El problema del liderazgo

This category centres on identification of gaps in the healthcare system and how NPs adjust their role to address the gaps. NP discussion of this category was frequent, intense and emerged consistently across all interviews. The importance of evolving the role and advancing the specialty was to improve patient care quality and safety, and sustain the NP role. One NP described the importance of evolving the role and advancing the specialty as:

“To practice our role in the way we feel, within our scope of practice, is appropriate for the service that we’re working with, the population we’re working with, and the workload we’re working with…” (NP #1)

This category has two related sub-categories; create and evolve the NP role, and responding to program gaps.

4.3.1.1 Create and evolve the NP role

Creating and evolving the NP role was daunting to many. Most NPs discussed the importance of building trust in both the NP role and themselves as key to successful role implementation. Most NPs described support from hospital leaders, physicians, and NP peers as key to success and when support was lacking, NPs felt unvalued and unable to enact an effective role. Overpowering leaders and physicians restricting the NP role were major influencers of NP role dissatisfaction and resignation.

“The NP role was not empowered by the physicians at all; they hadn’t asked for it, they didn’t want it, they had no interest in it.” (NP #16)

NPs described negotiating, and challenging powerful roles as important when support was lacking to ensure an effective role.

“When they define your job from an administrative point of view but they don’t have any data to support why they want you to do that, I always have a question of why.” (NP #14)

Leadership skills and mentoring were discussed as key to create and evolve an effective NP role.

“Leadership [skill] is ultimate to be able to [create the role]; if you’re not a leader, if you don’t have the skills, because I think anybody can learn the clinical piece to being an NP, it’s having the skills to actually implement that role that makes you a successful NP.” (NP #11)

NPs were concerned with the degree of understatement of leadership within the team perspective framework. NPs stated when time spent in leadership activities was unrealized by team members it devalued the extent of NP contribution.

“No one person really knows the extent to the numbers of things that I’m involved with from patient care and its various aspects to the projects, to other activities, the phone calls that I take from community patients; no one person particularly sees the full breadth of the work that I do.” (NP #17)

Flexibility to evolve the role was described as important by all participants. Flexibility remained a challenge for new NPs who were unaware of the necessity to constantly engage in evolving. Role evolution fostered role effectiveness and sustainment; however, it may hinder role clarity.

“I replaced a nurse practitioner after eight and half years and I thought I’d be walking into an established nurse practitioner role, but it’s not. It’s constantly in flux and it’s, you’re sort of defined as you roll along.” (NP #13)

Role flexibility and leadership skills enabled the NP to evolve in response to new and changing program gaps. Most indicated an importance of involvement in activities such as program visioning to engage leadership and research skills. These skills supported alignment of evidence with program and patient population needs. Active involvement in broad organizational and specialty knowledge augmented exposure of new and changing needs or gaps. Flexibility in role enactment enabled effective and timely NP response to address gaps.

“You know I’ve got one foot in the box and I’m scared that [management is]going to close me into a box and I’m not going to get that freedom of vision that you need as an NP to grow the program and to help the program to move along.” (NP #14)

4.3.1.2 Responding to program gaps

Most participants held in-depth discussions of the importance of involvement in

monitoring gaps and evolving the NP role. The ability to evolve the role and fill gaps in a timely manner influenced safety and efficiency. Participants described frustration with ineffective “gap filling” suggesting this was common when NP representation was not included in strategy planning. One participant shared frustration of a lack of senior leadership vision when he/she chose to fill “physician holes” with temporary NP assignments:

“It’s just the ease with which they think they can pluck the NP’s out of the

important work that they do to put them on another assignment.” “It’s like ‘oh well we’ll just yank a couple of NPs from emerg and put them on this gap’ not really knowing what kind of a gap that’s going to create in emerg.” (NP #8)