Gayle A.
Fishman
Attending Registered Nurses:
Evolving Role Perceptions in
Clinical Care Teams
EXECUTIVE SUMMARY
Multiple new leadership roles in
nursing have been described for
which the impact on the quality
and safety of care deliv-ery and
on the costs of care delivery
remain to be defined. Further, the
appropriateness of training and
the optimal deploy-ment of
personnel have not been
investigated.
In this study, in one such care
model, attending registered
nurses’ perceptions of their role
evolves from functional thinking
to “looking at the big picture,”
underscoring an increased level of
insight over time.
The data highlight the impor-
tance of ensuring “buy-in” from
peers to ensure success in
leadership roles.
These observations are mutual-ly
reinforcing; improved leader-ship
and communication skills
produces greater acceptance by
peers.
GAYLE A. FISHMAN, DNP, MBA, RN, NEA-
BC, is Nursing Director, Endoscopy Units,
Massachusetts General Hospital, MA.
12
A CALL FOR INNOVATIVE care
delivery models that im -
prove care, enhance quali-
ty, and reduce healthcare
costs is a key strategy to improve
the U.S. healthcare system
(Berwick, Nolan, & Whittington,
2008). Health care systems are
implement-ing different approaches
to achiev-ing these interdependent
goals known as the Triple Aim. New
care delivery models are emerging
along the fragmented continuum of
care and present solutions to some
aspects of the healthcare crisis.
One strategy to reduce frag-
mentation in the hospital setting is
the attending registered nurse (ARN)
role, designed to support delivery of
integrated, patient-cen-tered care at
Massachusetts General Hospital
(MGH) in Boston, MA (Erickson,
Ditomassi, & Adams, 2012). The
ARN is an experienced staff nurse
who, with the attending physician, is
responsible for ensur-ing the
consistent and timely pro-gression
of each patient’s care from
admission to discharge. The ARN
maintains a constant presence on
the unit 5 days per week as a
resource for both patients and fam-
ilies and other staff. The ARN is
NURSING ECONOMIC$/January-February 2018/Vol. 36/No. 1
accountable for ensuring patient
care meets clinical standards (evi-
dence-based practice) and coordi-
nates decision making and commu-
nication, notably during transitions in
care. The goal for this new role is to
provide continuity of care for
patients and families with optimal
coordination of care, including dis-
charge planning. It was anticipated
this intervention, coupled with other
simultaneous administrative
changes (e.g., improved handoffs of
care, earlier discharge planning,
increased attention to patient and
family education, enhanced pre-
admission evaluations, daily care
coordination rounds) would reduce
length of stay and readmissions,
enhance patient satisfaction, and,
ultimately, improve patient safety
and quality of care.
According to Benner’s model for
knowledge and skill acquisition in
nursing, skills and acquisition of
nursing expertise develop within five
levels: novice, advanced begin-ner,
competent, proficient, and expert
(Benner, 1984). Nurses at each
level demonstrate changes in three
key aspects of practice: move-ment
from dependence on con-cepts to
use of accumulated experi-
ences as exemplars; a change from
compiling individual situational
events to appreciating more holis-tic
views; and movement from observer
to involved performer. In this
framework, the ARN role lever-ages
both the knowledge base and
leadership experience of selected
staff nurses to coordinate care for
complex patients often across mul-
tiple teams of providers, mentor-ship
of nursing staff, and applica-tion of
hospital guidelines and other
educational resources to clin-ical
care.
The purpose of this qualitative
descriptive study was to describe
changes in the perception by ARNs
of their role after working in the
position for 2 years. Seven ARNs,
who were interviewed in 2012, were
re-interviewed in 2014 using the
same semi-structured interview
guide to assess changing role
perceptions over time.
Background
The Institute of Medicine (IOM)
Report, Crossing the Quality Chasm: A
New Health System for the 21st
Century, described a healthcare
delivery system poorly organized to
meet national health-care needs.
“The delivery of care often is overly
complex and un-coor dinated,
requiring steps and patient handoffs
that slow down care and decrease
rather than improve safety” (IOM,
2001, p. 1). This report called for
redesigned priorities for providers to
funda-mentally improve care. These
in-cluded “reengineered care pro-
cesses; effective use of information
technologies; knowledge and skills
management; development of effec-
tive teams; and coordination of care
across patient conditions, services,
and sites of care over time” (p. 2).
The IOM (2001) described six aims
to improve individual and commu-
nity healthcare services: safe, effec-
tive, patient-centered, timely, effi-
cient, and equitable care. The
changing healthcare environment
provides an opportunity to reexam-
ine staffing roles and processes
within the acute care setting.
A review of the literature was
conducted using key search terms
including attending registered nurse,
care delivery model, collabo-ration,
continuity of care, navigator, nursing
role, patient care facilitator, and
practice innovation. Search engines
used to conduct the search included
CINAHL, Cochrane Data-base of
Systematic Reviews, and the Na
tional Guidelines Clear ing House
via interfaces including EBSCOhost,
Ovid, and Nursing@ Ovid. The
study focused on evalua-tion of
evidence related to forma-tive
experiences contributing to
development of skills required for
the ARN role. Inclusion criteria also
included evidence describing where
nurses develop skills (acade-mic
preparation, specific job train-ing, or
experience in the role), inno-vative
care delivery models de-scribing
specific nursing attributes in the
role, and articles written in English.
The literature described four
general categories of nursing roles
focusing on patient-centered care:
faculty-led attending nurse
models, advanced practice RN-led
models; clinical nurse leaders-led
models, and RN-led models. This
review focused on RN-led models.
RN-led models of care evolved
from traditional models including
patient-focused care and case
management roles (Deutschendorf,
2003). Common programmatic com-
ponents contributing to success in-
clude elevating the RN role, in-
creasing focus on patient and fami-
ly involvement in care, smoothing
patient transitions and handoffs,
leveraging technology to enable
care model redesign, and providing
results-driven care (Kimball, Joynt,
Cherner, & O’Neil, 2007).
A series of inpatient models
address the need for patient-fo-
cused clinical care and improved
handoffs across the healthcare sys-
tem to enhance nursing leadership
and participation in care. Ac-cord-
ing to Clark (2004), the 12-bed hos-
pital at the Baptist Hospital of Miami
provides a care model for a cure-
dominated environment. The
patient care facilitator position pro-
vides clinical leadership roles for
nurses within smaller areas of
patient responsibility. The aim was
to ensure a caring and professional
practice culture for patients and
clinical staff (Brown et al. 2005).
Brown and colleagues conducted a
qualitative and quantitative multi-
method study to measure the
patient care facilitator role (inde-
pendent variable) on continuity of
care and caregiving behaviors of the
nursing staff (dependent variable).
Batcheller, Burkman, Armstrong,
Chappell, and Carelock (2004) stud-
ied the impact of an innovative
nursing infrastructure in a seven-
hospital network in which the nurse
retained the primary over-sight role,
provided long-term men-torship for
new employees, and provided the
primary interface with patients. In
these studies, RN-led models using
experienced nurses as the team
leader demonstrated positive
outcomes including im-provement in
nurses’ perceptions of the frequency
of assessment by experienced RNs
of patient readi-ness for discharge,
physician per-ceptions of the
availability of expe-rienced RNs,
reduction in RN staff turnover,
reduction in medication errors
(Batcheller et al., 2004), and
improved patient perceptions of staff
knowledge of care and dis-charge
plans (Brown et al., 2005). The
economic implications of these
observations include direct health-
care benefits of nurse retention (var-
iously estimated at 0.75-2 times the
salary of each lost nurse), reduced
patient length of stay, and reduced
potential exposures to medication
errors (Jones & Gates, 2007).
Erickson and coauthors (2012)
described the Attending Registered
Nurse Model at MGH. Innovation
units were created on 12 inpatient
units to “improve clinical out-comes,
enhance patient and staff
satisfaction, as well as reduce costs
and lengths of stay for hospitalized
patients” (p. 283). While 12 inter-
ventions were implemented simul-
taneously on innovation units, the
ARN was considered the consistent

NURSING ECONOMIC$/January-February 2018/Vol. 36/No. 1 13

 presence on the clinical team, working
5 days per week, providing continuous
relationships with patients, families,
and healthcare team. The ARN
developed and coor-dinated
interprofessional teams’ clinical plans
for inpatient admis-sions. The ARNs
were experienced, highly respected
nurses who partic-ipated in a
comprehensive curricu-lum including
role-specific educa-tion for the
innovation unit pro-gram. The program
augments ARN’s skills related to
conflict reso-lution, resiliency, and
communica-tion. ARN discussion
groups pro-vided forums to share
experiences, observations, and best
practices. This model was designed to
sup-port the challenge of delivering
integrated, patient-centered care at a
large academic health center. To date,
there are no published out-comes of
the ARN model. Quan-titative data will
be evaluated in the future including
culture of safety surveys, Hospital
Consumer As-sess ment of
Healthcare Provi ders and Systems
(HCAHPS) survey, length of stay,
quality indicators, patients’
perceptions of feeling known, cost per
case mix, and staff retention.
In addition to the economic
benefits of nurse retention and
reduction in clinical errors, the ARN
has an important role in the
maintenance of the nursing knowl-
edge base and in mentorship. A key
element is the identification of those
skills required to evolve into the
leadership role. Benner’s Novice to
Expert model, used to guide the
study, encompasses pro-gression
from novice to expert cli-nician.
Benner adapted Dreyfus and
Dreyfus’ Model of Skill Acquisition
and Skill Development to clinical
nursing practice (Benner, 1984).
“The Dreyfus and Dreyfus model
provides concepts to differ-entiate
between what is taught by precept
(i.e., teaching) and what must be
learned experientially from
comparison of similar and dissimi-lar
cases” (Benner, 1984, p. 186).
Benner (1984) posited that
development of knowledge in nurs-
14
ing is the extension of practical
knowledge through research and
description of experiences in clini-
cal practice. She proposed expert
nurses develop skills and under-
standing of patient care over time
as a function of both education
and experience. She suggested
clini-cians could gain knowledge
and skills (knowing how) without
learn-ing theory (knowing that).
Benner, Hughes, and Sutphen
(2008) suggested a cycle exists
between experiential knowledge and
scientific investigation: experi-ential
knowledge stimulates scien-tific
investigation and scientific
investigation fuels a cycle of further
experiential learning. In Benner’s
construct, the repository of clinical
knowledge and experience is in the
clinical team with responsibility for
optimizing clinical care (Benner,
2001). The ARN model builds on the
team concept by providing team
leadership to leverage the experi-
ence of senior staff to provide men-
torship and knowledge transfer
within care teams. The clinician’s
past experience from specific clini-
cal cases positions him or her to
identify future similar cases which
provides educational and research
opportunities. Benner suggested
nurses develop skills and under-
standing of patient care over time
through a sound educational base
and a multitude of clinical experi-
ences. Clinical situations are more
complicated and dynamic than the-
oretical scenarios; practice provides
a valid source of knowledge evolu-
tion. Through experiences and study
of clinical practice, nurses discover
new knowledge.
Methods
This study used a qualitative
descriptive design (Sandelowski,
2000). Data were collected using a
semi-structured interview tem-
plate developed in 2012 and
applied to the same subjects.
Initial interview data from 2012
were collected as part of a larger
project in which ARNs were inter-
viewed to assess adoption of 12
interventions from innovation units
NURSING ECONOMIC$/January-February 2018/Vol. 36/No. 1
at MGH and ARN perceptions of
that role. For this study, the same
interview guide was used to re-
interview ARNs remaining in the
position 2 years later. Key elements
of the interview are described
below. Study subjects included all
nurses in the ARN role for at least 2
years at the selected time points.
Setting and sample. The MGH is
an academic medical center within
Partners Healthcare, the largest
healthcare system in
Massachusetts. The author con-
ducted the interviews in 2012 and
2014. All ARNs from the 2012
study were invited to participate.
Eligibility criteria included partic-
ipating ARNs who had been inter-
viewed in June 2012 and were
identified by the department of
nursing as remaining active in the
role. All ARNs meeting eligibility
criteria agreed to participate in the
study. Interviews were conducted
with 16 subjects in 2012 and all of
the 7 remaining ARNs in 2014.
Data collection. Interview data
were collected by the author using
a semi-structured interview guide.
Key elements of the interview
included subject’s perceptions of
relationship-based care and ARN
role; the adequacy of training and
resources provided for subjects
and clinical staff; barriers to suc-
cessful job performance; role-spe-
cific changes in interactions with
patients, families, and staff; and
the role of technology in job per-
formance. Participants were inter-
viewed individually in a private
hospital conference room. The
interviewer took notes during the
meeting. Following each inter-
view, the author’s typed summary
of responses was emailed to sub-
jects within 24 hours. Each partic-
ipant was invited to edit or com-
ment on the written summary until
satisfied with his or her answers.
This editing and refine-ment
process was done via email to
ensure process validation. Some
participants provided detailed
changes, which were incorporated
into a final document. All partici-
pants provided final email confir-
mation their responses for each
perception were described accu-
rately. Following email confirma-
tion, data were de-identified,
replacing participants’ names with
numbers.
Ethical considerations. The
MGH Institutional Review Board
and the Spaulding Rehabilitation
Hospital Institutional Review
Board approved the 2014 study.
Informed consent and authoriza-
tion were implied by voluntary
participation in the interview. The
author had no conflicts of interest
related to the study.
Data analysis. Data generated
from each interview were organ-
ized in a matrix to allow direct
comparison between individuals
and over time. The author and
Ruth Palan Lopez, PhD, GNP-BC,
a researcher with expertise in
qualitative analysis, analyzed
written notes from both interview
periods using an iterative process
of description, analysis, and inter-
pretation (Wolcott, 1994). The
process included three levels of
coding: coded concepts for major
themes; assess similarities and
create higher-level categories; and
identify relationships between
categories across individuals and
over time. During first-level cod-
ing, interview reports were read
jointly line-by-line, highlighting key
words and assigning a code to
each concept. During second-level
coding, similarities in concepts
were identified that were col-
lapsed into higher-level cate-
gories. In third-level coding, cate-
gories were analyzed to identify
relationships and differences over
time. Themes were compared
between individuals over time (see
Table 1).
Strategies were employed to
enhance the trustworthiness and
credibility of study processes and
findings. An audit trail was main-
tained of research methods, sam-
pling processes, data collection,
respondent validation, content
management, data analysis, and
data re-presentation (Mays & Pope;
2000; Patton, 1990; Sandelowski,
NURSING ECONOMIC$/January-February 2018/Vol. 36/No. 1
Table 1.
Themes and Subthemes
Theme 1: From Tasks to Teams
Subthemes
2012
Care plans
Discharge planning
Patient education
Theme 2: From
Subthemes
2012
Role confusion
Ambiguity
Negative response
2000). An audit trail was main-
tained for participant response
confirmation. Performing joint data
analysis targeted increased
reflexivity, diminished bias, and
enhanced internal consistency.
Discussions ensured consensus
around each theme. Data analysis
was refined until higher levels of
categories accounted for all ques-
tions included in the study.
Results
Available subjects were inter-
viewed at both time points. Parti-
cipants were all RNs, female, 30-56
years of age (mean 45.6; SD 10.6).
All participants were Caucasian and
had at least 6 years nursing
experience on their units. Five
nurses had a bachelor of science
degree in nursing and two had mas-
ters in nursing degrees. All nurses
had at least 4 years experience in
leadership roles on the unit (charge
or resource roles) prior to assuming
the ARN role in 2012. All partici-
pants had been an ARN for 2 years.
Findings
Analysis of interview data from
2012 and 2014 revealed par-
ticipants demonstrated greater
insight into their roles after 2
years. Changes in perception
included two major themes at the
highest level: (a) ARNs demon-
strated increased awareness of
Subthemes
2014
Communication
Team builder
Continuity
Individualized plan of care
Pushback to Buy-In
Subthemes
2014
Role clarification
Collaboration
Positive response
roles related to team-based func-
tions (2014) as compared with
nar-rower task-oriented roles
(2012) (from tasks to teams); and
(b) reduced staff pushback to the
role (2012) with greater buy-in or
acceptance (2014) (from pushback
to buy-in). All ARNs demonstrat-ed
increased clarity in under-standing
of the ARN role and con-fidence in
that role over the study period
(see Table 1).
From tasks to teams. When asked
about role perception in year 1, ARN
responses centered on spe-cific
tasks including developing care
plans, planning for discharge, and
conducting patient education. In
contrast, when asked about the role
in year 2, they described
responsibilities including commu-
nication, team builder, continuity,
and individualized plans of care (see
Table 1). In 2012, ARNs used terms
such as ensure continuity of the plan
of care, being present daily, support the
patient’s discharge planning needs,
helper, and extra pair of hands. By
contrast, in 2014, all ARNs
described the role with terms
including communication,
collaboration, team builder, and
knowing patient and family. One ARN
described her role as “collabo-rative
– like part of a braided pony-tail”
using strong communication skills to
help bring together all members of
the nursing team. She
15
 felt the role was to ensure the
team was in agreement regarding
care plans for patient and family.
She believed this to be supportive
of relationship-based care. All
ARNs described a focus on team
building through collaboration and
facili-tating communication. Each
ARN told patients nurses were to
care for them “for the day” and the
ARN would manage the care “for
the stay.” Communication, team-
work, presence, knowing the patient,
and individualizing plans for care
were terms used to describe the
ARN role in 2014. This suggests
an increased aware-ness of the
potential value of the role and the
ability to look at the bigger picture.
This understanding allowed ARNs
to be more active in support of
staff nurses and in dis-charge
planning.
From pushback to buy-in. In
2012, in response to the new role,
all ARNs described pushback from
the staff nurses on their units. In
contrast, interview data from year 2
revealed ARNs report-ed buy-in
and acceptance by the staff.
Pushback was described by ARNs
as role confusion, ambigui-ty, and
negative responses by staff nurses.
ARNs experienced a major
challenge in describing the new
role to the staff. Unit staff nurses
were concerned ARNs were not
assigned patients, especially when
there were absences. One ARN
noted, “The staff exhibited some
strong reactions and some bitter-
ness to my role change.” Another
ARN said, “The biggest challenge
comes from the staff pushing back
when working with them, pa -
tients, and families.”
In 2014, evidence of buy-in
included various subthemes includ-
ing increased understanding of the
ARN role by staff nurses (role clari-
fication) as well as collaboration and
positive responses from staff nurses
(see Table 1). In the 2014
interviews, all of the ARNs
described buy-in from nursing peers
with a supportive team environ-ment
on each unit. Each of the ARNs said
leadership of the unit
16
nursing director was key to suc-
cessful transition into the effective
ARN role. The ARNs said nursing
directors held regular staff meet-
ings when the role was initiated to
manage negative perceptions and
allow staff to voice concerns and
address issues. Another factor in
successful transition into the role
was weekly ARN peer support
groups, called “brown bag lunch-
es.” These lunches provided a
forum for ARNs to share individ-
ual challenges, experiences, and
successes in a safe environment.
One ARN learned to provide sup-
port to the staff by helping with
some functional nursing tasks
such as medications or bathroom
requests. She believed such
assis-tance accelerated role
acceptance. All of the ARNs noted
contribu-tions of the nursing
director, brown bag lunches, and
provision of added support
enhanced under-standing and
acceptance by staff of the ARN
position over 2 years. These shifts
resulted in greater acceptance of
ARNs, enhancing their function
and the quality of the experience.
Discussion
This study was designed to
examine how ARNs perceived
changes in their role after 2 years
of experience. The data demon-
strate that with experience, ARNs’
perceptions of the role changed
from a task focus to a team focus,
and from staff pushback to accept-
ance. They described greater
understanding of the purpose of
their role within the totality of
patient care.
While research supports the
benefits of an RN-led model of care
(Batcheller et al., 2004; Brown et al.,
2005; Clark, 2004), less is known
about experience of nurses in these
roles. The findings of this study
related to the task to team theme are
consistent with Benner’s concept of
movement between novice, advanced
practitioner, and competent nurse.
The novice demonstrates rule-
governed behav-ior that is rigid and
limited while
NURSING ECONOMIC$/January-February 2018/Vol. 36/No. 1
with experience, the nurse demon-
strates the increased ability to rec-
ognize patterns and gain perspec-tive
and greater efficiency in deci-sion
making (Benner, 1984). In 2014 in this
study, movement was demonstrated
toward looking beyond narrow tasks
and evaluating the entire clinical
scenario includ-ing patients, families,
and care teams. While the new role
was ini-tially challenging from both
pur-pose and peer-acceptance
perspec-tives, ARNs described staff
as increasingly accepting of the posi-
tion over time as ARNs improved
communication skills, supported unit
staff, and led the care team in
managing patient care plans and
discharges. The key element for suc-
cess in both areas was a supportive
environment created by peers and by
unit and hospital leadership.
Benner (1984) suggested
practi-tioners could gain knowledge
and skills without learning theory.
She noted clinical situations are
more complicated and dynamic than
the-oretical scenarios, so clinical
prac-tice provides a valid source of
knowledge evolution. Through both
experience and studying of clinical
practice, nurses discover new
knowledge. This study
demonstrates ARNs’ role percep-
tions evolved over time from task-
oriented (care plans, discharge
plans, and patient education) to
viewing the whole care delivery
process (communication, team-
work, presence and knowing the
patient, and individualizing the plan
of care). In 2014, ARNs described a
focus on the “patient’s stay, not just
the day.” This growth in awareness
allows ARNs to pro-vide more
substantive support to staff nurses
in patient care and ensure patients
experienced smooth-er clinical care
and discharge plan-ning processes.
In creased role clari-ty and
confidence appeared to enhance job
performance, satisfac-tion,
communication skills, and
acceptance by staff.
The lack of acceptance of the
ARN role by staff nurses has not
been addressed in previous stud-
ies of new nursing leadership
roles. It is notable that of the 16
nurses in the initial ARN group
interviewed, only 7 remained at 2
years into the program. The basis
for this observation is unknown.
The available data indicate the
need for institutional and local
support as well as the importance
of specific training for ARNs and
staff nurses that anticipates
adverse responses to the new
lead-ership roles. In a more
general framework, introduction of
new leadership roles will require
clear articulation of goals and
expecta-tions of such positions
and met-rics to assess acceptance
and impact of such innovations.
The observation that resistance to
the role dissipated over time
suggests adaptation of ARNs to
their new roles alleviates
resistance by care teams.
Despite growth in individual and
group skills related to the ARN role,
although asked, none of the
interviewees provided specific evi-
dence of the ARN role on patient
safety, quality assurance, or patient
satisfaction – major elements of
modern clinical care. This may reflect
the questionnaire used or the training
received by these individu-als. Future
studies should assess the contribution
of ARNs to such important nurse-
sensitive indica-tors including staff
turnover, job sat-isfaction, and patient
safety (Batcheller et al., 2004), and
cost per case mix (Erickson et al.,
2012). Prior studies suggest
institutional-ization of care teams,
including unit-based utilization of
knowledge-able nursing leadership,
would have a beneficial impact on
patient satis-faction, reduction in
medication errors, retention of
experienced nurses, and job
satisfaction as well as reduced patient
length of stay and readmissions
(Batcheller et al., 2004; Jones &
Gates, 2007). Preliminary data
(unpublished) at MGH demon-strate
an overall 5% reduction in length of
stay and improved patient satisfaction
(HCHAPS) on the inno-vation units
compared with the same units at
baseline which incor-
NURSING ECONOMIC$/January-February 2018/Vol. 36/No. 1
porated multiple administrative
changes at the time of introduction
of the ARN role. Data on staff nurse
retention are not yet available from
the ARN-based innovation units. An
assessment of quality and safe-ty
data, readmissions, and other
financial indicators is ongoing.
Limitations
Small heterogeneous sample,
derived from one hospital on
seven inpatient units, limits gen-
eralizability. However, findings
illustrate the importance of a
development process for nurse
leaders. As nurses assume new
roles in the healthcare delivery
system, including major leader-
ship roles, they will require train-
ing and support specific to those
new positions. When the ARN role
was introduced in 2012, mul-tiple
care interventions at the same
time were propelled by ris-ing
costs of healthcare delivery. This
environment may have influ-enced
perceptions of the ARN role. In
addition, data collection was
restricted to interviews that did not
include observations of practice of
ARNs on their units. ARNs who
participated in this study were
those who remained in their role
for 2 years. This provid-ed insight
into those who imple-mented the
role successfully. Conclusions
cannot be drawn about those who
left the role dur-ing that period.
Conclusion
Multiple newer leadership
roles in nursing have been
described for which impact on the
quality and safety of care delivery
and on costs of care delivery
remain to be defined. Further,
appropriateness of training and
optimal deployment of personnel
have not been investigated. In this
study, in one such care model,
ARNs’ perceptions of their role
evolved from functional thinking to
“looking at the big picture,”
underscoring an increased level of
insight over time. Data highlight
the importance of ensuring buy-in
from peers to ensure success in
leadership roles. These observa-
tions are mutually reinforcing;
improved leadership and commu-
nication skills produce greater
acceptance by peers. These find-
ings should influence design of
training and support programs for
nursing leadership positions in the
future. Structured orientation for
other staff to introduce new clinical
leadership positions will be
essential. Such roles will be
pivotal in the evolution of inter-
professional clinical care and to
improve transitions of care.
However, to be successful, they
require significant investment in
training and support by local lead-
ership. Each new intervention will
require parallel evaluation of the
sustainability of clinical and
financial benefits for the health-
care system. $
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