This article will discuss how an advanced nurse practitioner (ANP) influenced organizational change within an established structure in primary care. This ultimately led to better outcomes for patient care, subsequently allowing more consultation time for the doctors. Additionally this change facilitated both empowerment and utilization of the practitioner’s skills and knowledge.
This was achieved through identifying the need for the change and how the change was implemented through collaborative working; ultimately leading to a win-win situation.
There has been a considerable growth in the field of advanced practice in the last decade, often with underlying confusion over the context and nature of the role (Smith & Headley 2010). The Scottish Government (2008) recognizing this confusion and recognizing the need to conceptualize advanced practice developed the Advanced Practice Toolkit (www.advancepractice.scot.nhs.uk) to provide both consistency and clarity. More recently the Scottish Government (2010) acknowledged that advanced practice roles are pivotal in the delivery of services. On reflection and after consideration of the developments that advanced practice is continuing to generate, I recognized a need within my own place of work that required me as an ANP to address and subsequently influence change.
Prior to me undertaking my current role, should a patient require to be admitted to hospital throughout the day, the general practitioner (GP) facilitated this using the Emergency Response Centre (ERC). This system was implemented in 2008 to operate Monday to Friday from 08:00 – 18:00hr. It would smooth the progress of all emergency medical and surgical GP calls and arrange transportation of patients to the required hospital (www.shiftingthebalance.scot.nhs.uk2010). The main objectives of ERC were as follows: Streamline patients to the appropriate point of care
Explore alternatives to admission Appropriate use of resources ( avoid duplication) More efficient use of Scottish ambulance Service (SAS) vehicles Incorporate discharge dispatch and community care.
The GP interface of ERC is highlighted links that would facilitate admission of patients into hospital. In addition to this ERC would be used as part of performance indicators in A Plan for Modernizing Health Care Services (Lawrie 2008).
Despite the obvious advantages of this service (www.shiftingthebalance.scot.nhs.uk2010, www.lanarkshire.org.uk ), it allowed only the GP’s to admit directly to the acute sector. However, as an advanced nurse practitioner (ANP) within the primary care setting this then became an area where I would also hold responsibility. I realized that to meet these responsibilities and to ensure high quality efficient care for patients, there would need to be an organizational change and some collaborative decision making to facilitate this role.
Although Marquis and Huston (2000) stipulate that problem solving and decision making are not synonymous with each other, there are a number of authors (Swanburg & Swanburg 2002, Convey 1999, Wedderburn Tate 2001, Yoder-Wise 2002) who argue that problem solving and decision making are parallel with each other. I could relate more fully to the latter argument, as I found myself in the situation that was indeed
problematic to me – I had the necessary skills and knowledge to facilitate such a role but clearly the decision needed to be made which would enable me to be allowed to access the ERC system facilitating admission of my patients.
I was very much aware that recognizing the need for a change in the established system may have met with some degree of conflict. However as argued by Huczynski and Buchanan (1999) conflict is a state of mind and it has to be perceived by the two or more parties. Furthermore, Huczynski and Buchanan (1999) argue that if two or more parties are not involved then no conflict exists. None-the-less this perceived conflict can result in feelings of frustration as identified by Kinney & Hurst (1989), Hurst & Kinney (1989) and Huczyski & Buchanan (1999). Subsequently, and arguably this then acts as a blockade for teams to achieve their ultimate goal. However my perceptions of conflict were indeed unfounded, as the working relationship within my team is such that the problem was recognized and understood.
I approached my GP colleagues and engaged in open discussion with them, highlighting the benefits that would be ascertained by allowing me to access the ERC, when and if, I needed to admit a patient to hospital, without their sanction. My suggestion was met more with intrigue than opposition; some of my GP colleagues had simply not considered the need for me to access this resource. However, as a result of open discussions, fuller consideration was given to the time that would be freed for the GP’s, allowing them a greater degree of flexibility. Ultimately a common understanding of the need for this change was recognized and subsequently made possible. Working in collaboration, enabled the change that was required to facilitate the progression of my role and independence as a practitioner.
Often, we as practitioners can see benefits of how a change in our working environment can improve an established organizational structure. We may also feel disempowered to be able to construct a change within that establishment. However with the correct approach and engaging in collaborative negotiation a positive resolution can often be achieved. It undoubtedly did in my circumstance and what was once considered non essential is now part of the working life in the practice in which I am currently employed.
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Emergency Response Centre (2010) http:// www.shiftingthebalance.scot.nhs.uk [available] online [accessed] 29/3/2011
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