La identidad virtual

Exploration of HB NP actions using IP theory provides an understanding of HB NP practice within the complex context of IP hospital teams. The review of recent NP literature in chapter two identified limited exploration of HB NP practice within the context of interprofessionality. Purposeful comparison of the HB NP IP practice framework with IP theory provides fresh insights into construction of meanings and actions within the IP context. NPs described a goal of building an engaged team to enable quality patient care delivery within the category of Focus on Team Working. Chapter four identified congruencies between actions within the category and the four levels of IP working described in the Contingency Framework (teamwork, collaboration,

coordination, and networking) (Reeves, Lewin, Espin, & Zwarenstein, 2010). The identified congruence suggests HB NPs play a key role in building cohesive teams and fostering smooth team transitions to appropriate levels of IP work based on team and patient needs. Further exploration of the HB NP IP practice framework reveals known IP factors within all three concepts.

NP actions mirror IP factors identified in the literature review in chapter two. These actions were described as coordinating, formal and informal knowledge sharing,

respectful language use, early engagement of IP team members, inviting team members perspectives, and connecting team members. Therefore, within the IP context, the HB NP

is a key player in promoting interprofessionality within the IP team. Actions reflective of IP factors are apparent throughout the HB NP IP practice framework. Respectful,

frequent, and timely communication ensured both patients and team members are well informed of the plan of care. Networking, described as valuable within all categories, aided in coordination of interdependent team tasks, smooth patient transitions, and fostered national and international specialty connections. Connecting team members, early engagement, and sharing leadership suggest that HB NPs value collaborative working.

Collaboration competencies, described as role clarification, team functioning, dealing with interprofessional conflict, and collaborative leadership, are presented as a National Interprofessional Competency Framework (NICF) (Bainbridge, Nasmith, & Orchard, 2010). The legitimate authority to change patient care plans coupled with the above- mentioned IP factors used by HB NPs to build an engaged team, suggest a high

competency level for collaborative leadership. The multiple NP actions identified within the category Focus on Team Working illustrate competency in team functioning.

Exploration of power and privilege exposes where and how IP conflict can arise. The HB NP IP practice framework provides insights for NPs to work toward positive approaches to deal with IP conflict. For example, building trust, balancing actions, and maintaining awareness of degree of role overlap can mitigate tensions and conflict. In contrast to the NICF, the HB NP IP practice framework goes beyond IP understanding. Both the theory and the dimensions of HB NP role position highlight how NP role flexibility, and access to broad organizational information and resources can mitigate clinical IP role tensions triggered by organizational efficiency activities generated by state required outcomes. The ability of the HB NP to foster clinical and system quality and change depends on hospital leader support of role flexibility along the three dimensions of HB NP role position.

The HB NP IP practice framework identified the importance of role flexibility and evolution. This may be describing the challenge HB NPs face in attaining the NICF competency of self-role clarification. The three dimensions of HB NP role position

suggests role clarity cannot be well defined through the compartmentalization or clear delineation of tasks we traditionally rely on to determine role success. The perpetual motion of HB NP role position among the dimensions allows the HB NP to effectively fill gaps, initiate change, and foster changing levels of IP team working. This suggests achieving role clarity in the traditional sense would impede HB NP role function thus negatively impact desired patient and system outcomes.

The described contributions raise the HB NP IP practice framework to that of a

substantial theory grounded in the lived experience of team members and HB NPs. The team perspective is the interpretive base of the theory and provides role value meaning, action based properties of this meaning, and the importance of resultant outcomes. The team perspective introduces the importance of building trust and balancing the extent of actions (extending within boundaries of others’ professional role) to role effectiveness. Role value meaning arises as three conceptual categories, or practice foci, (evolve NP role and advance the specialty, focus on team working, and hold patient care together) grounded in process, rather than themes, thus provides more than role description (Charmaz, 2006). The HB NP perspective provides substantiation of the existing categories and adjusts their levels of importance to balance the perspectives. HB NP insights enhance category definitions making them clear and more abstract. Missing and understated actions further understanding of important role actions. Exploration of privilege integrates socio-political influences and furthers abstraction. The socio-political position of the HB NP emerges as the intersection of three continua illustrating the importance of perpetual role change based on identified team, system, and patient needs. The socio-political position affects construction of role value meaning creating privilege, subordination, inequality, or power. Exposure of power enhances depth of the categories (Charmaz, 2005). Understanding the cause of tensions from professional, managerial, and informational inequities enables predicting action outcomes and can guide toward

effective role implementation, and integration. Grounding of the HB NP framework with existing IP theory furthers abstraction and depth of the categories (Charmaz, 2006). The grounding with IP theory links how and why HB NPs construct actions with IP factors, collaboration competencies, and transitions through multiple levels of IP work.

Therefore, the described contributions justify the generation of HB NP IP practice as an emerging substantial theory (Appendix H).