Nancye R. Feistritzer, DNP, RN∗nancye.feistritzer@vanderbilt.edu and Pam O. Jones, DNP, RN, NEA-BC,     Vanderbilt University Hospital, Hospital Administration, MCN AA-1204 21st Aveune South, Nashville, TN 37232, USA

∗Corresponding author.

The quest for decreased cost of care and improved outcomes has created the need for highly effective clinical roles and teams. This article describes the role of a unit-based advanced practice registered nurse (APRN) within a proof-of-concept implementation of a new care delivery model, the Vanderbilt Anticipatory Care Team. Role clarity is central to both structural empowerment of the APRN and team effectiveness. A modified PeaceHealth Team Development Measure tool measured baseline role clarity as a component of overall team effectiveness. A role description for the unit-based APRN based on a comprehensive assessment of the proof-of-concept unit is provided.

Keywords

Structural empowerment

Role clarity

Team effectiveness

Anticipatory care

APRN role

Key points

Improving the US health care delivery system is a national priority. Patient care within the US health care system is often reactive and unreliable, resulting in escalating health care costs and inherent inefficiencies in the current system. As the recent Institute of Medicine (IOM) report revealed, patients are at significant risk of harm from hospital-acquired conditions and medical errors. Significant attention by the health care industry over the past decade has been focused on efficiency, quality, safety, and the implementation of evidence-based care. This has forced an evaluation and redesign of care delivery models throughout the continuum of care. Nursing leadership holds the call to action to create innovative models of care delivery to provide safe and efficient quality care.

Despite recent efforts, health care spending remains high and accepted measures of health outcomes remain relatively poor.1 The United States ranks the highest on health care spending per capita in a comparison of 30 industrialized countries.1 This spending has not contributed to significant improvement in life expectancy, which ranks in the bottom quartile.1 The United States also has the highest rate of mortality amenable to health care, which is further evidence of a failed system.1

Large-scale health care reform and improvement efforts are important to create a culture of improvement and innovation. The effective execution of most improvement efforts, however, occurs within clinical microsystems, such as at the nursing unit or intensive care unit level within a large hospital.2 The Vanderbilt Anticipatory Care Team (vACT) is an improvement effort within a medical-surgical clinical microsystem that has the potential to significantly impact the organization’s care delivery model.

vACT

Vanderbilt University Medical Center (VUMC) embarked on the development of a new care delivery model, vACT, to address the deficiencies inherent in the existing system of care. Nursing leadership challenged the status quo of care and created a model focused on change. The aim of the vACT project is to create improvements in patient care delivery by embedding highly effective teams, process, and informatics tools within the clinical microsystem. A conceptual model depicting vACT across the patient care continuum is included (Fig. 1).

The initial proof of concept of vACT is focused on the inpatient setting from June 2013 to present on an adult surgical nursing unit. The proof of concept interventions include the following:

A comprehensive discussion of the broad vACT project is outside the scope of this article. The concept of role clarity of the APRN unit-based provider, structured communication, and team effectiveness, however, are central to the vACT care delivery model and are described here. The position of the unit-based team relative to the patient is represented in Fig. 2.

Structural empowerment

A fundamental component of the vACT model is enhancement of the unit-based care team that is geographically located on the inpatient unit. The intent is for an APRN to lead this enhanced unit-based team. Although the unit-based APRN within the context of vACT is a new role for the medical center, this role has been introduced in the literature.

Cowan and colleagues3 published a study of the effectiveness of a unit-based APRN working in collaboration with a physician-hospitalist to manage patients on a general medicine unit in an academic medical center. Acutely ill medical patients (n = 1207) were assigned to experimental and control units based on the hospital standard bed assignment routine.3 Interventions included increased physician collaboration with the unit-based APRN and daily multidisciplinary rounds.3 The results of the study included a decreased length of stay by 1 day and an increase in net profit of $1591 for each patient in the experimental group.3 There was no statistically significant difference between the 2 groups in the proportion of patients who died over the course of 4 months (P = .31).3 This study provides some preliminary evidence in support of a model of care including a unit-based APRN by providing efficient care at a lower cost.

The significance of this new model of care for nursing and advanced practice nursing is clear. This model creates nursing roles that are consistent with the IOM recommendations related to nurses working at the highest level of their education and training.4 The vACT project promotes an interprofessional team with important roles for APRNs, staff nurses, charge nurses, and nurse leaders. The opportunity for development of APRNs is particularly significant through the key roles envisioned on the unit-based team and the dynamic intervention teams. The expanded roles are in complete alignment with the IOM recommendations.4

Hiring a well-qualified APRN and placing that individual within the proof-of-concept unit team will not be enough to ensure success of the person, or the role. Structural empowerment, including careful role definition, is required for the implementation and sustainability of this APRN role. Role clarity is an important contributor and must be considered before implementation of a new APRN role.5 In addition, the APRN must function as a member of a highly effective team.

The concept of structural empowerment is based on the work of Kanter,6,7 related to the organizational characteristics and circumstances that contribute to employees being empowered. In Kanter’s publications,6,7 she described the Theory of Structural Power in Organizations, which is the seminal work for subsequent evidence. The basis for the theory is that employees derive power through formal and informal structures in the workplace. The concepts associated with structural empowerment are foundational to the design and implementation of the unit-based APRN role and provide an important conceptual framework for this project. The organizational structure, leadership structure, physician relationships, role function of the unit-based APRN, and support requirements must all be considered. Role definition is of particular importance.

Definition of the unit-based APRN role

Bryant-Lukosius and Dicenso5 conceptualized a framework for implementation and evaluation of APRN roles (PEPPA) that is logically congruent with the principles of structural empowerment. The PEPPA framework provides a “participatory, evidence-based,...