Publications by authors named "Alba Dicenso"

72 Publications

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

Int J Nurs Stud 2017 Jul 4;72:71-82. Epub 2017 May 4.

Department of Community Health Sciences and Faculty of Medicine, Cumming School of Medicine, University of Calgary, Health Research Innovation Centre, Room 3C58, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada. Electronic address:

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.
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http://dx.doi.org/10.1016/j.ijnurstu.2017.04.012DOI Listing
July 2017

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

Int J Nurs Stud 2016 Oct 26;62:156-67. Epub 2016 Jul 26.

Department of Clinical Epidemiology and Biostatistics, McMaster University, Canada; Department of Family Medicine, Canada.

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.
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http://dx.doi.org/10.1016/j.ijnurstu.2016.07.022DOI Listing
October 2016

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

J Adv Nurs 2016 Sep 27;72(9):2138-52. Epub 2016 Apr 27.

Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Alberta, Canada.

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.
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http://dx.doi.org/10.1111/jan.12989DOI Listing
September 2016

Relationship Between Clinical Nurse Specialist Role Implementation, Satisfaction, and Intent to Stay.

Clin Nurse Spec 2016 May-Jun;30(3):159-66

Author Affiliations: Assistant Professor, Faculty of Nursing, Université de Montreal, Affiliate Faculty, Canadian Centre for Advanced Practice Nursing Research, and Researcher, Hôpital Maisonneuve-Rosemont Research Centre, Montréal, Quebec (Dr Kilpatrick); Assistant Professor, Department of Nursing, Université du Québec (Dr Tchouaket); Assistant Professor, School of Nursing, McMaster University, and Affiliate Faculty, Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario (Dr Carter); Associate Professor, School of Nursing and Department of Oncology, McMaster University, and Co-Director, Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario (Dr Bryant-Lukosius); and Professor Emeritus, School of Nursing, and Department of Clinical Epidemiology & Biostatistics, McMaster University, and Senior Advisor, Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario, Canada (Dr DiCenso).

Purpose/objective: There is a lack of research examining the relationship between role satisfaction and intent to remain in one's professional role from the perspective of nurses in advanced practice roles. The purpose of this study is to examine the strength of the relationship between clinical nurse specialist (CNS) role implementation, role satisfaction, and intent to remain in a CNS role.

Design: We conducted a secondary analysis of data from a cross-sectional survey.

Setting: The setting of this study was Canada.

Sample: We included 423 of 471 (90%) questionnaires of graduate-prepared CNSs.

Methods: We surveyed all CNSs in Canada from April to August 2011. Cronbach's α (.79-.96) was used to assess the reliability of the portion of the questionnaire that measured CNS role dimensions. Using logistic regression analysis, we examined the relationship between CNS role implementation, role satisfaction, and intent to stay.

Results: Clinical, research, scholarly and professional development, and consultation activities were significantly associated with improved CNS role satisfaction, and role satisfaction positively influenced intent to stay. However, CNS roles heavily focused on consultation activities negatively influenced CNS intent to stay. Only scholarly and professional development activities both improved role satisfaction and indirectly influenced intent to stay in the role.

Conclusion/implications: There is a small positive association between some CNS role dimensions and role satisfaction, and role satisfaction positively influences intent to stay. However, too many consultation activities decreased CNS intent to remain in the role. Given the multidimensional role of the CNS and unique patient needs, CNSs will want to work closely with their managers to design a role that meets patient needs and optimizes CNS satisfaction and intent to stay in the role. Further research is needed to understand if CNS role implementation influences CNS departures and the relationship between intending to leave and actual departures from a CNS role.
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http://dx.doi.org/10.1097/NUR.0000000000000203DOI Listing
October 2016

Structural and Process Factors That Influence Clinical Nurse Specialist Role Implementation.

Clin Nurse Spec 2016 Mar-Apr;30(2):89-100

Author Affiliations: Assistant Professor, Faculty of Nursing, Université de Montreal, Affiliate Faculty, Canadian Centre for Advanced Practice Nursing Research, and Researcher, Hôpital Maisonneuve-Rosemont Research Centre, Montréal, Quebec (Dr Kilpatrick); Assistant Professor, Department of Nursing, Université du Québec en Outaouais, Saint-Jérôme, Québec (Dr Tchouaket); Assistant Professor, School of Nursing, McMaster University, and Affiliate Faculty, Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario (Dr Carter); Associate Professor, School of Nursing and Department of Oncology, McMaster University, and Codirector, Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario (Dr Bryant-Lukosius); and Professor Emeritus, School of Nursing and Department of Clinical Epidemiology & Biostatistics, McMaster University, and Senior Advisor, Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario (Dr DiCenso), Canada.

Purpose/objectives: The aim of this study was to examine the influence of structure and process on clinical nurse specialist (CNS) role implementation.

Design: We conducted a secondary analysis of cross-sectional survey data.

Setting: The study was performed in Canada.

Sample: The authors included 445 of 471 questionnaires (94.5%) of graduate-prepared CNSs.

Methods: Based on Donabedian's framework, we conducted a secondary analysis of CNS responses using hierarchical regression. The internal consistency of the 6 CNS role dimensions and team dynamics subscales was excellent.

Results: The use of a framework to guide CNS role implementation influences all the role dimensions. Employer understanding of the CNS role, working in an urban catchment area, specialty certification, and more years in a CNS role had a direct positive influence on team dynamics. Full-time employment exerted a direct negative influence on this dimension. Furthermore, team dynamics (as a mediator variable), seeing patients in practice, and having an office in the clinical unit exerted a direct positive influence on the clinical dimension. Having an annual performance appraisal and a job description exerted a direct negative influence on the clinical dimension. Employer understanding, working in an urban area, full-time employment, and specialty certification had an indirect effect on the clinical dimension. Accountability to a nonnurse manager exerted a direct negative influence on the education dimension. The research and scholarly/professional development dimensions were influenced by more years in a CNS role. Accountability to a nurse manager exerted a direct positive influence on the organizational leadership dimension; unionization and seeing patients in practice had a direct negative influence on this dimension. Seeing patients in practice and full-time employment exerted a direct positive influence on the consultation dimension.

Implications: The identification of structures and processes that influence CNS role implementation may inform strategies used by providers and decision makers to optimize these roles across healthcare settings and support the delivery of high-quality care.
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http://dx.doi.org/10.1097/NUR.0000000000000182DOI Listing
November 2016

A Systematic Review of the Cost-Effectiveness of Clinical Nurse Specialists and Nurse Practitioners in Inpatient Roles.

Nurs Leadersh (Tor Ont) 2015 Sep;28(3):56-76

Professor Emeritus, School of Nursing and Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON.

The objective of this systematic review was to synthesize the evidence of the effectiveness and cost-effectiveness of clinical nurse specialists (CNSs) and nurse practitioners (NPs) working in alternative or complementary roles in inpatient settings. Those in alternative roles substitute for another provider and deliver similar services. Those in complementary roles deliver additional services to meet patient health needs. We searched 10 electronic databases, reference lists, pertinent journals and websites from 1980 to July 2012 with no language, publication or geographical restrictions. Study identification and assessment were completed independently by two-member teams. Internal validity was assessed using the Cochrane Risk of Bias tool. The quality of the economic analysis was evaluated using the Quality of Health Economic Studies (QHES) instrument. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was used to assess outcome-specific quality of evidence. Three dated trials evaluated CNS and NP inpatient roles; they were conducted in North America and included 488 adults and 821 neonates. In one study, CNSs in complementary provider roles, when compared with usual care, were equally effective with equal resource use (very low-quality evidence). In two studies, NPs in alternative roles, when compared with physicians, were equally effective with equal-to-more resource use and equal costs (low- to moderate-quality evidence). The quality of the economic analyses was poor. Only three dated studies were identified. More research is needed to determine cost-effectiveness and inform policies and decisions related to the implementation of CNSs and NPs working exclusively in inpatient roles.
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September 2015

Interprofessional dietary assessment practices in primary care: A mixed-methods study.

J Interprof Care 2016 20;30(1):77-82. Epub 2016 Jan 20.

d School of Nursing , McMaster University , Hamilton , Ontario , Canada.

Patients in primary care (PC) are often counselled on diet, and assessment of current food intake is a necessary prerequisite for individualized nutrition care. This sequential mixed-methods study explored current diet assessment (DA) practices in team-based PC in Ontario, Canada, with interdisciplinary focus groups (FGs) followed by a web-based survey. Eleven FGs (n = 50) discussed key patient groups and health conditions requiring DA, as well as facilitators and barriers to accurate DA. Interpretative analysis revealed three themes: DA as a common activity that differed by health profession, communication of DA results within the team, and nutrition care as a collaborative team activity. A total of 191 providers from 73 Family Health Teams completed the web-based survey, and confirmed that many providers are frequently doing DA and that methods vary by discipline. Most providers conducted DAs every day or almost every day. As expected, dietitians used more formal and detailed methods to assess diet than other disciplines, who were more likely to ask a few pointed questions. These baseline data provide information on the range of current DA practices in team-based PC that can inform development of new, more accurate approaches that may improve counselling effectiveness.
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http://dx.doi.org/10.3109/13561820.2015.1064877DOI Listing
February 2017

The Development of Evidence Briefs to Transfer Knowledge About Advanced Practice Nursing Roles to Providers, Policymakers and Administrators.

Nurs Leadersh (Tor Ont) 2015 Mar;28(1):11-23

Professor Emeritus, School of Nursing and Department of Clinical Epidemiology & Biostatistics McMaster University, Hamilton, ON.

The transfer of health-related research knowledge between producers and users is a complex, dynamic and iterative process. There has been little research describing the preferred knowledge transfer strategies used by different stakeholder groups, including healthcare providers, policymakers and administrators. The purpose of the survey was to gain an understanding of the content and preferred dissemination strategies of knowledge users of briefing notes about the effectiveness of advanced practice nursing (APN) roles in Canada. An on-line cross-sectional survey was conducted from December 2011 to January 2012. Purposeful sampling was used to identify the target audience. The questionnaire included six items. The response rate was 44% (n=75/170). Participants identified that the briefing note should concisely summarize definitions for APN roles and information about the safety, effectiveness, cost savings and effective role implementation strategies. Multiple approaches were favoured to disseminate the information. Preferred dissemination strategies included personalized emails, meeting with briefing note recipients, engaging nurse practitioners and clinical nurse specialists in organizations where APN roles have been successfully implemented, engaging the media and using social media. The use of briefing notes has shown promise. More research is needed to evaluate the effectiveness of tailored briefing notes.
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http://dx.doi.org/10.12927/cjnl.2015.24236DOI Listing
March 2015

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

J Eval Clin Pract 2015 Oct 1;21(5):763-81. Epub 2015 Jul 1.

School of Nursing and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.

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.
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http://dx.doi.org/10.1111/jep.12401DOI Listing
October 2015

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

BMJ Open 2015 Jun 8;5(6):e007167. Epub 2015 Jun 8.

School of Nursing and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.

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.
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http://dx.doi.org/10.1136/bmjopen-2014-007167DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4466759PMC
June 2015

Use of electronic dietary assessment tools in primary care: an interdisciplinary perspective.

BMC Med Inform Decis Mak 2015 Feb 25;15:14. Epub 2015 Feb 25.

School of Nursing and Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada.

Background: Dietary assessment can be challenging for many reasons, including the wide variety of foods, eating patterns and nutrients to be considered. In team-based primary care practice, various disciplines may be involved in assessing diet. Electronic-based dietary assessment (e-DA) instruments available now through mobile apps or websites can potentially facilitate dietary assessment. Providers views of facilitators and barriers related to e-DA instruments and their recommendations for improvement can inform the further development of these tools. The objective of this study was to explore provider perspectives on e-DA tools in mobile apps and websites.

Methods: The exploratory sequential mixed methods design included interdisciplinary focus groups followed by a web-based survey sent to Family Health Teams throughout Ontario, Canada. Descriptive and bivariate analyses were completed. Focus group transcripts contributed to web-survey content, while interpretive themes added depth and context.

Results: 11 focus groups with 50 providers revealed varying perspectives on the use of e-DA for: 1) improving patients' eating habits; 2) improving the quality of dietary assessment; and, 3) integrating e-DA into the care process. In the web-survey 191 respondents from nine disciplines in 73 FHTs completed the survey. Dietitians reported greater use of e-DA than other providers (63% vs.19%; p = .000) respectively. There was strong interest among disciplines in the use of e-DA tools for the management of obesity, diabetes and heart disease, especially for patient self-monitoring. Barriers identified were: patients' lack of comfort with using technology, misinterpretation of e-DA results by patients, time and education for providers to interpret results, and time for providers to offer counselling.

Conclusions: e-DA tools in mobile apps and websites may improve dietary counselling over time. Addressing the identified facilitators and barriers can potentially promote the uptake of e-DA into clinical practice.
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http://dx.doi.org/10.1186/s12911-015-0138-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4364652PMC
February 2015

Hospital to community transitional care by nurse practitioners: a systematic review of cost-effectiveness.

Int J Nurs Stud 2015 Jan 6;52(1):436-51. Epub 2014 Aug 6.

School of Nursing and Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4L8, Canada. Electronic address:

Objectives: To determine the cost-effectiveness of nurse practitioners delivering transitional care.

Design: Systematic review of randomised controlled trials.

Data Sources: Ten electronic databases, bibliographies, hand-searches, study authors, and websites.

Review Methods: We included randomised controlled trials that compared formally trained nurse practitioners to usual care and measured health system outcomes. Two reviewers independently screened articles and assessed study quality using the Cochrane Risk of Bias and the Quality of Health Economic Studies tools. We pooled data for similar outcomes and applied the Grading of Recommendations Assessment, Development and Evaluation tool to rate the quality of evidence for each outcome.

Results: Five trials met the inclusion criteria. One evaluated one alternative provider nurse practitioner (154 patients) and four evaluated six complementary provider nurse practitioners (1017 patients). Two were at low and three at high risk of bias and all had weak economic analyses. The alternative provider nurse practitioner had similar patient outcomes and resource use to the physician (low quality). Complementary provider nurse practitioners scored similarly to the control group in patient outcomes except for anxiety in rehabilitation patients (MD: -15.7, 95%CI: -20.73 to -10.67, p<0.001) (very low quality) and patient satisfaction after an abdominal hysterectomy (MD: 14, 95%CI: 3.5-24.5, p<0.01) (low quality), both favouring nurse practitioner care. Meta-analyses of index re-hospitalisation up to 42 days (n=766, pooled relative risk (RR): 0.69, 95%CI: 0.34-1.43, I(2)=0%) and any re-hospitalisation up to 180 days (n=800, pooled RR: 0.87, 95%CI: 0.69-1.09, I(2)=32%) were inconclusive (low quality). Complementary provider nurse practitioners significantly reduced index re-hospitalisation over 90 days (RR: 0.55, 95%CI: 0.32-0.94, p=0.03) and 180 days (RR: 0.62, 95%CI: 0.40-0.95, p=0.03) in complex care patients (both low quality) and they significantly reduced the number and duration of rehabilitation patient-to-staff consultation calls (p<0.05).

Conclusions: Given the low quality evidence, weak economic analyses, small sample sizes, and small number of nurse practitioners evaluated in each study, evidence of the cost-effectiveness of nurse practitioner-transitional care is inconclusive and further research is needed.
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http://dx.doi.org/10.1016/j.ijnurstu.2014.07.011DOI Listing
January 2015

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

Pain Manag Nurs 2015 Apr 6;16(2):78-88. Epub 2014 Nov 6.

Psychology Department, University of Regina, Regina, Saskatchewan, Canada.

Pain management for older adults in long-term care (LTC) has been recognized as a problem internationally. The purpose of this study was to explore the role of a clinical nurse specialist (CNS) and nurse practitioner (NP) as change champions during the implementation of an evidence-based pain protocol in LTC. In this exploratory, multiple-case design study, we collected data from two LTC homes in Ontario, Canada. Three data sources were used: participant observation of an NP and a CNS for 18 hours each over a 3-week period; CNS and NP diaries recording strategies, barriers, and facilitators to the implementation process; and interviews with members of the interdisciplinary team to explore perceptions about the NP and CNS role in implementing the pain protocol. Data were analyzed using thematic content analysis. The NP and CNS used a variety of effective strategies to promote pain management changes in practice including educational outreach with team members, reminders to nursing staff to highlight the pain protocol and educate about practice changes, chart audits and feedback to the nursing staff, interdisciplinary working group meetings, ad hoc meetings with nursing staff, and resident assessment using advanced skills. The CNS and NP are ideal champions to implement pain management protocols and likely other quality improvement initiatives.
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http://dx.doi.org/10.1016/j.pmn.2014.04.002DOI Listing
April 2015

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

Nurs Res Pract 2014 1;2014:896587. Epub 2014 Sep 1.

School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8 ; Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8.

Background. Improved quality of care and control of healthcare costs are important factors influencing decisions to implement nurse practitioner (NP) and clinical nurse specialist (CNS) roles. Objective. To assess the quality of randomized controlled trials (RCTs) evaluating NP and CNS cost-effectiveness (defined broadly to also include studies measuring health resource utilization). Design. Systematic review of RCTs of NP and CNS cost-effectiveness reported between 1980 and July 2012. Results. 4,397 unique records were reviewed. We included 43 RCTs in six groupings, NP-outpatient (n = 11), NP-transition (n = 5), NP-inpatient (n = 2), CNS-outpatient (n = 11), CNS-transition (n = 13), and CNS-inpatient (n = 1). Internal validity was assessed using the Cochrane risk of bias tool; 18 (42%) studies were at low, 17 (39%) were at moderate, and eight (19%) at high risk of bias. Few studies included detailed descriptions of the education, experience, or role of the NPs or CNSs, affecting external validity. Conclusions. We identified 43 RCTs evaluating the cost-effectiveness of NPs and CNSs using criteria that meet current definitions of the roles. Almost half the RCTs were at low risk of bias. Incomplete reporting of study methods and lack of details about NP or CNS education, experience, and role create challenges in consolidating the evidence of the cost-effectiveness of these roles.
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http://dx.doi.org/10.1155/2014/896587DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4167459PMC
September 2014

The use of triangulation in qualitative research.

Oncol Nurs Forum 2014 Sep;41(5):545-7

Department of Oncology, Faculty of Health Sciences, McMaster University, Canada.

Triangulation refers to the use of multiple methods or data sources in qualitative research to develop a comprehensive understanding of phenomena (Patton, 1999). Triangulation also has been viewed as a qualitative research strategy to test validity through the convergence of information from different sources. Denzin (1978) and Patton (1999) identified four types of triangulation: (a) method triangulation, (b) investigator triangulation, (c) theory triangulation, and (d) data source triangulation. The current article will present the four types of triangulation followed by a discussion of the use of focus groups (FGs) and in-depth individual (IDI) interviews as an example of data source triangulation in qualitative inquiry.
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http://dx.doi.org/10.1188/14.ONF.545-547DOI Listing
September 2014

The effectiveness and cost-effectiveness of clinical nurse specialists in outpatient roles: a systematic review.

J Eval Clin Pract 2014 Dec 5;20(6):1106-23. Epub 2014 Jul 5.

Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario, Canada; Faculty of Nursing, Université de Montreal, Montreal, Quebec, Canada; Hôpital Maisonneuve-Rosemont Research Centre, Montreal, Quebec, Canada.

Rationale, Aims And Objectives: Increasing numbers of clinical nurse specialists (CNSs) are working in outpatient settings. The objective of this paper is to describe a systematic review of randomized controlled trials (RCTs) evaluating the cost-effectiveness of CNSs delivering outpatient care in alternative or complementary provider roles.

Methods: We searched CINAHL, MEDLINE, EMBASE and seven other electronic databases, 1980 to July 2012 and hand-searched bibliographies and key journals. RCTs that evaluated formally trained CNSs and health system outcomes were included. Study quality was assessed using the Cochrane risk of bias tool and the Quality of Health Economic Studies instrument. We used the Grading of Recommendations Assessment, Development and Evaluation to assess quality of evidence for individual outcomes.

Results: Eleven RCTs, four evaluating alternative provider (n = 683 participants) and seven evaluating complementary provider roles (n = 1464 participants), were identified. Results of the alternative provider RCTs (low-to-moderate quality evidence) were fairly consistent across study populations with similar patient outcomes to usual care, some evidence of reduced resource use and costs, and two economic analyses (one fair and one high quality) favouring CNS care. Results of the complementary provider RCTs (low-to-moderate quality evidence) were also fairly consistent across study populations with similar or improved patient outcomes and mostly similar health system outcomes when compared with usual care; however, the economic analyses were weak.

Conclusions: Low-to-moderate quality evidence supports the effectiveness and two fair-to-high quality economic analyses support the cost-effectiveness of outpatient alternative provider CNSs. Low-to-moderate quality evidence supports the effectiveness of outpatient complementary provider CNSs; however, robust economic evaluations are needed to address cost-effectiveness.
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http://dx.doi.org/10.1111/jep.12219DOI Listing
December 2014

Clinical nurse specialists in Canada: why are some not working in the role?

Nurs Leadersh (Tor Ont) 2014 Mar;27(1):62-75

Affiliate Faculty, Canadian Centre for Advanced Practice Nursing Research, Assistant Professor, School of Nursing, McMaster University, Hamilton, ON.

Clinical nurse specialists (CNSs) are advanced practice nurses. They contribute to the quality and safety of patient care by providing an advanced level of clinical care to patients and families and by supporting healthcare team members to deliver evidence-based care. CNSs help to reduce healthcare costs when the roles are fully deployed and all the dimensions of the CNS role are implemented. The dimensions of the CNS role include clinical care, organizational leadership, research, education, professional development and consultation to provide patient care. There is a paucity of research on CNSs in Canada. We conducted the first Canada-wide survey of CNSs and asked each nursing regulatory body to identify the CNSs in their registration database. One-quarter (n=196/776) of the regulator-identified CNS respondents whom we contacted for the study were no longer or had never been a CNS. Currently, adequate mechanisms are lacking to identify and track CNSs in Canada, and little is known about the factors that influence CNSs' decisions to leave their role. The non-employed CNS respondents in our survey highlighted that the lack of role clarity, their inability to find employment as a CNS and the inability to implement all the dimensions of the CNS role were key factors in their decision not to work as a CNS. These findings have important implications, given that these factors are potentially modifiable and amenable to decisions made by nursing leaders in organizations and regulatory bodies. Mechanisms to identify and track CNSs in Canada are needed to develop an effective workforce plan and maximize the integration of CNSs in the workforce.
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http://dx.doi.org/10.12927/cjnl.2014.23738DOI Listing
March 2014

Knowledge Transfer and Dissemination of Advanced Practice Nursing Information and Research to Acute-Care Administrators.

Can J Nurs Res 2014 Mar;46(2):10-27

School of Nursing, McMaster University.

The objective of this study was to ascertain the information needs and knowledge-dissemination preferences of acute-care administrators with respect to advanced practice nursing (APN). Supportive leadership is imperative for the success of APN roles and administrators need up-to-date research evidence and information, but it is unclear what the information needs of administrators are and how they prefer to receive the information. A survey tool was developed from the literature and from the findings of a qualitative study with acute-care leaders. Of 107 surveys distributed to nursing administrators in 2 teaching hospitals, 79 (73.8%) were returned. Just over half of respondents reported wanting APN information related to model of care and patient and systems outcomes of APN care; the majority expressed a preference for electronic transmission of the information. Researchers need multiple strategies for distributing context-specific APN evidence and information to nursing administrators.
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http://dx.doi.org/10.1177/084456211404600203DOI Listing
March 2014

Knowledge gaps regarding APN roles: what hospital decision-makers tell us.

Nurs Leadersh (Tor Ont) 2013 Dec;26(4):60-75

Professor, Nursing and Clinical Epidemiology & Biostatistics, McMaster University Hamilton, ON.

The implementation of advanced practice nursing (APN) roles can yield improvements in patient and health system outcomes, and supportive leadership is integral in facilitating the implementation of such roles. The purpose of this study was to explore the awareness and understanding of APN roles among hospital decision-makers, and to learn about the information they require and the ways in which they prefer to receive that information. Fifteen administrators and leaders from two multi-site acute care organizations were interviewed. Their practical knowledge of APN roles was based on experience developing the roles or working with APNs in hospital programs. The most common sources of APN information were internal contacts (i.e., APNs) and documents from nursing organizations. Participants reported difficulty distinguishing between the roles of nurse practitioners (NPs) and clinical nurse specialists (CNSs), and identified knowledge regarding CNS roles as their greatest need. They required specific information regarding the "value-added" benefits offered by an APN role. Strategies to address the knowledge gaps of healthcare leaders are urgently needed in order to support the implementation of new APN roles and to sustain existing ones.
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http://dx.doi.org/10.12927/cjnl.2013.23629DOI Listing
December 2013

Mobilization patterns of patients after an acute myocardial infarction: a pilot study.

Clin Nurs Res 2015 Apr 12;24(2):139-55. Epub 2013 Nov 12.

McMaster University, Hamilton, Ontario, Canada.

This study was aimed to identify the mobilization patterns of acute myocardial infarction (AMI) patients during their first three days in the coronary care unit (CCU) by performing a prospective observational pilot study design. The study included 31 diagnosed AMI patients admitted to three CCUs. Mobilization patterns classified as bed rest, semi-fowler, transfer to chair, and standing/walking were documented by CCU nurses for 72 consecutive hours after patient admission to the CCU. Of 2,232 possible mobilization periods (72 hr × 31 patients), 1,385 recorded observations of mobilization (62%) were obtained. Bed rest and semi-fowler positions were the most common mobilization patterns; together they accounted for 70% of the documented positions over the first 72 hr in the CCU. Patients who experience an uncomplicated AMI spend the majority of their first 72 hr in CCU in bed.
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http://dx.doi.org/10.1177/1054773813508132DOI Listing
April 2015

Incorporating a health policy practicum in a graduate training program to prepare advanced practice nursing health services researchers.

Policy Polit Nurs Pract 2012 Nov 1;13(4):224-33. Epub 2013 May 1.

School of Nursing and Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada.

Health services research benefits from the active engagement of researchers and policy makers from generation through to application of research-based knowledge. One approach to help graduate students learn about the policy world is through participation in a policy practicum. This is an opportunity to work for a defined period of time in a setting where policy decisions are made. This article focuses on the integration of the policy practicum into graduate nursing education for advanced practice nurses. Ten graduate students and two postdoctoral fellows who had recently completed their practicums and three policy makers who had recently supervised students in provincial, federal, and international practicum projects were invited to submit a narrative about the experience. Based on qualitative analysis of the narratives, this article outlines objectives of the practicum, the policy practicum journey, student learning, and finally, the benefits and challenges of the experience.
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http://dx.doi.org/10.1177/1527154413484067DOI Listing
November 2012

Practice patterns and perceived impact of clinical nurse specialist roles in Canada: results of a national survey.

Int J Nurs Stud 2013 Nov 30;50(11):1524-36. Epub 2013 Mar 30.

Canadian Centre for Advanced Practice Nursing Research, Faculty of Nursing, Université de Montréal, Centre de recherche de l'Hôpital Maisonneuve-Rosemont, Hôpital Maisonneuve-Rosemont, CSA - RC - Aile bleue - Bureau F121, 5415 boul. l'Assomption, Montréal, QC, Canada H1T 2M4. Electronic address:

Background: Clinical nurse specialists are recognized internationally for providing an advanced level of practice. They positively impact the delivery of healthcare services by using specialty-specific expert knowledge and skills, and integrating competencies as clinicians, educators, researchers, consultants and leaders. Graduate-level education is recommended for the role but many countries do not have formal credentialing mechanisms for clinical nurse specialists. Previous studies have found that clinical nurse specialist roles are poorly understood by stakeholders. Few national studies have examined the utilization of clinical nurse specialists.

Objective: To identify the practice patterns of clinical nurse specialists in Canada.

Design: A descriptive cross-sectional survey.

Participants: Self-identified clinical nurse specialists in Canada.

Methods: A 50-item self-report questionnaire was developed, pilot-tested in English and French, and administered to self-identified clinical nurse specialists from April 2011 to August 2011. Data were analyzed using descriptive and inferential statistics and content analysis.

Results: The actual number of clinical nurse specialists in Canada remains unknown. The response rate using the number of registry-identified clinical nurse specialists was 33% (804/2431). Of this number, 608 reported working as a clinical nurse specialist. The response rate for graduate-prepared clinical nurse specialists was 60% (471/782). The practice patterns of clinical nurse specialists varied across clinical specialties. Graduate-level education influenced their practice patterns. Few administrative structures and resources were in place to support clinical nurse specialist role development. The lack of title protection resulted in confusion around who identifies themselves as a clinical nurse specialist and consequently made it difficult to determine the number of clinical nurse specialists in Canada.

Conclusions: This is the first national survey of clinical nurse specialists in Canada. A clearer understanding of these roles provides stakeholders with much needed information about clinical nurse specialist practice patterns. Such information can inform decisions about policies, education and organizational supports to effectively utilize this role in healthcare systems. This study emphasizes the need to develop standardized educational requirements, consistent role titles and credentialing mechanisms to facilitate the identification and comparison of clinical nurse specialist roles and role outcomes internationally.
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http://dx.doi.org/10.1016/j.ijnurstu.2013.03.005DOI Listing
November 2013

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

J Adv Nurs 2013 Oct 25;69(10):2148-61. Epub 2013 Mar 25.

Daphne Cockwell School of Nursing, Ryerson University, Toronto, Ontario, Canada.

Aim: To report quantitative evidence of the effectiveness of advanced practice nursing roles, clinical nurse specialists and nurse practitioners, in meeting the healthcare needs of older adults living in long-term care residential settings.

Background: Although studies have examined the effectiveness of advanced practice nurses in this setting, a systematic review of this evidence has not been conducted.

Design: Quantitative systematic review.

Data Sources: Twelve electronic databases were searched (1966-2010); leaders in the field were contacted; and personal files, reference lists, pertinent journals, and websites were searched for prospective studies with a comparison group.

Review Methods: Studies that met inclusion criteria were reviewed for quality, using a modified version of the Cochrane Effective Practice and Organisation of Care Review Group risk of bias assessment criteria.

Results: Four prospective studies conducted in the USA and reported in 15 papers were included. Long-term care settings with advanced practice nurses had lower rates of depression, urinary incontinence, pressure ulcers, restraint use, and aggressive behaviours; more residents who experienced improvements in meeting personal goals; and family members who expressed more satisfaction with medical services.

Conclusion: Advanced practice nurses are associated with improvements in several measures of health status and behaviours of older adults in long-term care settings and in family satisfaction. Further exploration is needed to determine the effect of advanced practice nurses on health services use; resident satisfaction with care and quality of life; and the skills, quality of care, and job satisfaction of healthcare staff.
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http://dx.doi.org/10.1111/jan.12140DOI Listing
October 2013

Continuing education for primary health care nurse practitioners in Ontario, Canada.

Nurse Educ Today 2013 Apr 11;33(4):353-7. Epub 2012 Aug 11.

School of Nursing, McMaster University, 1280 Main Street West, Room HSC 3N28C, Hamilton, ON, Canada L8S 4K1.

The Council of Ontario University Programs in Nursing offers a nine-university, consortium-based primary health care nurse practitioner education program and on-line continuing education courses for primary health care nurse practitioners. Our study sought to determine the continuing education needs of primary health care nurse practitioners across Ontario, how best to meet these needs, and the barriers they face in completing continuing education. Surveys were completed by 83 (40%) of 209 learners who had participated in continuing education offered by the Council of Ontario University Programs in Nursing between 2004 and 2007. While 83% (n=50) of nurse practitioners surveyed indicated that continuing education was extremely important to them, they also identified barriers to engaging in continuing education offerings including; time intensity of the courses, difficulty taking time off work, family obligations, finances and fatigue. The most common reason for withdrawal from a continuing education offering was the difficulty of balancing work and study demands. Continuing education opportunities are important to Ontario primary health care nurse practitioners, and on-line continuing education offerings have been well received, but in order to be taken up by their target audience they must be relevant, readily accessible, flexible, affordable and offered over brief, intense periods of time using technology that is easy to use and Internet sites that are easily navigated.
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http://dx.doi.org/10.1016/j.nedt.2012.07.018DOI Listing
April 2013

The evaluation of an interdisciplinary pain protocol in long term care.

J Am Med Dir Assoc 2012 Sep 26;13(7):664.e1-8. Epub 2012 Jun 26.

School of Nursing, McMaster University, 1280 Main Street West, Hamilton, Ontario, Canada.

Objectives: To evaluate the effectiveness of (1) dissemination strategies to improve clinical practice behaviors (eg, frequency and documentation of pain assessments, use of pain medication) among health care team members, and (2) the implementation of the pain protocol in reducing pain in long term care (LTC) residents.

Design: A controlled before-after design was used to evaluate the effectiveness of the pain protocol, whereas qualitative interviews and focus groups were used to obtain additional context-driven data.

Setting: Four LTC facilities in southern Ontario, Canada; 2 for the intervention group and 2 for the control group.

Participants: Data were collected from 200 LTC residents; 99 for the intervention and 101 for the control group.

Intervention: Implementation of a pain protocol using a multifaceted approach, including a site working group or Pain Team, pain education and skills training, and other quality improvement activities.

Measurements: Resident pain was measured using 3 assessment tools: the Pain Assessment Checklist for Seniors with Limited Ability to Communicate, the Pain Assessment in the Communicatively Impaired Elderly, and the Present Pain Intensity Scale. Clinical practice behaviors were measured using a number of process indicators; for example, use of pain assessment tools, documentation about pain management, and use of pain medications. A semistructured interview guide was used to collect qualitative data via focus groups and interviews.

Results: Pain increased significantly more for the control group than the intervention group over the 1-year intervention period. There were significantly more positive changes over the intervention period in the intervention group compared with the control group for the following indicators: the use of a standardized pain assessment tool and completed admission/initial pain assessment. Qualitative findings highlight the importance of reminding staff to think about pain as a priority in caring for residents and to be mindful of it during daily activities. Using onsite champions, in this case advanced practice nurses and a Pain Team, were key to successfully implementing the pain protocol.

Conclusions: These study findings indicate that the implementation of a pain protocol intervention improved the way pain was managed and provided pain relief for LTC residents.
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http://dx.doi.org/10.1016/j.jamda.2012.05.013DOI Listing
September 2012

Utilization of nurse practitioners to increase patient access to primary healthcare in Canada--thinking outside the box.

Nurs Leadersh (Tor Ont) 2010 Dec;23 Spec No 2010:239-59

CHSRF/CIHR in Advanced Practice Nursing, Director, Ontario Training Centre in Health Services & Policy Research, McMaster University, Hamilton, ON.

In the past decade, all Canadian provinces and territories have launched various team-based primary healthcare initiatives designed to improve access and continuity of care. Nurse practitioners (NPs) are increasingly becoming integral members of primary healthcare teams across the country. This paper draws on the results of a scoping review of the literature and qualitative key informant interviews conducted for a decision support synthesis about advanced practice nursing in Canada. We describe and analyze two novel approaches to NP integration designed to address the gap in patient access to primary healthcare: (1) the integration of NPs in traditional fee-for-service practices in British Columbia, and (2) the creation of NP-led clinics in Ontario. Although fee-for-service remuneration has been a barrier to collaborative practice, the integration of government-salaried NPs into fee-for-service practices in British Columbia has enabled the creation of inter-professional teams, and based on early evaluation findings, has increased patient access to care and patient and provider satisfaction. NP-led clinics are designed to provide inter-professional care in communities with high numbers of patients who do not have a regular primary healthcare provider. Given the shortage of physicians in communities where these clinics are being introduced, the ratio of physicians to NPs is lower than in other primary healthcare delivery models, and physicians function in more of a consulting role. Initial evaluation of the first of 26 NP-led clinics indicates increased access to care and high levels of patient and provider satisfaction. Implementing a creative mosaic of collaborative primary healthcare models that are responsive to patient needs challenges traditional assumptions about professional roles and responsibilities. To address this challenge, we endorse a recommendation that governments establish a mechanism to bring together both physician and non-physician primary healthcare providers to advise on primary healthcare policy development and implementation.
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http://dx.doi.org/10.12927/cjnl.2010.22281DOI Listing
December 2010

Factors enabling advanced practice nursing role integration in Canada.

Nurs Leadersh (Tor Ont) 2010 Dec;23 Spec No 2010:211-38

CHSRF/CIHR in Advanced Practice Nursing, Ontario Training Centre in Health Services & Policy Research, McMaster University, Hamilton, ON.

Although advanced practice nurses (APNs) have existed in Canada for over 40 years and there is abundant evidence of their safety and effectiveness, their full integration into our healthcare system has not been fully realized. For this paper, we drew on pertinent sections of a scoping review of the Canadian literature from 1990 onward and interviews or focus groups with 81 key informants conducted for a decision support synthesis on advanced practice nursing to identify the factors that enable role development and implementation across the three types of APNs: clinical nurse specialists, primary healthcare nurse practitioners and acute care nurse practitioners. For development of advanced practice nursing roles, many of the enabling factors occur at the federal/provincial/territorial (F/P/T) level. They include utilization of a pan-Canadian approach, provision of high-quality education, and development of appropriate legislative and regulatory mechanisms. Systematic planning to guide role development is needed at both the F/P/T and organizational levels. For implementation of advanced practice nursing roles, some of the enabling factors require action at the F/P/T level. They include recruitment and retention, role funding, intra-professional relations between clinical nurse specialists and nurse practitioners, public awareness, national leadership support and role evaluation. Factors requiring action at the level of the organization include role clarity, healthcare setting support, implementation of all role components and continuing education. Finally, inter-professional relations require action at both the F/P/T and organizational levels. A multidisciplinary roundtable formulated policy and practice recommendations based on the synthesis findings, and these are summarized in this paper.
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http://dx.doi.org/10.12927/cjnl.2010.22279DOI Listing
December 2010

Clinical nurse specialists and nurse practitioners: title confusion and lack of role clarity.

Nurs Leadersh (Tor Ont) 2010 Dec;23 Spec No 2010:189-201

Affiliate Faculty, Daphne Cockwell School of Nursing, Ryerson University, CHSRF/CIHR Program in Advanced Practice Nursing, Toronto, ON.

Title confusion and lack of role clarity pose barriers to the integration of advanced practice nursing roles (i.e., clinical nurse specialist [CNS] and nurse practitioner [NP]). Lack of awareness and understanding about NP and CNS roles among the healthcare team and the public contributes to ambiguous role expectations, confusion about NP and CNS scopes of practice and turf protection. This paper draws on the results of a scoping review of the literature and qualitative key informant interviews conducted for a decision support synthesis commissioned by the Canadian Health Services Research Foundation and the Office of Nursing Policy in Health Canada. The goal of this synthesis was to develop a better understanding of advanced practice nursing roles and the factors that influence their effective development and integration in the Canadian healthcare system. Specific recommendations from interview participants and the literature to enhance title and role clarity included the use of consistent titles for NP and CNS roles; the creation of a vision statement to articulate the role of CNSs and NPs across settings; the use of a systematic planning process to guide role development and implementation; the development of a communication strategy to educate healthcare professionals, the public and employers about the roles; attention to inter-professional team dynamics when introducing these new roles; and addressing inter-professionalism in all health professional education program curricula.
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http://dx.doi.org/10.12927/cjnl.2010.22276DOI Listing
December 2010

The role of nursing leadership in integrating clinical nurse specialists and nurse practitioners in healthcare delivery in Canada.

Nurs Leadersh (Tor Ont) 2010 Dec;23 Spec No 2010:167-85

Junior Faculty, CHSRF/CIHR Program in Advanced Practice Nursing, McMaster University, Hamilton, ON.

Supportive nursing leadership is important for the successful introduction and implementation of advanced practice nursing roles in Canadian healthcare settings. For this paper, we drew on pertinent sections of a scoping review of the literature and key informant interviews conducted for a decision support synthesis on advanced practice nursing to describe and explore organizational leadership in planning and implementing advanced practice nursing roles. Leadership strategies that optimize successful role integration include initiating systematic planning to develop the roles based on patient and community needs, engaging stakeholders, using established Canadian role implementation toolkits, ensuring utilization of all dimensions of the role, communicating clear messages to increase awareness about the roles in the organization, creating networks and facilitating mentorship for those in the role, and negotiating role expectations with physicians and other members of the healthcare team. Leaders face challenges in creating and securing sustainable funding for the roles and providing adequate infrastructure support.
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http://dx.doi.org/10.12927/cjnl.2010.22274DOI Listing
December 2010

The clinical nurse specialist role in Canada.

Nurs Leadersh (Tor Ont) 2010 Dec;23 Spec No 2010:140-66

School of Nursing and Department of Oncology, McMaster University, CHSRF/CIHR Program in Advanced Practice Nursing, Canadian Centre of Excellence in Oncology Advanced Practice Nursing at the Juravinski Cancer Centre, Hamilton, ON.

The clinical nurse specialist (CNS) provides an important clinical leadership role for the nursing profession and broader healthcare system; yet the prominence and deployment of this role have fluctuated in Canada over the past 40 years. This paper draws on the results of a decision support synthesis examining advanced practice nursing roles in Canada. The synthesis included a scoping review of the Canadian and international literature and in-depth interviews with key informants including CNSs, nurse practitioners, other health providers, educators, healthcare administrators, nursing regulators and government policy makers. Key challenges to the full integration of CNSs in the Canadian healthcare system include the paucity of Canadian research to inform CNS role implementation, absence of a common vision for the CNS role in Canada, lack of a CNS credentialing mechanism and limited access to CNS-specific graduate education. Recommendations for maximizing the potential and long-term sustainability of the CNS role to achieve important patient, provider and health system outcomes in Canada are provided.
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http://dx.doi.org/10.12927/cjnl.2010.22273DOI Listing
December 2010
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