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2015 HSR&D/QUERI National Conference Abstract

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3162 — Boundary Spanners: The Unique Role of the Nurse Practitioner in Developing Acute Stroke Care Programs within the VA

Rattray NA, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center; Damush TM, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center; Luckhurst C, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center; Bauer-Martinez CJ, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center; Miech EJ, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center;

Objectives:
As professionals uniquely situated to span boundaries between nurses and physicians, nurse practitioners (NPs) play an important role in the context of developing and coordinating acute stroke care programs within the Veterans Health Administration.

Methods:
This analysis was part of a prospective, mixed methods, three-year evaluation of acute stroke care at 11VA sites. Through semi-structured interviews with clinical providers, we examined the role of NPs in developing and implementing acute stroke care programs at individual VAMCs as well as in providing and improving acute stroke care at those facilities. A multidisciplinary team analyzed interview data through thematic analysis using descriptive codes and by applying constructs from the Consolidated Framework for Implementation Research (CFIR) directly to the qualitative data.

Results:
We found that in multiple sites, NPs emerged as "boundary spanners" across services as well as across disciplines. In VAMCs where the NP served as the stroke coordinator, their impact included: ensuring a facility-wide approach through the implementation of stroke protocols; convening regular meetings of a formal stroke work group or committee; providing direct care to stroke patients; creating a sense of continuity during periods of staff turnover; and monitoring stroke care through ongoing data review and reporting. NPs were universally seen by their colleagues as stroke champions actively engaged with staff and patient education and care of Veterans. NPs who bridged the physician-nurse partnership were deemed approachable and respected by both disciplines.

Implications:
Wide variation existed in the implementation of acute stroke care practices, policies and programs across VAMCs in this study. Nurse practitioners emerged as critical boundary spanners and enhanced communication within and across clinical microsystems, provided staff and Veteran education, and helped to meet the requirements of the 2011 VA national stroke directive. Staffing stroke coordinator positions with NPs benefited both Veterans and VA staff at multiple facilities and may have wider implications for how VA providers organize themselves as a group to provide and improve care.

Impacts:
By facilitating cross-service communication, providing care, analyzing data, convening committee meetings, and coordinating educational activities, NPs can help improve the quality and safety of acute stroke care for Veterans.