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.

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.

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.

Modulo Dos: Enfermería con práctica avanzada: una estrategia para lograr la cobertura universal de salud y el acceso universal a la salud. Rev. Latino-Am. Enfermagem 2017;25:e2826 DOI: 10.1590/1518-8345.1677.2826 www.eerp.usp.br/rlae

Programa de Monitoreo sobre Enfermedades Crónicas No Transmisibles Es un curso para Fortalecer el sistema de atención de pacientes con enfermedades crónicas no Transmisibles, dado por el Equipo de la Secretaría de Salud Pública y Ambiente de la Facultad de Ciencias Médicas de la UNC. y Equipo de la Red integrada de salud del Hospital Italiano de Córdoba. Analizar la literatura relacionada con los roles de la EPA, su despliegue en el mundo y la eficacia de EPA en relación con la cobertura de salud universal y el acceso a la salud.

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.

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.

Advanced Practice Nursing: A Strategy for Achieving Universal Health Coverage and Universal Access to Health.

OBJECTIVE:: to examine advanced practice nursing (APN) roles internationally to inform role development in Latin America and the Caribbean to support universal health coverage and universal access to health. METHOD:: we examined literature related to APN roles, their global deployment, and APN effectiveness in relation to universal health coverage and access to health. RESULTS:: given evidence of their effectiveness in many countries, APN roles are ideally suited as part of a primary health care workforce strategy in Latin America to enhance universal health coverage and access to health. Brazil, Chile, Colombia, and Mexico are well positioned to build this workforce. Role implementation barriers include lack of role clarity, legislation/regulation, education, funding, and physician resistance. Strong nursing leadership to align APN roles with policy priorities, and to work in partnership with primary care providers and policy makers is needed for successful role implementation. CONCLUSIONS:: given the diversity of contexts across nations, it is important to systematically assess country and population health needs to introduce the most appropriate complement and mix of APN roles and inform implementation. Successful APN role introduction in Latin America and the Caribbean could provide a roadmap for similar roles in other low/middle income countries. OBJETIVO:: analisar o papel da enfermagem com prática avançada (EPA) a nível internacional para um relatório do seu desenvolvimento na América Latina e no Caribe, para apoiar a cobertura universal de saúde e o acesso universal à saúde. MÉTODO:: análise da bibliografia relacionada com os papéis da EPA, sua implantação no mundo e a eficácia da EPA em relação à cobertura universal de saúde e acesso à saúde. RESULTADOS:: dada a evidência da sua eficácia em muitos países, as funções da EPA são ideais como parte de uma estratégia de recursos humanos de atenção primária de saúde na América Latina para melhorar a cobertura universal de saúde e o acesso à saúde. Brasil, Chile, Colômbia e México estão bem posicionados para construir esta força de trabalho. Barreiras à implementação destas funções incluem: a falta de clareza do seu papel, a legislação/regulamentação, educação, financiamento, e a resistência médica. Uma liderança forte de enfermagem é necessária para alinhar o papel da EPA com as prioridades políticas e trabalhar em colaboração com os profissionais de atenção primária e os decisores políticos para a implementação bem sucedida das suas funções. CONCLUSÕES:: dada a diversidade de contextos dos diferentes países, é importante avaliar sistematicamente as necessidades de saúde do país e da população para introduzir a combinação mais adequada e complementar dos papéis da EPA e formatar sua aplicação. A introdução bem sucedida do papel da EPA na América Latina e no Caribe poderia fornecer um roteiro para funções semelhantes noutros países de baixa/média renda. OBJETIVO:: examinar el rol de la enfermería con práctica avanzada (EPA) a nivel internacional para informar de su desarrollo en América Latina y el Caribe, en apoyo a la cobertura de salud universal y el acceso universal a la salud. MÉTODO:: se analizó la literatura relacionada con los roles de la EPA, su despliegue en el mundo y la eficacia de EPA en relación con la cobertura de salud universal y el acceso a la salud. RESULTADOS:: dada la evidencia de su eficacia en muchos países, las funciones de la EPA son ideales como parte de una estrategia de recursos humanos de atención primaria de salud en América Latina para mejorar la cobertura de salud universal y el acceso a la salud. Brasil, Chile, Colombia y México están bien posicionados para construir esta fuerza de trabajo. Las barreras a la implementación de estas funciones incluyen: la falta de claridad de su rol, la legislación/regulación, educación, financiamiento, y la resistencia de los médicos. Se necesita un liderazgo fuerte de enfermería para alinear los roles de la EPA con las políticas prioritarias, y trabajar en colaboración con los profesionales de atención primaria y los responsables de las políticas para la implementación exitosa de sus funciones. CONCLUSIONES:: teniendo en cuenta la diversidad de los contextos en diferentes naciones, es importante evaluar sistemáticamente las necesidades de salud del país y de la población para introducir la combinación más adecuada y complementaria de los papeles de la EPA y dar un formato a su aplicación. La introducción con éxito del papel de la EPA en América Latina y el Caribe podría proporcionar una hoja de ruta para funciones similares en otros países de bajos/medios ingresos.

Partners in research: building academic-practice partnerships to educate and mentor advanced practice nurses.

RATIONALE: Clinical practice is the primary focus of advanced practice nursing (APN) roles. However, with unprecedented needs for health care reform and quality improvement (QI), health care administrators are seeking new ways to utilize all dimensions of APN expertise, especially related to research and evidence-based practice. International studies reveal research as the most underdeveloped and underutilized aspect of these roles. AIMS: To improve patient care by strengthening the capacity of advanced practice nurses to integrate research and evidence-based practice activities into their day-to-day practice. METHODS: An academic-practice partnership was created among hospital-based advanced practice nurses, nurse administrators, and APN researchers to create an innovative approach to educate and mentor advanced practice nurses in conducting point-of-care research, QI, or evidence-based practice projects to improve patient, provider, and/or system outcomes. A practice-based research course was delivered to 2 cohorts of advanced practice nurses using a range of teaching strategies including 1-to-1 academic mentorship. All participants completed self-report surveys before and after course delivery. RESULTS: Through participation in this initiative, advanced practice nurses enhanced their knowledge, skills, and confidence in the design, implementation, and/or evaluation of research, QI, and evidence-based practice activities. CONCLUSION: Evaluation of this initiative provides evidence of the acceptability and feasibility of academic-practice partnerships to educate and mentor point-of-care providers on how to lead, implement, and integrate research, QI and evidence-based activities into their practices.

Perspectives of Nurse Practitioner-Physician Collaboration among Nurse Practitioners in Canadian Long-Term Care Homes: A National Survey.

Nurse practitioners (NPs) can play an important role in providing primary care to residents in long-term care (LTC) homes. However, relatively little is known about the day-to-day collaboration between NPs and physicians (MDs) in LTC, or factors that may influence this collaboration. Survey data from NPs in Canadian LTC homes were used to explore these issues. Thirty-seven of the 45 (82%) identified LTC NPs across Canada completed the survey. NPs worked with an average of 3.4 MDs, ranging from 1-26 MDs. The most common reasons for collaborating included managing acute and chronic conditions, and updating MDs on resident status changes. Satisfaction with NP-MD collaboration was high, and did not significantly differ among NPs working full versus part time, NPs working in a single versus multiple homes, or NPs with more versus less experience. By understanding the nature of NP-MD collaboration, we can identify ways of supporting and enhancing collaboration between these professionals.

Advanced Practice Nursing: A Strategy for Achieving Universal Health Coverage and Universal Access to Health / Enfermagem com prática avançada: uma estratégia para atingir cobertura universal de saúde e acesso universal à saúde / Enfermería con práctica avanzada: una estrategia para lograr la cobertura universal de salud y el acceso universal a la salud

ABSTRACT Objective: to examine advanced practice nursing (APN) roles internationally to inform role development in Latin America and the Caribbean to support universal health coverage and universal access to health. Method: we examined literature related to APN roles, their global deployment, and APN effectiveness in relation to universal health coverage and access to health. Results: given evidence of their effectiveness in many countries, APN roles are ideally suited as part of a primary health care workforce strategy in Latin America to enhance universal health coverage and access to health. Brazil, Chile, Colombia, and Mexico are well positioned to build this workforce. Role implementation barriers include lack of role clarity, legislation/regulation, education, funding, and physician resistance. Strong nursing leadership to align APN roles with policy priorities, and to work in partnership with primary care providers and policy makers is needed for successful role implementation. Conclusions: given the diversity of contexts across nations, it is important to systematically assess country and population health needs to introduce the most appropriate complement and mix of APN roles and inform implementation. Successful APN role introduction in Latin America and the Caribbean could provide a roadmap for similar roles in other low/middle income countries.

RESUMO Objetivo: analisar o papel da enfermagem com prática avançada (EPA) a nível internacional para um relatório do seu desenvolvimento na América Latina e no Caribe, para apoiar a cobertura universal de saúde e o acesso universal à saúde. Método: análise da bibliografia relacionada com os papéis da EPA, sua implantação no mundo e a eficácia da EPA em relação à cobertura universal de saúde e acesso à saúde. Resultados: dada a evidência da sua eficácia em muitos países, as funções da EPA são ideais como parte de uma estratégia de recursos humanos de atenção primária de saúde na América Latina para melhorar a cobertura universal de saúde e o acesso à saúde. Brasil, Chile, Colômbia e México estão bem posicionados para construir esta força de trabalho. Barreiras à implementação destas funções incluem: a falta de clareza do seu papel, a legislação/regulamentação, educação, financiamento, e a resistência médica. Uma liderança forte de enfermagem é necessária para alinhar o papel da EPA com as prioridades políticas e trabalhar em colaboração com os profissionais de atenção primária e os decisores políticos para a implementação bem sucedida das suas funções. Conclusões: dada a diversidade de contextos dos diferentes países, é importante avaliar sistematicamente as necessidades de saúde do país e da população para introduzir a combinação mais adequada e complementar dos papéis da EPA e formatar sua aplicação. A introdução bem sucedida do papel da EPA na América Latina e no Caribe poderia fornecer um roteiro para funções semelhantes noutros países de baixa/média renda.

RESUMEN Objetivo: examinar el rol de la enfermería con práctica avanzada (EPA) a nivel internacional para informar de su desarrollo en América Latina y el Caribe, en apoyo a la cobertura de salud universal y el acceso universal a la salud. Método: se analizó la literatura relacionada con los roles de la EPA, su despliegue en el mundo y la eficacia de EPA en relación con la cobertura de salud universal y el acceso a la salud. Resultados: dada la evidencia de su eficacia en muchos países, las funciones de la EPA son ideales como parte de una estrategia de recursos humanos de atención primaria de salud en América Latina para mejorar la cobertura de salud universal y el acceso a la salud. Brasil, Chile, Colombia y México están bien posicionados para construir esta fuerza de trabajo. Las barreras a la implementación de estas funciones incluyen: la falta de claridad de su rol, la legislación/regulación, educación, financiamiento, y la resistencia de los médicos. Se necesita un liderazgo fuerte de enfermería para alinear los roles de la EPA con las políticas prioritarias, y trabajar en colaboración con los profesionales de atención primaria y los responsables de las políticas para la implementación exitosa de sus funciones. Conclusiones: teniendo en cuenta la diversidad de los contextos en diferentes naciones, es importante evaluar sistemáticamente las necesidades de salud del país y de la población para introducir la combinación más adecuada y complementaria de los papeles de la EPA y dar un formato a su aplicación. La introducción con éxito del papel de la EPA en América Latina y el Caribe podría proporcionar una hoja de ruta para funciones similares en otros países de bajos/medios ingresos.

An Assessment of How Nurse Practitioners Create Access to Primary Care in Canadian Residential Long-Term Care Settings.

The aim of this paper is to explore the role and activities of nurse practitioners (NPs) working in long-term care (LTC) to understand concepts of access to primary care for residents. Utilizing the "FIT" framework developed by Penchanksy and Thomas, we used a directed content analysis method to analyze data from a pan-Canadian study of NPs in LTC. Individual and focus group interviews were conducted at four sites in western, central and eastern regions of Canada with 143 participants, including NPs, RNs, regulated and unregulated nursing staff, allied health professionals, physicians, administrators and directors and residents and family members. Participants emphasized how the availability and accessibility of the NP had an impact on access to primary and urgent care for residents. Understanding more about how NPs affect access in Canadian LTC will be valuable for nursing practice and healthcare planning and policy and may assist other countries in planning for the introduction of NPs in LTC settings to increase access to primary care.

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.

The effectiveness of a nurse practitioner-led pain management team in long-term care: A mixed methods study.

BACKGROUND: Considering the high rates of pain as well as its under-management in long-term care (LTC) settings, research is needed to explore innovations in pain management that take into account limited resource realities. It has been suggested that nurse practitioners, working within an inter-professional model, could potentially address the under-management of pain in LTC. OBJECTIVES: This study evaluated the effectiveness of implementing a nurse practitioner-led, inter-professional pain management team in LTC in improving (a) pain-related resident outcomes; (b) clinical practice behaviours (e.g., documentation of pain assessments, use of non-pharmacological and pharmacological interventions); and, (c) quality of pain medication prescribing practices. METHODS: A mixed method design was used to evaluate a nurse practitioner-led pain management team, including both a quantitative and qualitative component. Using a controlled before-after study, six LTC homes were allocated to one of three groups: 1) a nurse practitioner-led pain team (full intervention); 2) nurse practitioner but no pain management team (partial intervention); or, 3) no nurse practitioner, no pain management team (control group). In total, 345 LTC residents were recruited to participate in the study; 139 residents for the full intervention group, 108 for the partial intervention group, and 98 residents for the control group. Data was collected in Canada from 2010 to 2012. RESULTS: Implementing a nurse practitioner-led pain team in LTC significantly reduced residents' pain and improved functional status compared to usual care without access to a nurse practitioner. Positive changes in clinical practice behaviours (e.g., assessing pain, developing care plans related to pain management, documenting effectiveness of pain interventions) occurred over the intervention period for both the nurse practitioner-led pain team and nurse practitioner-only groups; these changes did not occur to the same extent, if at all, in the control group. Qualitative analysis highlighted the perceived benefits of LTC staff about having access to a nurse practitioner and benefits of the pain team, along with barriers to managing pain in LTC. CONCLUSIONS: The findings from this study showed that implementing a nurse practitioner-led pain team can significantly improve resident pain and functional status as well as clinical practice behaviours of LTC staff. LTC homes should employ a nurse practitioner, ideally located onsite as opposed to an offsite consultative role, to enhance inter-professional collaboration and facilitate more consistent and timely access to pain management.

Arts-Based Learning: A New Approach to Nursing Education Using Andragogy.

BACKGROUND: Learner-oriented strategies focusing on learning processes are needed to prepare nursing students for complex practice situations. An arts-based learning approach uses art to nurture cognitive and emotional learning. Knowles' theory of andragogy aims to develop the skill of learning and can inform the process of implementing arts-based learning. This article explores the use and evaluation of andragogy-informed arts-based learning for teaching nursing theory at the undergraduate level. METHOD: Arts-based learning activities were implemented and then evaluated by students and instructors using anonymous questionnaires. RESULTS: Most students reported that the activities promoted learning. All instructors indicated an interest in integrating arts-based learning into the curricula. Facilitators and barriers to mainstreaming arts-based learning were highlighted. Findings stimulate implications for prospective research and education. CONCLUSION: Findings suggest that arts-based learning approaches enhance learning by supporting deep inquiry and different learning styles. Further exploration of andragogy-informed arts-based learning in nursing and other disciplines is warranted. [J Nurs Educ. 2016;55(7):407-410.].

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.

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.

Engaging Street-Involved Youth in Dialectical Behaviour Therapy: A Secondary Analysis.

OBJECTIVE: The objective of this secondary analysis was to identify factors associated with engagement of street-involved youth in a Dialectical Behavioural Therapy (DBT) intervention. METHODS: This was a cross-sectional correlational study. Youth were recruited from two agencies providing services to street-involved youth in Canada. Mental health indicators were selected for this secondary analysis to gain a better understanding of characteristics that may account for levels of engagement. RESULTS: Three distinct groups of participants were identified in the data, a) youth who expressed intention to engage, but did not start DBT (n=16); b) youth who started DBT but subsequently dropped out (n=39); and c) youth who completed the DBT intervention (n=67). Youth who did engage in the DBT intervention demonstrated increased years of education; increased depressive symptoms and suicidality; and lower levels of resilience and self-esteem compared to youth participants who did not engage in the intervention. CONCLUSIONS: These findings indicate that it is possible to engage street-involved youth in a DBT intervention who exhibit a high degree of mental health challenges. Despite the growing literature describing the difficult psychological and interpersonal circumstances of street-involved youth, there remains limited research regarding the process of engaging these youth in service.

OBJECTIF: L'objectif de cette analyse secondaire était d'identifier les facteurs associés à l'engagement des adolescents de la rue dans une intervention de thérapie comportementale dialectique (TCD). MÉTHODES: Il s'agissait d'une étude corrélationnelle transversale. Les adolescents ont été recrutés dans deux organismes offrant des services aux adolescents de la rue du Canada. Des indicateurs de la santé mentale ont été sélectionnés pour cette analyse secondaire afin de mieux comprendre les caractéristiques qui peuvent rendre compte des niveaux d'engagement. RÉSULTAT: Trois groupes de participants distincts ont été identifiés dans les données: a) les adolescents qui ont exprimé l'intention de s'engager, mais n'ont pas commencé la TCD (n = 16); b) les adolescents qui ont commencé la TCD mais l'ont ensuite abandonnée (n = 39); et c) les adolescents qui ont terminé l'intervention de TCD (n = 67). Les adolescents qui se sont engagés dans l'intervention de TCD ont démontré plus d'années de scolarité, des symptômes accrus de dépression et de suicidabilité, et des niveaux plus faibles de résilience et d'estime de soi comparativement aux adolescents participants qui ne se sont pas engagés dans l'intervention. CONCLUSIONS: Ces résultats indiquent qu'il est possible d'engager dans une intervention de TCD des adolescents de la rue qui présentent un degré élevé de problèmes de santé mentale. Malgré la littérature croissante décrivant les circonstances psychologiques et interpersonnelles difficiles des adolescents dans la rue, la recherche demeure limitée à l'égard du processus d'engager ces adolescents dans les services.

The clinical effectiveness and cost-effectiveness of clinical nurse specialist-led hospital to home transitional care: a systematic review.

RATIONALE, AIMS AND OBJECTIVES: Clinical nurse specialists (CNSs) are major providers of transitional care. This paper describes a systematic review of randomized controlled trials (RCTs) evaluating the clinical effectiveness and cost-effectiveness of CNS transitional care. METHODS: We searched 10 electronic databases, 1980 to July 2013, and hand-searched reference lists and key journals for RCTs that evaluated health system outcomes of CNS transitional care. Study quality was assessed using the Cochrane Risk of Bias and Quality of Health Economic Studies tools. The quality of evidence for individual outcomes was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool. We pooled data for similar outcomes. RESULTS: Thirteen RCTs of CNS transitional care were identified (n = 2463 participants). The studies had low (n = 3), moderate (n = 8) and high (n = 2) risk of bias and weak economic analyses. Post-cancer surgery, CNS care was superior in reducing patient mortality. For patients with heart failure, CNS care delayed time to and reduced death or re-hospitalization, improved treatment adherence and patient satisfaction, and reduced costs and length of re-hospitalization stay. For elderly patients and caregivers, CNS care improved caregiver depression and reduced re-hospitalization, re-hospitalization length of stay and costs. For high-risk pregnant women and very low birthweight infants, CNS care improved infant immunization rates and maternal satisfaction with care and reduced maternal and infant length of hospital stay and costs. CONCLUSIONS: There is low-quality evidence that CNS transitional care improves patient health outcomes, delays re-hospitalization and reduces hospital length of stay, re-hospitalization rates and costs. Further research incorporating robust economic evaluation is needed.

Cost-effectiveness of nurse practitioners in primary and specialised ambulatory care: systematic review.

OBJECTIVE: To determine the cost-effectiveness of nurse practitioners delivering primary and specialised ambulatory care. DESIGN: A systematic review of randomised controlled trials reported since 1980. DATA SOURCES: 10 electronic bibliographic databases, handsearches, contact with authors, bibliographies and websites. INCLUDED STUDIES: Randomised controlled trials that evaluated nurse practitioners in alternative and complementary ambulatory care roles and reported health system outcomes. RESULTS: 11 trials were included. In four trials of alternative provider ambulatory primary care roles, nurse practitioners were equivalent to physicians in all but seven patient outcomes favouring nurse practitioner care and in all but four health system outcomes, one favouring nurse practitioner care and three favouring physician care. In a meta-analysis of two studies (2689 patients) with minimal heterogeneity and high-quality evidence, nurse practitioner care resulted in lower mean health services costs per consultation (mean difference: -€6.41; 95% CI -€9.28 to -€3.55; p<0.0001) (2006 euros). In two trials of alternative provider specialised ambulatory care roles, nurse practitioners were equivalent to physicians in all but three patient outcomes and one health system outcome favouring nurse practitioner care. In five trials of complementary provider specialised ambulatory care roles, 16 patient/provider outcomes favouring nurse practitioner plus usual care, and 16 were equivalent. Two health system outcomes favoured nurse practitioner plus usual care, four favoured usual care and 14 were equivalent. Four studies of complementary specialised ambulatory care compared costs, but only one assessed costs and outcomes jointly. CONCLUSIONS: Nurse practitioners in alternative provider ambulatory primary care roles have equivalent or better patient outcomes than comparators and are potentially cost-saving. Evidence for their cost-effectiveness in alternative provider specialised ambulatory care roles is promising, but limited by the few studies. While some evidence indicates nurse practitioners in complementary specialised ambulatory care roles improve patient outcomes, their cost-effectiveness requires further study.