The acute care nurse practitioner (ACNP) role was developed in Canada in the late 1980s to offset rapidly increasing physician workloads in acute care settings and to address the lack of continuity of care for seriously ill patients and increased complexity of care delivery. These challenges provided an opportunity to develop an advanced practice nursing role to care for critically ill patients with the intent of improving continuity of care and patient outcomes. For this paper, we drew on the ACNP-related findings of a scoping review of the literature and key informant interviews conducted for a decision support synthesis on advanced practice nursing. The synthesis revealed that ACNPs are working in a range of clinical settings. While ACNPs are trained at the master's level, there is a gap in specialty education for ACNPs. Important barriers to the full integration of ACNP roles into the Canadian healthcare system include lack of full utilization of role components, limitations to scope of practice, inconsistent team acceptance and funding issues. Facilitators to ACNP role implementation include clear communication about the role, with messages tailored to the specific information needs of various stakeholder groups; supportive leadership of healthcare managers; and stable and predictable funding. The status of ACNP roles continues to evolve across Canada. Ongoing leadership and continuing research are required to enhance the integration of these roles into our healthcare system.
The objective of this decision support synthesis was to identify and review published and grey literature and to conduct stakeholder interviews to (1) describe the distinguishing characteristics of clinical nurse specialist (CNS) and nurse practitioner (NP) role definitions and competencies relevant to Canadian contexts, (2) identify the key barriers and facilitators for the effective development and utilization of CNS and NP roles and (3) inform the development of evidence-based recommendations for the individual, organizational and system supports required to better integrate CNS and NP roles into the Canadian healthcare system and advance the delivery of nursing and patient care services in Canada. Four types of advanced practice nurses (APNs) were the focus: CNSs, primary healthcare nurse practitioners (PHCNPs), acute care nurse practitioners (ACNPs) and a blended CNS/NP role. We worked with a multidisciplinary, multijurisdictional advisory board that helped identify documents and key informant interviewees, develop interview questions and formulate implications from our findings. We included 468 published and unpublished English- and French-language papers in a scoping review of the literature. We conducted interviews in English and French with 62 Canadian and international key informants (APNs, healthcare administrators, policy makers, nursing regulators, educators, physicians and other team members). We conducted four focus groups with a total of 19 APNs, educators, administrators and policy makers. A multidisciplinary roundtable convened by the Canadian Health Services Research Foundation formulated evidence-informed policy and practice recommendations based on the synthesis findings. This paper forms the foundation for this special issue, which contains 10 papers summarizing different dimensions of our synthesis. Here, we summarize the synthesis methods and the recommendations formulated at the roundtable.
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.
Nurs Leadersh (Tor Ont). 2010 Dec;23 Spec No 2010:140-66
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.
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.
There are many challenges in delivering rural health services; this is particularly true for the delivery of palliative care. Previous work has identified consistent themes around end-of-life care, including caregiver burden in providing care, the importance of informal care networks and barriers imposed by geography. Despite these well-known barriers, few studies have explored the experience of palliative care in rural settings. The purpose of the present study was to compare the experiences of rural family caregivers actively providing end-of-life care to the experiences of their urban counterparts.
Caregivers' perceived health status, the experience of burden in caregiving, assessment of social supports and the pattern of formal care used by the terminally ill were explored using a consistent and standardized measurement approach. A cross-sectional survey study was conducted with 100 informal caregivers (44 rural, 56 urban) actively providing care to a terminally ill patient recruited from a publicly funded community agency located in northeastern Ontario, Canada. The telephone-based survey included questions assessing: (i) caregiver perceived burden (14-item instrument based on the Caregiver's Burden Scale in End-of-Life Care [CBS-EOLC]); (ii) perceived social support (modified version of the Multidimensional Scale of Perceived Social Support [MSPSS] consisting of 12 items); and (iii) functional status of the care recipient (assessed using the Eastern Collaborative Oncology Group performance scale).
Rural and urban caregivers were providing care to recipients with similar functional status; the majority of care recipients were either capable of all self-care or experiencing some limitation in self-care. No group differences were observed for caregiver perceived burden: both rural and urban caregivers reported low levels of burden (CBS-EOLC score of 26.5 [SD=8.1] and 25.0 [SD=9.2], respectively; p=0.41). Urban and rural caregivers also reported similarly high levels of social support (mean MSPSS total score of 4.3 [SD=0.7] and 4.1 [SD=0.8], respectively; p=0.40). Although caregivers across both settings reported using a comparable number of services (rural 4.8 [SD=1.9] vs urban 4.5 [SD=1.8]; p=0.39), the types of services used differed. Rural caregivers reported greater use of family physicians (65.1% vs 40.7%; p=0.02), emergency room visits (31.8% vs 13.0%; p=0.02) and pharmacy services (95.3% vs 70.4%; p=0.002), while urban caregivers reported greater use of caregiver respite services (29.6% vs 11.6%; p=0.03).
Through the use of standardized tools, this study explored the experiences of rural informal family caregivers providing palliative care in contrast to the experiences of their urban counterparts. The results of the present study suggest that while there are commonalities to the caregiving experience regardless of setting, key differences also exist. Thus, location is a factor to be considered when implementing palliative care programs and services.
The purpose of this study was to examine the psychometric properties (test-retest and interrater reliability, criterion concurrent validity) of 3 verbal pain-assessment tools (Faces Pain Scale, Numerical Rating Scale, Present Pain Intensity Scale) and a behavioural pain-assessment scale for use with an elderly population. The study used a repeated-measures design to examine the reliability and validity of the tools across 4 groups of participants with varying levels of cognitive impairment using a non-random stratified sample of 130 elderly long-term-care residents. The findings support the test-retest and interrater reliability of the behavioural pain-assessment tool across all levels of cognitive impairment, whereas the same measures of reliability for the verbal-report tools decreased with increasing cognitive impairment; however, the majority of elderly with mild to moderate cognitive impairment were able to complete at least 1 of these tools. The findings are discussed in relation to their clinical and research implications.
Improving the quality of life for long-term care (LTC) residents is of vital importance. Researchers need to involve LTC staff in planning and implementing interventions to maximize the likelihood of success. The purposes of this study were to (a) identify barriers and facilitators of LTC homes' readiness to implement evidence-based interventions, and (b) develop strategies to facilitate their implementation. A mixed methods design was used, primarily driven by the qualitative method and supplemented by two smaller, embedded quantitative components. Data were collected from health care providers and administrators using 13 focus groups, 26 interviews, and two surveys. Findings revealed that participants appreciated being involved at early stages of the project, but receptiveness to implementing innovations was influenced by study characteristics and demands within their respective practice environment. Engaging staff at the planning stage facilitated effective communication and helped strategize implementation within the constraints of the system.
In Canada, education programs for the clinical nurse specialist (CNS) and nurse practitioner (NP) roles began 40 years ago. NP programs are offered in almost all provinces. Education for the CNS role has occurred through graduate nursing programs generically defined as providing preparation for advanced nursing practice. 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 the following: (1) history of advanced practice nursing education in Canada, (2) current status of advanced practice nursing education in Canada, (3) curriculum issues, (4) interprofessional education, (5) resources for education and (6) continuing education. Although national frameworks defining advanced nursing practice and NP competencies provide some direction for education programs, Canada does not have countrywide standards of education for either the NP or CNS role. Inconsistency in the educational requirements for primary healthcare NPs continues to cause significant problems and interferes with inter-jurisdictional licensing portability. For both CNSs and NPs, there can be a mismatch between a generalized education and specialized practice. The value of interprofessional education in facilitating effective teamwork is emphasized. Recommendations for future directions for advanced practice nursing education are offered.
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.
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.
Four LTC facilities in southern Ontario, Canada; 2 for the intervention group and 2 for the control group.
Data were collected from 200 LTC residents; 99 for the intervention and 101 for the control group.
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.
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.
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.
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.