76. 41 Kilpatrick K, Lavoie-Tremblay M, Ritchie J, Lamothe L, Doran D. Boundary work and the introduction of acute care nurse practitioners in healthcare teams. J Adv Nurs 2012; 68: 1504–11. 42 Cummings G, Fraser K, Tarlier D. Implementing advanced nurse

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Table 2 Noblit and Hare0 s Phases of Meta-synthesis (33,34) 1. 2. 3. 4.

Identify a topic Decide which qualitative studies are relevant to the topic. Read the studies to be included in the synthesis multiple times. Determine how the studies are related to each other by making a list of themes or metaphors in each study and their relationship to each other. 5. Translate the studies into one another, exploring and explaining similarities and contradictions. 6. Synthesise the translations, determine whether the same metaphors/themes can be combined together. 7. Express the result of the synthesis/interpretation in a transparent and clear manner

several face-to-face meetings until a consensus about the quality of the studies, the categorisation and the synthesis was reached. The first author of this review (ACA) is one of the first graduated NPs in surgical care in Sweden. The second author (EJ) has been involved in the implementation of NPs in clinical practice. The authors’ preunderstanding of the field is based on their experiences with different hospitals and county councils in Sweden, as well as their experiences of courses at a university in the United States and of playing or observing the NP role as enacted in the healthcare team (31).

Results This synthesis is based on 26 studies from outpatient and inpatient care facilities in seven countries. Four key themes related to the introduction of a new member— the Nurse Practitioner—to the team collaboration was identified: ‘a threat to professional boundaries’, ‘a resource for the team’, ‘the quest for autonomy and control’ and ‘the ability to develop an interprofessional collaboration’. Based on these ‘themes, the synthesis was created, made visible and presented as a metaphorical journey: a tortuous journey towards a partially unknown destination. Table 3 provides an overview of the synthesis and the themes, which are described below.

the NP role belonged to nursing or medicine seemed to end, both disciplines were integrated into the new role, and the NP functioned as an important bridge between the nursing and medical disciplines. The nurses also seemed to feel that the NP role strengthened nursing care and made it more visible in the team (41, 46–48). Many doctors recognised the NP not as a medical colleague, but more as an important team member, and they expected the NP to adapt to the physician’s way of working (47, 49–51). The team collaboration significantly improved after the content of the NP role became clearer and more visible (40, 52). The combination of an undefined NP role and a variety of doctors on the team led to uncertainty and unsuccessful collaboration (43). Some NPs described the teamwork as efficient and satisfactory, while others described it as quiet, tense and solitary (53). More experienced nurses initially felt that the NP took over their roles as mentors and experts on the team, and the new NPs often felt that some nurses did not trust or respect them (42, 45, 54, 55). Initially, some inexperienced doctors felt a threat to their role because they worried that the NP would limit their opportunities for learning. NPs had to balance their work to avoid conflicts (40, 56). After the initial period of tension, however, trust and acceptance of the new role increased, and cooperation on the team improved (41, 52, 57, 58). In several studies, the nurses felt that physicians were the superior profession because of traditional hierarchical structures and as such a barrier to effective collaboration utilising all professions’ skills. NPs felt that physicians ruled by delegation and prescriptions (49–52, 55). Both nurses and doctors felt that lack of information about the NP’s role was the greatest threat to effective collaboration, and doctors felt that they were poorly informed about the NPs’ education and skills. This could also be a reason that the NPs’ competencies were not fully utilised, leading to conflicts within the team (44, 45, 48, 50, 51, 53, 57–60).

A resource for the team A threat to professional boundaries In the first theme, it was evident that it was initially difficult to find a place and a role for the new NP in the team. The team needed to have time to adapt to the new situation and the new professional role (40, 41). Nurses and doctors also had different opinions about what the NP role should be and what the NP should focus on. Nurses felt that the NP role had too medical focus and requested it be more nursing oriented (42, 43). Some doctors equated NPs with new resident physicians, while others identified the new NP role as that of a medical assistant or as an adjunct to the team (42, 44–46). In several studies after a number of years discussion of whether

In this theme, it is evident that when the NP is accepted on the team, both nurses and doctors identify the NP as a resource and a source of knowledge. This led to improved communication within and outside the team (41, 48, 53, 57, 59). NPs felt as if they were “a cornerstone” of the team and described the collaboration as central to their role (47, 53, 61, 62). Some clinicians and managers had expectations that the NP would manage the role as a clinical leader (63). The NPs represented continuity in the clinical work that junior doctors could not because of their temporary stay in the department. The NPs were a support for both nurses and physicians, which was especially important © 2014 Nordic College of Caring Science

The tortuous journey of introducing the NP

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Table 3 Main metaphor and summary of key themes, new themes and the articles that contributed to each theme Main metaphor: ‘A tortuous journey towards a partially unknown destination’ Key themes

New themes

Author and year

Problems defining the nurse practitioner’s (NP’s) function on the team Hierarchical structures Friction between medicine and nursing Lack of information

A threat to professional boundaries

Accessibility, security, and continuity Coordination and relief functions Supervising function

A resource for the team

Responsibility and authority Obstacles to an independent team member Need for support and guidance

The quest for autonomy and control

The importance of the NP’s personal qualities and experience Being able to handle the pressure

The ability to develop an interprofessional collaboration

Bailey et al. (52), Burgess & Purkis (53), Carryer et al. (63)*, €m & Glasberg Chang et al. (58), Cummings et al. (42), Fagerstro (60), Fang & Tung (46), Fleming & Carberry (40), Fletcher et al. (44), Gardner A. et al. (62)*, Gardner et al. (61), Gould et al. (55), Hallas et al. (49), Hoffman et al. (54), Kilpatrick et al. (41, 43)*, Lindblad et al. (59), Martin et al. (50, 51), O’Brien et al. 2009*, Rashotte & Jensen (47), Reavy et al. (65), Soeren et al. (48), Trasher & Purc-Stephenson (45), Williamson et al. (56), Wilson et al. (57) Bailey et al. (52), Carryer et al. (63), Cummings et al. (42), €m & Glasberg (60), Fang & Tung (46), Fleming & Fagerstro Carberry (40), Fletcher et al. (44), Hallas et al. (49), Hoffman et al. (54), Kilpatrick et al. (41, 43), Lindblad et al. (59), Martin et al. (50, 51)*, O’Brien et al. 2009*, Reavy et al. (65), Soeren et al. (48), Trasher & Purc-Stephenson (45), Williamson et al. (56) Bailey et al. (52), Chang et al. (58), Cummings et al. (42), €m & Glasberg (60), Fleming & Carberry (40), Fagerstro Fletcher et al. (44), Hallas et al. (49), Hoffman et al. (54), Kilpatrick et al. (41, 43), Lindblad et al. (59), Martin et al. (50, 51)*, O’Brien et al. 2009*, Williamson et al. (56), Wilson et al. (57) Bailey et al. (52), Burgess & Purkis (53), Chang et al. (58), €m & Glasberg (60), Fang & Cummings et al. (42), Fagerstro Tung (46), Fleming & Carberry (40), Hallas et al. (49), Kilpatrick et al. (41, 43), Martin et al. (50, 51)*, O’Brien et al. 2009*, Rashotte & Jensen (47), Reavy et al. (65), Trasher & Purc-Stephenson (45), Williamson et al. (56), Wilson et al. (57)

*Based on the same survey, but different articles and purposes.

both when inexperienced physicians and nurses were in charge, and in the care of critically ill patients (40, 46, 48, 50, 54, 56, 59, 64). The nurses felt that the NPs were more available than the doctors and that it was easier to ask them questions. Having access to a decision-maker facilitated the nurses’ work (40, 48, 54, 56). Some doctors felt relieved of some of their duties by the NP, but the biggest advantage was that NP focused on duties that had not previously been performed satisfactorily. Other physicians, however, felt responsible for supervising the NP and thought it took so much time that their workload was unchanged (44, 50, 54, 60). In this theme, it is evident that the NPs generally reduced the workload for the other team members and also decreased the risk that assignments might “fall through the cracks” (40, 44–46, 48, 54, 56, 64, 65).

The quest for autonomy and control The mentor is very important to the NP’s development, and new NPs wanted more face-to-face supervision (40, © 2014 Nordic College of Caring Science

42, 49, 58, 59, 64). Physicians felt that the NPs needed to prioritise every opportunity to learn, while NPs felt that the doctor did not always invite them to do this (42, 50, 51). The NPs described their role as an independent one, with support from physicians only in more complex patient cases—and many NPs asked for more autonomy —physicians mostly described the NP role as dependent and in need of supervision (44, 49, 50, 57, 59). Some nurses on the team felt there was a risk that they would not use their knowledge and skills to full potential when the NP was available, leading to their own decreased independence (56).

The ability to develop an interprofessional collaboration The successful implementation of the NP in the team collaboration requires the new team member to have a pioneering spirit. The new NP needs to conquer and fight for the new role’s scope of practice. Difficulties reaching an optimal collaboration were often attributed to missing role

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models and no job descriptions (42, 56, 58). The role of NP requires good interpersonal skills and the ability to communicate in order to cooperate effectively on the team. Flexibility and proactive problem-solving skills are also essential characteristics for gaining acceptance from the team, as well as for showing respect and value for the work of others. The collaboration was facilitated if the NP could handle stress and was friendly and accountable (41, 42, 46, 51, 64). Physicians pointed out the importance of the NP’s having extensive experience, preferably within the relevant discipline, and said it was also an advantage if the NP were known in the department (42, 46, 52, 57, 59). The majority of all new NPs experienced their first assignment as stressful. They had left safe roles and workplaces, and they felt lonely and alienated. They lost their confidence, although they were experienced nurses, and were anxious that they were not fully qualified for their job as an NP. The NPs felt all by themselves in the discipline, suspended between doctors and nurses. Their introduction was often medically oriented, and they initially lost their identity as nurses. They felt that though they shadowed the doctor, they were not really a part of the team, and it took some time before they found their role and scope of practice (40, 47, 52, 53, 58).

Main metaphor-A tortuous journey towards a partially unknown destination The introduction of new roles and functions in the interprofessional team begins a journey for all members of the team that can be described as long and tortuous (i.e. full of twists and turns, and unnecessarily complex) towards a partially unknown destination. Travellers will encounter both dead ends and temporary detours that need to be faced with a pioneering spirit. Moreover, when the destination of the journey is not obvious, it may be difficult to find the energy and motivation to continue moving forward. Initially the new team member—here the newly trained NP—may feel alone and lost. This feeling may be reinforced when team members have different views on what direction the journey should take. It is essential for everyone on the team to receive and to have access to information about the role and function of the new member. The journey must become a common voyage of discovery leading to effective teamwork that takes advantage of the skills and expertise of each member. The physician may be viewed as the driver, who steers the vehicle in cooperation with the NP, who acts as tour guide. These two must depend on each other and communicate in order for the journey to succeed. They must also be sensitive and realise that the destination of the journey may need to be adjusted to meet the various needs and wishes of the team in their quest to offer the patient the best care possible.

A successful journey also requires infrastructure and oversight—the employer—to provide favourable conditions and support before the journey is begun and regularly during the trip. The value of publicising the journey should also not be underestimated, since more tour guides will need to be trained for future journeys. When recruiting new tour guides, it is important to remember that their personal qualities are crucial to making everyone on the team feel important, confident and involved. It is also helpful if tour guides are proactive, experienced, willing to share their knowledge and able to bridge differences between other team members. Tour guides must have patience and be able to keep the team going in the face of headwinds. When the trip is successful and approaching its destination, tour guides may be seen to have developed in their roles and to have gained an accepted place on the team as the cornerstone of interprofessional cooperation and the lodestone of team continuity.

Discussion This study adds to our knowledge and understanding of the development of the NP role and the effect of this new role on the collaborative healthcare team. The metaphor ‘tortuous journey towards a partially unknown destination’ describes the process of an NP’s introduction to the healthcare team, a process often full of twists, turns and unnecessary complexity. The metaphor, based on the four main themes described above, allows us to envision the new NP as a tour guide with a pioneering spirit who accepts and bears great responsibility for the cooperation of the team in completing the journey towards the best care and outcome for the patient. When the journey begins, the destination is not always clear, and there may be many challenges involved in informing the team and the organisation about the new and unfamiliar role (41, 42, 52, 56–58). It is necessary to change ingrained practices and find new ways to make room for the new role in the healthcare team. This might lead to conflicts if the team members feel a threat to their traditional professional boundaries (41, 43). This has been highlighted in previous research, and it is evident in strongly hierarchical organisations, in which different health professions may be set against each other because of their different views and knowledge paradigms (20, 21, 24, 25). On the one hand, we know that it is difficult for the team to ensure and deliver optimal care (3, 8) and that the addition of an NP has been shown internationally to have positive effects on patient safety, effective care and patient satisfaction (3, 9). An important finding in several studies (40, 48, 56) was that team members felt it a great advantage that the NP focused on duties previously not performed satisfactorily. Other studies, however, show that nurses and physicians often felt © 2014 Nordic College of Caring Science

The tortuous journey of introducing the NP their own identities and roles on the team threatened by the introduction of the NP. These team members did not initially understand knowledge and advantages the NP could bring to the team (40–42, 45, 54, 55). To ensure the delivery of high-quality care in a hospital setting, we maintain that a high level of expertise in advanced nursing in direct patient care is paramount. We believe that the introduction of NPs in the healthcare team will fill a gap of competence between nurses and physicians without impinging on their areas of expertise. The NPs’ personal qualities were highlighted in several of the included studies. It is evident that it is helpful if a new NP has a pioneering spirit, a vision and a strong desire to make “the journey.” The new NP must not be afraid to leave the nursing team and the safety it brings to find a new path and new cooperation based on their new skills (40, 47, 52, 53, 58). The results also demonstrate the importance of the NP’s ability to find a way to cooperate so that experienced nurses and junior doctors do not feel stressed or undervalued. Showing respect for all professions and valuing the work of others are certainly important qualities of both NPs and their new team members, and respect was a key word in several studies (42, 45, 54, 55). This is consistent with the theory (67) about normal reactions to the introduction of a change in a team. Information and dialogue prior to the introduction of the NP might prevent and reduce conflicts, but we believe that the whole team also needs time to adjust and to find new ways to cooperate. Several articles in this study concern the challenge new NPs encounter in their role development. NPs described how they initially lost confidence and felt a considerable degree of stress in their new role. The NPs felt that their performance did not match the other team members’ expectations of them, and this led to stress and a consequent inability to perform to their full potential. The results suggest that it may take from 6 months to 3 years before the new NPs regain their confidence, find their way and become accepted on the team (40, 47, 52, 53, 58). These results are consistent with the theory of Benner (66), who describes how an experienced nurse could perform as a novice when placed in a new position or on a new team. New NPs might put high pressure on themselves when returning with higher education to their former workplaces, expecting and expected to take up an independent position and to have the right answers. A main difference of this entry to that of a novice Registered Nurse is that the first new NPs in Sweden will not have an experienced NP to guide them. New NPs need to take responsibility not only for fulfilling and developing their own positions and roles on the healthcare team, but also for informing the team and others about their role at their hospital. Our findings show that the introduction of the NP to the team is easier when the © 2014 Nordic College of Caring Science

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nurse is experienced, already known to team members, and has confidence in the current clinic and healthcare team (42, 46, 52, 57, 59). However, we believe that it also could be difficult to return to previous colleagues and take a higher position among them. For the implementation of NPs in the healthcare team to succeed, this review shows that a clear strategy is necessary to identify facilitators who involve stakeholders in spreading information at different levels (43, 52, 53, 64). The introduction of a new role in an existing healthcare system is associated with many challenges: lack of support and resources at the national level, lack of understanding of the role and the impact of the role on patient care, and difficulties in changing ingrained roles in a traditional hierarchy are all factors that make change difficult (30, 49, 67). Several studies emphasise the importance of clarifying and defining the advanced clinical nursing role to present its national implementation positively (4, 5, 29), which is in line with the findings of this review (44, 45, 48, 50, 51, 53, 57–60). The question that arises is whether the Swedish healthcare system and the different professions will be willing and able to support the introduction of the NP role in Sweden (31). We have found that it is a challenge to find the right information pathways for introducing the new NP into the healthcare team, and it is also a challenge to inform team members and others about a new role of which none have previous knowledge or experience. The ongoing debate in Sweden is whether the academic requirement of a master’s degree in science is necessary. We argue that the requirement for a master’s degree is in fact necessary for Swedish NPs to be able to meet international standards (6, 7, 68). Our findings show that acceptance of this new role in the healthcare team increases when a high academic level is required (6, 8, 28). We are convinced that it is a positive development for the Swedish healthcare system that NPs with high competence in their field are now being introduced to direct clinical practice. Earlier, a master’s degree in nursing care in our country has mostly led to work in administrative services or as a nurse educator at the university.

Limitations and strengths One limitation of this review and synthesis relates to the fact that only English-language studies are included. However, the studies included are from different parts of the world, not only from European countries, as the NP role is rather new in Europe (1), and few qualitative studies have been performed here. A strength of the review is that we undertook a systematic evaluation of the quality of the studies using national guidelines and quality templates (39), and the majority of the studies included were estimated to be of high quality. According

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to the extensive search strategy, we conclude that data saturation for the review was fulfilled. A limitation is that consequently, some studies might have been missed. Also, some findings about NP and teamwork from the papers may also have been missed or incorrectly extracted. However, the search was also performed with a professional librarian.

Implications and future research This synthesis depicts the incorporation of the NP into the healthcare team as a tortuous journey on a road full of twists and turns; learning from previous experience may help to straighten that road. Healthcare organisations need to have clear, long-term strategies for implementing this new nursing role, and they need to identify facilitators and stakeholders in order to spread information about the NP’s role and scope of practice. New NPs also need to take responsibility for the development of their role in the healthcare team and be accountable in specific ways for helping to make the team collaboration succeed. Additional research is needed to evaluate the NP’s role and incorporation into healthcare teams in the various countries in which it is introduced. An important finding, reported in several studies (41, 46–48), is that nurses found that the introduction of the NP to the team strengthened nursing care and made it more visible. The main purpose of integrating NPs into the healthcare team is to improve patient care. This strategy seems to be successful, but it is important to study it further. The patient’s perspective was not the focus of this review, but it is important that future qualitative studies and reviews of qualitative studies be conducted and that they involve the patient in the sample and describe the meaning of the NP role in the healthcare team from the patient’s perspective. Because healthcare

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systems and cultures are different in different countries, we considered it important to evaluate the particular development of the NP role in Sweden. With national evidence for its value, implementation of the NP role may be expected to be supported and encouraged at different levels in the Swedish healthcare system. We hope this review may be helpful in devising strategies for the incorporation of NPs not only in Sweden, but also internationally.

Conclusion The implementation of a new nursing role in a traditional and hierarchical healthcare team is a complex process influenced by many factors and can be described as “a tortuous journey towards a partially unknown destination.” The synthesised obstacles and opportunities drawn from international studies may help healthcare organisations, teams, and new NPs to prepare for and optimise the implementation of this new nursing role. The systematic review and the synthesis identified the need for further qualitative studies of the introduction of the NP to the team in various countries. Such studies should deepen the understanding of how the role is developed both in Sweden and internationally.

Author contributions ACA and EJ were together responsible for the study design, the analysis of the data and writing the manuscript. ACA performed the data collection.

Funding No outside funding was received to support this study. The authors declare no conflict of interest.

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