Healthcare reform challenges the chief nursing officer (CNO) to position nursing to meet an increasing demand for safe, high-quality, and effective patient-centered care.1 The Institute of Medicine's (IOM's) landmark report, The Future of Nursing: Leading Change, Advancing Health,2 offers an evidence-based blueprint and agenda to transform nursing practice, patient care, health systems, and education.3 Central to this report is the recommendation that nurse leaders participate in healthcare redesign in full partnership with physicians and remove barriers that prevent nurses at all levels from practicing to the full extent of their education and training.1,4 Reform measures paving the way to support new models of care between physicians, nurse practitioners, patients, and families align with the triple aim of better health, better healthcare experience, and lower cost.5,6 With a projected healthcare workforce shortage of more than 200000 primary care providers by 2025,7 the ability to meet these goals is dependent on healthcare professionals practicing at their full scopes.7 At present, each state independently determines individual scope of practice for advanced practice RNs (APRNs).8,9 In addition, organizational policy determines privileges for APRNs. The CNO can be a catalyst for change in influencing and transforming the breadth and impact of the practice environment for nurse practitioners at all levels. Kotter's10 8-step process of creating major change provides a conceptual framework to sequence transformative change that is relevant to the scope of practice discussion (Figure 1).

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Figure 1. Adapted from the 8 step process for leading change. From Kotter.

The Setting

Founded as a 6-bed frontier hospital in Boise, Idaho, in 1902, St Luke's Treasure Valley is composed of 2 hospitals (548 beds), 90 provider-based clinics, 5 regional cancer centers, home care and hospice services, and 3 ambulatory surgery centers serving a population of approximately 750000. Recognized 3 times with Magnet^(R) designation, St Luke's 2060 nurses include 54 nurse practitioners.

Process Steps

Establishing a Sense of Urgency

In early 2010, the need to expand APRN privileges emerged as a priority for both physician and nursing leadership. To position St Luke's for accountable care while addressing the triple aims of the IOM report,2 members of the medical staff began expressing interest in partnering with nurse practitioners in establishing collaborative practice environments. This was a marked change in medical staff philosophy and organizational policy that had traditionally restricted hospital privileges of APRNs to include mandated physician supervision. In Idaho, APRNs are recognized as having "additional specialized knowledge, skills, and experience through a post-basic program of study, authorized to perform advanced nursing practice, which may include acts of diagnosis and treatment, and the prescribing, administering, and dispensing of therapeutic pharmacologic and nonpharmacologic agents."11^(p25) Medical staff bylaws explicitly prohibited nurse practitioners from admitting and discharging patients, writing orders, conducting history and physicals, rounding, and diagnosing. Outdated terms used to describe nurse practitioners in existing documents include dependent, midlevel, physician-extender, and of limited licensure. The CNO initially validated her vision for change with the chief executive officer and chief medical officer, then catalyzed and convened a physician-led task force on APRN privileges, with the chief of the medical staff serving as task force cochair in collaboration with the CNO.

Creating the Guiding Coalition

A situational briefing document was created using the SBAR (situation, background, assessment, recommendation) framework12 to provide a succinct outline of the problem for leadership, staff, and physicians. More than 20 physicians who expressed interest in the issue and/or were from departments that were of strategic importance to the success, for example, emergency department and hospitalists, were invited to participate in the task force by the CNO. The SBAR was used as a tool to orient task force members to the problem and existing APRN definitions, as well as clearly define task force objectives in advance of the 1st meeting.

Developing the Vision and Strategy

A goal of the nursing strategic plan was to pave the way for nurse practitioners to expand privileges in concert with scope of practice delivering patient-centered care across the continuum. The strategy was to convene a physician-led task force that would identify core clinical privileges aligned across the organization, with specialty privileges delineated by individual departments. A core tenet agreed upon early in the process was that individual departments could add to the core privileges created by the task force, but could not remove away.

Communicating the Change Vision

The SBAR12 was extremely effective in outlining the vision for nurse practitioner practice and addressing the need to sunset outdated terminology (Figure 2). A significant clarification agreed upon was that physicians should not supervise nurse practitioner practice any more than nurse practitioners could or should not oversee physician practice. Each was recognized as a unique discipline with a separate but related body of knowledge. Also, the CNO was acknowledged as holding the highest-level authority for nursing practice outcomes, parameters, and determination.13 The vision for a collaborative practice environment was described by the CNO as one where APRNs and physicians work in partnership to care for their patients.

Figure 2. Talking points: outdated terms used to describe APRNs. Adapted from J. Clavelle.

Empowering Broad-Based Action

The task force on APRN privileges focused on core privileges spanning departments and practice sites: admission, discharge, history and physical examinations, consults, writing orders, and prescriptive authority. Each department facilitated a concurrent process for specialty-specific privileges. This decentralized approach was designed to expedite the time to finalize recommendations and navigate the approval process through the medical staff and the board. Topics for consideration included understanding the difference between a nurse practitioner and physician's assistant, exploring how were handled in other organizations, understanding the Board of Nursing practice regulations, nursing practice guidelines, nursing peer review, and adoption of the word sponsoring versus supervising to describe the physician relationship with an APRN for shared patients.

Generating Short-term Wins

After 1 year, new core privileges for APRNs were approved, allowing them to practice within their full scope of practice as identified by the state of Idaho in collaboration with physician colleagues. The impact of this adoption upon the nursing and physician cultures was immediate. By exemplifying the Magnet model component of exemplary professional practice,14 advancing nurse practitioner privileges accomplished a core goal of the nursing strategic plan while aligning with the IOM report2 recommendations. In the month following board approval, a new component of the shared governance structure was initiated by the CNO, the nurse practitioner forum (NPF). The NPF is an interactive forum spanning the care continuum, designed to shape and influence nursing practice, research, education, and organizational policy. Local schools of nursing were quick to pick up the changes in privileges, aligning these employers with their plans to expand nurse practitioner and DNP programs.

Consolidating the Gains

Building upon the momentum of expanded nurse practitioner privileges, the CNO continues to engage key stakeholders, including the chief medical officer, physician, nursing and administrative leaders, and caregivers, in ensuring an effective operational framework is in place to support exemplary nursing practice. Expanded nurse practitioner privileges necessitated a change in medical staff bylaws, medical records policies, nurse and physician documentation standards, peer review, and professional practice evaluations. Along with these changes, continuous education of key providers and staff needs to be timely and clear, with the CNO working to articulate and achieve role clarity in the coordination and consistency of care across practice settings.

Recommendations

To influence organizational policy and transform the nursing practice environment for APRNs, CNOs must rise to the challenge to lead and transform care delivery models by partnering with their physician colleagues. The creation of a physician-led task force identified, addressed and removed scope of practice barriers, improved organizational clarity, met physician expectations and communication needs, and created a more robust and rewarding nursing practice environment for patient care. St Luke's is still raising the bar on nursing excellence. This process is one step in achieving our ultimate goals of improving the health of our communities in the most cost-effective and resource-sensitive manner.

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