Publications by authors named "Faith Donald"

53 Publications

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

Nurs Leadersh (Tor Ont) 2020 Jun;33(2):67-79

Senior Methodologist, Institute for Clinical Evaluative Sciences, Toronto, ON.

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.
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http://dx.doi.org/10.12927/cjnl.2020.26236DOI Listing
June 2020

Who benefits most? A preliminary secondary analysis of stages of change among street-involved youth.

Arch Psychiatr Nurs 2019 04 29;33(2):143-148. Epub 2018 Nov 29.

Covenant House Pennsylvania, 31 E. Armat Street, Philadelphia, PA, United States of America. Electronic address:

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http://dx.doi.org/10.1016/j.apnu.2018.11.011DOI Listing
April 2019

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

J Adv Nurs 2019 Jun 24;75(6):1306-1315. Epub 2019 Mar 24.

Ministère de la Santé et des Services sociaux, Quebec, QC, Canada.

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.
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http://dx.doi.org/10.1111/jan.13962DOI Listing
June 2019

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

J Child Adolesc Psychiatr Nurs 2017 May 28;30(2):98-104. Epub 2017 Sep 28.

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

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.
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http://dx.doi.org/10.1111/jcap.12179DOI Listing
May 2017

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

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

Rev Lat Am Enfermagem 2017 Jan 30;25:e2826. Epub 2017 Jan 30.

MSc, Nurse Practitioner (NP), Halton Region Health Unit, Oakville, ON, Canada.

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.
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http://dx.doi.org/10.1590/1518-8345.1677.2826DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5288863PMC
January 2017

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

Nurs Leadersh (Tor Ont) 2017 ;30(4):10-25

Associate Professor, Daphne Cockwell School of Nursing, Ryerson University, Toronto, ON.

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.
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http://dx.doi.org/10.12927/cjnl.2017.25452DOI Listing
November 2018

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

J Eval Clin Pract 2017 Apr 1;23(2):382-390. Epub 2016 Nov 1.

School of Nursing, McMaster University, Hamilton, ON, Canada.

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.
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http://dx.doi.org/10.1111/jep.12630DOI Listing
April 2017

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

Nurs Leadersh (Tor Ont) 2016 ;29(2):45-63

Associate Professor, Daphne Cockwell School of Nursing, Ryerson University, Adjunct Scientist, Institute of Clinical Evaluative Sciences, Li Ka Shing Knowledge Institute, St. Michael's Hospital and West Park Healthcare Centre, Toronto, ON.

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.
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http://dx.doi.org/10.12927/cjnl.2016.24806DOI Listing
April 2018

Nurse practitioner caseload in primary health care: Scoping review.

Int J Nurs Stud 2016 Oct 25;62:170-82. Epub 2016 Jul 25.

School of Nursing, Dalhousie University, Box 15000, 5869 University Ave., Halifax, NS, B3H 4R2, Canada.

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.
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http://dx.doi.org/10.1016/j.ijnurstu.2016.07.019DOI Listing
October 2016

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

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

J Nurs Educ 2016 Jul;55(7):407-10

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.].
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http://dx.doi.org/10.3928/01484834-20160615-10DOI Listing
July 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

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

Nurse practitioner interactions in acute and long-term care: an exploration of the role of knotworking in supporting interprofessional collaboration.

BMC Nurs 2015 14;14:50. Epub 2015 Oct 14.

Health, Social Care & Education, Kingston University & St George's, University of London, London, UK.

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.
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http://dx.doi.org/10.1186/s12912-015-0102-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4606543PMC
October 2015

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

J Can Acad Child Adolesc Psychiatry 2015 31;24(2):116-22. Epub 2015 Aug 31.

Associate Professor, Daphne Cockwell School of Nursing, Ryerson University, Toronto, Ontario.

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.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4558982PMC
September 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

A survey of interprofessional activity of acute and long-term care employed nurse practitioners.

J Am Assoc Nurse Pract 2015 Sep 20;27(9):507-13. Epub 2015 Feb 20.

Health, Social Care & Education, Kingston University, London, United Kingdom.

Purpose: To describe activities of interprofessional (IP) care, a key aspect of high-quality care, performed by nurse practitioners (NPs) employed in acute and long-term care institutions.

Data Sources: We developed and tested a new theory-driven process tool to quantify NP everyday activities of IP care. We then invited NPs in acute and long-term care to complete the IP self-assessment tool (IPSAT).

Conclusions: The IPSAT is a validated tool shown to be reliable for use with NPs. Testing with other healthcare professionals is suggested. More than 50% of NPs engage in all activities of IP care. Many engage in shared decision making, professional relationship, communication, and partnership or collaboration activities on most work days. Less-common activities were interdependence and collective problem solving including efforts to create role clarity.

Implications For Practice: It is important to evaluate the everyday use of activities that enhance high-quality care. Awareness and enhanced knowledge of IP care activities such as promoting interdependence, collective problem solving, and ensuring role clarity will improve care quality. The tool results are valuable for practicing NPs and their educators to reflect on practice and advance knowledge to influence purposeful engagement in interprofessional care.
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http://dx.doi.org/10.1002/2327-6924.12213DOI Listing
September 2015

A mixed methods study of the work patterns of full-time nurse practitioners in nursing homes.

J Clin Nurs 2015 May 19;24(9-10):1327-37. Epub 2014 Dec 19.

School of Nursing, Dalhousie University, Halifax, NS, Canada; Canadian Centre for Advanced Practice Nursing Research, School of Nursing, McMaster University, Hamilton, ON, Canada.

Aims And Objectives: The aim of this study was to explore the integration of the nurse practitioner role in Canadian nursing homes to enable its full potential to be realised for resident and family care. The objective was to determine nurse practitioners' patterns of work activities.

Background: Nurse practitioners were introduced in Canadian nursing homes a decade ago on a pilot basis. In recent years, government and nursing home sector interest in the role has grown along with the need for data to inform planning efforts.

Design: The study used a sequential mixed methods design using a national survey followed by case studies.

Methods: A national survey of nurse practitioners included demographic items and the EverCare Nurse Practitioner Role and Activity Scale. Following the survey, case studies were conducted in four nursing homes. Data were collected using individual and focus group interviews, document reviews and field notes.

Results: Twenty-three of a target population of 26 nurse practitioners responded to the survey, two-thirds of whom provided services in nursing homes with one site and the remainder in nursing homes with as many as four sites. On average, nurse practitioners performed activities in communicator, clinician, care manager/coordinator and coach/educator subscales at least three to four times per week and activities in the collaborator subscale once a week. Of the 43 activities, nurse practitioners performed daily, most were in the clinician and communicator subscales. Case study interviews involved 150 participants. Findings complemented those of the survey and identified additional leadership activities.

Conclusion: Nurse practitioners undertake a range of primary health care and advanced practice activities which they adapt to meet the unique needs of nursing homes.

Relevance To Clinical Practice: Knowledge of work patterns enables nursing homes to implement the full range of nurse practitioner roles and activities to enhance resident and family care.
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http://dx.doi.org/10.1111/jocn.12741DOI Listing
May 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 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

Development of a measure to assess healthcare providers' implementation of patient-centered care.

Worldviews Evid Based Nurs 2014 Aug 15;11(4):248-57. Epub 2014 Jul 15.

Professor and Canada Research Chair, Daphne Cockwell School of Nursing, Ryerson University, Toronto, ON, Canada.

Background: Patient-centered care (PCC) is a vaguely defined element of high-quality care, which precludes its consistent and precise operationalization. A conceptualization of PCC was derived from the literature and guided the development of an instrument to assess implementation of PCC by healthcare providers. The items of the instrument capture specific activities that reflect three components of PCC: holistic, collaborative, and responsive care. This paper reports on the measure's content and construct validity and reliability.

Methods: Content validity was evaluated in a sample of 11 nurse practitioners who rated the relevance of each items' content in reflecting the respective component of PCC. The content validity index (CVI) was estimated. Construct validity and internal consistency reliability were examined in a survey of 149 nurse practitioners employed in acute care institutions, using factor analysis and the KR-20 coefficient, respectively.

Results: The CVIs were 100% for the three subscales assessing the holistic, collaborative, and responsive care components of PCC. The items in each subscale loaded on one factor. The KR-20 coefficients were .66, .70, and .42, respectively. Overall, the majority (>70%) of respondents indicated performance of the activities comprising the three components of PCC.

Linking Evidence To Action: The PCC measure demonstrated acceptable psychometric properties. The low variance in responses, which is anticipated for instruments assessing fidelity of intervention implementation, accounts for the low reliability coefficients. Additional testing of the measure's psychometric properties in different groups of healthcare providers is warranted. The measure can be used to monitor healthcare providers' implementation of PCC in their usual practice.
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http://dx.doi.org/10.1111/wvn.12047DOI Listing
August 2014

A value-added benefit of nurse practitioners in long-term care settings: increased nursing staff's ability to care for residents.

Nurs Leadersh (Tor Ont) 2013 Sep;26(3):24-37

Esther Sangster-Gormley, RN, PhD, Associate Professor, University of Victoria School of Nursing, Victoria, BC.

The number of people living longer is increasing, and those with physical or cognitive impairments may need admission into long-term care settings. In long-term care there is a need to increase nursing staff's capacity to meet the care needs of residents, develop a team approach to providing care and provide opportunities for staff to improve their knowledge and skills. One approach to meet these needs has been to employ a nurse practitioner (NP). The purpose of this paper is to examine nursing staff's perceptions of how working with an NP affected their ability to provide care, function as a team and increase their knowledge and skill. Data used in this paper were obtained from nursing staff and managers who participated in focus groups that were part of case studies conducted in the second phase of a larger sequential, two-phase mixed-methods study. NPs used multiple approaches to increase staff knowledge and skills and improve quality of care. These findings describe the benefits of employing NPs in long-term care settings.
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http://dx.doi.org/10.12927/cjnl.2013.23552DOI Listing
September 2013

Role of the nurse practitioner in providing palliative care in long-term care homes.

Int J Palliat Nurs 2013 Oct;19(10):477-85

Associate Professor, School of Nursing, McMaster University, Ontario, Canada.

Aim: The purpose of this study, which was part of a large national case study of nurse practitioner (NP) integration in long-term care (LTC), was to explore the NP role in providing palliative care in LTC.

Methods: Using a qualitative descriptive design, data was collected from five LTC homes across Canada using 35 focus groups and 25 individual interviews. In total, 143 individuals working in LTC participated, including 9 physicians, 20 licensed nurses, 15 personal support workers, 19 managers, 10 registered nurse team managers or leaders, 31 allied health care providers, 4 NPs, 14 residents, and 21 family members. The data was coded and analysed using thematic analysis.

Findings: NPs provide palliative care for residents and their family members, collaborate with other health-care providers by providing consultation and education to optimise palliative care practices, work within the organisation to build capacity and help others learn about the NP role in palliative care to better integrate it within the team, and improve system outcomes such as accessibility of care and number of hospital visits.

Conclusions: NPs contribute to palliative care in LTC settings through multifaceted collaborative processes that ultimately promote the experience of a positive death for residents, their family members, and formal caregivers.
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http://dx.doi.org/10.12968/ijpn.2013.19.10.477DOI Listing
October 2013

Resident and family perceptions of the nurse practitioner role in long term care settings: a qualitative descriptive study.

BMC Nurs 2013 Sep 27;12(1):24. Epub 2013 Sep 27.

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

Background: Research evidence supports the positive impact on resident outcomes of nurse practitioners (NPs) working in long term care (LTC) homes. There are few studies that report the perceptions of residents and family members about the role of the NP in these settings. The purpose of this study was to explore the perceptions of residents and family members regarding the role of the NP in LTC homes.

Methods: The study applied a qualitative descriptive approach. In-depth individual and focus group interviews were conducted with 35 residents and family members from four LTC settings that employed a NP. Conventional content analysis was used to identify themes and sub-themes.

Results: Two major themes were identified: NPs were seen as providing resident and family-centred care and as providing enhanced quality of care. NPs established caring relationships with residents and families, providing both informational and emotional support, as well as facilitating their participation in decision making. Residents and families perceived the NP as improving availability and timeliness of care and helping to prevent unnecessary hospitalization.

Conclusions: The perceptions of residents and family members of the NP role in LTC are consistent with the concepts of person-centred and relationship-centred care. The relationships NPs develop with residents and families are a central means through which enhanced quality of care occurs. Given the limited use of NPs in LTC settings, there is an opportunity for health care policy and decision makers to address service inadequacies through strategic deployment of NPs in LTC settings. NPs can use their expert knowledge and skill to assist residents and families to make informed choices regarding their health care and maintain a positive care experience.
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http://dx.doi.org/10.1186/1472-6955-12-24DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3849937PMC
September 2013

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

Can Fam Physician 2013 Jun;59(6):e282-9

Département de médecine de famille et de médecine d'urgence, Université de Montréal, CRCHUM, Hôtel-Dieu - Pavillon Vimont, local 3:230, 3840 St-Urbain, Montréal, QC H2W 1T8, Canada.

Objective: To evaluate the effect of the Provider and Patient Reminders in Ontario: Multi-Strategy Prevention Tools (P-PROMPT) reminder and recall system and pay-for-performance incentives on the delivery rates of cervical and breast cancer screening in primary care practices in Ontario, with or without deployment of nurse practitioners (NPs).

Design: Before-and-after comparisons of the time-appropriate delivery rates of cervical and breast cancer screening using the automated and NP-augmented strategies of the P-PROMPT reminder and recall system.

Setting: Southwestern Ontario.

Participants: A total of 232 physicians from 24 primary care network or family health network groups across 110 different sites eligible for pay-for-performance incentives.

Interventions: The P-PROMPT project combined pay-for-performance incentives with provider and patient reminders and deployment of NPs to enhance the delivery of preventive care services.

Main Outcome Measures: The mean delivery rates at the practice level of time-appropriate mammograms and Papanicolaou tests completed within the previous 30 months.

Results: Before-and-after comparisons of time-appropriate delivery rates (< 30 months) of cancer screening showed the rates of Pap tests and mammograms for eligible women significantly increased over a 1-year period by 6.3% (P < .001) and 5.3% (P < .001), respectively. The NP-augmented strategy achieved comparable rate increases to the automated strategy alone in the delivery rates of both services.

Conclusion: The use of provider and patient reminders and pay-for-performance incentives resulted in increases in the uptake of Pap tests and mammograms among eligible primary care patients over a 1-year period in family practices in Ontario.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3681471PMC
June 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
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