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Health Policy 117 (2014) 151–169

Contents lists available at ScienceDirect

Health Policy

journa l h om epa ge: www.elsev ier .com/ locate /hea l thpol

eview

eframing professional boundaries in healthcare: systematic review of facilitators and barriers

o task reallocation from the domain of medicineo the nursing domain

aartje G.H. Niezen ∗, Jolanda J.P. Mathijssenilburg University, Department Tranzo, Netherlands

r t i c l e i n f o

rticle history:eceived 20 August 2013eceived in revised form 24 March 2014ccepted 22 April 2014

eywords:rofessional delegationdvanced Practice Nursingurse practitionersrganisational innovationhysician–nurse relationsystematic review

a b s t r a c t

Aim: To explore the main facilitators and barriers to task reallocation.Background: One of the innovative approaches to dealing with the anticipated shortage ofphysicians is to reallocate tasks from the professional domain of medicine to the nurs-ing domain. Various (cost-)effectiveness studies demonstrate that nurse practitioners candeliver as high quality care as physicians and can achieve as good outcomes. However, thesestudies do not examine what factors may facilitate or hinder such task reallocation.Method: A systematic literature review of PubMed and Web of Knowledge supplementedwith a snowball research method. The principles of thematic analysis were followed.Results: The 13 identified relevant papers address a broad spectrum of task reallocation (del-egation, substitution and complementary care). Thematic analysis revealed four categoriesof facilitators and barriers: (1) knowledge and capabilities, (2) professional boundaries, (3)organisational environment, and (4) institutional environment.Conclusion: Introducing nurse practitioners in healthcare requires organisational redesign

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and the reframing of professional boundaries. Especially the facilitators and barriers inthe analytical themes of ‘professional boundaries’ and ‘organisational environment’ shouldbe considered when reallocating tasks. If not, these factors might hamper the cost-effectiveness of task reallocation in practice.

© 2014 Elsevier Ireland Ltd. All rights reserved.

. Introduction

Various healthcare settings (e.g. within primary care,hild healthcare and hospitals) are facing shortages ofedical staff and specifically physicians. Simultaneously,

∗ Corresponding author. Current address: Tilburg University, Depart-ent TILT, Tilburg Institute for Technology, Law & Society, Netherlands.

el.: +31 13 466 2407.E-mail addresses: m.g.h.niezen@tilburguniversity.edu

M.G.H. Niezen), j.j.p.mathijssen@tilburguniversity.edu (J.J.P. Mathijssen).

http://dx.doi.org/10.1016/j.healthpol.2014.04.016168-8510/© 2014 Elsevier Ireland Ltd. All rights reserved.

there is an increased demand for healthcare in general andfor more specific and more intensive patient treatments[1–3], while the explosive growth of healthcare expendi-ture continues to dominate many policy agendas [4]. One ofthe innovative approaches to dealing with the anticipatedshortage of physicians and/or attempting to control health-care expenditure is to introduce new nursing roles, such asthe nurse practitioner (NP) [5]. NPs are registered nurses

specially educated to take on tasks previously performedby professionals of the medical domain. This implies thattasks are shifted from the traditional professional domainof medicine (cure) to the domain of nursing (care).

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152 M.G.H. Niezen, J.J.P. Mathijsse

Several studies have demonstrated that appropriatelytrained nurses can deliver as high quality care as physiciansand achieve equally good outcomes in terms of patienthealth, care processes, use of resources and economic vari-ables [6–10]. Reviews by Horrocks et al. and Laurant et al.on NPs in primary care settings yield numerous indicationsthat NPs can deliver equivalent quality of care as physi-cians, hand in hand with patient satisfaction, although thecost-effectiveness of NP delivered care remains somewhatunclear [7,9]. Similarly, Bissinger et al. and Sakr et al. showthat NPs can provide safe and high quality care in neona-tology and emergency care settings, respectively [6,8].

Nevertheless, debates on workforce changes demon-strate that introducing new roles in healthcare practicesis not a straightforward process [6,11,12]. For one, work-force changes often put pressure on workforce boundaries.Traditional workforce boundaries become dynamic dueto the identification of new work areas or by adoptingnew roles normally fulfilled by other professionals [6].In response, however, established professionals may seekto protect and maintain boundaries or to expand theirareas of control via institutional work (e.g. the creation ofrules that facilitate, supplement and support institutions)[11]. Consequently, the newly introduced roles, againstthe background of (anticipated) physician shortages and/orthe reduction of healthcare costs, generate fundamentalquestions concerning professionalism and the provisionof public services such as healthcare. In other words, thechanging position of professionals not only raises powerand privilege issues at the individual level of professionals,but also involves context and social transformations at theprofessional, organisational and institutional levels [13].

Introducing new nursing roles in healthcare prac-tices thus often implies redesigning the organisation andraises discussions on workforce change and professional-ism. This applies especially when these roles operate inbetween, and in the overlap of, the traditional professionaldomains of medicine and nursing. This paper focuses onthe introduction of new nursing roles that cause or war-rant interdisciplinary workforce change. The disciplinaryboundaries of nursing are expanded by taking on work thatis traditionally performed by other disciplines, particularlyphysicians [6]. Before redesigning health organisations toenable the introduction of NPs, it is important to under-stand what facilitators and barriers may be expected intask reallocation. If these factors are not taken into accountthey might hamper the (cost-)effective execution of taskreallocation in actual practice [14].

This review explores what facilitators and barriers havebeen found in earlier evaluations and studies of task real-location from the professional domain of medicine to thedomain of nursing. The questions addressed in this revieware: (a) What forms of task reallocation can be observed inhealthcare? (b) What barriers and facilitators are perceivedwhen task reallocation occurs – specifically in relation tothe ability of NPs to perform their role? and (c) How are thedifferent types of task reallocation and perceived facilita-

tors/barriers related?

The multi-layered concept of professionalism by Brand-sen et al. is used to explore task reallocation from oneprofessional to another professional domain [13]. The

h Policy 117 (2014) 151–169

professional is first deconstructed in terms of essentialcomponents: (a) relying on specific knowledge and exper-tise; (b) belonging to a closed community of people withsimilar knowledge and expertise characterised by sharednorms and values, institutions for socialisation and regula-tion; (c) this closed nature of the community is consideredlegitimate by society at large; and (d) discretionary orprofessional autonomy are allowed at both an individualand community level. Task reallocation and the speciallytrained NPs challenge the boundaries of the specific knowl-edge and expertise these closed communities rely on.According to Brandsen et al., professionalism should there-fore be considered multi-layered, with the professionalchallenged at different levels of analysis: (1) at the indi-vidual level, (2) within his/her professional community,(3) within his/her organisational community and (4) at thelevel of the general public or society [13].

Using the multi-layered concept of professionalismenabled the emergence of a networked model. Thisnetworked model describes the internal and external struc-tures positioning the NP in relation to the facilitators andbarriers in task reallocation. This model might contribute tothe organisational redesign processes and successful adop-tion by stakeholders (e.g. hospital managers, NPs) to meetfuture requirements of access to and quality of care [15].

The next section describes our research methods. TheResults section presents the different categories of facil-itators and barriers in task reallocation, followed by aDiscussion of how the networked model, positioning theNP in relation to the facilitators and barriers in task reallo-cation at different analytical levels, answers our researchquestions, and of the restrictions of the presented review.

2. Materials and methods

2.1. Design

We conducted a systematic literature review to iden-tify facilitators and barriers to reallocating tasks from thetraditional domains of medicine to nursing. This “verticalsubstitution involves the delegation or adoption of tasksacross disciplinary boundaries where the levels of trainingor expertise (and generally power and autonomy) are notequivalent between workers” [5, p. 909]”.

Inclusion criteria for literature consisted of: popu-lation, intervention/topic of interest, study design andoutcomes. We included articles that discuss the role ofspecially trained nurses adopting new tasks that previ-ously belonged to the medicine domain. These nurses arereferred to as either nurse practitioner (NP), advancedpractice nurse (APN), nurse specialist (NS), or generalnurses specially trained for a new task. APN is an umbrellaterm containing both the NP and NS, although they havevarying levels of authority. APN can be defined in differ-ent ways, yet most studies seem to use the definition usedby the International Council of Nurses or a definition with

similar content.

A Nurse Practitioner/Advanced Practice Nurse isa registered nurse who has acquired the expertknowledge base, complex decision-making skills and

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clinical competencies for expanded practice, the char-acteristics of which are shaped by the contextand/or country in which s/he is credentialed topractice. A master’s degree is recommended for entrylevel (see: http://www.icn-apnetwork.org, accessedDecember 2012, emphasis added).

From here on, this paper only uses the term NP for clarityeasons.

Included are papers on the topic of ‘task reallocationrom medicine to nursing’. Task reallocation concerns aroad spectrum of shifting tasks and responsibilities fromedicine to nursing, ranging from minimal delegation to

omplete substitution and also the introduction of com-lementary care. With delegation the care provision shiftsrom a higher grade (physician) to a lower grade personNP), yet medical responsibility remains with the higherrade professional [1,16]. Substitution entails that one typef professional is exchanged for another. These substitutesanage a wide variety of patient problems, without refer-

nce to a physician [9,16]. The NP as a complementary role,.e. supplementation, means that an NP extends the care ofhe physician by providing a new care service [9].

The studies eligible for the review are not limited toCTs and quasi-experimental research, but can report onither qualitative, quantitative or both types of evidencend are published in peer-reviewed journals. Moreover, thecope of the literature review is not limited to one partic-lar type of healthcare setting or country. The outcomesf interest are facilitators and barriers in task reallocation.he papers must therefore discuss at least one facilitator orarrier. A facilitator is defined as any factor that stimulatesr expands task reallocation from the medical to the nurs-ng domain. A barrier is defined as any factor that limits orestricts task reallocation from the medical to the nursingomain.

.2. Search methods

We searched English-language articles only that wereublished between 1950 and February 2012, using theubMed and Web of Knowledge databases.

We conducted two searches: (1) using MeSH terms only,nd (2) using relevant key words, since the MeSH termsikely do not incorporate all relevant papers. Using theearch strategy as shown in Box 1, we identified 519 papers.he exclusion of ‘jurisprudence’ was not part of the originalearch strategy, but the result of our progressive under-tanding. After identifying duplicate papers via EndNote3, 358 papers were included for further review.

.3. Search outcome

Box 2 is a flowchart of the selection process. The selec-ion of papers was validated by using two independenteviewers (MN & JM). Differences were discussed untilonsensus was reached. In the first selection phase, titles

f all 358 papers were screened based on the inclusionriteria: (1) focus on task reallocation from medicine toursing, (2) new nursing roles were the subject of the studynd (3) facilitators and barriers to task substitution were

h Policy 117 (2014) 151–169 153

considered. First, a 10% sample of the papers (36) wasreviewed and compared by both reviewers (94% agreementbetween the two reviewers). Based on this comparison, MNindividually conducted further reviews. Any article that ful-filled two of the inclusion criteria, or that the reviewer wasuncertain about, proceeded to the next selection phase. Thesecond selection phase comprised independent judgementof the abstracts, and if not available the full text paperwas scanned by both reviewers. The third review roundinvolved a critical reading of each study’s full paper to seewhether inclusion criteria truly were met (MN). Any uncer-tainties in the selection of the articles were resolved byconsulting the second reviewer (JM). Based on this assess-ment, four more papers were excluded. Two papers wereexcluded based on content and two papers because theywere literature reviews. The snowball method resulted inthe addition of three papers. The previously excluded liter-ature reviews [17,18] were scanned for additional originalstudies relevant for this review [19–21]. The final selectiontherefore involved 13 papers.

2.4. Quality appraisal

The quality of the qualitative/behavioural studieswas assessed through a combination of appraisal toolsderived from Harden [31] and Dixon-Woods et al. [32].The one outcomes-based trial in the final selectionwas assessed using the CASP assessment tool for RCTs(http://www.sph.nhs.uk/sph-files/casp-appraisal-tools/)(see Tables 1 and 2). All studies were independentlyassessed by MN & JM, overall agreement of 73%, remaininguncertainties or disagreements were resolved throughdiscussion.

The quality appraisal was used to assign weight to eachof the studies; either being of good quality (A) or being oflesser quality (B). The papers denoted as lesser quality hadat least two negative assessments [19,23,25,26,33]. Takinginto account the limited number of available studies andthe possibility of robust findings in the less valued papers,none of the papers were excluded based on the qualityassessment. However, in the identification and interpre-tation of relevant themes we checked whether the themeswere not based on findings only presented in one of the lessvalued papers, but were confirmed by at least one otherstudy.

2.5. Data abstraction and synthesis

In order to synthesise both qualitative and quantitativeevidence we made use of thematic analysis [34]. The fol-lowing information was abstracted from each article: thetype of task reallocation, description of facilitator and/orbarrier, and study characteristics (e.g. type of evidence,health setting and sample size). We used an inductiveapproach to identify all recurrent facilitators and barri-ers by reading and open coding all the text labelled as‘results’ or ‘findings’ in the included studies, allowing for

the determination of key concepts, themes and patterns.The quantitative evidence in the outcomes-based trial wasconverted into a description of the key findings, mak-ing use of the discussion of the outcomes [33]. These

154 M.G.H. Niezen, J.J.P. Mathijssen / Health Policy 117 (2014) 151–169

Box 1: Search strategyMeSH term search

a. Nurse clin icians OR nurse pr actition ers OR advance d pract ice nursin g

b. Ca pacity building OR personnel delega tion OR dele gation, prof essiona l

c. jurisprude nce

Search: a AND b NOT c

Key words search a. Nurse practitioners OR nurse special ists OR sp ecialist nurs es OR advanced practic e

nurses OR nurse clinicians OR practice nurses

b. Delegation OR substitution OR diversificati on OR task al location OR skil l mix OR

interprof ess ional workforc e OR service transf er OR interd isc iplin ary healthcare teams

c. Boundaries OR barriers OR facilitators OR organisational change

d. Jurisprude nce

Search: a AND b AND c NOT d PubMe d WOK Mesh Terms 101 195Key word s 62 161

Box 2: Selection processWOK N = 356

Search results combined N = 519

DuplicatesN = 161

First review rou nd: articles screened based on title (and abstract) N = 358

Second review round: re ading abstracts by two independent revie wers N = 76

Excluded N = 2 82 (79%) Not original res earch or revie w N = 12 (4%) No task rearran gement N = 248 (88% ) No delegation / substitution N = 5 (2% ) Delegation / subst itution i s no t from cure to care N = 16 (6%) Language is not English N = 1 (0% )

Final selectio n N = 13

Excluded by bot h independent reviewers N = 5 1 Not original res earch or revie w N = 18 (35%) No focus on facilitators and barrie rs N = 15 (2 9%) No delegation / substitution N = 6 (12%) Delegation / subs titution i s no t from cure to care N = 5 (10%) Focus is on nurse-prescribing , evidence-based n ursing, nurse-led care and/or education models N = 5 (1 0%) No full text available within the Netherlands N = 2 (4%) Discussion between two

reviewers N = 25 (19 in clusion with doubt, 6 direct inclusion)

Third review round: reading full text N = 14

Excluded after consensus discussion between two independent reviewers N = 11

PubMed N 163

Excluded N = 2 No focus on facilitators and barrie rs N = 1 (50%) Focus is on nurse-prescribing , evidence-based n ursing, nurse-led care and/or education models N = 1 (5 0%)

Included N = 1

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Table 1Quality of non-experimental and qualitative research.a

Study Theoreticalframe-work/literaturereviewdescribed?

Aims,objectives,researchquestionsclearlydescribed?

Contextclearlydescribed?

Sample andrecruitmentdescribed?

Sampleappropriateto researchquestion?

Method ofdatacollectionand analysisclearlydescribed?

Method of datacollection andanalysisappropriate toresearchquestion?

Attempts madeto establishreliability orvalidity of dataanalysis?

Are data,interpretationsand conclusionsclearlyintegrated?

Pilot workcon-ductedanddescribed?

Participationrespondents(pro-cess/consent)?

Usefulcontribution?

Bonnel et al., 2000[19], B

Y Y Y Y Y Y Y N Y N.A. N Y

Brodsky and VanDijk, 2008 [22], A

Y Y Y Y Y Y Y ? Y Y N.A. Y

Fletcher et al. 2007[22], B

Y Y Y N Y Y N N N N.A. N.A. N

Kaasalainen et al.2010 [24], A

N Y Y Y Y Y Y Y Y ? Y Y

Lindblad et al. 2010[25], B

N Y Y Y Y Y Y ? Y ? N Y

Middleton et al.2011 [26], B

N N Y Y Y Y Y N.A. Y N.A. N.A. Y

Offredy et al., 2007[20], A

Y Y Y Y Y Y Y Y Y N.A. Y Y

Pearson, 2009 [21], A N Y Y Y Y Y Y Y Y Y N.A. YTye and Ross, 2000

[27], AY Y Y Y Y Y Y Y Y N.A. Y Y

Van Offenbeek et al.2009 [28], A

Y Y Y Y Y Y Y Y Y N Y Y

Wilson et al. 2002[29], A

Y Y Y Y Y Y Y Y Y N Y Y

Zwijnenberg andBours, 2012 [1], A

Y Y Y Y Y Y Y Y Y Y N.A. Y

A, good quality.B, lesser quality.Y, yes.N, no.?, Can’t tell.N.A., not applicable.a The assessment of the quality of the non-experimental and qualitative research is based on the combination of two existing appraisal tools derived from Harden [31] and Dixon-Woods et al. [32].

156 M.G.H. Niezen, J.J.P. Mathijssen / Healt

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h Policy 117 (2014) 151–169

descriptions were open coded. Subsequently, the resultsof the open coding of the primary studies were orga-nised to form descriptive themes. The descriptive themeswere revised and merged by discussing the themes, sub-themes and the relations between the (sub)themes. Newcodes were created to capture the meaning of groups ofinitial codes (see Appendix A for the Coding tree). Thecoding and construction of thematic themes was peerreviewed by three independent reviewers (RZ, JH and EG).Last, we generated analytical themes by subsuming thedescriptive themes identified in the primary studies into ahigher-order theoretical structure. The goal of the analyti-cal themes was to obtain answers to our review questions,specifically what facilitators and barriers to task realloca-tion can be identified, and how do they relate? We madeuse of the inductive analysis of study findings in combi-nation with a deductive approach, that is, the theoreticalstructure offered by Brandsen et al. on the multi-layerednature of professionalism [13].

3. Results

3.1. Study characteristics

The thirteen studies included in the review were pub-lished between 2000 and 2011. Study characteristics aredepicted in Table 3.

3.2. Barriers and facilitators

Our analysis led to four analytical themes of facilitatorsor barriers: (1) knowledge and capabilities, (2) profes-sional boundaries, (3) organisational environment, and (4)institutional environment. In Table 4 we structured theinformation about the articles reviewed. The ‘plus’ and‘minus symbols added to the table contents refer to how theidentified factors were categorised in these articles. How-ever, factors considered ‘plus’ sometimes can, for exampleat other points in time, be ‘minus’ as well and vice versa.Each identified analytical theme comprises a set of fac-tors influencing the NP role at a different level of analysis(Fig. 1). These different levels of analysis provide insightinto the type of changes in attitudes towards task realloca-tion that can be identified in each layer, either proactivelyby individual NPs or through governing mechanisms (e.g.law).

3.2.1. Knowledge and capabilitiesFour studies described facilitators and barriers related

to NPs’ knowledge and capabilities. The NPs’ knowledgeand capabilities theme is divided in two subcategories:(1) self-knowledge, and (2) interpersonal skills. NPs’self-knowledge, specifically NPs’ insight into their ownlimitations and confidence in their capabilities is con-sidered important since it may encourage NPs to make

decisions. Lack thereof likely causes NPs to refer patientsto physicians, which hampers the task reallocation process[1,20,23,27]. NPs’ effective interpersonal skills are seen asa strength in NP consultations and have contributed to the

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Table 3Study characteristics.

Author(s) Study Type of evidence Country Health setting Type ofnurse

Sample

Bonnel et al.,2000 [19]

Descriptive study of NPs’ challenges and strategies ininitiating an effective role in a nursing facility.

Qualitative research analysing written journals of 5NPs and 2 group discussions.

U.S.A. Long-term care;geriatrics

NP 5 NPs

Brodsky and VanDijk, 2008 [22]

Evaluate attitudes of nurses and physicians to theintroduction of new nursing roles and to expanding thescope of nursing practice.

Quantitative: questionnaires distributed accordingto a convenience sample method.

Israel 3 hospitals and 15community clinics

ANP 325 nurses/physicians

Fletcher et al.,2007 [23]

Descriptive study on NPs’ and MDs’ perceptions of the role ofNPs, the degree of collegiality between professions, and NPs’feelings of acceptance.

Qualitative and quantitative: a descriptive studyincluding both closed and open-ended questions,and Likert-type questions.

U.S.A. Primary care in 7Veterans HealthAdministrationfacilities

NP 153 physicians and NPS,with 109 responses to 4open-ended surveyquestions

Kaasalainenet al., 2010 [24]

Descriptive study on the perceptions of long-term care teammembers and nurse managers about barriers and facilitatorsto optimal use of NPs to manage residents’ pain.

Qualitative: an exploratory descriptive designmaking use of focus groups and individualinterviews.

Canada 2 long-term caresettings

NP 5 focus groups withnurses (N= between 6 and10/focus group), and 14individual interviewswith other health careteam members and nursemanagers.

Lindblad et al.,2010 [25]

Descriptive study on the experiences of APNs and theirsupervising GPs regarding the new role and scope of practiceof APNs.

Qualitative: four individual interviews with NPsfollowed by one focus group with supervising GPs.

Sweden General practice APN 9 (APNs/physicians)

Middleton et al.,2011 [26]

Study to profile NPs and their practice in Australia in 2009and to descriptively compare these to the data from 2007.

Quantitative: Self-administered questionnaire Australia All settings whereNPs are allowed topractice in Australia

NP 293 NPs

Offredy et al.,2007 [20]

Explorative study of two primary care trusts (UK) on nurseprescribers’ pharmacological knowledge anddecision-making and factors enabling practitioners’willingness to be nurse prescribers.

Qualitative: Interviews and case scenarios, makinguse of purposive sampling.

UnitedKingdom

Primary care trusts Qualifiednurseprescribers

25 qualified nurseprescribers (7 in training)

Pearson, 2009[21]

Study providing an overview of nurse practitioner legislationand reimbursement issues.

Quantitative: Compilations of the numbers ofaccumulated occurrences in the NationalPractitioner Data Bank (NPDB) and the HealthcareIntegrity and Protection Data Bank (HIPDB) fornurse practitioners (NPs), doctors of osteopathy(DOs) and medical doctors (MDs).

U.S.A All settings whereNPs are allowed topractice in the U.S.A.

NP 147,295 NPs 56,754doctors of osteopathy961,473 medical doctors

Pioro et al., 2001[33]

Explorative study on the applicability and limitations ofNP-based care in academic teaching hospitals.

Quantitative: outcomes-based trial of an inpatientNP service for general medical patients.

U.S.A Hospital care,heterogeneouspatient population

NP 381 patients (193NP-based care/188 housestaff care)

Tye and Ross,2000 [26]

Case study of the NP role in an Accident & Emergencydepartment.

Qualitative: Case study with nine face-to-facesemi-structured interviews

UnitedKingdom

Accident &Emergency Care

NP 9 key stakeholders (e.g.NPs, A&E consultants andDirector of NursingService)

Van Offenbeeket al., 2009 [28]

Comparative study to explore which (combination of)theory/theories best explains redesign in care organisations

Qualitative: Case studies of four subunits thatintroduced NPs, using interviews and observations.

Netherlands Pre- andpost-operative care;extramuralrheumatology care;post-operativeneurosurgical care;minor traumatologyat emergency care

NP 64 (NPs, medicalspecialists, nursemanagers, nurses, interns,etc.)

Wilson et al.,2002 [29]

Explorative study on the views of GPs on barriers indeveloping an advanced nursing role in GP.

Qualitative; a focus group study of GPs in fourgeneral practices

UnitedKingdom

General practice NP 25 GPs

Zwijnenberg andBours, 2012 [1]

Study exploring the role of NPs and PAs, the extent ofsubstitution and the barriers and facilitators experienced byNPs and PAs as a consequence of substitution in publichospitals.

Qualitative and quantitative: Interviews andquestionnaires.

Netherlands Hospital care NP and PA 43 NPs/13 PAs

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Table 4Facilitators and barriers.

Author(s) Facilitators and barriers + = reported facilitator, − = reported barrier, +/−, reported barrier and facilitator

Individual characteristics Professional boundaries Organisational environment Institutional environment

Bonnel et al.,2000 [19]

NPs proactive communicationapproaches and efficientinformation management wereidentified as a basis for goodpractice (+). Level ofknowledge/skill likely impactstransition to NP role (+/−).

Blurring boundaries between each professional’s roles.The type of physician delegation of tasks can be abarrier in a nursing facility (−). A close collaborationbetween doctor and NP can positively affect the NP’srole (+). Also, the role negotiation, about tasks to beperformed is important (+). Educate staff about NProle (+).

Familiarity with the environment is an early need tomake sense of the regulatory environment,understand the role and functions of various membersof the interdisciplinary team, and figure out how toget the work done (+). Formal procedures to credentialor grant privileges to NP or physicians implementeddifferently in the different settings (−). Setting up aphysical environment (a corner, closet) facilitates theinitiation of nursing facility practices (+). Lack of goodresources, people, computers, references hampers NPsfirst year settling (−).

Learning and understanding thespectrum of responsibilities under federalregulations complicated practice (−).Regulatory and financial issues arebarriers (−). Examples reported arereimbursement issues and Medicare andMedicaid that only allow for partialsubstitution for some physician services.

Brodsky andVan Dijk, 2008[22]

Feelings towards expanding NPs’ scope of practicewere affected by the amount of medical responsibilitydelegated to the NPs (+/−).The perceived added value of NPs was influenced bythe education of physicians (country) (+/−) and theamount of experience (seniority) of the physicians(+/−). More seniority had a negative influence. InIsrael educated physicians were more supportive thanoverseas educated colleagues to NPs.

The type of health setting appeared to influencephysicians’ attitudes towards NPs. Community clinicstended to be less supportive to NPs than hospitals(+/−).The type of care, especially the complexity of care,influences the attitude towards NPs. The les complexthe care, the more positive the attitude (+/−).

Fletcher, Bakeret al., 2007[23]

NPs insight in their ownlimitations is an important factorin the acceptance of NPs asproviders of primary care (+/−).

The possible roles of the NP include various levels ofmedical responsibility and independence. The amountof (in)dependence is related to the type ofcollaboration between the NP and physician (+/−).There is a tension between practicing withoutadequate supervision and not being able to practiceindependently within scope of training andexperience (+/−).

The complexity of care provided is an important factorin the acceptance of NPs as providers of primary care(+/−).

Kaasalainenet al., 2010[24]

Role NP is nurse with added skills that can be used as aconduit between nursing staff and physicians (+). Theextent of the NP/physician collaboration is influencedby the level of trust between the two of them (+/−).The amount of trust, in fact, is mentioned as the keyaspect in influencing the perceptions of the differenthealth professionals.The scope of practice regarding e.g. (restrictions in)prescribing affects the different perceptions (−).

Employment arrangements can limit or enhance thefull integration of NP into the team. An importantfactor is the (lack of) clarity of the NP role (−).The availability of the NP, onsite (+) or offsite position(−), affects the perception of healthcare teammembers and nurse managers regarding the NP role inpain management in long term care.

Legislative boundaries are environmentalfactors influencing the perceptions on theNP role (−).

Lindblad et al.,2010 [25]

The NP is positioned on the continuum betweennurses with extended level of competency and amini-doctor, or even as a complete new vocation.Depending on what type of definition is given for theNP and what amount of teamwork is common, theexperience with the NP changes (+/−).The scope of practice depends on the authority toprescribe and order treatments. A lack of expandedrights negatively influences the NPs experiences inSweden. Having authority is fundamental forindependent work (−).Mutual confidence and trust between NP and GP isnecessary. Confidence can be gained throughsupervision (+/−).

The familiarity with NPs skills (NP as amatured/gradually developed new function) versusNP as a newly introduced function influences theexperience of the first advanced practice nurses inSwedish health care (+/−).The (lack of) clear conception of NPs role changes theGP’s role to consultant of the NP (−).Also, the (lack of) demarcation of the NP allows for(no) full time NP’s (−). The study argues for a cleardefinition of roles, rights and responsibilities needed(+).

A functional pressure is the clinical careeropportunity for nurses and coping withGP shortages, due to the new role of NPs(+). For the NP, it provides greaterresponsibility, the opportunity to developpersonal competencies, yet also mountspressure on the healthcare system (+/−).

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Table 4 (Continued)

Author(s) Facilitators and barriers + = reported facilitator, − = reported barrier, +/−, reported barrier and facilitator

Individual characteristics Professional boundaries Organisational environment Institutional environment

Middleton et al.,2011 [26]

Barriers of authority are related to the lack ofadmission privileges (−), no prescription authority (−)and no authority to issue workers compensationcertificates or sick certificates (−).It is the accessibility and uniformity of qualificationand authorisation of the NP workforce that is animportant limiting or facilitating factor regarding thestatus of the NP (−).

Often reported barriers in the institutional setting arerelated to the lack of organisational support. NPs areoften (still) waiting for approval for clinical protocols(−).The inter-professional collegiality often is low, NPsreport they experience a lack of support from withinthe nursing profession (−).

Reported financial barriers are thenon-availability of Medicare providernumbers for NPs (−) as well as the lack ofauthorisation to prescribe medicationsthrough the Pharmaceutical BenefitsScheme (−). These financial barriers areclosely related to legislative boundaries.Another reported barrier is theprofessional indemnity of NPs. There areno limits set by professional indemnityinsurance (−).

Offredy et al.,2007 [20]

Lack of appropriatepharmacological knowledge andconfidence inhibits nurses’ability to make prescribingdecisions (−).

Support by GP’s can positively affect the nurseprescribers’ role (+).

Pearson, 2009[21]

Professional tensions reported are credentialing NPsonly in case of physician shortage (−). NPs should beheld accountable for their contributions to primarycare (+). The tension between responsibility andindependence becomes visible in the collaborationrequirements for prescriptive authority (−). However,there is no rationale for supervision of NPs byphysicians based on the described malpractice andmalfeasance ratios and figures (−).

Payment policies, in which NPs arereimbursed only a proportion ofphysicians’ reimbursement for the samework, enclose the way primary careservices are valued in general (−).Equitable credentialing andreimbursement for NP primary careproviders will remain elusive as long aslaws do not enforce such credentialing(−).

Pioro et al., 2001[33]

Ultimate responsibility for patient care rested withpatients’ attending doctors, and not the NPs (−). Thetype of task rearrangement influenced the outcomesof the inpatient NP service trial (−).Also, the requests for cross-overs reflected concernson NPs capabilities and value for patient care (−).Doctors should be educated on the value of NPs forgeneral medical patients in hospitals (+).

The type of care delivered, especially the complexityof provided care, affected the cross-over of patientsfrom the NP ward to the house staff ward.Moreover the availability of nursing based protocolswas less critical than the availability of house staff forthe successful implementation of NP-based care in thehospital.The availability and flexibility of NPs on the ward arefactors influencing the outcome of an inpatient NPservice for general medical patients.

Tye and Ross,2000 [27]

The varying levels of confidenceby the NPs affect the NPs’ role inpractice. Also, effectiveinterpersonal skills vary betweenthe individual NPs (+/−).

The position of the NP varies from complementary tomedicine (more holistic than medicine) – to –replacement of medicine (doctor substitute).Depending on the position of the NP on this scale, therole boundaries become more blurred (+/−). Especiallyregarding the professional de-skilling of physiciansand the medicalisation of the NP, physicians holdsome reservations (−).Medical opinion was conservative to expansion of NPsrole–there were especially concerns regardingtraining requirements. The (absence of) educationalstandardisation affects the management ofuncertainty regarding NPs’ role (−).

The (lack of) clear definition of NPs role, for examplethrough local protocolization facilitates or hinders theNPs’ role (−).In addition, general and technical support affects theimplementation of the NPs role in the health setting.For example, the (amount of) isolation from thenursing team–e.g. uniform/shifts/etc.–canfacilitate/hinder the NPs role (−). The operationalconfiguration of the NP role–staffing shortages forcesENPs to relinquish duties. Inconsistency of serviceprovision created confusion amongst medical staff (−).

Functional pressures such as providingcareer opportunities and enhancingprofessional status of nursing havefacilitated the NP’s role (+).Legislative boundaries create legal doublestandards, e.g. the professional indemnityof NPs (−).

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Table 4 (Continued)

Author(s) Facilitators and barriers + = reported facilitator, − = reported barrier, +/−, reported barrier and facilitator

Individual characteristics Professional boundaries Organisational environment Institutional environment

Van Offenbeeket al., 2009[28]

The potential overlap in tasks adds to blurringprofessional boundaries as well as the discussion ofthe ownership of medical responsibility and need forsupervision (−). The flexibility of role division can belimited by professional demarcations andidentifications (−).Yet, doctors do perceive NPs to be more aware of theirown limitations than junior doctors (+).

The type of care and cure (routine versus non-routine)provide opportunities for formalisation and thereforedelegation/substitution (+/−).Task environmental influences affect work structure(re)design (+/−).The availability of the NP in the health setting relatesto the amount of continuity in care provided (+).

Functional pressures for NP suggest achanged workload for physicians (+). Inpractice the amount of decreasedworkload varies (−).

Wilson et al.,2002 [29]

The perceived threats to the doctor’s role; job andfinancial security affect professional boundaries (−).The perceived threats relate to association of the NPwith de-skillization. And, the amount of loss of statusand self-esteem (−).The amount of personal experience develops theconfidence in NP’s role in practice (+). Yet, there areGPs concerns regarding the overconfidence of NPs and(limited) insight in their own competencies (−).Also, the scope of practice is determined by theavailability of authorisation to prescribe (−).NPs (do not) have the necessary training, skills andintellect to adequately assess patient and diagnosedisease (−).There is a (lack of) confidence in the ability of nursesto take on the NP role. The adequacy of NP training isdoubted (−).

The role of patients/patient satisfactioncan hinder or facilitate the NP role. Forexample, patients do (not) want to seeNPs. Moreover, patients’ feelings towardslegitimising their illness by seeing adoctor play a role (−).Financial boundaries are for example the(financial) means for adequate trainingand the financial structure of UK generalpractice (−).Lastly, legislative issues can play a role.There is a (lack of) clarity with regard tothe legal responsibilities of the GPs,should a NP make a mistake resulting inharm to the patient (−).

Zwijnenbergand Bours,2012 [1]

NPs own success, personality,own initiative and years of workexperience facilitate taskreallocation (+).

Extent of substitution/type of delegation depends onNPs responsibility (+/−).NPs authority to prescribe medication and order testsand treatments is often restricted (−).The collaboration between NP and doctor is visible inthe motivation of specialists to provide guidanceduring NPs’ training (+).

Facilities-related problems refer to not having one’sown office or treatment space and own computer, aswell as the acceptance of office hours by patients (−).Moreover NPs experience that often a protocol, policyplan, or verbal arrangement embedding the NPs role isnot available. These plans (should) contain a clearvision of job responsibilities beforehand. (−)The inter-professional collegiality is also an importantfactor in supporting the NPs role: support, effort andtrust from management as well as other healthcareprofessionals and enthusiasm from people involved(+).Lastly, an institutional setting provides support to theNP when there is freedom to develop the NP’s role,training opportunities are provided as well aschallenge and opportunities for personal development(+).

A legal framework giving NPs authority toprescribe medication and order tests andtreatments is lacking (−).Moreover financial problems relate to theuncertainty about the budget to fund theNP’s employment (−).

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ed facil

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uality of care and specifically to patient satisfaction, andherefore may stimulate task rearrangement [27].

.2.2. Professional boundariesThe consequences of the introduction of the NP are,

mongst others, shifting professional boundaries betweenhe domains of medicine and nursing. All studies reportn these shifting boundaries as an important barrier andotential facilitator in task reallocation. We identifiedix subcategories: (1) type of task reallocation, (2) trust,3) Physician-NP collaboration, (4) NPs’ qualification, (5)hysicians’ education, and (6) physicians’ job security.

All studies described task delegation, although the stud-

es often referred to cases in which both delegation andartial substitution occurred. The position of the NP withinhese different types of task reallocation ranged fromuper-nurse to mini-doctor, or was depicted as an entirely

itators and barriers to task reallocation.

new vocation [23–25,27]. The super-nurse is a nurse witha higher level of competency, whereas the mini-doctoris a nurse performing tasks formerly located in, subse-quently replacing, the medical domain. For example, Tyeand Ross describe how NPs put more emphasis on theirholistic rather than medical approach to underline theircomplementary role (supplementation) to physicians [27].Their emphasis on not replacing or substituting for physi-cians increased their acceptance by other professionals,as professional boundaries were not crossed. In contrast,Lindblad et al. describe how the structural reallocation ofphysician tasks to NPs, like prescribing medications, did notmaterialise. This type of task reallocation, that is substitu-

tion, explicitly involved crossing the traditional boundariesbetween medicine and nursing, creating boundary ten-sions [25]. The type of task reallocation thus interacts withthe positions NPs fulfil, since the extent of delegation or

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substitution is linked to the ownership of medical respon-sibility, NPs’ level of (in)dependence, the required supervi-sion, and the (restrictions in) authorisation [1,22–29]. Forexample, the ownership of medical responsibility affectsthe authority of NPs to perform their tasks. As reportedin the survey by Zwijnenberg and Bours “70.8% (n = 17) ofthe NPs indicated that tasks were reallocated on a perma-nent basis (substitution). In addition, 87% of the NPs (n = 20)reported that tasks were reallocated, but that they werenot predominantly responsible for these tasks (delegation),56.5% (n = 13) reported a combination of structural real-location and delegation of tasks” [1, p. 6]. Van Offenbeek,Sorge and Knip confirm that ultimate responsibility oftenremains with the (attending) physician. Subsequently,supervision did not decrease despite increased experi-ence and even caused NPs to leave a healthcare settingon account of insufficient professional growth potential[28]. Physicians especially have reservations towards themedicalisation of NPs and often still hold or claim ultimateresponsibility for patient care [1,28,33]. In other words, theorganised opposition to NPs’ independence is high whentask allocation entails giving up tasks previously ‘owned’ bythe domain of medicine and part of medical responsibility.Consequently, the level of independence experienced byNPs was often low and delegation of tasks limited.

The level of trust in NPs’ ability to provide good patientcare, the collaboration between physicians and NPs, andthe qualification of NPs are three factors affecting theprofessional boundaries between medicine and nursing.Two studies report how trust is related to the amountof supervision, NPs’ perceived competencies and the typeof collaboration between the NP and physician [20,21].Five studies demonstrate how the collaboration betweenphysician and NP not only can build trust by gaining expe-rience with a NP in practice, but can facilitate independentpractice by NPs and can positively affect the NPs’ role aswell [1,19,23,24,29]. Also the debate on NPs’ qualificationaffects task reallocation, often discussed in relation to thestandardisation, quality and adequacy of their education.It is the accessibility and uniformity of qualification andauthorisation of the NP workforce that form an importantfactor regarding the NP’s status [21,26–29]. Wilson, Pear-son and Hassey describe “a belief that nurse training atpresent was generally inadequate for an advanced role.”[29, p. 643]. Subsequently, they state, these feelings “mayimpede the development of advanced nursing roles in gen-eral practice” [29, p. 644]. However, a survey by Middletonet al. shows that a more clearly defined pathway to becom-ing an NP in Australia has stimulated the sustainability ofthe NP workforce in terms of accessibility and uniformityof qualification and authorisation [26]. Nevertheless, it isthe perceived absence of educational standardisation thatnegatively affects task reallocation [26,27].

Physicians’ education and job security are describedas both barriers and potential facilitators [19,22,27,29,33].Physicians’ education can either be a barrier or a facilitatorin the acceptance of NPs [22,33], since the perceived added

value of NPs is influenced by the physicians’ education.The more traditional the education, the more hierarchi-cal and defined the work structure is organised and themore the nurses’ autonomy level is restricted. The NPs’

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(perceived) threat to physicians’ job and financial securitywas described as a barrier to developing the NP role since itresulted in less delegation and more resistance to expand-ing the NPs’ scope of practice [29]. There are reports of someambivalence on the part of professional regulatory bodiesregarding NP development. On the one hand the potentialof NP roles is acknowledged, on the other hand medical staffhave reservations about where future boundaries should bedrawn, as transferring medical knowledge involves givingup an exclusive claim to this knowledge [27].

3.2.3. Organisational environmentEleven studies reported on the impact of the organisa-

tional environment on task reallocation [1,19,21–28,33].The organisational environment imposes a set of factors,located outside the professional communities of physiciansand NPs, which influences the successful implementa-tion of NPs in a healthcare setting. In total, we definedeight subcategories: (1) organisational policy support, (2)complexity of cure and care provided, (3) facility arrange-ments, (4) employment arrangements, (5) institution’sfamiliarity with the (regulatory) environment (6) type ofhealth setting, (7) experience in working with NPs, and (8)(inter)professional collegiality.

The first factor, organisational policy support, wasaddressed in eight studies, and encompasses a demarcationof the NP’s role, that professional tensions are addressed,that protocols or formal procedures are available andthat unwarranted restrictions, such as limited prescriptionauthority, are removed [1,19,23–27,33]. A lack of demarca-tion – a clear definition of roles, rights and responsibilities– can make it difficult for NPs to practice to their poten-tial. Furthermore, the availability of (clinical) protocols andformal procedures can facilitate the task reallocation fromphysicians to NPs [1,19,23,26].

Four studies indicate that the complexity of the cureand care provided is an important factor in the acceptanceof NPs as cure providers. The less complex the cure com-ponent (medicine), the more positive the attitude towardsNPs fulfilling these tasks [22,23,28,33]. Van Offenbeek et al.reflect on the routine versus non-routine nature of bothcure and care-oriented tasks [28]. NPs contribute mostin task environments where patients require non-routinecare and routine cure. It is assumed that less complex, moreroutine, cure-oriented tasks offer scope for formalisationand therefore task reallocation to the nursing domain [28].

Both facility and employment arrangements influencethe ability of NPs to perform their role. The lack of properfacility arrangements, such as not having one’s ownoffice/treatment space and computer, was experiencedas a barrier to task reallocation [1,19,27]. Like facilityarrangements, employment arrangements can limit orenhance the full integration of NPs into a team or clinicalpractice [24,27,28,33]. The availability of the NP on thework floor affects healthcare team members’ and (nurse)managers’ perception regarding the NP role. NPs rotating

on different sites, and therefore seen as working in aconsultative or ‘offsite’ position, were considered to con-tribute less to provided care and subsequently were lessvalued [24]. In comparison, Bonnel et al. show how setting

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p a physical environment was one of the strategies usedy NPs to initiate nursing facility practices [19].

Other factors within the organisational environmenthat can facilitate/hinder task substitution are: theealth setting’s familiarity with (governmental) regula-ions and rules [21], the type of health setting [28],he amount of (previous) experience with NPs [25], andinter)professional collegiality [1,26]. Institutions need tonow how (the interaction between) regulations and rulesan either facilitate or hinder the roles and functions of NPs21]. The type of health setting focuses on the differenceetween, for example, a community clinic and a hospital;he former being less supportive of expanding the scope ofursing practice roles to the domain of medicine than the

atter, as it has different expectations and often less experi-nce with NPs [28]. (Inter)professional collegiality refers tohe perceived support from within the nursing professions26], the support, effort and trust from management andhe enthusiasm from other people involved [1].

.2.4. Institutional environmentThe institutional environment comprises a set of factors

hat has the strongest external influence on task realloca-ion from the domain of medicine to the nursing domain.nstitutional environment entails the influences of legal,olitical and societal institutions in shaping the healthcareystem. These external factors can have a strong impactince they involve: (1) legislation, (2) socio-economicorces, (3) governmental (research) policy, and (4) patients’erceptions.

Legislation is referred to as a barrier by six studies1,21,24,26,27,29]. State laws define the NPs’ roles, artic-late supervisory requirements and govern practice andrescriptive authorities [21]. However, such legal frame-orks are often lacking or inadequate [1]. The legislative

oundaries are intertwined with the issue of professionalndemnity. There is a lack of clarity with regard to the legalesponsibilities of physicians, should an NP make a mistakehat results in harm to the patient [26,29]. Mistakes madey NPs are judged more severely than mistakes made byhysicians, since the NPs are a new profession with no priorest case. This increases the pressure on NPs to be carefulnd to avoid mistakes, which might hinder task reallocation27].

The socio-economic forces shaping NP care are reportedn seven studies [1,21,25–29]. Innovation, in the form ofask reallocation, is seen as an important stimulating fac-or for NP-delivered healthcare [25,27,28]. For example,he rising demand for healthcare, requiring more and spe-ialised nurses, enhances the professional status of nursingnd has facilitated the NP’s role. Also, coping with physi-ian shortages and the promise of a changed workload forhysicians increases the need for NPs, thereby stimulatingask reallocation. Four studies report how financial barri-rs, such as uncertainty about funding NPs’ employment1,29], the financial resources for adequate training [29], oreimbursement issues [21,26], can negatively affect inter-

isciplinary task reallocation.

Other and more obstructive factors described are: gov-rnmental (research) policy, and patients’ perceptions onP care. Two studies point to the lack of policy regarding

h Policy 117 (2014) 151–169 163

the funding for the NP workforce expansion and for the con-tinued professional education of NPs as a barrier [20,21].Patients’ perceptions on NP care relate to the need of legit-imising one’s disease. The wish to be seen by a doctor sincethis legitimises a patient’s illness is a societal countermove-ment that should not be ignored [29].

4. Discussion

Our analysis of the literature sought to determine thebarriers and facilitators encountered when reallocatingtasks from the domain of cure to the domain of care byimplementing a new professional role in practice. Theimplementation of the NP served to tackle issues suchas expected shortages in workforce and value for money.Research confirmed that the quality of care provided byNPs offers at least equivalent health outcomes to care pro-vided by physicians [6–10]. However, the effectivenessof NP delivered care is greatly affected by its imple-mentation, the required organisational redesign, and thereframing of professionalism. Transferring tasks from themedical to the nursing domain also creates uncertainty, forinstance because traditional professional identities are bro-ken down. This uncertainty or other barriers might in facthinder effective task reallocation. Therefore, we aimed tounderstand the different facilitators and barriers at playby categorising those reported in earlier studies. Impor-tantly, one should bear in mind that although an identifiedfactor may be viewed as a facilitator in the articles (seealso Table 4), they might be perceived as barriers in othercontexts, and vice versa.

4.1. Different types of task reallocation and theirfacilitators and barriers

First, we wanted to learn more about what forms of taskreallocation can be observed in different health settings.The types of task reallocation identified are delegation, sub-stitution, and supplementation. The most common form oftask reallocation is task delegation, often in combinationwith partial substitution. Delegation instead of completesubstitution is more likely to occur, as with delegationthe medical responsibility remains in the medical domain.However, it is likely that NPs’ legal and regulatory inde-pendence will grow in due time and that substitutionand supplementation will increase. This applies especiallysince legal frameworks regarding prescription authority,responsibility and indemnity are still in their infancy. Theincreased governmental concern for physician shortagesand efficient healthcare delivery will stimulate furtherregulatory support for substitution [e.g. 25,27,28]. Themodernisation processes in, for example, the UK (NHS),the Netherlands (youth healthcare/GP care) and the USA(response to decreased accessibility to care) will furtherstimulate and modify the position of professionals inhealthcare [16,35–37].

Second, we explored the perceived barriers and facil-

itators when task reallocation occurred, resulting in aframework consisting of four categories that range frominternal to external factors: (1) knowledge and capa-bilities, (2) professional boundaries, (3) organisational

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environment and (4) institutional environment. Ourframework includes the perspective “that the constructionand maintenance of boundaries is crucial to professionaldevelopment, and demands constant ‘boundary work’ topreserve or expand them” [5, p. 903]. The NPs’ knowledgeand capabilities are the most internal factors influencingthe ability of the NP to perform his/her role in practice. Theprofessional boundaries closely reflect the daily practiceof NPs, yet are less internal in nature. Based on the type oftask reallocation and the NP’s role, professional boundariesbecome blurred to lesser or greater extent. With delegationphysicians maintain medical responsibility, whereas sub-stitution requires the transfer of responsibility to NPs andentails shrinking the physicians’ professional domain. NPsare part of this renegotiation of professional boundaries.However, in practice, the reallocation of tasks often entailsa combination of substitution, complementary care anddelegation, making these negotiations even more complex.The organisational environment imposes a set of externalfactors on the professional domains which influences thesuccessful implementation of NPs in the healthcare set-ting, for example through facility arrangements or healthsetting characteristics. This organisational environment ismore difficult for NPs to influence, yet has a strong influ-ence on NPs’ ability to perform their tasks. For example,while the type of complexity of cure and care providedis unlikely to change to fit the NPs’ work profile, facilityarrangements can be adjusted. Finally, the institutionalenvironment represents the most external factors. Theyoften cannot be targeted or changed locally, but need tobe addressed through professional organisations.

Last, we focussed on how the different forms of taskreallocation and perceived facilitators and barriers wererelated. A key finding, interwoven in the four categories,was the interaction between the type of task reallocationand the NPs’ position, since the extent of delegation orsubstitution is linked to the ownership of medical responsi-bility, NPs’ level of independence, the required supervision,and the (restrictions in) level of authority. Delegation oftasks is more likely to take place since medical responsi-bility remains in the medical domain, with NPs positionedas super-nurses without ultimate medical responsibility,but with additional and specialised nursing competen-cies. However, full substitution in the sense that medicalresponsibility is entirely transferred to the nursing domain,is more difficult. Complete substitution is not only hinderedby professional boundaries, in the sense that physicians arereluctant to grant NPs their acquired authority in practice,but also by the organisational (e.g. availability of protocols)and institutional environment (e.g. legislation and financialsupport). Another external factor is the complexity of thecure and care-oriented tasks provided in the health set-ting. The complexity of cure and care greatly determineswhat tasks are reallocated to NPs and whether delega-tion or substitution occurs. Especially Van Offenbeek et al.show how the complexity of the cure and the possibilityto formalise cure in protocols or to select specific patient

groups affects the type and amount of tasks allocated andentrusted to the NPs [28]. The possibility to standardisecure-oriented tasks then legitimises the delegation or sub-stitution of tasks. The legal framework also influences the

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type of task reallocation that can take place. As long asprescription authority, responsibility and indemnity regu-lations are not fully established and/or not translated intolocal protocols and regulations, NPs face (in)dependenceand responsibility issues when substituting for physicians.The type of task reallocation thus greatly determines whatfacilitators and barriers are experienced, while vice versa,the existing facilitators and barriers may determine whattype of task reallocation can occur.

4.2. Interactions between different professional layersand innovation

Although the networked model (Fig. 1) depicts theanalytical themes separately, the arrows indicate theimportance of the interactions between the differentprofessional layers. For instance, the organisational envi-ronment affects the professional autonomy of physiciansand NPs (at the level of professional boundaries) since itdevelops its own set of controls and hierarchies. In otherwords, the driving and restraining forces of workforcechange are located especially at the intersection of thesedifferent analytical levels. For example, even if NPs areaccepted as complementary care professionals, the lack ofa clear definition of the role was identified as a major prob-lem [27]. Similarly, physicians might be willing to allocatetasks to NPs, yet legal problems such as the lack of author-ity to prescribe medication can still complicate the actualallocation of these tasks [1].

A comparison between the well-known model for inno-vations in health service organisations by Greenhalgh et al.[14] and our networked model might provide more insightin the interrelationship between the different analyti-cal themes and the introduction of new nursing roles inhealthcare. Especially since our networked model does notexplicitly demonstrate the different stages of diffusion, dis-semination and implementation [14]. Greenhalgh et al.conducted a meta-narrative review of Rogers’ overview ofthe diffusion of innovation [38] and other key researchstudies on innovations in service delivery and organisa-tion [see 39]. They examine the following determinants:(a) the innovation, (b) adoption by individuals, (c) assim-ilation of the innovation by the system, (d) diffusion anddissemination, (e) system antecedents for innovation, (f)system readiness for innovation, (g) the outer context, (h)implementation and routinisation and (i) linkage amongthe different components (a–h). As they are closely linkedto the different layers of professionalism, in each analyticaltheme we may expect to find several of these determinants.

First, the NP’s knowledge and expertise represents theNP’s role design (the content) more than the process of NPimplementation. In line with Greenhalgh et al., our modelargues for individual antecedents for innovation (b). NPs donot have a passive role in ‘the innovation’, rather they are(the stimulus or forcing factor in) the innovation (a). Subse-quently, in expanding their professional skills NPs need todemonstrate their relative advantage in practice. For exam-

ple, interpersonal skills are needed to ensure that otherprofessions affected by the NPs’ introduction recognisehow their own values and perceived needs are compat-ible with the NPs’ values and needs. As a consequence,

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f NPs lack such interpersonal skills or lack confidence inheir ability to perform their role as NP, the antecedentsa, b) of the innovation are not strongly represented and auccessful adoption is less likely.

Second, the analytical theme of professional boundarieseflects the facilitators and barriers to task reallocationithin the professional community. These are, for example,

nfluences that help spread NPs care such as the profes-ional networks in which the NPs need to operate (d). SincePs and physicians often tend to have different types ofetworks, the collaboration between the two professions isssential for the diffusion of NP care. However, our modelocuses more on the driving and restraining factors in theequired reframing of professionalism to support the intro-uction of a new nursing profession, whereas Greenhalght al. focus on how existing professional boundaries can beddressed [14]. Subsequently, we highlight the tensions forhange as described in the system readiness for innovationf).

The third analytical theme, organisational environment,ncompasses many elements of Greenhalgh’s model [14].ith respect to the assimilation (c), the focus is on the envi-

onment in which changes are required. Similarly, we havedentified several aspects such as organisational policy sup-ort, facility and employment arrangements, required toven facilitate NP care. Especially organisational policyupport is called for if NP care requires active disseminationd). However, the main overlap between the two modelsan be found in the determinants of organisational innova-iveness (e), for example the determinants of complexitynd type of health setting. The system readiness for inno-ation (f) is reflected in the organisational policy supportactor.

Fourth, as described in our review, the institutionalnvironment mainly coincides with the outer context (g),pecifically the political directives. A policy push is requiredo boost the chances of success of workforce change.esearch policies, however, are depicted by Greenhalght al. as an element of an organisation’s system readinessor innovation [14]. They focus on innovations in serviceelivery and organisation fitting within current laws andegulations. However, the introduction of a new professionoes not necessarily fit current laws and regulations. For-ulating research policy, in this case, should be perceived

s a needed stimulus or incentive by government and noty the organisational community solely.

Both models thus have apparent similarities and there-ore we can argue that the networked model can providensight in the innovation process of introducing new nurs-ng roles in healthcare. Nevertheless, our networked modelffers a different, approach to the introduction of NPs inealthcare, compared to Greenhalgh et al.’s somewhat lin-ar model for innovations in health service organisations.he networked model emphasizes the dynamic interplayetween the different facilitators and barriers to taskeallocation that affect the positioning of (the professionf) NPs in healthcare. The introduction of a new profes-

ion not only addresses changes in service delivery andrganisation, but implies a reframing of professionalismn multiple layers of the healthcare system. The net-

orked model demonstrates how different determinants

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play a role in each layer of professionalism which shouldbe taken into account prior to and during the implemen-tation of NPs in healthcare. In other words, each layerof professionalism has its own set of rules, values andsocial context influencing the introduction of the NP inhealthcare. We believe that a successful introduction ofeffective NP care must start by addressing these factors ineach layer and seeking the interaction between these dif-ferent layers. Understanding how the different factors inthese different layers can facilitate or hinder the introduc-tion of NPs will provide policy and practice with hands-oninformation as to what determinants to address to pro-mote the adoption of NP care. This especially concernsthe facilitators and barriers of the ‘professional bound-aries’ and ‘organisational environment’ categories reportedin (almost) all studies. Negotiating the NPs’ position inthe overlap between the cure and care domain in rela-tion to responsibility should be an important spearhead inthe organisational redesign. Clearly demarcating the NPs’position within the organisational environment throughprotocols, but also in facility arrangements such as techno-logical support, can further facilitate the implementationof NP delivered care in practice. The networked model, webelieve, is better suited to research and/or stimulate theintroduction of new nursing roles and subsequent task real-location in healthcare, than Greenhalgh et al.’s model forinnovations in health service organisations.

An implication of this approach could be that the para-dox of the need for NP care due to (expected) physicianshortages and the perceived threat of NPs expanding theirprofessional domain at the expense of the medicine domaincan be discussed more openly at the different professionallayers. For one, a better description of the NP role in theorganisational environment can be followed by a descrip-tion of opportunities for physicians as a result of this taskreallocation. However, the absence of the former, as oftendescribed in our reviewed studies, so far prohibits the lat-ter.

Moreover, the insights of the networked modelapproach might be generalised and used in other similarsituations of task reallocations between other health-care professions. For example, task reallocation has notonly taken place between physicians and NPs, but alsobetween physicians and physician assistants (hospitals),between physicians and practice nurses (primary care)and also between NPs and general nurses (youth health-care/hospital). Our networked model has integrated andabstracted findings from the context of task reallocationfrom the medical to the nursing domain in such way thatthe results might be transferable to other situations ifdeemed comparable.

4.3. Methodological strengths and weaknesses

Importantly, we understand there might be serious con-cerns with generalising the results of various qualitativeresearch studies (i.e. studies that rely on qualitative data

collection and analysis). “Qualitative research, it is oftenproposed, is not generalisable and is specific to a partic-ular context, time and group of participants” [40, p. 46].Although the de-contextualisation of findings is a serious

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166 M.G.H. Niezen, J.J.P. Mathijsse

concern we do not contest, we also believe that our findingsare not only based on the interpretation of the empiricalfindings in the 13 studies we reviewed, but are backedup by the literature on professionalism and innovation inpublic services. Bringing this information together wouldmoreover enable its wider use in policy and practice [40].

A methodological issue for a follow-up review wouldbe to refine the search. For one, the search for relevantliterature can be extended to, for example, elaborative cita-tion tracking and book chapters. The papers found via thecurrent search method (database search combined withsnowball method) at least demonstrates that compara-tively little rigorous research has been published on thetopic of facilitators and barriers in task reallocation and theintroduction of new nursing roles thus far. However, thereviewed studies are all fairly recent (published between2000 and 2011), indicating a growing interest for this typeof research.

The limited number of relevant studies also calls forsome caution in the interpretation of the studies’ findingsand the synthesis of these findings. For one, the papers’quality assessment showed differences in quality. How-ever, whether quality appraisal of qualitative research (asdepicted in Table 1) should be undertaken for purposesof a systematic review is a matter of some debate [30].One could argue that weak qualitative papers or papersthat do not meet quality standards should be excluded.Another approach would be to grade or weigh the differ-ent papers, so that only the soundly based findings (e.g.confirmed in stronger studies) are included. The diversityof qualitative study designs and approaches makes it dif-ficult to apply generally valid quality criteria a priori. Wechose to assess the quality of the qualitative/behaviouralstudies with a combination of appraisal tools derived fromHarden and Dixon-Woods et al. [31,32]. Importantly, thepapers we regard as being of ‘lesser quality’ do not playa dominant role in the results. Second, the studies incor-porate different care-settings, different types of physiciansand different types of nursing in the papers. Therefore,generalising our findings on task reallocation from cure tocare is not unproblematic. However, as our focus lies onthe common facilitators and barriers in implementing anew nursing role, we believe these different settings androles to be of subordinate significance in the process oftask substitution from cure to care in general. Limitingthe focus to one type of healthcare setting or country was

deemed unnecessary and undesirable, as this study aimsto find general driving and restraining forces in task reallo-cation. Also, we acknowledge that the findings presentedin this review, such as certain professional boundaries, are

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historical by nature, involving a traditional organisation ofhealthcare. It might therefore be expected that the situa-tions will change as experience accumulates. Nonetheless,similar facilitators or barriers will continue to exist andshould be reckoned with when implementing new healthprofessional roles.

5. Conclusions

Introducing NPs in different care settings is one of theinnovative ways in which the different healthcare systemsaround the world have addressed the growing demandfor healthcare and, specifically, the anticipated shortage ofphysicians in future. Existing evidence demonstrates thatsubstitution or delegation from cure to care is effective,yet there is little research available on the implementa-tion of NP-delivered care in practice so far. Even less isknown about the different factors that either facilitate orhinder the effective deployment of NPs and reallocationof tasks from the cure to care domain. The identificationof facilitators and barriers in our task reallocation frame-work potentially contributes to a better management of theintroduction of NPs in various health settings, and mighteven contribute to the (cost)effectiveness and quality ofcare provided. However, our framework also acknowl-edges that innovation, in this case the introduction of NPsin healthcare, is not a linear process. One should expectthat the implementation of new professional roles or theextending of existing roles requires changing the system atvarious levels, ranging from the individual level and theprofessional communities to the organisational environ-ment and its outer context, the institutional environment.In other words, the introduction of NPs in healthcare notonly requires organisational redesign, but also the refram-ing of professionalism and professional boundaries at themultiple layers of the healthcare system.

Conflict of interest

No conflict of interest has been declared by the authors.

Funding

We acknowledge financial support from TheNetherlands Organisation for Health Research and

uitvoeringspraktijk Jeugdgezondheidszorg’ (RenewalImplementing practice Youth Healthcare), project156511007.

n / Health Policy 117 (2014) 151–169 167

A

Open coding

Insigh t in one ’s own limitationsConfidence in on e’s capab ili tiesNP’s yea rs of expe rience

NP’s ( inter) persona l skil ls

NP as a super-nu rseNP as a mini-doctorNP providing complemen tary careAuthorityMed icali zation of the NPOwne rship of medical responsibility

(amount of) supe rvisionPerceived competencies of NP s by physiciansNPs’ perceived level of skil ls, intellect and compe tencies by physicians

NP’s ( in)de pend ence(Un)equ al relation NP – ph ysicianPhysician supervision

Standa rdization, qua lity and adequ acy of NPs’ educationAcc essibili ty of ed ucationUniformity of qua lification

Trad ition al edu cation / str ong hierarchic thinkingCountr y specific

Professiona l de-skill ing of ph ysiciansPhysician s’ feeling of fina ncial security

rtDemarcation of NP s r ole Availab ili ty of protocols / formal procedu resAdd ressing professiona l tensions(no) mana gerial r estr ictions to NP s execution of profession(un )eq ual pa yment phys icians and NPs

Complexity of tasks pe rformed by NPFormali zation oppo rtun ities of to -be-delegated tasksNP performs (non) rou tine cure NP performs (non) rou tine care Possibili ty for pa tien t selection

Compu ter / IT support

M.G.H. Niezen, J.J.P. Mathijsse

ppendix A. Coding tree

Analyti cal th eme De scriptive t heme Kno wledge and cap abilities

Self-kno wledg e

Interpersona l skil ls

Professiona l bo unda riesType of task r eall ocation

Trust

Physician-NP collabo ration

NPs’ quali fication

Physician s’ edu cation

Physician s’ job security

Organ isationa l environmentOrganisational policy suppo

Complexity of cure and careprovide d

Facili ty arr ang ements

Own ‘office/trea tmen t’ spa ceSuppo rting staff

Employmen t arr angemen tsNP’s flexibili ty in working hou rs

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168 M.G.H. Niezen, J.J.P. Mathijsse

Institution ’s famili arity with (regu latory) environment

Type of hea lth setting

Expe rien ce in working with

(inter) profession al colleg iali

Institution al environmen tLegislation

Socio-economic forces

Governmen tal (resea rch) po

Patien ts’ pe rcep tions

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