Optimizing enactment of nursing roles: Redesigning care processes and structures

Abstract

Background: Effective and efficient use of nursing human resources is critical. The Nursing Role Effectiveness Model conceptualizes nursing practice in terms of key clinical role accountabilities and has the potential to inform redesign efforts. The aims of this study were to develop, implement, and evaluate a job redesign intended to optimize the enactment of registered nurse (RN) clinical role accountabilities. Methods: A job redesign was developed and implemented in a single medical patient care unit, the redesign unit. A mixed-methods design was used to evaluate the job redesign; a second medical patient care unit served as a control unit. Data from administrative databases, observations, interviews, and demographic surveys were collected pre-redesign (November 2005) and post-redesign (October 2007). Results: Several existing unit structures and processes (eg, model of care delivery) influenced RNs’ ability to optimally enact their role accountabilities. Redesign efforts were hampered by contextual issues, including organizational alignment, leadership, and timing. Overall, optimized enactment of RN role accountabilities and improvements to patient outcomes did not occur, yet this was predictable, given that the redesign was not successful. Although the results were disappointing, much was learned about job redesign. Conclusion: Potential exists to improve the utilization of nursing providers by situating nurses’ work in a clinical role accountability framework and attending to a clear organizational vision and well-articulated strategic plan that is championed by leaders at all levels of the organization. Health care leaders require a clear understanding of nurses’ role accountabilities, support in managing change, and leadership development opportunities.