Commentary: Intraprofessional Collaborative Practice: Strengthening Nursing to Support Health System Transformation.

The complexity of nursing in Canada is evident in the diverse designations and jurisdictional approaches to legislation and regulation of the profession. The ever-evolving scope of practice of each designation of nursing shows the ability of nursing and nurses to adapt to the external environment and evolve to meet the needs of clients, the profession and the healthcare system. This commentary highlights the "made-in-Canada" research regarding intraprofessional collaboration. It also presents recommendations to strengthen intraprofessional collaboration over the next decade.

Collaboration among Registered Nurses and Licensed Practical Nurses: A Scoping Review of Practice Guidelines.

Professional associations, nurse scholars, and practicing nurses suggest that intraprofessional collaboration between nurses is essential for the provision of quality patient care. However, there is a paucity of evidence describing collaboration among nurses, including the outcomes of collaboration to support these claims. The aim of this scoping review was to examine nursing practice guidelines that inform the registered nurse (RN) and registered/licensed practical nurse (R/LPN) collaborative practice in acute care, summarize and disseminate the findings, and identify gaps in the literature. Ten practice guidelines, all published in Canada, were included in the final scoping review. The findings indicate that many of the guidelines were not evidence informed, which was a major gap. Although the guidelines discussed the structures needed to support intraprofessional collaboration, and most of the guidelines mention that quality patient care is the desired outcome of intraprofessional collaboration, outcome indicators for measuring successful collaborative practice were missing in many of the guidelines. Conflict resolution is an important process component of collaborative practice; yet, it was only mentioned in a few of the guidelines. Future guidelines should be evidence informed and provide outcome indicators in order to measure if the collaborative practice is occurring in the practice setting.

Getting Comfortable with "It Depends": Embracing the Impermanence of Scope of Practice.

Scope of practice of nursing roles is continually evolving to meet the ever-changing needs of patient populations and the healthcare system and to reflect changes in legislation, regulation and education requirements. As such, leaders must embrace the impermanence of scope of practice rather than constructing mental models, policies and practices as if the foundation will never change. Impermanence is the only constant, as the complexities within healthcare require that nurses be knowledgeable and flexible to fully leverage our individual and collective contributions to not only our patients but also our profession.

Collaboration among registered nurses and practical nurses in acute care hospitals: A scoping review.

AIM: This study examined the extent, range, and nature of registered nurse (RN) and practical nurse (PN) collaboration in acute care hospitals and identified research gaps in the existing literature. BACKGROUND: Optimal patient care requires collaboration between RNs and PNs. A lack of unity and unresolved tension among different types of nurses influences collaboration and has significant implications on practice and the organizations where nurses work. METHODS: Using Arksey and O'Malley's (2005) framework, a scoping review was undertaken to answer the research question: what is known from the existing literature about the structures, processes, and outcomes of RN-PN collaboration in hospitals? RESULTS: Twenty-nine studies were included with the majority coming from North America. Donabedian's model assisted with the identification of three themes: scope of practice, interpersonal skills, and nurse and patient-related outcomes. CONCLUSION: The findings demonstrate there is a paucity of research specific to RN-PN collaboration. Nurse administrators/managers play an important role in addressing the interpersonal skills of nurses and providing an ongoing education on collaboration in the practice setting. Additional studies should focus on the development of nursing collaborative practice models of patient care, the examination of interventions to improve RN-PN collaborative practice, and the assessment of outcomes relating to collaboration among nurses.

Enhancing Role Clarity for the Practical Nurse: A Leadership Imperative.

OBJECTIVE: The aim of this study was to determine factors contributing to practical nurse (PN) role confusion and the impact on nursing intraprofessional team collaboration. BACKGROUND: There is limited literature describing the intraprofessional relationship of the RN and PN in areas such as role conflict, scope of practice, and team collaboration. METHODS: A mixed-methods design was used targeting Ontario RNs and PNs, including an online survey and focus groups. RESULTS: Results (N = 1101) revealed varying levels of knowledge regarding the distinct and overlapping scope of practice for each role, with shared opinions regarding areas such as respect, teamwork, and the role of leadership. CONCLUSIONS: Nurses' roles will continue to evolve in response to changes in patient populations and healthcare systems. As such, role clarity is essential to support optimal use of nursing knowledge for safe patient care. Leadership is key to establishing parameters for professional practice and creating a culture of collaboration and respect.

Physician level reporting of surgical and pathology performance indicators: a regional study to assess feasibility and impact on quality.

BACKGROUND: There is increased awareness that, to minimize variation in clinician practice and improve quality, performance reporting should be implemented at the provider level. This optimizes physician engagement and creates a sense of professional responsibility for quality and performance measurement at the individual and organizational levels. METHODS: Individual provider level reporting was implemented within a provincial health region involving 56 clinicians (general surgeons, surgical oncologists, urologists and pathologists). The 2 surgical pathology indicators chosen were colorectal cancer (CRC) lymph node retrieval rate and pT2 prostate cancer margin positivity rate. Surgical resections for all prostate and colorectal cancer performed between Jan. 1, 2011, and Mar. 30, 2012, were included. We used a pre- and postsurvey design to obtain physician perceptions and focus groups with program leadership to determine organizational impact. RESULTS: Survey results showed that respondents felt the data provided in the reports were valid (67%), consistent with expectations (70%), maintained confidentiality (80%) and were not used in a punitive manner (77%). During the study period the pT2 prostate margin positivity rate decreased from 57.1% to 27.5%. For the CRC lymph node retrieval rate indicator, high baseline performance was maintained. CONCLUSION: We developed a robust process for providing physicians with confidential, individualized surgical and pathology quality indicator reports. Our results reinforce the importance of individual physician feedback as a strategy for improving and sustaining quality in surgical and diagnostic oncology.

Closing the quality loop: facilitating improvement in oncology practice through timely access to clinical performance indicators.

PURPOSE: Health care organizations and professionals are being called on to develop clear and transparent measures of quality and to demonstrate the application of the data to performance improvement at the system and provider levels. MATERIALS AND METHODS: Cancer Care Ontario (CCO) initiated a pathology reporting project aimed at improving the quality of cancer pathology by standardizing the content, format, and transmission of reports to a central registry and enabling the information to be available for planning, quality measurement, and quality improvement. This population-based quality-improvement project involved more than 400 Ontario pathologists and more than 100 hospitals. Clinically relevant quality indicators that used the newly available data were developed and shared. Synoptic pathology data were electronically captured at the point of report development and used to automate the timely generation of clinical performance indicators that support quality improvement in surgical oncology. These reports provided comparison data at the organizational, regional, and population levels. RESULTS: Monthly quality indicator reports are generated and distributed to each cancer center and are used to generate dialogue at the professional, organizational, and regional levels regarding evidence-informed quality-improvement opportunities. Since the launch of the project, colorectal lymph node retrieval rates have increased from 76% to 87%, and pT2 prostatectomy margin positivity rates have decreased from 37% to 21%. CONCLUSION: High-quality, complete cancer pathology reports are important not only for contemporary oncological practice, but also for secondary users of pathology information including tumor registries, health planners, epidemiologists, and others involved in quality-improvement activities and research.

Standardized synoptic cancer pathology reports - so what and who cares? A population-based satisfaction survey of 970 pathologists, surgeons, and oncologists.

CONTEXT: Cancer Care Ontario implemented synoptic pathology reporting across Ontario, impacting the practice of pathologists, surgeons, and medical and radiation oncologists. The benefits of standardized synoptic pathology reporting include enhanced completeness and improved consistency in comparison with narrative reports, with reported challenges including increased workload and report turnaround time. OBJECTIVE: To determine the impact of synoptic pathology reporting on physician satisfaction specific to practice and process. DESIGN: A descriptive, cross-sectional design was utilized involving 970 clinicians across 27 hospitals. An 11-item survey was developed to obtain information regarding timeliness, completeness, clarity, and usability. Open-ended questions were also employed to obtain qualitative comments. RESULTS: A 51% response rate was obtained, with descriptive statistics reporting that physicians perceive synoptic reports as significantly better than narrative reports. Correlation analysis revealed a moderately strong, positive relationship between respondents' perceptions of overall satisfaction with the level of information provided and perceptions of completeness for clinical decision making (r = 0.750, P < .001) and ease of finding information for clinical decision making (r = 0.663, P < .001). Dependent t tests showed a statistically significant difference in the satisfaction scores of pathologists and oncologists (t169 = 3.044, P = .003). Qualitative comments revealed technology-related issues as the most frequently cited factor impacting timeliness of report completion. CONCLUSION: This study provides evidence of strong physician satisfaction with synoptic cancer pathology reporting as a clinical decision support tool in the diagnosis, prognosis, and treatment of cancer patients.

Professional practice leadership roles: the role of organizational power and personal influence in creating a professional practice environment for nurses.

Professional practice leadership (PPL) roles are those roles responsible for expert practice, providing professional leadership, facilitating ongoing professional development, and research. Despite the extensive implementation of this role, most of the available literature focuses on the implementation of the role, with few empirical studies examining the factors that contribute to PPL role effectiveness. This article will share the results of a research study regarding the role of organizational power and personal influence in creating a high-quality professional practice environment for nurses. Survey results from nurses and PPLs from 45 hospitals will be presented. Path analysis was used to test the hypothesized model and relationships between the key variables of interest. Results indicate that there is a direct and positive relationship between PPL organizational power and achievement of PPL role functions, as well as an indirect, partially mediated effect of PPL influence tactics on PPL role function. There is also a direct and positive relationship between PPL role functions and nurses' perceptions of their practice environment. The evidence generated from this study highlights the importance of organizational power and personal influence as significantly contributing to the ability of those in PPL roles to achieve desired outcomes. This information can be used by administrators, researchers, and clinicians regarding the factors that can optimize the organizational and systematic strategies for enhancing the practice environment for nursing and other health care professionals.

The Top 30 Rising Stars Program: an inter-organizational approach to leadership succession planning.

An effective leadership development program is an organizational investment that advances individual performance while strengthening organizational capabilities. The Top 30 Rising Stars Program is a leadership succession program designed to enable leadership capacity building within and across organizations. Key components of the program include formal learning, stretch opportunities, and mentorship. Evaluation results reveal high participant satisfaction and an increase in reported self-confidence in their ability to assume a formal leadership position.

The ALIVE program: developing a web-based professional development program for nursing leaders in the home healthcare sector.

Home healthcare nurses often work in isolation and rarely have the opportunity to meet or congregate in one location. As a result, nurse leaders must possess unique leadership skills to supervise and manage a dispersed employee base from a distance. The nature of this dispersed workforce creates an additional challenge in the ability to identify future leaders, facilitate leadership capacity, and enhance skill development to prepare them for future leadership positions. The ALIVE (Actively Leading In Virtual Environments) web-based program was developed to meet the needs of leaders working in virtual environments such as the home healthcare sector. The program, developed through a partnership of three home healthcare agencies, used nursing leaders as content experts to guide program development and as participants in the pilot. Evaluation findings include the identification of key competencies for nursing leaders in the home healthcare sector, development of program learning objectives and participant feedback regarding program content and delivery.

Changing physician practice: an evaluation of knowledge transfer strategies to enhance physician documentation of cancer stage.

This paper describes the knowledge transfer strategies used by Cancer Care Ontario, in partnership with 14 regional cancer centres, with the aim of improving the cancer stage data in Ontario. As physicians are directly responsible for the documentation of cancer stage, the success of this initiative is directly related to improvements in physician documentation practices. Knowledge transfer strategies included the use of local opinion leaders, educational sessions, and audit/feedback loops. Evaluation results reveal an increase in the provincial cancer stage data from 30 to 68%. The information presented here will be of interest to organizations implementing practice changes requiring physician engagement.

Exploring a theoretical foundation for the professional practice leader role.

Professional practice leader (PPL) roles have been a common part of the healthcare Landscape for several years, yet the manner in which the role is operationalized varies significantly. This variability leads to ambiguity about the role, its purpose and the value added to the profession, the organization and the healthcare system. Some ambiguity may be due to the lack of a theoretical framework as a foundation for the role. In this climate of evidence-based practice, nursing leaders must demonstrate the rationale for innovations such as the PPL role. The focus of this paper will be to contextualize the PPL role within Kanter's Theory of Structural Empowerment in order to provide a common language for the various stages of evolution of the PPL role (i.e., design, implementation and evaluation). A content analysis of existing PPL role descriptions in Ontario will be used to demonstrate the applicability of Kanter's theory to the PPL role. This paper will be of interest to nursing Leaders and professional practice leaders as an example of how theory can provide direction and support to the operationalization of professional practice roles, functions and outcomes.

Describing the essential elements of a professional practice structure.

The proliferation of program management coupled with the Introduction of the Regulated Health Professions Act, prompted many healthcare organizations in Ontario to introduce professional practice models. In addition, the Magnet Hospitals research (Kramer and Schmalenberg 1988) identified the existence of a professional practice model as a key element for recruitment and retention of professional staff. Professional practice models were introduced to address issues of accountability, identity and overlapping scopes of practice as experienced by healthcare professionals and organizations across the continuum of care. The authors of this paper describe exploratory work done through the Professional Practice Network of Ontario to identify the essential elements of the "ideal" professional practice structure, key areas of challenge and strategies for adapting these elements into an organization. The paper presents a list of 16 essential elements of an ideal professional practice structure with a further discussion on four key areas consistently identified as areas of challenge. This paper is intended to report, not the findings of a formal research study, but rather the result of facilitated dialogue among professional practice leaders in Ontario. The information will be of interest to healthcare organizations across the continuum of care and to professional associations and academic institutions, as we all address the challenges of creating a quality work environment that supports and fosters excellence in professional practice.