Implementing primary healthcare nurse practitioners in long-term care teams: A qualitative descriptive study.

AIM: To identify the conditions needed to implement nurse practitioners (NP) in long-term care (LTC) in Québec, Canada. DESIGN: A qualitative descriptive study was undertaken. METHODS: Semi-structured interviews (N = 91) and socio-demographic questionnaires were completed with providers and managers from May 2016-March 2017. Nurse practitioner activity logs were compiled at three sites. Content analysis was used. RESULTS: All sites initially implemented a shared care model but not all sites successfully implemented a consultative model. The progression was influenced by physicians' level of comfort in moving towards a consultative model. Weekly meetings with physicians and nurse managers and an office for NPs located near healthcare teams facilitated communication and improved implementation. Half-time NP positions facilitated recruitment. Improvements were noted in timely care for residents, family involvement and quality of documentation of the healthcare team. Regulatory restrictions on prescribing medications used frequently in LTC and daily physician presence at some sites limited implementation. CONCLUSION: The project fostered an understanding of the conditions needed to successfully implement NPs in LTC. An examination of the perspective of residents and families is needed.

Cost-effectiveness of a nurse practitioner-family physician model of care in a nursing home: controlled before and after study.

AIMS: To examine the cost-effectiveness of a nurse practitioner-family physician model of care compared with family physician-only care in a Canadian nursing home. BACKGROUND: As demand for long-term care increases, alternative care models including nurse practitioners are being explored. DESIGN: Cost-effectiveness analysis using a controlled before-after design. METHODS: The study included an 18-month 'before' period (2005-2006) and a 21-month 'after' time period (2007-2009). Data were abstracted from charts from 2008-2010. We calculated incremental cost-effectiveness ratios comparing the intervention (nurse practitioner-family physician model; n = 45) to internal (n = 65), external (n = 70) and combined internal/external family physician-only control groups, measured as the change in healthcare costs divided by the change in emergency department transfers/person-month. We assessed joint uncertainty around costs and effects using non-parametric bootstrapping and cost-effectiveness acceptability curves. RESULTS: Point estimates of the incremental cost-effectiveness ratio demonstrated the nurse practitioner-family physician model dominated the internal and combined control groups (i.e. was associated with smaller increases in costs and emergency department transfers/person-month). Compared with the external control, the intervention resulted in a smaller increase in costs and larger increase in emergency department transfers. Using a willingness-to-pay threshold of $1000 CAD/emergency department transfer, the probability the intervention was cost-effective compared with the internal, external and combined control groups was 26%, 21% and 25%. CONCLUSION: Due to uncertainty around the distribution of costs and effects, we were unable to make a definitive conclusion regarding the cost-effectiveness of the nurse practitioner-family physician model; however, these results suggest benefits that could be confirmed in a larger study.

Positioning clinical nurse specialists and nurse practitioners as change champions to implement a pain protocol in long-term care.

Pain management for older adults in long-term care (LTC) has been recognized as a problem internationally. The purpose of this study was to explore the role of a clinical nurse specialist (CNS) and nurse practitioner (NP) as change champions during the implementation of an evidence-based pain protocol in LTC. In this exploratory, multiple-case design study, we collected data from two LTC homes in Ontario, Canada. Three data sources were used: participant observation of an NP and a CNS for 18 hours each over a 3-week period; CNS and NP diaries recording strategies, barriers, and facilitators to the implementation process; and interviews with members of the interdisciplinary team to explore perceptions about the NP and CNS role in implementing the pain protocol. Data were analyzed using thematic content analysis. The NP and CNS used a variety of effective strategies to promote pain management changes in practice including educational outreach with team members, reminders to nursing staff to highlight the pain protocol and educate about practice changes, chart audits and feedback to the nursing staff, interdisciplinary working group meetings, ad hoc meetings with nursing staff, and resident assessment using advanced skills. The CNS and NP are ideal champions to implement pain management protocols and likely other quality improvement initiatives.

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.

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.

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.

A systematic review of the effectiveness of advanced practice nurses in long-term care.

AIM: To report quantitative evidence of the effectiveness of advanced practice nursing roles, clinical nurse specialists and nurse practitioners, in meeting the healthcare needs of older adults living in long-term care residential settings. BACKGROUND: Although studies have examined the effectiveness of advanced practice nurses in this setting, a systematic review of this evidence has not been conducted. DESIGN: Quantitative systematic review. DATA SOURCES: Twelve electronic databases were searched (1966-2010); leaders in the field were contacted; and personal files, reference lists, pertinent journals, and websites were searched for prospective studies with a comparison group. REVIEW METHODS: Studies that met inclusion criteria were reviewed for quality, using a modified version of the Cochrane Effective Practice and Organisation of Care Review Group risk of bias assessment criteria. RESULTS: Four prospective studies conducted in the USA and reported in 15 papers were included. Long-term care settings with advanced practice nurses had lower rates of depression, urinary incontinence, pressure ulcers, restraint use, and aggressive behaviours; more residents who experienced improvements in meeting personal goals; and family members who expressed more satisfaction with medical services. CONCLUSION: Advanced practice nurses are associated with improvements in several measures of health status and behaviours of older adults in long-term care settings and in family satisfaction. Further exploration is needed to determine the effect of advanced practice nurses on health services use; resident satisfaction with care and quality of life; and the skills, quality of care, and job satisfaction of healthcare staff.

Effect of provider and patient reminders, deployment of nurse practitioners, and financial incentives on cervical and breast cancer screening rates.

OBJECTIVE: To evaluate the effect of the Provider and Patient Reminders in Ontario: Multi-Strategy Prevention Tools (P-PROMPT) reminder and recall system and pay-for-performance incentives on the delivery rates of cervical and breast cancer screening in primary care practices in Ontario, with or without deployment of nurse practitioners (NPs). DESIGN: Before-and-after comparisons of the time-appropriate delivery rates of cervical and breast cancer screening using the automated and NP-augmented strategies of the P-PROMPT reminder and recall system. SETTING: Southwestern Ontario. PARTICIPANTS: A total of 232 physicians from 24 primary care network or family health network groups across 110 different sites eligible for pay-for-performance incentives. INTERVENTIONS: The P-PROMPT project combined pay-for-performance incentives with provider and patient reminders and deployment of NPs to enhance the delivery of preventive care services. MAIN OUTCOME MEASURES: The mean delivery rates at the practice level of time-appropriate mammograms and Papanicolaou tests completed within the previous 30 months. RESULTS: Before-and-after comparisons of time-appropriate delivery rates (< 30 months) of cancer screening showed the rates of Pap tests and mammograms for eligible women significantly increased over a 1-year period by 6.3% (P < .001) and 5.3% (P < .001), respectively. The NP-augmented strategy achieved comparable rate increases to the automated strategy alone in the delivery rates of both services. CONCLUSION: The use of provider and patient reminders and pay-for-performance incentives resulted in increases in the uptake of Pap tests and mammograms among eligible primary care patients over a 1-year period in family practices in Ontario.

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.

Practice Patterns of Nurse Practitioners in a Multi-Site Academic Healthcare Setting.

OBJECTIVE: The objective of this paper is to describe the day-to-day activities, known as practice patterns, of nurse practitioners (NPs) across a four-site academic healthcare network in Ontario, which comprises acute, primary, rehabilitation and complex continuing care. BACKGROUND: Information regarding NP practice patterns is available from other jurisdictions and practice settings, but information specific to large, urban and multi-site organizations is available to a lesser extent. This information can inform and support leaders' decisions about NP roles and responsibilities. METHOD: A cross-sectional online survey was sent to the 125 NPs employed in this healthcare network. RESULTS: Respondents (n = 45) were primarily experienced, graduate-prepared NPs, who work with specialized populations and support the education of healthcare professional trainees. The majority of these NPs' activities focused on direct and indirect care, with fewer activities centred on leadership/administration, education, research and personal breaks. Clinical care activities varied among NPs and were contextual to the population and program. CONCLUSION: While direct and indirect care are vital components of NP practice, the overwhelming emphasis on these components indicates that the organization and the healthcare system are losing opportunities to capitalize on advanced nursing practice knowledge and skills in the domains of leadership, research and education.

The nurse practitioner role in pain management in long-term care.

AIM: This paper is a report of a study exploring the perceptions of long-term care team members and nurse managers about barriers and facilitators to optimal use of nurse practitioners to manage residents' pain in long-term care settings. BACKGROUND: Considering the high rates of pain in long-term care, research is needed to explore innovations in health-services delivery, including the emerging nurse practitioner role. METHODS: For this study, an exploratory descriptive design was used to collect data in spring 2007 from five focus groups of nurses and 14 individual interviews with other healthcare team members and nurse managers. Data were analysed using thematic content analysis. FINDINGS: Five pain management activities performed by nurse practitioners were identified, including assessing pain, prescribing pain medications, monitoring pain levels and side effects of pain medications, consulting and advocating for staff and patients, and leading and educating staff related to pain management. Factors that influenced the implementation of the nurse practitioner role included the availability of the nurse practitioner, scope of practice, role clarity, perceived added value of nurse practitioner role, terms of employment, nurse practitioner-physician relationship. Perceived outcomes of the nurse practitioner role were also described. CONCLUSIONS: The findings from this study contribute to our understanding of how the nurse practitioner role is perceived by other healthcare professionals, particularly in pain management. Stronger interprofessional collaborative relationships need to be facilitated within a model of care that includes a nurse practitioner, with the ultimate goal of improving pain management services in long-term care.

An action-based approach to improving pain management in long-term care.

PURPOSE: The study purposes were twofold: (1) to explore barriers to pain management and those associated with implementing a pain management program in long-term care (LTC); and (2) to develop an interprofessional approach to improve pain management in LTC. METHODS: A case study approach included both qualitative and quantitative components. We collected data at two LTC sites using seven focus groups for the licensed nurses, unregulated care providers and physicians, and 10 interviews with other health care provider groups, administration, and residents. We reviewed documents and administered a short survey to study participants to assess perceptions of barriers to pain management. RESULTS: The findings revealed barriers to effective LTC pain management at the resident/family, health care provider, and system levels. We then developed a six-tiered model with proposed interventions to address these barriers. CONCLUSIONS: This model can guide the development of innovative approaches to improving pain management in LTC settings.

Nurse Practitioner Activities in Ontario Family Health Teams: Comparing Three Different Data Sources.

BACKGROUND: Despite the increase in nurse practitioners (NPs) working in primary healthcare, little standardized data are available to understand NP activities at the system level. The Nurse Practitioner Access Reporting system (NPAR), a pilot project underway at 40 family health teams in Ontario, involves NPs recording and submitting standardized codes. The codes are intended to reflect NPs' clinical activities, using an existing physician claim system. The study compared how well data collected through NPAR reflect NPs' activities. METHODS: The mixed-methods approach was used involving NPAR data, focus groups and time and motion data. RESULTS: All data sources indicated that NPs spent the majority of their time on direct patient care. Qualitative data and time and motion data revealed gaps in NPAR data, for example, codes that fail to capture activities unique to the NP role. CONCLUSION: Analysis of NPAR, time and motion and qualitative data provided a distinctive opportunity to examine NP-reported activities and patient characteristics; however, NPAR data did not adequately describe the scope or breadth of activities of NPs practising in primary healthcare.

Nurse practitioner and physician collaboration in long-term care homes: survey results.

This survey assessed the extent of and satisfaction with collaboration between physicians and nurse practitioners (NPs) working in Ontario long-term care homes. Questionnaires, which included the Measure of Current Collaboration and Provider Satisfaction with Current Collaboration instruments, were mailed to NPs and physicians with whom the NP most frequently worked. The 14 matched-pairs of NPs and physicians reported similar levels of collaboration; however, physicians were significantly more satisfied with collaboration than were NPs (z = -2.67, p = 0.008). The majority of physicians (85%) and NPs (86%) indicated that collaboration was occurring, and 96 per cent of physicians and 79 per cent of NPs were satisfied with their collaboration. About one third of physicians reported that the NP had a negative effect on their income, but their satisfaction with collaboration did not differ from those who reported a positive effect. Overall, these physicians and NPs collaborate in delivering care and are satisfied with their collaboration.

Patient views on reminder letters for influenza vaccinations in an older primary care patient population: a mixed methods study.

OBJECTIVES: To explore the perspectives of older adults on the acceptability of reminder letters for influenza vaccinations. METHODS: We randomly selected 23 family physicians from each Family Health and Primary Care network participating in a demonstration project designed to increase the delivery of preventive services in Ontario. From the roster of each physician, we surveyed 35 randomly selected patients over 65 years of age who recently received a reminder letter regarding influenza vaccinations from their physician. The questionnaires sought patient perspectives on the acceptability and usefulness of the letter. We also conducted follow-up telephone interviews with a subgroup of respondents to explore some of the survey findings in greater depth. RESULTS: 85.3% (663/767) of patients completed the questionnaire. Sixty-five percent of respondents recalled receiving the reminder (n=431), and of those, 77.3% found it helpful. Of the respondents who recalled the letter and received a flu shot (n=348), 11.2% indicated they might not have done so without the letter. The majority of respondents reported that they would like to continue receiving reminder letters for influenza vaccinations (63.0%) and other preventive services (77.1%) from their family physician. The interview participants endorsed the use of reminder letters for improving vaccination coverage in older adults, but did not feel that the strategy was required for them personally. CONCLUSIONS: The general attitude of older adults towards reminder letters was favourable, and the reminders appear to have contributed to a modest increase in influenza vaccination rates.

Optimizing the role of the nurse practitioner to improve pain management in long-term care.

The purpose of this study was to examine the role of the nurse practitioner (NP) within an interdisciplinary model of pain management in long-term care (LTC). In a cross-sectional survey, 16 NPs in the Canadian province of Ontario (89%) indicated whether they currently performed and whether they should be performing 33 activities related to pain management and identified barriers to the fulfilment of their pain-management role. Most NPs (81.3%) reported use of pain-assessment tools, but less than half reported use of pain-management clinical practice guidelines. NPs were less involved in activities related to (a) prescribing and adjusting pain medications, (b) providing leadership in pain management, and (c) engaging in pain-related research initiatives. However, most felt that they should be more involved in these activities. Barriers to NP management of pain included time constraints; prescribing restrictions; lack of knowledge; difficulties with assessing pain; MD, staff, resident, and family reservations about use of opioids; and poor collaboration with physicians. The results indicate that NPs are not being used to their full potential in managing pain among elderly LTC residents.

Primary health care nurse practitioners in Canada.

Canada, like many countries, is in the midst of primary health care reform. A key priority is to improve access to primary health care, especially in remote communities and areas with physician shortages. As a result, there is an increased emphasis on the integration of primary health care nurse practitioners. As of March 2006, legislation exists in all provinces and two territories in Canada that allows nurse practitioners (NPs) to implement their expanded nursing role. In this paper, we will briefly review the historical development of the NP role in Canada and situate it in the international context; describe the NP role, supply of NPs in the country, and the settings in which they work; propose an NP practice model framework; summarize facilitators and barriers to NP role implementation in primary health care delivery; and outline strategies to address the barriers.

Engaging street-involved youth using an evidence-based intervention: A preliminary report of findings.

PROBLEM: Street-involved youth experience many barriers to accessing health and social services. There is a literature gap in the literature regarding evidence-based interventions to facilitate engagement with street-involved youth. METHODS: A qualitative descriptive study of preliminary findings from a large mixed-methods study was undertaken to assess the impact of a resilience-based motivational intervention. This intervention was grounded in frameworks including strengths-based and resilience-based communication using the Seven C's Model of Resilience, positive youth development, and motivational interviewing that are particularly relevant to youth. Individual interviews were conducted with two subsets of youth who participated (n = 3) or did not participate (n = 3) in the intervention. Thematic analysis was conducted to identify themes between the intervention and comparison groups. FINDINGS: Preliminary themes identified across the sample include (1) establishing a trusting relationship, (2) strengthening self-worth and resilience, (3) focusing on goals, and (4) perceiving a sense of hope and possibility. CONCLUSIONS: The themes identified the importance of positive relationships with care providers built upon a foundation of trust to engage youth to remain motivated and focused on their goals.