Response and innovations of advanced practice nurses during the COVID-19 pandemic: A scoping review.

AIM: Identify and map international evidence regarding innovations led by or involving advanced practice nurses in response to COVID-19. BACKGROUND: COVID-19 necessitated unprecedented innovation in the organization and delivery of healthcare. Although advanced practice nurses have played a pivotal role during the pandemic, evidence of their contributions to innovations has not been synthesized. Evidence is needed to inform policies, practices, and research about the optimal use of advanced practice nurses. METHODS: A scoping review was conducted and reported using the PRISMA-ScR checklist. Electronic databases were searched for peer-reviewed articles published between January 2020 and December 2021. Papers were included that focused on innovations emerging in response to COVID-19 and involved advanced practice nurses. RESULTS: Fifty-one articles were included. Four themes were identified including telehealth, supporting and transforming care, multifaceted approaches, and provider education. Half of the articles used brief and mostly noncomparative approaches to evaluate innovations. CONCLUSION: This is the first synthesis of international evidence examining the contributions of advanced practice nurses during the pandemic. Advanced practice nurses provided leadership for the innovation needed to rapidly respond to healthcare needs resulting from COVID-19. Innovations challenged legislative restrictions on practice, enabled implementation of telehealth and new models of care, and promoted evidence-informed and patient-centered care. IMPLICATIONS FOR PRACTICE: Advanced practice nurses led, designed, implemented, and evaluated innovations in response to COVID-19. They facilitated the use of telehealth, supported or transformed models of care, and enabled health providers through education, mentorship, and mental health support. IMPLICATION FOR POLICY: Advanced practice nurses are a critical resource for innovation and health system improvement. Permanent removal of legislative and regulatory barriers to their full scope of practice is needed.

Effectiveness of registered nurses on patient outcomes in primary care: a systematic review.

BACKGROUND: Globally, registered nurses (RNs) are increasingly working in primary care interdisciplinary teams. Although existing literature provides some information about the contributions of RNs towards outcomes of care, further evidence on RN workforce contributions, specifically towards patient-level outcomes, is needed. This study synthesized evidence regarding the effectiveness of RNs on patient outcomes in primary care. METHODS: A systematic review was conducted in accordance with Joanna Briggs Institute methodology. A comprehensive search of databases (CINAHL, MEDLINE Complete, PsycINFO, Embase) was performed using applicable subject headings and keywords. Additional literature was identified through grey literature searches (ProQuest Dissertations and Theses, MedNar, Google Scholar, websites, reference lists of included articles). Quantitative studies measuring the effectiveness of a RN-led intervention (i.e., any care/activity performed by a primary care RN) that reported related outcomes were included. Articles were screened independently by two researchers and assessed for bias using the Integrated Quality Criteria for Review of Multiple Study Designs tool. A narrative synthesis was undertaken due to the heterogeneity in study designs, RN-led interventions, and outcome measures across included studies. RESULTS: Forty-six patient outcomes were identified across 23 studies. Outcomes were categorized in accordance with the PaRIS Conceptual Framework (patient-reported experience measures, patient-reported outcome measures, health behaviours) and an additional category added by the research team (biomarkers). Primary care RN-led interventions resulted in improvements within each outcome category, specifically with respect to weight loss, pelvic floor muscle strength and endurance, blood pressure and glycemic control, exercise self-efficacy, social activity, improved diet and physical activity levels, and reduced tobacco use. Patients reported high levels of satisfaction with RN-led care. CONCLUSIONS: This review provides evidence regarding the effectiveness of RNs on patient outcomes in primary care, specifically with respect to satisfaction, enablement, quality of life, self-efficacy, and improvements in health behaviours. Ongoing evaluation that accounts for primary care RNs' unique scope of practice and emphasizes the patient experience is necessary to optimize the delivery of patient-centered primary care. PROTOCOL REGISTRATION ID: PROSPERO: International Prospective Register of Systematic Reviews. 2018. ID=CRD42 018090767 .

Effectiveness of registered nurses on system outcomes in primary care: a systematic review.

BACKGROUND: Internationally, policy-makers and health administrators are seeking evidence to inform further integration and optimal utilization of registered nurses (RNs) within primary care teams. Although existing literature provides some information regarding RN contributions, further evidence on the impact of RNs towards quality and cost of care is necessary to demonstrate the contribution of this role on health system outcomes. In this study we synthesize international evidence on the effectiveness of RNs on care delivery and system-level outcomes in primary care. METHODS: A systematic review was conducted in accordance with Joanna Briggs Institute methodology. Searches were conducted in CINAHL, MEDLINE Complete, PsycINFO, and Embase for published literature and ProQuest Dissertations and Theses and MedNar for unpublished literature between 2019 and 2022 using relevant subject headings and keywords. Additional literature was identified through Google Scholar, websites, and reference lists of included articles. Studies were included if they measured effectiveness of a RN-led intervention (i.e., any care/activity performed by a primary care RN within the context of an independent or interdependent role) and reported outcomes of these interventions. Included studies were published in English; no date or location restrictions were applied. Risk of bias was assessed using the Integrated Quality Criteria for Review of Multiple Study Designs tool. Due to the heterogeneity of included studies, a narrative synthesis was undertaken. RESULTS: Seventeen articles were eligible for inclusion, with 11 examining system outcomes (e.g., cost, workload) and 15 reporting on outcomes related to care delivery (e.g., illness management, quality of smoking cessation support). The studies suggest that RN-led care may have an impact on outcomes, specifically in relation to the provision of medication management, patient triage, chronic disease management, sexual health, routine preventative care, health promotion/education, and self-management interventions (e.g. smoking cessation support). CONCLUSIONS: The findings suggest that primary care RNs impact the delivery of quality primary care, and that RN-led care may complement and potentially enhance primary care delivered by other primary care providers. Ongoing evaluation in this area is important to further refine nursing scope of practice policy, determine the impact of RN-led care on outcomes, and inform improvements to primary care infrastructure and systems management to meet care needs. PROTOCOL REGISTRATION ID: PROSPERO: International prospective register of systematic reviews. 2018. ID= CRD42018090767 .

Nurses who work in rural and remote communities in Canada: a national survey.

BACKGROUND: In Canada, as in other parts of the world, there is geographic maldistribution of the nursing workforce, and insufficient attention is paid to the strengths and needs of those providing care in rural and remote settings. In order to inform workforce planning, a national study, Nursing Practice in Rural and Remote Canada II, was conducted with the rural and remote regulated nursing workforce (registered nurses, nurse practitioners, licensed or registered practical nurses, and registered psychiatric nurses) with the intent of informing policy and planning about improving nursing services and access to care. In this article, the study methods are described along with an examination of the characteristics of the rural and remote nursing workforce with a focus on important variations among nurse types and regions. METHODS: A cross-sectional survey used a mailed questionnaire with persistent follow-up to achieve a stratified systematic sample of 3822 regulated nurses from all provinces and territories, living outside of the commuting zones of large urban centers and in the north of Canada. RESULTS: Rural workforce characteristics reported here suggest the persistence of key characteristics noted in a previous Canada-wide survey of rural registered nurses (2001-2002), namely the aging of the rural nursing workforce, the growth in baccalaureate education for registered nurses, and increasing casualization. Two thirds of the nurses grew up in a community of under 10 000 people. While nurses' levels of satisfaction with their nursing practice and community are generally high, significant variations were noted by nurse type. Nurses reported coming to rural communities to work for reasons of location, interest in the practice setting, and income, and staying for similar reasons. Important variations were noted by nurse type and region. CONCLUSIONS: The proportion of the rural nursing workforce in Canada is continuing to decline in relation to the proportion of the Canadian population in rural and remote settings. Survey results about the characteristics and practice of the various types of nurses can support workforce planning to improve nursing services and access to care.

Community health nurses' learning needs in relation to the Canadian community health nursing standards of practice: results from a Canadian survey.

BACKGROUND: CANADIAN COMMUNITY HEALTH NURSES (CHNS) WORK IN DIVERSE URBAN, RURAL, AND REMOTE SETTINGS SUCH AS: public health units/departments, home health, community health facilities, family practices, and other community-based settings. Research into specific learning needs of practicing CHNs is sparsely reported. This paper examines Canadian CHNs learning needs in relation to the 2008 Canadian Community Health Nursing Standards of Practice (CCHN Standards). It answers: What are the learning needs of CHNs in Canada in relation to the CCHN Standards? What are differences in CHNs' learning needs by: province and territory in Canada, work setting (home health, public health and other community health settings) and years of nursing practice? METHODS: Between late 2008 and early 2009 a national survey was conducted to identify learning needs of CHNs based on the CCHN Standards using a validated tool. RESULTS: Results indicated that CHNs had learning needs on 25 of 88 items (28.4%), suggesting CHNs have confidence in most CCHN Standards. Three items had the highest learning needs with mean scores > 0.60: two related to epidemiology (means 0.62 and 0.75); and one to informatics (application of information and communication technology) (mean = 0.73). Public health nurses had a greater need to know about "…evaluating population health promotion programs systematically" compared to home health nurses (mean 0.66 vs. 0.39, p <0.010). Nurses with under two years experience had a greater need to learn "… advocating for healthy public policy…" than their more experienced peers (p = 0.0029). Also, NPs had a greater need to learn about "…using community development principles when engaging the individual/community in a consultative process" compared to RNs (p = 0.05). Many nurses were unsure if they applied foundational theoretical frameworks (i.e., the Ottawa Charter of Health Promotion, the Jakarta Declaration, and the Population Health Promotion Model) in practice. CONCLUSIONS: CHN educators and practice leaders need to consider these results in determining where to strengthen content in graduate and undergraduate nursing programs, as well as professional development programs. For practicing CHNs educational content should be tailored based on learner's years of experience in the community and their employment sector.

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.

Nurse Retention: Multiple Strategies to Change Course in a Sea of Challenges.

Like the Canadian season of spring, this issue brings fresh ideas and insights about the layers of complexity and potential solutions to the significant challenges associated with the retention of the nursing workforce. As these challenges intensify, nursing leaders - formal and informal - are rallying to redefine the boundaries of what can be done. We are innovators who are transforming this crisis into an opportunity to shift our thinking and do things differently. We are optimizing our roles and expanding our deployment to areas of the system that have previously underutilized nurses and nurse practitioners. The value we bring to the health system is indisputable.

Retention of Canadian Advanced Practice Nurses: What Will It Take?

The retention of Canada's advanced practice nurses (APNs), including clinical nurse specialists and nurse practitioners, is a national health human resources issue. APNs are essential within the Canadian healthcare workforce for meeting patient and population health needs, often in underserved communities. A shortage of APNs will exacerbate barriers to access to care for patients across sectors, including primary, acute, long-term and transitional care settings. This paper provides highlights from literature reporting on the state of APN human resources in Canada, including influential barriers and facilitators, and recommendations for retaining these important leaders in the healthcare workforce.

Understanding and addressing changing administrative workload in primary care in Canada: protocol for a mixed-method study.

INTRODUCTION: Many Canadians struggle to access the primary care they need while at the same time primary care providers report record levels of stress and overwork. There is an urgent need to understand factors contributing to the gap between a growing per-capita supply of primary care providers and declines in the availability of primary care services. The assumption of responsibility by primary care teams for services previously delivered on an in-patient basis, along with a rise in administrative responsibilities may be factors influencing reduced access to care. METHODS AND ANALYSIS: In this mixed-methods study, our first objective is to determine how the volume of services requiring primary care coordination has changed over time in the Canadian provinces of Nova Scotia and New Brunswick. We will collect quantitative administrative data to investigate how services have shifted in ways that may impact administrative workload in primary care. Our second objective is to use qualitative interviews with family physicians, nurse practitioners and administrative team members providing primary care to understand how administrative workload has changed over time. We will then identify priority issues and practical response strategies using two deliberative dialogue events convened with primary care providers, clinical and system leaders, and policy-makers.We will analyse changes in service use data between 2001/2002 and 2021/2022 using annual total counts, rates per capita, rates per primary care provider and per primary care service. We will conduct reflexive thematic analysis to develop themes and to compare and contrast participant responses reflecting differences across disciplines, payment and practice models, and practice settings. Areas of concern and potential solutions raised during interviews will inform deliberative dialogue events. ETHICS AND DISSEMINATION: We received research ethics approval from Nova Scotia Health (#1028815). Knowledge translation will occur through dialogue events, academic papers and presentations at national and international conferences.

Out-of-pocket expenses related to aging in place for frail older people: a scoping review protocol.

OBJECTIVE: The objective of this scoping review is to describe the available evidence reporting out-of-pocket expenses for aging-in-place for frail older people and their caregivers. INTRODUCTION: There has been an increased focus on supporting frail older people to live in the community, rather than in costly long-term residential care. The out-of-pocket expenses associated with supporting older people with frailty to remain in their homes and communities contribute to caregiver burden and can influence decisions about where to live. INCLUSION CRITERIA: This scoping review will consider literature on community-dwelling older people 60 years and older who have been identified as frail. Research and policy papers that report the out-of-pocket expenses incurred by older people with frailty or by their family or friend caregivers to support aging well at home will be included. Studies in English will be considered with no date restriction. METHODS: The search strategy aims to find both published and unpublished literature (e.g. policy papers, theses and dissertations). Search databases include CINAHL, PubMed, Scopus, Embase, PsycINFO, Sociological Abstracts, and Public Affairs Index, as well as databases of unpublished sources. The language will be limited to English or French. Title and abstract screening, as well as full-text screening, will be completed by two reviewers. Data will be charted to describe the body of literature focusing on elements such as type of literature, methods used, setting and out-of-pocket expenses. Data will be presented graphically when possible, and accompanied by a narrative that describes the characteristics of the body of literature.

Describing the leadership capabilities of advanced practice nurses using a qualitative descriptive study.

AIM: The aim of this study is to explore advanced practice nurses' perceptions of their leadership capabilities. DESIGN: A qualitative descriptive methodology informed by a well-established leadership framework was used to explore advanced practice nurses' perceptions of their leadership. METHODS: Purposive sampling of advanced practice nurses working in tertiary acute care facilities in Eastern Canada was employed. Data sources included face-to-face interviews and document analysis. Fourteen advanced practice nurses participated in two audio-taped semi-structured interviews from March 2013-January 2014. Data were transcribed and analysed using NVIVO 10 software and content analysis. RESULTS: Two main themes were identified: "Patient-focused leadership" and "organization and system-focused leadership". These two themes are further described through leadership domains and capabilities that clearly articulate advanced practice nursing leadership and its contribution to improving the care environment for patients and families, nurses and other healthcare providers, organizations and the healthcare system.

Drug information resources used by nurse practitioners and collaborating physicians at the point of care in Nova Scotia, Canada: a survey and review of the literature.

BACKGROUND: Keeping current with drug therapy information is challenging for health care practitioners. Technologies are often implemented to facilitate access to current and credible drug information sources. In the Canadian province of Nova Scotia, legislation was passed in 2002 to allow nurse practitioners (NPs) to practice collaboratively with physician partners. The purpose of this study was to determine the current utilization patterns of information technologies by these groups of practitioners. METHODS: Nurse practitioners and their collaborating physician partners in Nova Scotia were sent a survey in February 2005 to determine the frequency of use, usefulness, accessibility, credibility, and current/timeliness of personal digital assistant (PDA), computer, and print drug information resources. Two surveys were developed (one for PDA users and one for computer users) and revised based on a literature search, stakeholder consultation, and pilot-testing results. A second distribution to nonresponders occurred two weeks following the first. Data were entered and analysed with SPSS. RESULTS: Twenty-seven (14 NPs and 13 physicians) of 36 (75%) recipients responded. 22% (6) returned personal digital assistant (PDA) surveys. Respondents reported print, health professionals, and online/electronic resources as the most to least preferred means to access drug information, respectively. 37% and 35% of respondents reported using "both print and electronic but print more than electronic" and "print only", respectively, to search monograph-related drug information queries whereas 4% reported using "PDA only". Analysis of respondent ratings for all resources in the categories print, health professionals and other, and online/electronic resources, indicated that the Compendium of Pharmaceuticals and Specialties and pharmacists ranked highly for frequency of use, usefulness, accessibility, credibility, and current/timeliness by both groups of practitioners. Respondents' preferences and resource ratings were consistent with self-reported methods for conducting drug information queries. Few differences existed between NP and physician rankings of resources. CONCLUSION: The use of computers and PDAs remains limited, which is also consistent with preferred and frequent use of print resources. Education for these practitioners regarding available electronic drug information resources may facilitate future computer and PDA use. Further research is needed to determine methods to increase computer and PDA use and whether these technologies affect prescribing and patient outcomes.

Nurse practitioner caseload in primary health care: Scoping review.

OBJECTIVES: To identify recommendations for determining patient panel/caseload size for nurse practitioners in community-based primary health care settings. DESIGN: Scoping review of the international published and grey literature. DATA SOURCES: The search included electronic databases, international professional and governmental websites, contact with experts, and hand searches of reference lists. Eligible papers had to (a) address caseload or patient panels for nurse practitioners in community-based primary health care settings serving an all-ages population; and (b) be published in English or French between January 2000 and July 2014. Level one testing included title and abstract screening by two team members. Relevant papers were retained for full text review in level two testing, and reviewed by two team members. A third reviewer acted as a tiebreaker. Data were extracted using a structured extraction form by one team member and verified by a second member. Descriptive statistics were estimated. Content analysis was used for qualitative data. RESULTS: We identified 111 peer-reviewed articles and grey literature documents. Most of the papers were published in Canada and the United States after 2010. Current methods to determine panel/caseload size use large administrative databases, provider work hours and the average number of patient visits. Most of the papers addressing the topic of patient panel/caseload size in community-based primary health care were descriptive. The average number of patients seen by nurse practitioners per day varied considerably within and between countries; an average of 9-15 patients per day was common. Patient characteristics (e.g., age, gender) and health conditions (e.g., multiple chronic conditions) appear to influence patient panel/caseload size. Very few studies used validated tools to classify patient acuity levels or disease burden scores. DISCUSSION: The measurement of productivity and the determination of panel/caseload size is complex. Current metrics may not capture activities relevant to community-based primary health care nurse practitioners. Tools to measure all the components of these role are needed when determining panel/caseload size. Outcomes research is absent in the determination of panel/caseload size. CONCLUSION: There are few systems in place to track and measure community-based primary health care nurse practitioner activities. The development of such mechanisms is an important next step to assess community-based primary health care nurse practitioner productivity and determine patient panel/caseload size. Decisions about panel/caseload size must take into account the effects of nurse practitioner activities on outcomes of care.

A systematic review of the cost-effectiveness of nurse practitioners and clinical nurse specialists: what is the quality of the evidence?

Background. Improved quality of care and control of healthcare costs are important factors influencing decisions to implement nurse practitioner (NP) and clinical nurse specialist (CNS) roles. Objective. To assess the quality of randomized controlled trials (RCTs) evaluating NP and CNS cost-effectiveness (defined broadly to also include studies measuring health resource utilization). Design. Systematic review of RCTs of NP and CNS cost-effectiveness reported between 1980 and July 2012. Results. 4,397 unique records were reviewed. We included 43 RCTs in six groupings, NP-outpatient (n = 11), NP-transition (n = 5), NP-inpatient (n = 2), CNS-outpatient (n = 11), CNS-transition (n = 13), and CNS-inpatient (n = 1). Internal validity was assessed using the Cochrane risk of bias tool; 18 (42%) studies were at low, 17 (39%) were at moderate, and eight (19%) at high risk of bias. Few studies included detailed descriptions of the education, experience, or role of the NPs or CNSs, affecting external validity. Conclusions. We identified 43 RCTs evaluating the cost-effectiveness of NPs and CNSs using criteria that meet current definitions of the roles. Almost half the RCTs were at low risk of bias. Incomplete reporting of study methods and lack of details about NP or CNS education, experience, and role create challenges in consolidating the evidence of the cost-effectiveness of these roles.