Understanding Top of License Nursing Practice: A Qualitative Study of Staff RNs Experiences

Purpose: Recommendations from the Institute of Medicine published report, The Future of Nursing:Leading Change, Advancing Health, indicate the emerging need to support top-of license (TOL) practice for Registered Nurses (Medicine, 2011). TOL nursing practices has been defined by Advisory Board and reflect practices that underscore professional knowledge and skills : (1) assess and clinical psychosocial patient needs; (2) establish patient goals and track progress; (3) provide patient centered, outcome focused care; (4) educate and engage patients and their families(5) manage key components of the clinical record; (6) coordinate care with interprofessional caregivers; (7) facilitate safe patient transitions to the next care setting; (8) assess and incorporate new technologies and evidenced-based practice (Center, 2013). TOL emphasizes the cognitive work of nurses with less focus on the accomplishments of tasks. Previous studies have clearly demonstrated that nurses spend considerable amounts of time on activities that are non-value added, and navigating organizational inefficiencies (Antinaho, Kivinen, Turunen, & Partanen, 2017; Laustsen & Brahe, 2018; Walter, Ling, Dunsmuir, & Westbrook, 2014). To date, there has been no empirical work that has examined nurses’ perception of TOL practices. The purpose of this study is to explore nurses’ perceptions of TOL practice and successes and barriers associated with achieving TOL practices.

Methods:

This qualitative study used a purposive sample of nurses (n=14) who work in an a large academic medical center. Inclusion criteria were: (1) working full-time; (2) more than 2 years of acute care experience; (3) employed more than 6 months on current unit. Exclusion criteria: (1) diploma graduate; (2) current enrollment in RN-BSN program; (3) masters or doctorally prepared. Four focus groups were conducted in a large academic medical center. Each focus group lasted between 45-60 minutes. Focus groups were facilitated by experienced member of the research team who guided the discussion using semi-structured questions. Focus group sessions were recorded and transcribed. Demographic information including age, gender, education and years of experience was collected.Data analysis was achieved using a thematic analysis approaches consistent with the Miles and Huberman’s process of selecting, simplifying, abstracting and transforming data and field notes (Miles, 2014). Using a constant comparative method, themes about nursing activities emerged.

Results:

The results of this study yield a model identifying scope of nursing practice. We categorized nurses’ scope of work into two primary categories: (1) Nurses’ Scope of Nursing Practice; and (2) Non-nursing Care Tasks. Within Scope of Nursing, we identified 4 subthemes, professional nursing care (physical and psychosocial), critical thinking, interprofessional communication and patient education. Several themes emerged related to the barrier to TOL practice. These include frustrating communication with other providers over patient’s plan of care, chaotic shifts with increasing cognitive load, no time to provide emotional support and patient education, and the performance of many non- nursing related tasks (e.g. housekeeping).

Conclusion:

Nurses in this study several TOL practices that align with the Advisory Board’s definition with the exception of the integration of new technologies and evidence-based practice. Nurses placed very high value on achieving TOL practices but felt that there were many barriers. Failed communication between caregivers, chaotic shifts and performing non-nursing and delegable tasks were particularly problematic. Nurses identified numerous tasks/activities that should be either delegated or reassigned to un-licensed personnel. This study is a beginning step in identifying administrative practices that could potentially support TOL practices. The ability to achieve true TOL practice will require new and innovative nursing care delivery models. Nursing administrators and researchers must collaborate to test these new models of care.