A mixed methods study of the work patterns of full-time nurse practitioners in nursing homes.

AIMS AND OBJECTIVES: The aim of this study was to explore the integration of the nurse practitioner role in Canadian nursing homes to enable its full potential to be realised for resident and family care. The objective was to determine nurse practitioners' patterns of work activities. BACKGROUND: Nurse practitioners were introduced in Canadian nursing homes a decade ago on a pilot basis. In recent years, government and nursing home sector interest in the role has grown along with the need for data to inform planning efforts. DESIGN: The study used a sequential mixed methods design using a national survey followed by case studies. METHODS: A national survey of nurse practitioners included demographic items and the EverCare Nurse Practitioner Role and Activity Scale. Following the survey, case studies were conducted in four nursing homes. Data were collected using individual and focus group interviews, document reviews and field notes. RESULTS: Twenty-three of a target population of 26 nurse practitioners responded to the survey, two-thirds of whom provided services in nursing homes with one site and the remainder in nursing homes with as many as four sites. On average, nurse practitioners performed activities in communicator, clinician, care manager/coordinator and coach/educator subscales at least three to four times per week and activities in the collaborator subscale once a week. Of the 43 activities, nurse practitioners performed daily, most were in the clinician and communicator subscales. Case study interviews involved 150 participants. Findings complemented those of the survey and identified additional leadership activities. CONCLUSION: Nurse practitioners undertake a range of primary health care and advanced practice activities which they adapt to meet the unique needs of nursing homes. RELEVANCE TO CLINICAL PRACTICE: Knowledge of work patterns enables nursing homes to implement the full range of nurse practitioner roles and activities to enhance resident and family care.

Using a mixed-methods design to examine nurse practitioner integration in British Columbia.

AIM: To discuss and provide examples of how mixed-methods research was used to evaluate the integration of nurse practitioners (NPs) into a Canadian province. BACKGROUND: Legislation enabling NPs to practise in British Columbia (BC) was enacted in 2005. This research evaluated the integration of NPs and their effect on the BC healthcare system. DATA SOURCES: Data were collected using surveys, focus groups, participant interviews and case studies over three years. REVIEW METHODS: Data sources and methods were triangulated to determine how the findings addressed the research questions. DISCUSSION: The challenges and benefits of using the multiphase design are highlighted in the paper. CONCLUSION: The multiphase mixed-methods research design was selected because of its applicability to evaluation research. The design proved to be robust and flexible in answering research questions. IMPLICATIONS FOR PRACTICE/RESEARCH: As sub-studies within the multiphase design are often published separately, it can be difficult for researchers to find examples. This paper highlights ways that a multiphase mixed-methods design can be conducted for researchers unfamiliar with the process.

Nurse practitioners changing health behaviours: one patient at a time.

In 2005, legislation was enacted allowing nurse practitioners (NPs) to practise in British Columbia, Canada. Although substantial human and financial resources had been dedicated to the implementation of the role, no evaluation has been conducted to date. As part of a larger multiphase, mixed-methods study design, which evaluated the integration of NPs into the British Columbia healthcare system, this article describes findings related to changes that result for patients and the implications for the healthcare system when NPs become part of the care process. Using survey and interview data, themes that emerged were patient satisfaction, access to care, and behavioural changes. Findings suggest that patients are satisfied with the care they receive from NPs and that NPs make positive changes to health behaviour.

Electronic Record Adoption and Use among Nurse Practitioners in British Columbia.

There has been a research focus on physician adoption of electronic medical records (EMRs). However, there has been less research into nurse practitioner (NP) use of EMRs. The authors present findings on the adoption and use of EMRs by NPs arising from a survey of the patterns of NP practices in the Canadian province of British Columbia. The research reveals a high rate of NP adoption of EMRs, with 82% of respondents indicating that they were using the technology. However, only 19% of NPs were using fully electronic records while 63% were using hybrid records, with only components of the electronic record being available. Respondents were found to be using several EMR features and functions, namely patient demographics, clinical notes, medication lists, laboratory results, and patient problems. NPs' high rate of EMR adoption suggests that there is much to be learned regarding the effect of eHealth strategies on EMR adoption.

L'adoption par les médecins de la tenue de dossiers médicaux électroniques (DME) a fait l'objet de nombreuses recherches. Toutefois, les recherches portant sur l'utilisation de DME par les infirmières praticiennes (IP) se font beaucoup plus rares. Les auteures présentent les résultats d'une étude portant sur les tendances relevées chez les IP œuvrant dans la province canadienne de la Colombie-Britannique, relativement à l'adoption et l'utilisation de DME. L'étude révèle un taux élevé d'IP travaillant avec des DME, 82 % d'entre elles indiquant qu'elles utilisent maintenant cette technologie. Cependant, seulement 19 % d'IP travaillent avec des dossiers entièrement informatisés alors que 63 % utilisent des dossiers hybrides, la partie électronique du dossier ne comportant que certains éléments. Les personnes qui ont répondu utilisent plusieurs fonctions électroniques, notamment celles permettant la gestion des données démographiques du patient, des notes cliniques, des listes de médicaments et des résultats de laboratoire ainsi que des données sur les troubles du patient. Le taux élevé d'adoption de cette technologie chez les IP suggère la nécessité d'étudier davantage les effets des stratégies de cybersanté sur l'utilisation de DME.

A case study of nurse practitioner role implementation in primary care: what happens when new roles are introduced?

BACKGROUND: At the time of this study (2009) the role of the nurse practitioner was new to the province of British Columbia. The provincial government gave the responsibility for implementing the role to health authorities. Managers of health authorities, many of whom were unfamiliar with the role, were responsible for identifying the need for the NP role, determining how the NP would function, and gaining team members' acceptance for the new role. METHOD: The purpose of the study was to explain the process of nurse practitioner role implementation as it was occurring and to identify factors that could enhance the implementation process. An explanatory, single case study with embedded units of analysis was used. The technique of explanation building was used in data analysis. Three primary health care settings in one health authority in British Columbia were purposively selected. Data sources included semi-structured interviews with participants (n=16) and key documents. RESULTS: The results demonstrate the complexity of implementing a new role in settings unfamiliar with it. The findings suggest that early in the implementation process and after the nurse practitioner was hired, team members needed to clarify intentions for the role and they looked to senior health authority managers for assistance. Acceptance of the nurse practitioner was facilitated by team members' prior knowledge of either the role or the individual nurse practitioner. Community health care providers needed to be involved in the implementation process and their acceptance developed as they gained knowledge and understanding of the role. CONCLUSION: The findings suggest that the interconnectedness of the concepts of intention, involvement and acceptance influences the implementation process and how the nurse practitioner is able to function in the setting. Without any one of the three concepts not only is implementation difficult, but it is also challenging for the nurse practitioner to fulfill role expectations. Implications for research, policy, practice and education are discussed.

Resident and family perceptions of the nurse practitioner role in long term care settings: a qualitative descriptive study.

BACKGROUND: Research evidence supports the positive impact on resident outcomes of nurse practitioners (NPs) working in long term care (LTC) homes. There are few studies that report the perceptions of residents and family members about the role of the NP in these settings. The purpose of this study was to explore the perceptions of residents and family members regarding the role of the NP in LTC homes. METHODS: The study applied a qualitative descriptive approach. In-depth individual and focus group interviews were conducted with 35 residents and family members from four LTC settings that employed a NP. Conventional content analysis was used to identify themes and sub-themes. RESULTS: Two major themes were identified: NPs were seen as providing resident and family-centred care and as providing enhanced quality of care. NPs established caring relationships with residents and families, providing both informational and emotional support, as well as facilitating their participation in decision making. Residents and families perceived the NP as improving availability and timeliness of care and helping to prevent unnecessary hospitalization. CONCLUSIONS: The perceptions of residents and family members of the NP role in LTC are consistent with the concepts of person-centred and relationship-centred care. The relationships NPs develop with residents and families are a central means through which enhanced quality of care occurs. Given the limited use of NPs in LTC settings, there is an opportunity for health care policy and decision makers to address service inadequacies through strategic deployment of NPs in LTC settings. NPs can use their expert knowledge and skill to assist residents and families to make informed choices regarding their health care and maintain a positive care experience.

Role of the nurse practitioner in providing palliative care in long-term care homes.

AIM: The purpose of this study, which was part of a large national case study of nurse practitioner (NP) integration in long-term care (LTC), was to explore the NP role in providing palliative care in LTC. METHODS: Using a qualitative descriptive design, data was collected from five LTC homes across Canada using 35 focus groups and 25 individual interviews. In total, 143 individuals working in LTC participated, including 9 physicians, 20 licensed nurses, 15 personal support workers, 19 managers, 10 registered nurse team managers or leaders, 31 allied health care providers, 4 NPs, 14 residents, and 21 family members. The data was coded and analysed using thematic analysis. FINDINGS: NPs provide palliative care for residents and their family members, collaborate with other health-care providers by providing consultation and education to optimise palliative care practices, work within the organisation to build capacity and help others learn about the NP role in palliative care to better integrate it within the team, and improve system outcomes such as accessibility of care and number of hospital visits. CONCLUSIONS: NPs contribute to palliative care in LTC settings through multifaceted collaborative processes that ultimately promote the experience of a positive death for residents, their family members, and formal caregivers.

Use of knowledge discovery techniques to understand nurse practitioner practice patterns and their integration into a healthcare system.

The objective of this study is to assess the feasibility of applying knowledge discovery techniques to identifying nurse practitioner practice patterns and enacted scope of practice. For the research, we plan to use data extracted from a Ministry of Health database. The data items are focused around: nurse practitioner demographics, health authorities, and encounter types. This analysis produces patterns that indicate relationships between the demographics, scope of practice and practice settings of nurse practitioners working in British Columbia.

How case-study research can help to explain implementation of the nurse practitioner role.

AIM: To discuss how case-study research was undertaken to explain the implementation of the nurse practitioner role in a Canadian province. BACKGROUND: In Canada, the nurse practitioner role was only recently introduced and one of the last provinces to implement it was British Columbia. At this time, no studies of the role's implementation in the province had been published and, although nurses refer to case studies more frequently in their research, the literature lacks concise explanations of the methodologies involved in creating them. DATA SOURCES: A case study of the implementation of the nurse practitioner role, including participant interviews and document review. RESEARCH METHODOLOGY: The development of an explanatory, single case study with embedded units of analysis in line with Yin's (2009) approach to case-study research. DISCUSSION: This article provides an overview of case-study research methodology and examples from a case study undertaken by the author. CONCLUSION: The use of case studies provides nurse researchers with opportunities to engage with phenomena of interest in their settings and so is suited to the complex nature of nursing practice. IMPLICATIONS FOR PRACTICE OR RESEARCH: Case-study research enables researchers to study areas of interest thoroughly and in the context in which they occur.

Nursing the Nuu-chah-nulth Way: Communities Driving Nursing Policy Priorities.

Rural and remote Indigenous communities face unique challenges, and they must drive solutions for sustaining and maintaining distinct nursing practices. Resourcing Indigenous community needs and aspirations for health depends on sustainable funding and an appropriately resourced nursing workforce. An Indigenous community-engaged research team led a program of study exploring Indigenous systems of care with three distinct communities. We used Indigenous research methodologies to identify obstacles to care and ways to advance nursing and healthcare delivery according to unique values and demographical and geographical influences. Using a collaborative analysis approach with communities, we identified themes related to resourcing nursing positions, supporting nursing education and valuing nursing influence in determining program priorities. The voice of the community in research is a powerful force for advocacy, ensuring that nurses are supported in relationships with communities and in designing programs that fit the community's vision for health and wellness. We recognize the essential contributions of nurse leaders to policy processes in formulating and coordinating ideas for program redesign across and within levels of organizations for health and social justice impacts. We conclude our paper by noting implications for nursing leadership in diverse settings with the goal of sustaining a nursing workforce to provide culturally safe, wellness-focused care.

Experiences and perceptions of health care professionals making treatment decisions for older adults with memory loss: a qualitative systematic review protocol.

OBJECTIVE: The objective of this review is to critically analyze and synthesize the experiences and perceptions of health care professionals making decisions that result in treatment recommendations for older adults living with memory loss who are experiencing health problems. INTRODUCTION: Health care professionals provide care to older adults living with memory loss and other coexisting health conditions across all clinical settings. Older adults living with memory loss most commonly experience impaired independent decision-making, which can challenge health care professionals when decisions about treatment need to be made. These challenges contribute to older adults with memory loss receiving inappropriate treatment and experiencing higher morbidity than those without memory loss. To date, existing reviews have not focused on the experiences and perceptions of health care professionals who are making treatment decisions when older adults living with memory loss experience health problems. A deeper exploration of this evidence is needed to understand health care professionals' experiences and perceptions of treatment decision-making to support the goal of improving care for older adults. INCLUSION CRITERIA: This systematic review will consider studies across all clinical settings focused on the experiences and perceptions of health care professionals making treatment decisions for older adults with memory loss who are experiencing health problems. METHODS: We will conduct a comprehensive systematic search using CINAHL, MEDLINE, PsycINFO, Scopus, and ProQuest Dissertations and Theses. Two reviewers will independently appraise the selected studies and extract qualitative data using the recommended JBI method for study selection, critical appraisal, data extraction, and data synthesis. The ConQual approach will be applied to provide a level of confidence for the review findings. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42021271485.

Factors affecting nurse practitioner role implementation in Canadian practice settings: an integrative review.

AIM: To review the literature about the Canadian experience with nurse practitioner role implementation and identify influencing factors. BACKGROUND: Although nurse practitioners have been in existence for more than 40 years, their integration into healthcare systems has been challenging. While frameworks exist to guide implementation of these roles, clear identification of factors influencing role implementation may inform best practices. Given that Canada has witnessed considerable growth in nurse practitioner positions in the past decade, an exploration of its experience with role implementation is timely. DATA SOURCES: A review of Canadian literature from 1997 to 2010 was conducted. Electronic databases including CINAHL, Cochrane Database of Systematic Reviews, Health Source: Nursing Academic Edition, Medline, Social Science Index, PubMed, Web of Science and PsychINFO and government and professional organization websites were searched. METHODS: An integrative review was performed guided by Whittemore and Knafl's method. RESULTS: Ten published studies and two provincial reports were included. Numerous facilitators and barriers to implementation were identified and analysed for themes. Three concepts influencing implementation emerged: involvement, acceptance and intention. Involvement is defined as stakeholders actively participating in the early stages of implementation. Acceptance is recognition and willingness to work with nurse practitioner. Intention relates to how the role is defined. CONCLUSION: This integrative review revealed three factors that influence nurse practitioner role implementation in Canada: involvement, acceptance and intention. Strategies to enhance these factors may inform best practice role implementation processes.

Indigenous peoples' positive experiences of culturally safe health care: a qualitative systematic review protocol.

OBJECTIVE: The purpose of this systematic review is to explore what is known about Indigenous peoples' positive experiences with culturally safe health care. INTRODUCTION: Research indicates that Indigenous people often experience stigma and discrimination from non-Indigenous health care providers when accessing health care services. One approach that has been put forward to address Indigenous health inequities is cultural safety. Studies have been conducted to identify what comprises culturally safe care for Indigenous people, however, many of these studies target the health care provider's perspective, rather than the perspective of the Indigenous person who is receiving the care. INCLUSION CRITERIA: This review will consider studies that involve Indigenous peoples' positive experiences with culturally safe health care from any study setting. Studies that present relevant qualitative findings including descriptions, examples, or stories about how a health care provider enacted cultural safety from Indigenous perspectives will be considered. METHODS: MEDLINE, CINAHL, Embase, PsycINFO, First Nations Periodical Index, the Native Health Database, the Indigenous Studies Portal, and the Arctic and Antarctic Regions Database will be searched for published studies. The search for unpublished studies will include Google and Google Scholar, ProQuest Dissertations and Theses, and OpenGrey. Databases will be searched from 1988 onward and only studies published in English will be included. The JBI systematic review guidelines will be followed. The JBI process of meta-aggregation will be used to identify categories and synthesize findings. The ConQual approach will be used to assess confidence in the review findings. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42020173003.

Philosophical Theories of Truth and Nursing: Exploring the Tensions.

In this paper, the authors explore three philosophical theories of truth and offer a critique of this foundational area of scholarship for nursing. A brief summary of key ideas related to the three substantial philosophical theories of truth-that is, correspondence, pragmatism, and coherence-serves to highlight various convictions and commitments that facilitate or discourage the growth of nursing knowledge in particular ways. The authors conclude that the coherence theory of truth offers a more inclusive view of truth and best captures and supports the diversity that exists within nursing knowledge and the regulative ideal to which nursing aspires.

Supporting nurse practitioner education: Preceptorship recruitment and retention.

OBJECTIVES: Clinical experience is an essential component of nurse practitioner (NP) education that relies heavily on preceptors. Recruitment and retention of preceptors is challenging due to many variables that can affect NP education and practice. We surveyed Canadian NP programs to understand their preceptorship structures, how they support preceptorship, and to identify gaps and challenges to recruitment and retention of preceptors. METHODS: An 18-item survey, developed by the NP Education Interest Group, was distributed to 24 universities across 10 Canadian provinces. Construct validity and reliability was assessed by experienced NPs and NP faculty. Data were analyzed using relative frequency statistics and thematic analysis. Participants consisted of administrative staff and/or faculty designated as responsible for recruitment and retention of NP preceptors. RESULTS: Seventeen returned surveys were analyzed and demonstrated more similarities than differences across Canada's NP programs, particularly related to barriers affecting recruitment and retention of preceptors. The findings identified NP programs have too many students for the number of available clinical sites/preceptors, resulting in overutilization, burnout, or refusal to take students. Competition with other health disciplines for clinical placements was identified as a challenge to placements. Respondents commented they lack time to recruit, provide follow-up, offer support, or seek preceptors' feedback due to competing work demands. They identified the need for standardized funding for preceptor remuneration and recognition across the country. CONCLUSION: The findings suggest the need for exploring a wider intraprofessional collaboration among graduate NP programs/faculty, clinical placement sites, and NPs to facilitate the recruitment and retention of preceptors.

Perspectives of Nurse Practitioner-Physician Collaboration among Nurse Practitioners in Canadian Long-Term Care Homes: A National Survey.

Nurse practitioners (NPs) can play an important role in providing primary care to residents in long-term care (LTC) homes. However, relatively little is known about the day-to-day collaboration between NPs and physicians (MDs) in LTC, or factors that may influence this collaboration. Survey data from NPs in Canadian LTC homes were used to explore these issues. Thirty-seven of the 45 (82%) identified LTC NPs across Canada completed the survey. NPs worked with an average of 3.4 MDs, ranging from 1-26 MDs. The most common reasons for collaborating included managing acute and chronic conditions, and updating MDs on resident status changes. Satisfaction with NP-MD collaboration was high, and did not significantly differ among NPs working full versus part time, NPs working in a single versus multiple homes, or NPs with more versus less experience. By understanding the nature of NP-MD collaboration, we can identify ways of supporting and enhancing collaboration between these professionals.

Nurse practitioners, canaries in the mine of primary care reform.

A strong and effective primary care capacity has been demonstrated to be crucial for controlling costs, improving outcomes, and ultimately enhancing the performance and sustainability of healthcare systems. However, current challenges are such that the future of primary care is unlikely to be an extension of the current dominant model. Profound environmental challenges are accumulating and are likely to drive significant transformation in the field. In this article we build upon the concept of "disruptive innovations" to analyze data from two separate research projects conducted in Quebec (Canada). Results from both projects suggest that introducing nurse practitioners into primary care teams has the potential to disrupt the status quo. We propose three scenarios for the future of primary care and for nurse practitioners' potential contribution to reforming primary care delivery models. In conclusion, we suggest that, like the canary in the coal mine, nurse practitioners' place in primary care will be an indicator of the extent to which healthcare system reforms have actually occurred.

An Assessment of How Nurse Practitioners Create Access to Primary Care in Canadian Residential Long-Term Care Settings.

The aim of this paper is to explore the role and activities of nurse practitioners (NPs) working in long-term care (LTC) to understand concepts of access to primary care for residents. Utilizing the "FIT" framework developed by Penchanksy and Thomas, we used a directed content analysis method to analyze data from a pan-Canadian study of NPs in LTC. Individual and focus group interviews were conducted at four sites in western, central and eastern regions of Canada with 143 participants, including NPs, RNs, regulated and unregulated nursing staff, allied health professionals, physicians, administrators and directors and residents and family members. Participants emphasized how the availability and accessibility of the NP had an impact on access to primary and urgent care for residents. Understanding more about how NPs affect access in Canadian LTC will be valuable for nursing practice and healthcare planning and policy and may assist other countries in planning for the introduction of NPs in LTC settings to increase access to primary care.

Nurse Practitioner Perceptions of the Impact of Electronic Medical Records Upon Clinical Practice.

A survey was conducted in the province of British Columba, Canada with nurse practitioners (NP). This paper reports on the quantitative and qualitative findings of the survey questions specifically focused on NP perceptions of the clinical impacts associated with using electronic medical records (EMRs) in a primary care setting. Findings suggest that although NPs perceived EMRs to improve the overall quality of clinical decisions, challenges remain in terms of tailoring the design of EMRs to address NP needs.