Attending Registered Nurses: Evolving Role Perceptions in Clinical Care Teams

Gayle A. Fishman, DNP, MBA, RN, NEA-BC


Nurs Econ. 2018;36(1):12-17. 

In This Article

Abstract and Introduction


A CALL FOR INNOVATIVE care delivery models that improve care, enhance quality, and reduce healthcare costs is a key strategy to improve the U.S. healthcare system (Berwick, Nolan, & Whittington, 2008). Health care systems are implementing different approaches to achieving 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 fragmentation in the hospital setting is the attending registered nurse (ARN) role, designed to support delivery of integrated, patient-centered 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 ensuring the consistent and timely progression 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 families and other staff. The ARN is accountable for ensuring patient care meets clinical standards (evidence-based practice) and coordinates decision making and communication, 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 discharge 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 preadmission 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 beginner, competent, proficient, and expert (Benner, 1984). Nurses at each level demonstrate changes in three key aspects of practice: movement from dependence on concepts to use of accumulated experiences as exemplars; a change from compiling individual situational events to appreciating more holistic views; and movement from observer to involved performer. In this framework, the ARN role leverages both the knowledge base and leadership experience of selected staff nurses to coordinate care for complex patients often across multiple teams of providers, mentorship of nursing staff, and application of hospital guidelines and other educational resources to clinical 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.