Nursing Leadership

Nursing Leadership 23(Special Issue) December 2010 : 186-188.doi:10.12927/cjnl.2010.22275

Close to the Tipping Point

Pam Hubley

Nursing leaders play a critical role in creating and enacting a vision for collaborative practice with advanced practice nurses (APNs). In this special issue, Nancy Carter and colleagues have identified many important influences and outcomes of successful nursing leadership in the context of promoting advanced practice nursing roles. The authors make a strong case for the importance of nursing leadership to facilitate large-scale systems change, noting the multiple levels on which nursing leaders work to ensure advanced practice nursing roles are well introduced to improve patient care. Nursing leadership can move an innovation like advanced practice nursing practice forward toward the "tipping point," when the new idea takes hold and becomes socially acceptable and desired, when the early adopters have influenced the early majority and about 15 to 20% of the population have adopted the idea (Berwick 2003). In many ways our nursing leaders have achieved this with advanced practice nursing roles, and we should celebrate. APNs are now more common, and certainly members of the public are proud to speak of the roles APNs play in their health services. An idea that once captured the minds of a select few has spread, thanks in large part to the nursing leaders who had a vision, believed in an idea, fought for it and worked to embed the change in the system.

Despite these early successes, awareness of advanced practice nursing roles among nursing leaders varies considerably. Yet widespread awareness is essential if we are to advance advanced practice nursing roles and realize the benefits of their potential. All 11 nursing leaders that Carter and colleagues interviewed for their study were well informed about advanced practice nursing roles and had practical experience in planning and implemented them. However, many nurses in leadership positions do not know what an APN is. How can this be? Are we educating ourselves and our future leaders sufficiently to find creative solutions to care delivery challenges? The authors recognize that further investigation of nursing leaders' information needs is required, particularly in small community hospitals, primary healthcare settings and long-term care facilities.

Carter and colleagues found many papers in their study that recognized the essential role of nursing leaders in facilitating and supporting the introduction of advanced practice roles into their organizations. Strategies are proposed in the literature for successfully introducing an advanced practice nursing role. No one would doubt the importance of meticulous planning, however, it is not the only way to introduce an advanced practice nursing role into the health system. In my experience, effectively supporting the advancement of advanced practice nursing roles has sometimes been deliberate, while at other times a product of synchronistic events – the consequence of stars aligning, some would say. While logical, systematic leadership is essential, advancing advanced practice nursing roles in a system that is slow to change sometimes happens when the right leaders, the right APN, the patient population, the right funding mechanism and the right timing come together, rather than when all is carefully planned.

Participants in Carter et al.'s study stressed the importance of using specifically designed toolkits to implement advanced practice roles. While successful leaders plan and carefully use systematic approaches like the PEPPA framework, they must also seek opportunities to align linear planning with creative and reflective processes. Paying attention to the idea of "emerging futures" connects practical planning with creative thinking and possibilities. One of the crucial elements to leadership I have learned is that leaders succeed when they see an emerging future and generate enthusiasm for its possibilities. Seeing that emerging future involves more than painting a picture of your vision; one must also use contextual cues to help catapult ideas and innovations, and know when to act and when to wait. In the context of advanced practice nursing, for example, when a team is talking about the complexities of patient care and their dissatisfaction with gaps in the system, an astute leader might facilitate a conversation about how things could be different, pulling out ideas about the potential contribution an APN could make, without directly or forcefully suggesting an advanced practice nursing role as the solution. This kind of leadership seizes the moment and draws on local intelligence and creativity, recognizing that timing is key and that change is dynamic and organic.

The future of advanced practice nursing integration into the healthcare system will require continued attention and collaboration across sectors. We need nursing leaders from practice settings, education, regulatory, health policy and government organizations deliberately working together to further shift systems of care delivery. We need researchers to examine best practices, answer questions about outcomes and their impact and generate new knowledge that APNs can apply in their practice. We need leaders in nursing administration to advocate for new ways of delivering care and focus efforts toward quality, safety and the creation of healthy and healing environments where diverse professionals offer value-added services. Our regulators and government agencies need to advocate for legislative frameworks that make sense and allow APNs to practise without barriers, without needing to create workarounds that waste time and money. We need more education programs for APNs and educators to teach nurses who are interested in becoming leaders how to advocate for advanced practice nursing roles and effect systems change. We need to teach them how to create supportive infrastructures and be effective nursing leaders, able to articulate business cases that advance collaborative models and engage physicians and other health providers in partnership and teamwork.

Ultimately, individual APNs who have been trailblazers have pushed the boundaries to create new partnerships and new ways of delivering patient care. Their success has been possible with support from nursing practice and academic leaders, creating infrastructures to sustain roles and education for building capacity in advanced practice nursing. In turn, scholarship has gathered the evidence to substantiate the impact that advanced practice nursing roles have made on the system and on patient care. The truth is, we all need each other, working together to shift the system to where there is no question about why an advanced practice nursing role would be useful and what an advanced practice nursing role could contribute. We have early adopters and we have influenced the early majority. Now we are close to the tipping point where we continue to spread the innovation of advanced practice nursing and collaborative models of care. Working in partnership, I am sure we will rise to this next leadership challenge!

About the Author(s)

Pam Hubley, RN, MSc, Associate Chief, Nursing Practice, The Hospital for Sick Children, Toronto, ON


Berwick, D.M. 2003. "Disseminating Innovations in Health Care." Journal of the American Medical Association 289 (15): 1969–75.


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