Patient roles in primary care interprofessional teams: a constructivist grounded theory of patient and health care provider perspectives.

Health care providers are increasingly asked to work in interprofessional teams to enhance the care provided to and health outcomes of their patients. However, there is little evidence on how to include patients in meaningful roles on these teams to support their health monitoring and management. The purpose of this study was to gain insight into roles that patients can assume within their health care teams and to understand the conditions and processes required for patient roles to be enacted. Ten patients and 10 health care providers from two Family Health Teams in Southwestern Ontario, Canada, participated in individual interviews to learn about their perspectives on patient roles in teams. Data collection and analysis strategies generated theoretical concepts, and member-checking interviews provided final feedback on the framework. This study resulted in a comprehensive framework of two roles and the conditions and processes required for patient-health care provider interactions within primary care interprofessional teams. Further researchers could use this framework to build knowledge of patient roles in interprofessional teams across varying health care settings and patient populations.

Exploring Differences in Patient-Centered Practices among Healthcare Professionals in Acute Care Settings.

There is limited evidence of the extent to which Healthcare professionals implement patient-centered care (PCC) and of the factors influencing their PCC practices in acute care organizations. This study aimed to (1) examine the practices reported by health professionals (physicians, nurses, social workers, other healthcare providers) in relation to three PCC components (holistic, collaborative, and responsive care), and (2) explore the association of professionals' characteristics (gender, work experience) and a contextual factor (caseload), with the professionals' PCC practices. Data were obtained from a large scale cross-sectional study, conducted in 18 hospitals in Ontario, Canada. Consenting professionals (n = 382) completed a self-report instrument assessing the three PCC components and responded to standard questions inquiring about their characteristics and workload. Small differences were found in the PCC practices across professional groups: (1) physicians reported higher levels of enacting the holistic care component; (2) physicians, other healthcare providers, and social workers reported implementing higher levels of the collaborative care component; and (3) physicians, nurses, and other healthcare providers reported higher levels of providing responsive care. Caseload influenced holistic care practices. Interprofessional education and training strategies are needed to clarify and address professional differences in valuing and practicing PCC components. Clinical guidelines can be revised to enable professionals to engage patients in care-related decisions, customize patient care, and promote interprofessional collaboration in planning and implementing PCC. Additional research is warranted to determine the influence of professional, patient, and other contextual factors on professionals' PCC practices in acute care hospitals.

Enhancing Self-Care Management of Interdialytic Fluid Weight Gain in Patients on Hemodialysis: A Pilot Study Using Motivational Interviewing.

Patients receiving hemodialysis are challenged with restricting their fluid intake to ensure appropriate interdialytic weight gains. While nurses endeavor to promote selfcare, the ability to manage fluid gain rests on the patient's understanding and decision to limit fluid intake. A mixed-methods pilot study was undertaken to determine if motivational interviewing, a patient-centered, conversational, and collaborative approach to stimulating behavior change and resolving ambivalence, enhances self-care fluid management. Participants felt that motivational interviewing was very helpful, although findings suggest self-care fluid management requires a toolkit of interventions. Key motivational interviewing actions for nurses are presented.

Diffusing Innovative Roles Within Ontario Hospitals: Implementing the Nurse Practitioner as the Most Responsible Provider.

Hospitals require identification of the most responsible provider (MRP) for care of admitted patients. Traditionally, the MRP has been a physician. However, legislation changes within Ontario authorize the nurse practitioner (NP) to admit and provide care for hospital in-patients. There is little evidence illustrating adoption of the NP-as-MRP model in Ontario. Reasons for a delayed adoption of this innovative model of care are unclear and warrant investigation. One hospital implemented the NP-as-MRP as an appropriate and beneficial model to maximize access to care for senior patients. Rogers' (2003) model of diffusion of innovation provides a framework to describe the processes undertaken that led to their adoption of the NP-as-MRP model. Detailed processes are highlighted for hospital leaders, hospital board members, and NPs. Other sites are encouraged to evaluate whether the NP-as-MRP model will be appropriate for specific populations; each site should undertake a process that is as detailed to ensure thorough preparation of all who will be affected by this change. Evaluation of the outcomes of the NP-as-MRP model is necessary and must be population- and institution-specific, as these provide new evidence in the early stages of this recent NP-related innovation in Ontario.

Nurse Practitioner Role Value in Hospitals: New Strategies for Hospital Leaders.

Hospital leaders in Canada are continuously seeking new ways to meet patient needs and Ministry of Health priorities. One approach, integrating nurse practitioners (NPs) into the interprofessional team of caregivers, has demonstrated the quality outcomes hospital leaders seek. However, hospital leaders report there is limited information available to them to clearly know NP role value. This is concerning, as these leaders make the employment and integration decisions that enable role success. The lack of information for leaders has left NP role integration success to chance. Without clear strategies, there is risk that hospital NP roles will not be integrated such that optimal practice and quality outcomes can be achieved. This paper aims to provide pragmatic information for hospital leaders using a real-life example of a hospital NP role. Optimal NP practice and outcomes are described using the three major practice foci of a new evidenced-based framework specific to the hospital NP role. New strategies to support successful integration and role value optimization are provided for hospital leaders, physicians and NPs.

Nurse practitioner interactions in acute and long-term care: an exploration of the role of knotworking in supporting interprofessional collaboration.

BACKGROUND: Interprofessional care ensures high quality healthcare. Effective interprofessional collaboration is required to enable interprofessional care, although within the acute care  hospital setting interprofessional collaboration is considered suboptimal. The integration of nurse practitioner roles into the acute and long-term care settings is influencing enhanced care. What remains unknown is how the nurse practitioner role enacts interprofessional collaboration or enables interprofessional care to promote high quality care. The study aim was to understand how nurse practitioners employed in acute and long-term care settings enable interprofessional collaboration and care. METHOD: Nurse practitioner interactions with other healthcare professionals were observed throughout the work day. These interactions were explored within the context of "knotworking" to create an understanding of their social practices and processes supporting interprofessional collaboration. Healthcare professionals who worked with nurse practitioners were invited to share their perceptions of valued role attributes and impacts. RESULTS: Twenty-four nurse practitioners employed at six hospitals participated. 384 hours of observation provided 1,284 observed interactions for analysis. Two types of observed interactions are comparable to knotworking. Rapid interactions resemble the traditional knotworking described in earlier studies, while brief interactions are a new form of knotworking with enhanced qualities that more consistently result in interprofessional care. Nurse practitioners were the most common initiators of brief interactions. CONCLUSIONS: Brief interactions reveal new qualities of knotworking with more consistent interprofessional care results. A general process used by nurse practitioners, where they practice a combination of both traditional (rapid) knotworking and brief knotworking to enable interprofessional care within acute and long-term care settings, is revealed.

A survey of interprofessional activity of acute and long-term care employed nurse practitioners.

PURPOSE: To describe activities of interprofessional (IP) care, a key aspect of high-quality care, performed by nurse practitioners (NPs) employed in acute and long-term care institutions. DATA SOURCES: We developed and tested a new theory-driven process tool to quantify NP everyday activities of IP care. We then invited NPs in acute and long-term care to complete the IP self-assessment tool (IPSAT). CONCLUSIONS: The IPSAT is a validated tool shown to be reliable for use with NPs. Testing with other healthcare professionals is suggested. More than 50% of NPs engage in all activities of IP care. Many engage in shared decision making, professional relationship, communication, and partnership or collaboration activities on most work days. Less-common activities were interdependence and collective problem solving including efforts to create role clarity. IMPLICATIONS FOR PRACTICE: It is important to evaluate the everyday use of activities that enhance high-quality care. Awareness and enhanced knowledge of IP care activities such as promoting interdependence, collective problem solving, and ensuring role clarity will improve care quality. The tool results are valuable for practicing NPs and their educators to reflect on practice and advance knowledge to influence purposeful engagement in interprofessional care.

Development of a measure to assess healthcare providers' implementation of patient-centered care.

BACKGROUND: Patient-centered care (PCC) is a vaguely defined element of high-quality care, which precludes its consistent and precise operationalization. A conceptualization of PCC was derived from the literature and guided the development of an instrument to assess implementation of PCC by healthcare providers. The items of the instrument capture specific activities that reflect three components of PCC: holistic, collaborative, and responsive care. This paper reports on the measure's content and construct validity and reliability. METHODS: Content validity was evaluated in a sample of 11 nurse practitioners who rated the relevance of each items' content in reflecting the respective component of PCC. The content validity index (CVI) was estimated. Construct validity and internal consistency reliability were examined in a survey of 149 nurse practitioners employed in acute care institutions, using factor analysis and the KR-20 coefficient, respectively. RESULTS: The CVIs were 100% for the three subscales assessing the holistic, collaborative, and responsive care components of PCC. The items in each subscale loaded on one factor. The KR-20 coefficients were .66, .70, and .42, respectively. Overall, the majority (>70%) of respondents indicated performance of the activities comprising the three components of PCC. LINKING EVIDENCE TO ACTION: The PCC measure demonstrated acceptable psychometric properties. The low variance in responses, which is anticipated for instruments assessing fidelity of intervention implementation, accounts for the low reliability coefficients. Additional testing of the measure's psychometric properties in different groups of healthcare providers is warranted. The measure can be used to monitor healthcare providers' implementation of PCC in their usual practice.

Labour saver or building a cohesive interprofessional team? The role of the nurse practitioner within hospitals.

Nurse practitioners (NP) are employed within hospital interprofessional (IP) teams in several countries worldwide. There have been some efforts to describe the nature of the NP role within IP teams largely focussing on how the role may augment care processes. Here, using a constructivist grounded theory approach, the perceptions of NPs about their role were compared and integrated into a previously published team perspective as the second phase of a larger study. Seventeen hospital-based (HB) NPs across Ontario, Canada, participated in group and individual interviews. The NP perspective substantiated and expanded the previously reported team perspective, resulting in an IP perspective. The three practice foci illustrating role value meaning of this perspective became: evolve NP role and advance the specialty, focus on team working, and hold patient care together. The IP perspective, juxtaposed with an existing contingency approach, revealed that NPs were promoting IP work, predominantly at the collaboration and teamwork levels, and aiding IP team transitions to appropriate forms of IP work. The practice, "focus on team working"' was strongly related to promoting IP work. The findings were consistent with HB NPs enacting a role in building IP team cohesiveness rather than merely acting as a labour saver. This is the first study to align NP and team understanding of HB NP role value using an IP framework.

Hospital-based nurse practitioner roles and interprofessional practice: a scoping review.

This scoping review provides current global understanding of the rapidly evolving nurse practitioner role within hospital settings, and considers the level of understanding of its enactment within interprofessional teamwork. Arksey and O'Malley's framework was used to explore recent primary research, reviews, and gray literature in two ways. First, hospital-based nurse practitioner literature was mapped to country of origin, and thematically summarized. Second, clearly developed and consistently defined key interprofessional concepts were identified in the interprofessional literature then conceptually mapped to the nurse practitioner studies by their operationalization. The nurse practitioner review located 103 abstracts. Twenty-nine, originating from four countries, met the inclusion criteria. The interprofessional concept review identified a total of 137 relevant abstracts, however, only ten met the inclusion criteria. Understanding the nurse practitioner role within hospital teams remains limited due to a small number of countries producing evidence, the lack of nurse practitioner role title standardization hindering consistent knowledgebase development, and limited application and inconsistent operationalization of concepts within nurse practitioner research. Research focused on role enactment is needed to understand the uniqueness of the hospital-based nurse practitioner role.

The value of the hospital-based nurse practitioner role: development of a team perspective framework.

There is a need to understand nurse practitioner (NP) interprofessional practice within hospital teams to inform effective role integration and evolution. To begin this understanding a supplementary analysis of 30 hospital team member focus groups was carried out using constructivist grounded theory methodology. This conceptual rendering of the team members' shared perspective of NP actions provides insight into the meaning and importance of the NP role. Participants emphasized three hospital-based (HB) NP practice foci as the meaning of role value; easing others' workload, holding patient care together and evolving practice. Trust emerged as a pre-requisite condition for HB NP role efficacy. A team member perspective framework of HB NP practice is presented as the first stage in developing a model of HB NP interprofessional practice within hospitals. The framework provides multiple perspectives to the meaning and value of the HB NP role beyond basic role description. The framework may be used by healthcare professionals, operational leaders, academia and HB NPs to enhance role respect and understanding.

The role of nurse practitioners in hospital settings: implications for interprofessional practice.

Expansion of the nurse practitioner (NP) role worldwide indicates a need to understand how the role functions in interprofessional healthcare teams. Through the adoption of a mixed methods approach that gathered on-site tracking and observation, self-recorded logs of consultations and focus group interviews of team members and NPs, we describe the extent of role activity and the nature of interprofessional practices of 46 NPs and their team members in nine hospital sites across the province of Ontario, Canada. Findings outline the nature of the NP role activities, which largely focused on providing clinical care, with the support of their team, to a range of patients across the study settings. We discuss how 'embedding' the NP in this way appears to contribute to utilization of expertise of all professions as well as enabling team members to promote evidence-based practices. We argue that the use of NPs augments interprofessional role utilization through their desire to consult with a range of professionals and the capacity to perform holistic care for patients that is not limited to traditional nursing boundaries.

The primary healthcare nurse practitioner in Ontario: a workforce study.

The role of the primary healthcare nurse practitioner (NP-PHC) has a long history in Ontario. In this paper, we describe the evolution of the role with a focus on geographic distribution, a profile of client populations and the services provided by NP-PHCs. Comparisons will be made to findings from previous studies and reports on the NP-PHC role in Ontario. In 2004 and 2005, two-thirds of the nurse practitioners registered with the College of Nurses of Ontario responded to a descriptive self-reporting survey. The data collected revealed that NP-PHCs work throughout the healthcare system, including with underserviced and marginalized populations, in community health centres and in outpatient areas within acute care hospitals. They provide the entire spectrum of primary healthcare services. Barriers to fully enacting the role are related to restrictive legislation that limits NP prescribing and diagnosing, and the ability to work to full scope of practice in hospitals (for example, in emergency departments). Targeted funding has promoted the role throughout the province. However, inadequate and insecure pilot funding continues to be a concern. Findings from this study indicate that policy decisions to support the NP role in rural and remote areas have resulted in expansion of the role across the province. Yet, NPs perceive that legislation has lagged and inhibits their ability to meet patient and health systems needs.

The acute care nurse practitioner in Ontario: a workforce study.

In spite of the long history of nurse practitioner practice in primary healthcare, less is known about nurse practitioners in hospital-based environments because until very recently, they have not been included in the extended class registration (nurse practitioner equivalent) with the College of Nurses of Ontario. Recent changes in the regulation of nurse practitioners in Ontario to include adult, paediatric and anaesthesia, indicates that a workforce review of practice profiles is needed to fully understand the depth and breadth of the role within hospital settings. Here, we present information obtained through a descriptive, self-reported survey of all nurse practitioners working in acute care settings who are not currently regulated in the extended class in Ontario. Results suggest wide acceptance of the role is concentrated around academic teaching hospitals. Continued barriers exist related to legislation and regulation as well as understanding and support for the multiple aspects of this role beyond clinical practice. This information may be used by nurse practitioners, nursing leaders and other administrators to position the role in hospital settings for greater impact on patient care. As well, understanding the need for regulatory and legislative changes to support the hospital-based Nurse Practitioner role will enable greater impact on health human resources and healthcare transformation.

Primary healthcare renewal in Canada: a glass half empty?

Primary healthcare renewal was an important government initiative arising in the early 21st century. This sector of the healthcare system in Canada had been under-resourced and ignored for decades. Recent changes include the development of salaried models for physician care, the use of other professionals in primary care, the integration of inter-professional teams, funding for information management systems and some incentives to provide directed primary care services. However, these changes are limited by a lack of overall policy direction to drive innovation, the absence of a shift in the locus of control of healthcare, a lack of education for healthcare providers to support inter-professional team-based practices and a failure to be more accountable to the Canadian public's needs. Without these innovations, the primary healthcare system will again be overwhelmed by future healthcare needs. Based on these limitations, we question whether this renewal represents lasting change in primary healthcare or a band-aid solution to the continued issue of primary healthcare delivery.

Impact of the opening of a specialized cardiac surgery recovery unit on postoperative outcomes in an academic health sciences centre.

PURPOSE: It is controversial as to whether cardiac surgery patients are optimally managed in a mixed medical-surgical intensive care unit (ICU) or in a specialized postoperative unit. We conducted a prospective cohort study in an academic health sciences centre to compare outcomes before and following the opening of a specialized cardiac surgery recovery unit (CSRU) in April 2005. METHODS: The study cohort included 2,599 consecutive patients undergoing coronary artery bypass grafting (CABG), valve and combined CABG-valve procedures from April 2004 to March 2006. From April 2004 to March 2005 (year 1) all patients received postoperative care in mixed medical-surgical ICUs at two different sites staffed by critical care consultants, fellows and residents. From April 2005 until March 2006 (year 2) patients were cared for in a newly-established CSRU on one site staffed by cardiac anesthesiology fellows, a nurse practitioner and consultants in critical care, cardiac anesthesiology and cardiac surgery. The effect of this change on in-hospital mortality, the incidence of ten major postoperative complications, postoperative ventilation hours, readmission rates and case cancellations due to a lack of capacity was assessed using Chi-square or Wilcoxon tests, where appropriate. RESULTS: Coronary artery bypass grafting, valve and combined CABG-valve mortality rates were similar in years 1 and 2. There was a significant reduction in the composite major complication rate (16.3% to 13.0%, P=0.02) and in median postoperative ventilation hours (8.8 vs 8.0 hr, P=0.005) from year 1 to 2. On multivariable logistic regression analysis, the pre-merger interval (year 1) was a significant independent predictor of the occurrence of death or major complications. CONCLUSION: A specialized CSRU with a multi-disciplinary consultant model was associated with stable or improved outcomes postoperatively, when compared to a mixed medical- surgical ICU model of cardiac surgical care.

Knot-So-Fast: a learning plan to minimize patient restraint in critical care.

In 2001, new legislation in Ontario, the Patient Restraint Minimization Act, mandated that all hospitals develop a policy to minimize the use of restraints. Since restraining patients was a common practice in our intensive care unit (ICU), a practice change was necessary. To do this, a learning plan was created to share key information pertaining to the Act that would support humane and dignified care for our critically ill patients. Change was accomplished through a survey of nursing staff to establish learning needs, the development of a learning plan titled "Knot-So-Fast", and the creation of a tool titled the "Restraint Decision Wheel" to support staff in making restraint decisions quickly and appropriately. To measure the effect of our Knot-So-Fast learning plan, the staff was resurveyed one year later. Results showed there was a statistically significant decrease in restraint use in our ICU. The learning plan and tools developed have been found to be adaptable to other hospital units and are provided. This article includes the educational content and methods used in our ICU to effect a change in restraint practice. Tools, such as a nursing survey and a decision wheel, developed to enhance learning are also included.