Differentiated nursing practice as a catalyst for transformations in nursing: A multiphase qualitative interview study.

AIM: To identify and follow-up on the transition towards differentiated nursing practice among bachelor trained and vocationally trained nurses in Dutch hospitals.
DESIGN: A multiphase general qualitative interview study.
METHODS: Fifty semi-structured interviews with project managers in charge of introducing differentiated nursing practice to their hospital were conducted. Purposive sampling was used, and data were collected in 2017, 2019 and 2020. A meta-analysis was conducted after independent primary thematic analysis of each data collection.
RESULTS: The introduction of differentiated nursing practice to Dutch hospitals was perceived as uncertain and ambiguous. Three themes were identified during the transition towards differentiated nursing practice: (1) call to action; (2) sitting and waiting; and (3) new beginnings and open ends. The change to differentiated nursing practice is not straightforward and these findings highlight the emerging awareness among project managers of the nature and complexity of the transition. During the study period, professionalization of the nursing profession was recognized as fundamental in hospital organizations.
CONCLUSION: Nursing cannot be separated from differentiated nursing practice. Visible leadership is important at all organizational levels and nurses' opinions must be considered as nurses are essential to such changes in healthcare. IMPACT: Differentiated nursing practice based on nursing education allows nurses to make the best use of their experience, skills and competencies, and could promote the provision of effective and high-quality patient care. However, in many cases, a nurse's practice role is based on their nursing licensure instead of their educational background. The change to differentiated nursing practice in hospitals is not straightforward and the nature and complexity of the transition needs to be acknowledged. Nurses have an important role in healthcare transformation and need to be active in developing and formulating rather than just implementing the changes.

INTRODUCTION

Healthcare systems are increasingly burdened by challenges, including increasing healthcare costs, increasing demand for care, growing care complexity and increasing pressure for enhanced patient experience and person‐centeredness (Byers, 2017; World Health Organization, 2016). Nurses play a major role in responding to these challenges and are at the front line in delivering vital healthcare (Allen, 2018; World Health Organization, 2020). However, nursing shortages fuelled by growing professional dissatisfaction are putting this vital role, and therefore high‐quality patient care, at risk. Investing in career development and improving the nursing work environment can help nurses to provide high‐quality patient care, encouraging them to come to and remain in clinical practice (World Health Organization, 2020).

Healthcare organizations worldwide have tried to strengthen their nursing workforces by redesigning nursing care delivery models to improve the quality of patient care and create challenging work environments that attract and engage nurses (Dubois et al., 2012; Havaei et al., 2019). Differentiated nursing practice is a nurse staffing model in which nursing roles are defined based on each individual's education and experience (Boston‐Fleischhauer, 2019; Dubois et al., 2012). This approach allows nurses to use their individual experience, skills and competencies to their full potential and may promote the provision of effective and high‐quality patient care (Dubois & Singh, 2009; Lavander et al., 2017). Differentiated nursing practice also enables the development of a mixed workforce where challenging roles for nurses are aligned with their educational background (Yoder‐Wise, 2019). Several studies have shown that a nurse's educational background affects the quality of patient care and that increasing the proportion of bachelor‐trained nursing staff could improve patient, personnel and organizational outcomes (Aiken et al., 2012; Butler et al., 2019; Haegdorens et al., 2019; Shin et al., 2018; Twigg et al., 2019).

The Dutch nursing organizational model has been described by van Oostveen et al. (2015) as a ‘basic functional model’ lacking a supportive climate for nursing professionalization. Nurses are dealing with inefficient work processes, high workload, and little managerial support, together with a lack of autonomy and authority (van Oostveen et al., 2015). Furthermore, there is no formal distinction between vocational‐ and bachelor‐educated registered nurses; they carry out the same activities, bear similar responsibilities, and receive similar wages (Huisman‐de Waal et al., 2019; van Schothorst‐van Roekel et al., 2020). Transforming the Dutch nursing organizational model may improve practice environments and patient outcomes (Dubois et al., 2013).

Background

For the last 40 years, various attempts to transform the organization of Dutch nursing care and to implement differentiated education‐based nursing practice have failed. There are three different educational pathways to becoming a registered nurse: gaining a diploma, vocational training and gaining a bachelor degree. Nursing diplomas are achieved through hospital in‐service training and considered equal to vocational training by the Minister of Health in the 1980s, but ended in 1997. Roles in nursing practice are based on nursing licensures rather than educational background. In June 2019, the Ministry of Health, Welfare and Sport announced a legislative change that made differentiating nursing practice based on educational background obligatory by law. In doing so, a formal distinction between bachelor and vocationally trained nurses would be made in the organization and design of nursing work. However, this bill was abolished after widespread resistance among nurses, which was widely publicized by the media. Vocationally trained nurses felt threatened and depreciated because they would receive a lower salary and fewer tasks and responsibilities than their bachelor‐trained colleagues. Because of this resistance, the Ministry abolished the amendment in October 2019 and handed the task of distinguishing nursing roles and functions over to the healthcare organizations. At the moment, effective measures remain undefined and reforms are prone to local resistance. In addition, the definition of differentiated nursing practice and what this means in practice remains unclear (Boston‐Fleischhauer, 2019; Lavander et al., 2017). These developments are reason to investigate the transition towards differentiated nursing practice in Dutch hospitals.

This research is part of a nationwide study on differentiated nursing practice in the Netherlands. This national research program is called ‘RN2Blend’ and is financed by the Dutch Ministry of Health, Welfare and Sports. The program focuses on the scientific substantiation and practical guidance of role advancement in the Dutch nursing profession. The aim of RN2Blend is to support the transition to new nursing roles, investigate the professional and economic effectiveness of role distinction, and determine the consequences on patient outcomes.

THE STUDY

The study was designed and executed in accordance with the consolidated criteria for reporting qualitative research (COREQ) checklist (Tong et al., 2007).

Aim

The aim of this paper is to investigate the transition towards differentiated education‐based nursing practice among bachelor and vocationally trained nurses in Dutch hospitals. These insights will (1) improve the design of new nursing roles, functions and differentiation models; (2) develop activities for successful differentiation; and (3) determine the clinical effectiveness of differentiated nursing practice.

Design

A multi‐phased general qualitative design was used to gain insight into the transition towards differentiated nursing practice in Dutch hospitals as well as the barriers and facilitators to the reorganization process (Percy et al., 2015). In 2017, 2019 and 2020, we conducted semi‐structured interviews with project managers in charge of introducing differentiated nursing practice into their hospitals. Figure 1 presents a schematic representation of the research design together with a timeline of the related legislative changes to nursing practice in the Netherlands.

FIGURE 1

Schematic representation of the research design and process

Participants

We selected hospitals with different characteristics, approaches to the transition, project initiators, and ratios in vocational to bachelor‐trained nurses to obtain more widespread information. Respectively four and two of the included hospitals in 2017 were also included in the 2019 and 2020 sample. The project managers were contacted by email and were informed about the aim of the study and invited to help plan an in‐depth interview. Contact details were obtained from the Dutch hospital association and the Dutch Federation of University Medical Centers. Seventeen participating project managers were specifically hired for the job as project manager. The others also held different positions and/or functions in the hospital but were all actively involved in introducing differentiated nursing practice and in transforming the nursing organizational model (Table 1).

TABLE 1

Characteristics of hospitals and participants

Year of data collection	2017	2019	2020
Hospital characteristics
Type of hospital
Academic	5	1	—
Teaching	15	5	5
General	2	4	5
Division of nurses
% vocationally educated nurses	60–87	50–90	40–80
% bachelor educated nurses	13–40	10–50	20–60
Total of participated hospitals	22	10	10
Participant characteristics
Gender
Male	3	1	1
Female	21	11	12
Age (years)
<25	—		—
25 to 35	3	3	3
35 to 45	13	6	2
45 to 55	6	3	3
>55	2	—	5
Education level
Vocational	—	—	—
Bachelor	7	3	5
Academic	17	9	8
Nursing background
Yes	19	7	12
No	5	5	1
Function
Project leader (hired for the job)	7	4	6
(Department) manager	1	2	—
Chair nursing advisory board	6	1	1
Member nursing advisory board	1	—	—
Manager educational department	5	2	1
Advisor educational department	1	—	2
Advisor human resources	1	3	2
Secretary hospital board	1	—	—
Nursing liaison officer	1	—	—
Policy officer	—	—	1
Implementation coach	—	—	1
Total responses (n)	24	12	13

n, population size.

Data collection

To gain the most information about how differentiated nursing practice was introduced, open‐ended questions were used in the interviews (Supplementary File S1). The main questions can be found in Box 1. The interview guide was structured by the five components of the model for managing complex change developed by Lippitt (Enterprise Management Limited): vision, skills, incentives, resources and action plan. The absence of one of these components could lead to resistance or implementation failures.

Which activities have already been performed in order to start/support the differentiated nursing practice?

Can you explain the vision behind the practice differentiation in your hospital? What do you hope to achieve?

Which skills, knowledge and resources were required to initiate differentiated practice?

How is differentiated nursing practice implemented in your hospital? What went well? What could have been improved?

In 2017, 2019 and 2020, 50 different project managers were interviewed. In three hospitals, the project managers preferred being interviewed in pairs as they held the same position. This was considered as appropriate since they were involved in the same processes and no power relations existed (Cartwright et al., 2016). The semi‐structured interviews were conducted in Dutch and were digitally recorded (with permission from the participants). The day, time and place of the interviews were arranged at the participants’ convenience. Interviews lasted between 45 and 60 min and were transcribed afterwards as data collection and analysis were parallel processes. Data saturation was reached since it was considered that further data collection would bring up similar results (Saunders et al., 2018).

In 2017, interviews were conducted face to face by CO and two nursing science graduates. In 2019, interviews were conducted face to face by JK. After the legislation on differentiated nursing practice was withdrawn, participants were interviewed again to identify any changes in their transitional approach. At this time, four participating project managers were no longer employed at the hospitals; two suggested we interview the new project managers instead. In 2020, interviews were conducted by AZ, one of which was by telephone because of COVID‐19 restrictions.

Ethical considerations

The local medical ethics review board approved the study but waived the need for ethical approval. Participation was voluntary, and the project managers were assured of confidentiality and anonymity. Project managers gave written consent to participate in the interviews and for the interviews to be audio recorded. They were fully informed about the study before giving consent and had the right to withdraw at any time. There were no personal relationships between the project managers and interviewers. Data were saved under identification numbers according to the rules and legislations of the participating institutions.

Data analysis

Data from the interviews conducted in 2017, 2019 and 2020 were analysed separately and directly after the first interviews were conducted. Various codes and themes were identified from these three data analyses. We compared these data and conducted a meta‐analysis to expand knowledge and to create an integrated view of the transition to differentiated nursing practice (Figure 1; Paterson et al., 2001).

Primary data analysis

Data were independently analysed using a thematic analysis approach, which is often used to analyse qualitative data and to better understand patterns and themes across data sets (Braun & Clarke, 2012). Using MaxQDA (version 12), Atlas‐ti (version 8.4.20) and NVIVO 12® software, we identified various subthemes and three or four main themes for each year studied (Figure 1).

Meta‐analysis of data

The next step of the data analysis was to find commonalities in and derive conclusions from the data collected in 2017, 2019 and 2020 (Paterson et al., 2001). This process goes beyond labelling data and allows the data to be fully comprehended (Thorne, 2020). Code interpretations and findings were discussed among all authors until consensus was reached. New meanings and interpretations were made and three common themes were created (Figure 1). These themes are defined in Box 2.

Call to action: related to themes that highlight the need for change and serve as a call for action (extrinsic motivation and minimal involvement of nurses).

Sitting and waiting: the wait‐and‐see attitude of hospitals did not appear to be helpful in initiating change. The introduction of a legislative change was not such a simple solution.

New beginnings and open ends: reference is made here towards the abolishment of the bill, increasing awareness of project managers and the freedom of hospitals to initiate their own transitions without external handles.

Rigour

We used various strategies to meet the rigour criteria as defined by Guba and Lincoln (1989). All authors were involved in the analysis and interpretation of the findings and in finalizing the article. The joint process of data analysis ensured an in‐depth exploration of differentiated practice. Member checks were performed by summarizing the interviews, reviewing the transcripts, and presenting and discussing the results with project managers. No adjustments were made to the identified themes. All authors are registered nurses and bracketing was used to distance from potentially present preconceptions (Tufford & Newman, 2012). JK is a female registered nurse and PhD candidate, and is trained in health and life sciences. CO works as a senior advisor and researcher and she has a post academic degree. PL is a senior researcher and he is experienced in qualitative research. AZ is trained in nursing sciences and she works as a lecturer at a Dutch nursing faculty. In addition, to reduce the risk of biased decisions and interpretations, an agent involved in organizational change reflected on the researchers’ interpretation of the results (Polit & Beck, 2012).

FINDINGS

All project managers found the transition to differentiated nursing practice to be unpredictable, but believed in the potential benefits of a differentiated nursing workforce and its contribution to future healthcare. Although all project managers recognized the importance of differentiated nursing practice, many were reluctant to embrace the need for change. We identified three crucial episodes during the transition to differentiated nursing practice: (1) call to action; (2) sitting and waiting; and (3) new beginnings and open ends. In the first episode, the value and necessity of differentiated nursing practice was not yet recognized, resulting in inefficient approaches and procedures. In the second episode, project managers became aware that the transition is complex and voiced the need for examples and frameworks. The inability to act because of uncertainties seemed to dominate the introduction of differentiated nursing practice in different hospitals. In the third episode, the national policy on differentiated nursing practice was withdrawn and frameworks moved away from these ‘wait‐and‐see’ attitudes. Project managers became aware of the nature and complexity of the transition and saw it as an opportunity to fully adapt the new practice to their hospital rather than depending on external forces to tell them what to do. At the heart of this were systemic changes, and the professionalization of the nursing profession was recognized as fundamental for the hospital as a whole.

Call to action

In the run‐up to the legislative change, hospitals initiated their transitions and recognized the need for change. Challenges facing the healthcare system were the main reasons for initiating differentiated nursing practice. These challenges included multimorbidity, high patient turnover rates, and the increasing complexity of healthcare. Almost all project managers expected the quality of care to increase through better use of the skills, knowledge and expertise of nurses.

By applying differentiated practice, every nurse will be deployed at his or her initial educational level. This enables optimal use of everyone's expertise and knowledge and quality of care will be improved. P23

At this time, introduction of the new legislation forced hospitals to revise their established nursing practices and career pathways, regardless of whether they considered differentiated nursing practice to be valuable or not.

Actually, it is born out of necessity because we are confronted with the new legislation. It is a must do. At the moment we still have to figure out how we will benefit from it. P29

This suggests that extrinsic motivation was the driving force for initiating differentiated nursing practice and professionalization of the nursing profession. This greatly reduced motivation and leadership among project managers. Ambiguity of the legislative changes, knowledge gaps, other large‐scale projects in the organization, and financial consequences all contributed to this reduction in motivation and leadership. Although extrinsic motivation from the introduced legislation did initiate a transition to differentiated nursing practice, it was too limited to completely change the nursing care model in hospitals.

Most hospitals responded to the new legislation by defining new roles for vocational‐ and bachelor‐trained nurses. However, this approach lacked strategic vision and only a few project managers saw the need to develop a broader vision for differentiated nursing practice.

You must be aware of the full impact of this transition. We have to advocate strongly for it and I’m sure we're not alone in this thinking. It would be smart to approach these complex transitions deliberately and comprehensively. P13

You must be able to explain the motives for change. What is your vision on nursing? That is the basis. Subsequently, you can talk about the actual content of the profession. P32

All project managers believed that a supportive hospital management board that recognized the importance of the nursing profession was necessary for making successful changes to nursing roles and functions. Transforming the nursing model by introducing differentiated practice achieved the organizations’ strategic objectives, but only a few hospitals were able to create a vision on nursing that was widely supported.

One of the board members was involved in developing the vision on nursing. She was personally motivated to do this and showed commitment and passion. Now she promotes this vision – and that is possible because she knows the vision by heart and is the board member responsible for this project. P9

Although a supportive hospital management board was essential for successful changes in nursing practice, we found that few were supportive.

At this moment we have a new hospital management board and they are the exact opposite. They do support the project, but there is a lack of alignment. At the moment, we do not have the wind at our back. We used to have it back then, but we do not have that anymore. P30

Creating an effective call to action strategy was challenging and all project managers recognized communication and collaboration between different management levels as essential. However, creating a connection between hospital management and hospital workers was difficult and this diminished the motivation to change.

We have to discuss the organization of care with each other. Now it is fragmented. Everybody advocates for his own ‘piece of the pie’ and ‘preaches for his own parish’. P19

The current governance structure demotivates nurses. Why should you professionalize at all if you are not involved in decision‐making and have to leave direct patient care if you want more control over nursing practice? For most of the nurses, patient interaction is their first passion. P1

Hospitals face political dynamics and awareness of different interests seemed to be an important issue. Nurses appeared to be minimally involved in shaping the nursing organizational model or their own work environment. Project managers reported a lack of knowledge, awareness and interest among nurses.

Nurses must take their profession seriously, so they have to take responsibility for their own professional development. Now they wait patiently until something happens, thinking, ‘we have always done it this way’, and ‘the management has to tell me when and how to change’. They have to exert and exercise greater guidance over the direction of their profession. P20

This quote highlights that, although the transition to differentiated nursing practice was directly relevant to nurses, they were not involved in directing the reorganization of their work. The minimal involvement of nurses together with extrinsic motivation and lack of strategic management highlighted the need for action to achieve the desired organizational changes.

Sitting and waiting

The external environment and national developments appeared to play a major role in getting the internal organization moving. The lack of clarity on educational requirements for new professional and function profiles complicated the enforced transition to differentiated nursing practice. The Dutch hospital association provided general guidelines for (1) developing local job descriptions; and (2) essential project elements and project management needed for successful differentiation. Some project managers saw this as helpful in preventing ambiguities that could reduce disagreement among nursing staff.

Hence, we have created something unique that fits the hospital. We did not come up with something we thought of ourselves, it is derived from the general guidelines. P31

Hospitals were responsible for translating new professional profiles into local job descriptions and for developing educational programs for new or neglected competencies. However, the legislative changes caused concerns and resistance among nurses making it difficult for some hospitals to continue their change process. This hindered the clear definition of nursing roles and functions. One project manager indicated that these uncertainties postponed change implementation in their organization:

We consciously did not call for action since this creates many concerns. We have seen this in other hospitals. There is simply still too much uncertainty. P29

Support for change was reduced by a lack of clarity on how successful the change would be and what the differentiation model should look like, for example the optimal ratio of vocational‐ to bachelor‐trained nurses. As a result, some project managers were waiting for a policy from the hospital association or practices from other organizations.

What kind of competencies are we actually talking about and what will be visible in practice? If that is not clear to me right now, why would it be clearer later? It requires a good conversation about the expectations and communication. P28

Strategic considerations were identified that postponed experimentation and action. Project managers observed the direct environment and based their actions on the decisions of other hospitals, which made the change process inert. This competitive element among hospitals led to complex dilemmas – on the one side, becoming an attractive employer by investing in development opportunities and on the other side, losing vocationally trained nurses because of depreciation.

There is consultation with surrounding hospitals about this project [red. differentiated nursing practice]. We are in a competitive environment […] The project can be of great influence whether you can easily attract nurses and whether you can easily lose them. P24

Although action was difficult at this time, project managers seemed increasingly aware of the scale and complexity of the change. Introducing new legislation was not a simple way to achieve successful change.

New beginnings and open ends

After the bill was withdrawn and the resistance among vocationally trained nurses dissipated, we expected hospitals would take no further steps to introduce differentiated nursing practice. To our surprise, the follow‐up interviews showed that all project managers were motivated to continue their projects. The extrinsic motivation from the legislation had made them aware of the possible benefits of practice differentiation.

The announcement of the legislative change was a nice catalyst. We had to talk to each other and think about it. You had to do something. That necessity has faded a bit now. P41

Many project managers now realized that introducing differentiated nursing practice was not just about introducing a simple new work procedure. They acknowledged that it was a process of change and that reform and developing a clear vision and strategy were important.

Our starting point was that the implementation of differentiated practice is a change process, where all wards must go through a development phase to experience what the implementation means and how it works side by side. P42

The transition of the nursing profession required vision and strategic direction. However, some hospitals adjusted their policies in response to resistance. For some organizations, the negative associations with differentiated nursing practice increased focus on labour market trends. Hospital managers were afraid of losing nurses and thought they could recruit and retain nurses by improving working conditions.

So we said above all, we will focus on the labor market. […] we have focused on our employees and the labor market as reason to continue. Not so much because the quality of care will be improved. Of course, it is a nice bycatch, but again if you have so many nursing shortages that will not be convincing. P35

Organizations had to explain why continued reforms were needed. To do this, they described positive experiences from departments that already experimented with differentiated practice.

This pilot ward is really enthusiastic, and we have seen satisfying results there. They are doing really well. That's so nice to see, that they get positive energy and go for it. P50

Opinions were divided now that the national legislation had been withdrawn. Some project managers were happy that they were finally able to organize and design the differentiation themselves, while others still felt dependent on national developments and practical frames.

I am a bit apprehensive since the consequences are unknown. Looking into the crystal ball is impossible and we don't know the effects of our choices. On the other hand, this does fit our hospital instead of doing something that is imposed by law. This comes from within the organization. In this way it is more natural and powerful. P39

The importance of a bottom‐up approach where nurses are involved in the change process was recognized by all project managers. Some tried to create safe and supportive environments by actively involving the unit managers. This encouraged communication with nurses. After the turbulent summer of 2019, project managers wanted to connect with nurses, create support and develop leadership. This promoted nurse accountability and ownership.

There is so much going on and we want to hear from the nurses themselves how they are doing. At this moment, the core is the development of the nursing profession. P33

Within the hospital, this is really something we like to develop bottom‐up. I notice that it brings very nice things and that nurses really get the feeling that they can show leadership and that it is up to them. P47

The cancellation of the proposed bill somehow served as a wake‐up call for action. Hospitals progressed in their different ways to shape their own vision for nursing. There was an incentive to embrace the historic and institutionalized complexity of the situation and to further develop and reinforce the nursing work environment. New beginnings and open ends seemed to stimulate a successful transition towards differentiated nursing practice as a forward‐facing discipline.

DISCUSSION

In this study, we found that the transition towards differentiated nursing practice in Dutch hospitals can be characterized by three crucial episodes: ‘call to action’, ‘sitting and waiting’, and ‘new beginnings and open ends’. The introduction of differentiated nursing practice was met with resistance at first because it was imposed upon hospitals by a new national legislation and was driven by extrinsic motives. Gradually, hospitals became aware of the importance of the transition and realized the need for intrinsic motives. Once the imposed legislation was withdrawn, many hospitals developed a bottom‐up approach and placed emphasis on creating a clear nursing vision.

Main findings

Project managers expected that differentiated practice would improve patient, nurse, and organizational outcomes in their hospitals. They were already following existing research on work satisfaction of nurses, health status of patients, quality of care, and adequate utilization of staffing levels in hospitals (Needleman et al., 2020; O'Brien‐Pallas et al., 2011), but a strategic vision on how to professionalize the nursing profession was not always present. Project managers were keen to invest in the skills and knowledge needed to meet the requirements of the new legislation, but did not realize the importance of a support system to help nurses consolidate these new responsibilities and behaviours (Wagner et al., 2010). This may reflect a lack of commitment or ignorance about nursing at the middle management (Lalleman et al., 2016) and strategic level (Rasheed et al., 2020). It seems probably that vast changes concerning the nursing profession and the organization of nursing care are kept into localities of the nursing silo and nursing is seen as a separate domain.

Project managers focused on the practical distinctions between new nursing roles and functions, such as the development of new function profiles and project plans for their nurses. However, the quality of nursing care was also relevant not only to nurse staffing and scope of practice but also to the nursing practice environment as a whole (Allen, 2018; Dubois et al., 2012). This raises the question of whether the transition to differentiated nursing practice was restricted to bachelor and vocationally trained nurses rather than transforming nursing functions, roles, and positions in hospitals. New roles and functions will create challenging new career opportunities for nurses and help them to develop a strong professional identity and leadership on all organizational levels (Ewens, 2003; van Oostveen et al., 2017).

The participating hospitals reported that they wanted to learn from the experiences of other hospitals about how to execute the differentiation. However, no major transitions were made in the past several years, suggesting that this ‘wait and see’ approach is not conducive to change. Austin et al. (2016) concluded that the ‘wait and see’ approach is ineffective at initiating complex change. The need to attract nurses and overcome the nurse shortage created a dilemma: on the one hand, focusing on practice differentiation could create new career paths that attract nurses. On the other hand, vocationally trained nurses could feel depreciated by the changes and quit. Strategic decision‐making processes varied between hospitals; some felt more dependent on national guidance and practical frames than others did. Although the bill was withdrawn, it motivated hospitals to make decisions and ultimately take further steps in transitioning towards a differentiated practice. This confirms that hospitals need to make strategic decisions based on long‐term visions (Austin et al., 2016).

The initial dependence of project managers on national guidance suggests that moves to transition towards differentiated practice would stop after the bill was abolished. However, all project managers chose to continue with the transition after the bill was withdrawn. The bill provided an external stimulus that initiated the change, which was then internalized. Many changes in healthcare are externally driven and it is important to understand how motivation can be encouraged at the individual level (Breckenridge et al., 2019). In this case, managers, policy makers, and politicians learned that making decisions on behalf of nurses can be disastrous (Felder et al., 2020). The legislative change triggered widespread resentment and demotivation among nurses, but helped them to realize that they needed to be involved in the transition towards new nursing practice. Emphasis must now be placed on joint decision‐making between nurses and hospital management (Rasheed et al., 2020). Seeing the long history of differentiated nursing practice (Matthias, 2015), the basic moral values of nursing must be debated and nurses must be emancipated and allowed to play a leading role in the transition to differentiated nursing practice (van der Cingel & Brouwer, 2021).

Over time, project managers started to realize that professionalization of the nursing profession was fundamental to the hospital. This kind of ‘episodic change’ is infrequent and discontinuous and strategic efforts are needed to guide the organization in the right direction (Johansen et al., 2018; Weick & Quinn, 1999). However, most project managers lacked the management skills needed to guide this transition, which might explain why the impact of the transition and the crucial role of nurses were underestimated. It would probably have helped if project managers recognized the importance of nurse role differentiation in hospitals from a ‘historic institutionalized’ perspective focused on continuous change (Suddaby et al., 2013).

Study limitations

There are a few limitations to the present study that should be considered when interpreting the results. First, the findings are only applicable to nursing practice in Dutch hospitals, although similar findings on differentiated nursing practice in the United States were described by Matthias (2015). Despite this, the present findings may help to predict trends in nursing practice transitions in other countries. The finding that a high number of bachelor‐ trained nurses is related to better patient outcomes has triggered hospitals worldwide to review their nursing care system (Aiken & Fagin, 2018). Finally, the differentiation of nursing practice is a dynamic process; however, we collected our data over time and believe that our results reflect the constant changes of the past few years.

Recommendations for practice

This study provides valuable insight into the reorganization of nursing practice. First, we showed that it is crucial that hospitals actively anticipate changes to their environment and strategically plan nursing work accordingly (Austin et al., 2016). Nurses should be involved in policy making and in the differentiation of nursing practice at the organizational and national level (Rasheed et al., 2020). This could be accomplished by formulating clear roles, responsibilities, and expected behaviours for nurses, and by establishing nursing shared governance allowing nurses to make decisions in the reorganization of nursing practice (McKnight & Moore, 2021). Furthermore, supportive, visible nursing leadership should be created (Lalleman et al., 2016; Lasater et al., 2020; van Oostveen & Vermeulen, 2017).

CONCLUSION

The introduction of differentiated nursing practice is not a straightforward change process and an external stimulus appeared to be needed to start and acknowledge the nature and complexity of the transition. The professionalization of the nursing profession is a great challenge for hospitals and cannot be realized by external motives such as the proposed legislative change. Visible leadership at all organizational levels is important wherein dialogues about the polyphony and multitude of perspectives need to be recognized. Nurses’ voices need to be heard since they are essential for transformation of the nursing organizational model.

CONFLICT OF INTEREST

The authors declare no conflicts of interest.

PEER REVIEW

The peer review history for this article is available at https://publons.com/publon/10.1111/jan.15001.

Supplementary Material

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