The Nurse Practitioner Role in Complex Malignant Hematology: A Qualitative Descriptive Study.

OBJECTIVES: Internationally, there is limited evidence about the role and impact of nurse practitioners (NPs) in complex malignant hematology (CMH). In one Canadian CMH program, NPs have existed for 20 years but not been evaluated. This study aimed to understand stakeholder perceptions of CMH NP role structures, processes, and outcomes and the extent to which the role meets patient and health service needs. METHODS: A qualitative descriptive study was conducted, guided by the PEPPA-Plus framework. Purposive sampling was used to recruit stakeholders who participated in focus groups and interviews. Content analysis was used to analyze the data. RESULTS: Participants included patients (n = 8) and healthcare professionals (n = 27). Themes about structures related to evolution of the CMH Program, model of care, and need for strategic vision. Process themes related to provision of accessible, comprehensive, and holistic care and NP workload. Positive and negative outcomes and lack of outcome measurement were identified. CONCLUSION: Structures related to patient and NP characteristics, organizational change, staffing, and how NP work is organized impacts on NP role implementation and outcomes. Organizational structures can be strengthened to improve the model of care and NP role implementation and workload. Value-added NP contributions related to providing comprehensive care with attention to safety and social determinants of health. Research is needed to evaluate NP role outcomes in CMH. IMPLICATIONS FOR NURSING PRACTICE: The results can inform role design and organization policies and strategies to promote the recruitment, retention, and optimization of NP roles in CMH settings. Priorities for future research are also identified.

Models of care with advanced practice nurses in the emergency department: A scoping review.

INTRODUCTION: Emergency departments play a critical role in healthcare systems internationally. Visits for emergency care continue to increase, related to poor access to primary care, the COVID-19 pandemic, and health human resource issues. International literature shows similar stressors in the emergency department. Extended wait times to see health providers lead to poor outcomes, and innovative models of care are needed to address emergency department overcrowding and to meet the needs of patients. Advanced practice nurses have the expertise and scope of practice to optimize and address primary and acute care needs and could be further integrated into the emergency healthcare systems. It is unclear what and how advanced practice nurses are functioning in emergency departments to improve patient and organization outcomes. METHODS: This scoping review was a comprehensive search of MEDLINE, EMCARE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and gray literature. Authors developed inclusion and exclusion criteria, performed title and abstract screening, and full text screening using review software. Data about models of care with advanced practice nurses were extracted and organized to understand patient, provider, and organizational outcomes. We also extracted information about the development and implementation of roles. RESULTS: Of the 6780 records identified, 76 met inclusion criteria. Emergency department models of care, mainly using nurse practitioners, include fast-track, generalized emergency, minor injury, orthopedics, pediatrics, geriatrics, specific populations, and triage. Reported patient outcomes include improvement in key metrics specific to emergency departments, such as total length of stay, wait times to be seen by a provider, left without being seen rates, treatment for pain, costs, and resource use. When comparing nurse practitioners to other providers, outcomes were similar or better for patient and organizational outcomes. DISCUSSION: Various models of care utilizing advanced practice nurses in emergency departments are present internationally and information about how they are developed, integrated, and utilized provides practical information to support and sustain new roles. There is an opportunity to expand the use of these roles into emergency departments as the nurse practitioner scope of practice grows. Given the current crisis across healthcare systems, there is need for innovation, and improving delivery of emergency services with these advanced practice nursing models of care can help to address important health policy priorities in Canada and other countries. TWEETABLE ABSTRACT: Advanced Practice Nurse models of care in emergency - Improved outcomes for patients and organizations - A review of the literature. @SamanthaH_RN.

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.

Effectiveness of system navigation programs linking primary care with community-based health and social services: a systematic review.

BACKGROUND: Fragmented delivery of health and social services can impact access to high-quality, person-centred care. The goal of system navigation is to reduce barriers to healthcare access and improve the quality of care. However, the effectiveness of system navigation remains largely unknown. This systematic review aims to identify the effectiveness of system navigation programs linking primary care with community-based health and social services to improve patient, caregiver, and health system outcomes. METHODS: Building on a previous scoping review, PsychInfo, EMBASE, CINAHL, MEDLINE, and Cochrane Clinical Trials Registry were searched for intervention studies published between January 2013 and August 2020. Eligible studies included system navigation or social prescription programs for adults, based in primary care settings. Two independent reviewers completed study selection, critical appraisal, and data extraction. RESULTS: Twenty-one studies were included; studies had generally low to moderate risk of bias. System navigation models were lay person-led (n = 10), health professional-led (n = 4), team-based (n = 6), or self-navigation with lay support as needed (n = 1). Evidence from three studies (low risk of bias) suggests that team-based system navigation may result in slightly more appropriate health service utilization compared to baseline or usual care. Evidence from four studies (moderate risk of bias) suggests that either lay person-led or health professional-led system navigation models may improve patient experiences with quality of care compared to usual care. It is unclear whether system navigation models may improve patient-related outcomes (e.g., health-related quality of life, health behaviours). The evidence is very uncertain about the effect of system navigation programs on caregiver, cost-related, or social care outcomes. CONCLUSIONS: There is variation in findings across system navigation models linking primary care with community-based health and social services. Team-based system navigation may result in slight improvements in health service utilization. Further research is needed to determine the effects on caregiver and cost-related outcomes.

A Novel Hospital-to-Home System for Children With Medical Complexities: Usability Testing Study.

BACKGROUND: Children with medical complexity (CMC) are a group of young people who have severe complex chronic conditions, substantial family-identified service needs, functional limitations, and high health care resource use. Technology-enabled hospital-to-home interventions designed to deliver comprehensive care in the home setting are needed to ease CMC family stress, provide proactive and comprehensive care to this fragile population, and avoid hospital admissions, where possible. OBJECTIVE: In this usability testing study, we aimed to assess areas of strength and opportunity within the DigiComp Kids system, a hospital-to-home intervention for CMC and their families and care providers. METHODS: Hospital-based clinicians, family members of medically complex children, and home-based clinicians participated in DigiComp Kids usability testing. Participants were recorded and tasked to think aloud while completing usability testing tasks. Participants were scored on the metrics of effectiveness, efficiency, and satisfaction, and the total usability score was calculated using the Single Usability Metric. Participants also provided insights into user experiences during the postusability testing interviews. RESULTS: A total of 15 participants (5 hospital-based clinicians, 6 family members, and 4 home-based clinicians) participated in DigiComp Kids usability testing. The participants were able to complete all assigned tasks independently. Error-free rates for tasks ranged from 58% to 100%; the average satisfaction rating across groups was ≥80%, as measured by the Single Ease Question. Task times of participants were variable compared with the task times of an expert DigiComp Kids user. Single Usability Metric scores ranged from 80.5% to 89.5%. In qualitative interviews, participants stressed the need to find the right fit between user needs and the effort required to use the system. Interviews also revealed that the value of the DigiComp Kids system was in its ability to create a digital bridge between hospital and home, enabling participants to foster and maintain connections across boundaries. CONCLUSIONS: Usability testing revealed strong scores across the groups. Insights gained include the importance of tailoring the implementation of the system to match individual user needs, streamlining key system features, and consideration of the meaning attached to system use by participants to allow for insight into system adoption and sustainment.

Adult newcomers' perceptions of access to care and differences in health systems after relocation from Syria.

BACKGROUND: In Canada, approximately 13% of the population lives with multiple chronic conditions. Newcomers, including refugees, have the same or higher risk of developing chronic diseases as their host population. In 2015-2016, Canada welcomed almost 40, 000 newcomers from Syria. This study aimed to (1) understand adult newcomer health needs for self-management of non-infectious chronic conditions; and (2) identify strategies to improve access to health care services to meet these needs. METHODS: This study used a qualitative descriptive design. Interviews and focus groups were conducted with consenting newcomers, service providers and community agency administrators. Interview guides were developed with input from community partners and snowball sampling was used. RESULTS: Participants included 22 Syrian newcomers and 8 service providers/administrators. Findings revealed the initial year of arrival as one of multiple adjustments, often rendering chronic disease management to a lower priority. Self-care and self-management were not routinely incorporated into newcomer lives though community health agencies were proactive in creating opportunities to learn self-management practices. Gaps in access to care were prevalent, including mental health services which typically were not well developed for trauma and post-traumatic stress disorder (PTSD), particularly for men. Newcomers expressed frustration with lengthy wait times and not being able to access specialists directly. Youth frequently played a key role in translation and disseminating information about services to their families. CONCLUSION: Chronic disease management was a low priority for newcomers who were focussed on resettlement issues such as learning English or finding work. Provision of practical supports such as bus tickets, translation, and information about the healthcare system were identified as means of improving access to care.

Optimizing the Meaningful Engagement of Older Adults With Multimorbidity and Their Caregivers as Research Partners: A Qualitative Study.

It is widely recognized that the engagement of older adults with multimorbidity and their caregivers as partners in health care research is important and invaluable. The objective of this study was to examine how researchers can best engage and support older adults with multimorbidity and informal friend or family caregivers of older adults with multimorbidity as research partners in health care research teams. The persona-scenario method was used for participants to create fictional stories. These stories were analyzed to shed light on specific strategies that can support older adults and caregivers as partners on health care research teams, such as a patient-centered approach, identifying and addressing barriers to engagement, and clarifying roles and responsibilities on the research team. The results from this study can be used to inform research, policy, and education on supporting older adults with multimorbidity and caregivers of older adults with multimorbidity as research partners.

Impact of nurse scientist-led digital health interventions on management of chronic conditions.

BACKGROUND: Chronic conditions are a major contributor to the burden of disease worldwide. Using innovative digital health technologies, nurse scientists are well-positioned to lead efforts to reduce the burden of chronic conditions on individuals, communities, and systems. PURPOSE: The purpose of this review was to summarize the outcomes commonly measured in nurse-led digital health interventions that target chronic conditions and pose recommendations for the education of future nurse scientists to lead these studies. METHODS: A rapid review of the literature was completed using CINAHL and Ovid Emcare. Studies were included if the research: a) was led by a nurse; b) described outcomes of a digital health intervention; and c) included any population with a prevalent chronic condition. FINDINGS: 26 studies were included in this review. Nurse-led digital health interventions are being used to support and manage a range of chronic conditions in varied settings. DISCUSSION: Digital health interventions are changing the delivery of healthcare for individuals living with chronic conditions. These interventions are bridging the gaps between the digital and physical worlds and are rapidly evolving. CONCLUSION: The recommendations posed in this review reiterate the importance of robust content and methods education for nurse scientists to address future research needs in a digital era.

Models of Care and Team Activities in the Delivery of Transgender Primary Care: An Ontario Case Study.

Purpose: Transgender individuals experience barriers accessing primary care. In Ontario, primary care is delivered through a variety of delivery models. Literature supports team delivery of primary care for transgender individuals, yet little is known about care delivery in Ontario and the role of primary care teams. We intend to explore how primary care for transgender individuals is delivered within the different primary care models in Ontario and the roles primary care team members enact in care delivery, barriers, enablers, and clinical competence of practitioners in delivering transgender care. Methods: Case study methodology was used to compare transgender care across three Ontario primary care models. Key informants identified cases known to provide transgender care for case selection. Qualitative interviews were conducted. Documentary evidence and field notes were collected. Results: Practitioners clearly articulated their role and activities they were responsible for in providing care, however, they tended to work independently. In cases with an interdisciplinary team there was limited collaboration. Nurse practitioners, physicians, and counselors contributed most to the delivery of care. Key challenges included lack of service coordination within organizations, and the need for practitioner education. Continuing educational sessions, guidelines, and mentorship aided capacity building. Conclusions: Providing primary care to transgender individuals is within the scope of practice for primary care practitioners and can be part of routine care delivered in different models of care. Primary care team collaboration can be strengthened by regular team meetings. Professional training needs to include transgender education and continuing education opportunities need development.

Exploring the implementation and delivery of primary care services for transgender individuals in Ontario: case study protocol.

BACKGROUND: Historically transgender adults have experienced barriers in accessing primary care services. In Ontario, Canada, health care for transgender adults is accessed through primary care; however, a limited number of practitioners provide care, and patients are often waiting and/or traveling great distances to receive care. The purpose of this protocol is to understand how primary care is implemented and delivered for transgender adults. The paper presents how the case study method can be applied to explore implementation of health services delivery for the transgender population in primary care. METHODS: Case study methodology will be used to explore this phenomenon in different primary care contexts. Normalization Process Theory is used as a guide. Three cases known to provide transgender primary care and represent different Ontario primary care models have been identified. Comparing transgender care implementation and delivery across different models is vital to understanding how care provision to this population can be supported. Qualitative interviews will be conducted. Participants will also complete the NoMAD (NOrmalization MeAsure Development) survey, a tool measuring implementation processes. The tool will be modified to explore the implementation of primary care services for transgender individuals. Documentary evidence will be collected. Cross-case synthesis will be completed to compare the cases. DISCUSSION: Findings will provide an Ontario perspective on the implementation and delivery of primary care for transgender adults in different primary care models. Results may be applicable to other primary care settings in Canada and other nations with similar systems. Barriers and facilitators in delivery and implementation will be identified. Providing an understanding and increasing awareness of the implementation and delivery of primary care may help to reduce the invisibility and disparities transgender individuals experience when accessing primary care services. Understanding delivery of care could allow care providers to implement primary care services for transgender individuals, improving access to health care for this vulnerable population.

Building a framework for the evaluation of knowledge translation for the Canadian Network for Observational Drug Effect Studies.

PURPOSE: The Canadian Network for Observational Drug Effect Studies (CNODES), a network of pharmacoepidemiologists and other researchers from seven provincial sites, provides evidence on the benefits and risks of drugs used by Canadians. The Knowledge Translation Team, one of CNODES' four main teams, evaluates the impact of its efforts using an iterative and emergent approach. This article shares key lessons from early evaluation phases, including identifying stakeholders and their evaluation needs, choosing evaluation theories and approaches, and developing evaluation questions, designs, and methods appropriate for the CNODES context. METHODS: Stakeholder analysis was conducted using documentary analysis to determine key contextual factors and research evidence needs of decision maker partners and other stakeholders. Selected theories and frameworks from the evaluation and knowledge translation literature informed decisions about evaluation design and implementation. A developmental approach to evaluation was deemed appropriate due to the innovative, complex, and ever-changing context. RESULTS: A theory of change, logic model, and potential evaluation questions were developed, informed by the stakeholder analysis. Early indicators of program impact (citation metrics, alternative metrics) have been documented; efforts to collect data on additional indicators are ongoing. CONCLUSION: A flexible, iterative, and emergent evaluation approach allows the Knowledge Translation Team to apply lessons learned from completed projects to ongoing research projects, adapt its approaches based on stakeholder needs, document successes, and be accountable to funders/stakeholders. This evaluation approach may be useful for other international pharmacoepidemiology research networks planning and implementing evaluations of similarly complex, multistakeholder initiatives that are subject to constant change.

Use of Synchronous Digital Health Technologies for the Care of Children With Special Health Care Needs and Their Families: Scoping Review.

BACKGROUND: Use of synchronous digital health technologies for care delivery to children with special health care needs (having a chronic physical, behavioral, developmental, or emotional condition in combination with high resource use) and their families at home has shown promise for improving outcomes and increasing access to care for this medically fragile and resource-intensive population. However, a comprehensive description of the various models of synchronous home digital health interventions does not exist, nor has the impact of such interventions been summarized to date. OBJECTIVE: We aim to describe the various models of synchronous home digital health that have been used in pediatric populations with special health care needs, their outcomes, and implementation barriers. METHODS: A systematic scoping review of the literature was conducted, guided by the Arksey and O'Malley Scoping Review Framework. MEDLINE, CINAHL, and EMBASE databases were searched from inception to June 2018, and the reference lists of the included systematic reviews and high-impact journals were hand-searched. RESULTS: A total of 38 articles were included in this review. Interventional articles are described as feasibility studies, studies that aim to provide direct care to children with special health care needs, and studies that aim to support family members to deliver care to children with special health care needs. End-user involvement in the design and implementation of studies is evaluated using a human-centered design framework, and factors affecting the implementation of digital health programs are discussed in relation to technological, human, and systems factors. CONCLUSIONS: The use of digital health to care for children with special health care needs presents an opportunity to leverage the capacity of technology to connect patients and their families to much-needed care from expert health care providers while avoiding the expenses and potential harms of the hospital-based care system. Strategies to scale and spread pilot studies, such as involving end users in the co-design techniques, are needed to optimize digital health programs for children with special health care needs.

Team Functioning And Beliefs About Team Effectiveness In Inter-Professional Teams: Questionnaire Development And Validation.

PURPOSE: Few validated instruments are available to measure team functioning in acute and primary care teams. To address this, we developed a questionnaire measuring healthcare provider perceptions of team effectiveness (Provider-PTE) and assessed its psychometric properties. PATIENTS AND METHODS: Empirical evidence and a conceptual model were used for item generation. The 41-item self-completed questionnaire was developed. A cross-sectional survey of healthcare providers (n=283) across a range of settings was performed. Psychometric properties were assessed for French and English language questionnaires using Cronbach alpha (α) for reliability, the feedback form for face validity, expert opinion for content validity, and the known-group technique for construct validity. Responsiveness was examined by comparing scores in high and low functioning teams. RESULTS: The mean time needed to complete the questionnaire was less than 9 mins. Respondents were typically female (84%), and employed full time (80%) in urban settings (82%). Cronbach α values were as follows: Team Processes = 0.88; PTE-Overall = 0.91; Outcomes = 0.72. Significant differences were found by professional group (p = 0.017), length of time in the team (p = 0.025), and presence of nurse practitioners. Responses to Outcomes varied by employment status (p = 0.017). Differences were identified in high and low functioning teams (p<0.001). Feedback indicated that two questions related to team meetings needed to be added. CONCLUSION: The study produced evidence of validity for English and French language Provider-PTE questionnaires. The revised 43-item instrument represents an important contribution by providing a validated questionnaire to measure team functioning across a range of settings that is consistent with a conceptual framework.

Baccalaureate Nursing Students' Perceptions of Learning in Mentored and Simulated Research Practica.

BACKGROUND: A simulated research practicum was developed in our nursing program to increase the number of quality research placements for our students. In order to evaluate the success of this simulation activity, we compared students' experiences in simulated and traditional mentored research placements. METHOD: A convenience sample of baccalaureate nursing students enrolled in an introductory research course in Ontario, Canada, was surveyed. A two-group posttest survey design was used to assess the research activities students experienced and their satisfaction with placements. Data were compared between the traditional mentored research placements (MRP) and simulated research placements (SRP) using descriptive and inferential statistical testing. RESULTS: Students in the SRP group had a statistically significant higher level of exposure to several aspects of the research process, although course satisfaction ratings were slightly better in the MRP group. CONCLUSION: The simulated practicum provided our organization with a feasible means of providing high-quality research placements by exposing undergraduate nursing students to several aspects of the research process. [J Nurs Educ. 2019;58(5):290-293.].

"Primary care is primary care": Use of Normalization Process Theory to explore the implementation of primary care services for transgender individuals in Ontario.

BACKGROUND: In Ontario, Canada, healthcare for transgender individuals is accessed through primary care; however, there are a limited number of practitioners providing transgender care, and patients are often on waiting lists and/or traveling great distances to receive care. Understanding how primary care is implemented and delivered to transgender individuals is key to improving access and eliminating healthcare barriers. The purpose of this study is to understand how the implementation of primary care services for transgender individuals compares across various models of primary care delivery in Ontario. METHODS: A qualitative, exploratory, multiple-case study guided by Normalization Process Theory (NPT) was used to compare transgender care delivery and implementation across three primary care models. Three cases known to provide transgender primary care and represent different primary care models in Ontario, Canada (i.e., family health team, community health centre, fee-for service physician) were explored. The NoMAD survey, a tool to measure implementation processes, and qualitative interviews with primary care practitioners and allied healthcare staff were administered. RESULTS: Using the NPT framework to guide analysis, key themes emerged about successful implementation of primary care services for transgender individuals. These themes include creating a safe space for patients, identifying gaps in services, understanding practitioners' roles, and the need for more training and education in transgender care for practitioners. CONCLUSIONS: Primary care services for transgender individuals can and should be delivered in all models of primary care. Training and awareness for healthcare practitioners are needed to develop capacity in providing primary care to transgender individuals. A greater number of practitioners and organizations are needed to take on this work, embedding and normalizing transgender care into routine practice to address barriers to access and improve quality of care for transgender individuals.

An Innovative Simulated Research Practicum for Undergraduate Nursing Students.

BACKGROUND: An understanding of the research process and familiarity with research methods is essential to nursing curricula to prepare graduates to participate in the generation of new nursing knowledge. A research practicum with nurse researchers is one way of providing intensive hands-on training. At our institution, research placements for students has become difficult for a number of reasons. METHOD: To solve the problem related to the low number of quality research placements available, simulation was used to create an innovative research practicum. RESULTS: The simulated research practicum increased the number of quality research projects available to students and allowed students to participate in a small study from start to finish. It also used fewer faculty resources. CONCLUSION: The simulated research practicum is an innovative strategy to provide practical research experience to undergraduate students and requires fewer faculty resources than traditional placements. [J Nurs Educ. 2019;58(2):114-116.].

Navigation delivery models and roles of navigators in primary care: a scoping literature review.

BACKGROUND: Systems navigation provided by individuals or teams is emerging as a strategy to reduce barriers to care. Complex clients with health and social support needs in primary care experience fragmentation and gaps in service delivery. There is great diversity in the design of navigation and a lack of consensus on navigation roles and models in primary care. METHODS: We conducted a scoping literature review following established methods to explore the existing evidence on system navigation in primary care. To be included, studies had to be published in English between 1990 and 2013, and include a navigator or navigation process in a primary care setting that involves the community- based social services beyond the health care system. RESULTS: We included 34 papers in our review, most of which were descriptive papers, and the majority originated in the US. Most of the studies involved studies of individual navigators (lay person or nurse) and were developed to meet the needs of specific patient populations. We make an important contribution to the literature by highlighting navigation models that address both health and social service navigation. The emergence and development of system navigation signals an important shift in the recognition that health care and social care are inextricably linked especially to address the social determinants of health. CONCLUSIONS: There is a high degree of variance in the literature, but descriptive studies can inform further innovation and development of navigation interventions in primary care.

Structural analysis of health-relevant policy-making information exchange networks in Canada.

BACKGROUND: Health systems worldwide struggle to identify, adopt, and implement in a timely and system-wide manner the best-evidence-informed-policy-level practices. Yet, there is still only limited evidence about individual and institutional best practices for fostering the use of scientific evidence in policy-making processes The present project is the first national-level attempt to (1) map and structurally analyze-quantitatively-health-relevant policy-making networks that connect evidence production, synthesis, interpretation, and use; (2) qualitatively investigate the interaction patterns of a subsample of actors with high centrality metrics within these networks to develop an in-depth understanding of evidence circulation processes; and (3) combine these findings in order to assess a policy network's "absorptive capacity" regarding scientific evidence and integrate them into a conceptually sound and empirically grounded framework. METHODS: The project is divided into two research components. The first component is based on quantitative analysis of ties (relationships) that link nodes (participants) in a network. Network data will be collected through a multi-step snowball sampling strategy. Data will be analyzed structurally using social network mapping and analysis methods. The second component is based on qualitative interviews with a subsample of the Web survey participants having central, bridging, or atypical positions in the network. Interviews will focus on the process through which evidence circulates and enters practice. Results from both components will then be integrated through an assessment of the network's and subnetwork's effectiveness in identifying, capturing, interpreting, sharing, reframing, and recodifying scientific evidence in policy-making processes. DISCUSSION: Knowledge developed from this project has the potential both to strengthen the scientific understanding of how policy-level knowledge transfer and exchange functions and to provide significantly improved advice on how to ensure evidence plays a more prominent role in public policies.

Economic evaluation of nurse practitioner and clinical nurse specialist roles: A methodological review.

BACKGROUND: Advanced practice nurses (e.g., nurse practitioners and clinical nurse specialists) have been introduced internationally to increase access to high quality care and to tackle increasing health care expenditures. While randomised controlled trials and systematic reviews have demonstrated the effectiveness of nurse practitioner and clinical nurse specialist roles, their cost-effectiveness has been challenged. The poor quality of economic evaluations of these roles to date raises the question of whether current economic evaluation guidelines are adequate when examining their cost-effectiveness. OBJECTIVE: To examine whether current guidelines for economic evaluation are appropriate for economic evaluations of nurse practitioner and clinical nurse specialist roles. METHODS: Our methodological review was informed by a qualitative synthesis of four sources of information: 1) narrative review of literature reviews and discussion papers on economic evaluation of advanced practice nursing roles; 2) quality assessment of economic evaluations of nurse practitioner and clinical nurse specialist roles alongside randomised controlled trials; 3) review of guidelines for economic evaluation; and, 4) input from an expert panel. RESULTS: The narrative literature review revealed several challenges in economic evaluations of advanced practice nursing roles (e.g., complexity of the roles, variability in models and practice settings where the roles are implemented, and impact on outcomes that are difficult to measure). The quality assessment of economic evaluations of nurse practitioner and clinical nurse specialist roles alongside randomised controlled trials identified methodological limitations of these studies. When we applied the Guidelines for the Economic Evaluation of Health Technologies: Canada to the identified challenges and limitations, discussed those with experts and qualitatively synthesized all findings, we concluded that standard guidelines for economic evaluation are appropriate for economic evaluations of nurse practitioner and clinical nurse specialist roles and should be routinely followed. However, seven out of 15 current guideline sections (describing a decision problem, choosing type of economic evaluation, selecting comparators, determining the study perspective, estimating effectiveness, measuring and valuing health, and assessing resource use and costs) may require additional role-specific considerations to capture costs and effects of these roles. CONCLUSION: Current guidelines for economic evaluation should form the foundation for economic evaluations of nurse practitioner and clinical nurse specialist roles. The proposed role-specific considerations, which clarify application of standard guidelines sections to economic evaluation of nurse practitioner and clinical nurse specialist roles, may strengthen the quality and comprehensiveness of future economic evaluations of these roles.

A narrative evaluation of a community-based nurse navigation role in an urban at-risk community.

AIMS: To explore community members' stories of their experiences with a Nurse Navigator programme serving an urban neighbourhood and primary care practice to address persistent health and social barriers adversely affecting health equity and well-being. BACKGROUND: In response to striking health and social inequalities existing across neighbourhoods in a large southern city in Ontario, Canada, a pilot programme was designed to improve health and social outcomes in a specific "at-risk" neighbourhood. The programme includes nurse-led navigation support for individuals and families and networking to facilitate improved service integration at a systems level. DESIGN: A narrative inquiry approach based on the Three-Dimensional Narrative Inquiry Space method, as described by Clandinin & Connelly (Narrative inquiry: Experience and story in qualitative research, ). METHODS: A thematic analysis of nine community members' life stories from narrative semi-structured interviews (January-June 2014) in conjunction with field notes, observations and documents. Participants' life stories created a common narrative of the experience of navigation in a community setting. FINDINGS: There were four main themes: "opening the door"; "more than just a conversation"; "making connections"; and "on a new trajectory". Participants valued the development of a therapeutic relationship, which optimized social inclusion, barrier reduction and connectivity to supportive health and social services. CONCLUSIONS: The relational process of navigation as an antecedent to barrier reduction has direct implications for programme development, continuing education of navigators and quality improvement of existing navigation services. Study findings have implications for development of navigation competencies for nurses working with priority populations to address health inequities.