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									Nurse Practitioners – Past, Present
and Future

        Alba DiCenso, RN, PhD
        Professor, McMaster University
        CHSRF/CIHR Chair in APN

           November 2010
   Objectives of Presentation

NP happenings in Canada:

• Past
• Present
• Future
         The Past

• 1971: McMaster University and the University of
  Montreal started programs that focused on preparing
  „family practice nurses‟ to work in urban settings

• 1972: Boudreau Report recommended that NPs be
  trained to meet PHC needs in Canada, proposing that
  NPs could be the first healthcare system contact

• 1973/1974: 2 landmark RCTs: „Southern Ontario
  Study‟ and the „Burlington Trial‟ demonstrated the
  effectiveness of the NP role
            The Past

• Mid-70s: NP role could not be sustained:
   •   financial disincentive for MDs
   •   perceived oversupply of physicians
   •   lack of NP role legislation
   •   insufficient public awareness of the role
   •   inadequate support from medical community & policy makers

• Many of the 250 NPs who graduated from Canadian
  university programs between 1970 and 1983 continued
  to practice through the 1980s and 90s, primarily in
  CHCs and northern remote health centres
            The Past

• 1988: CNS/NP role in tertiary level NICUs in Ontario:
   •   needs assessment
   •   role delineation
   •   evaluations of the graduate level education program
   •   RCT to evaluate the effectiveness of the role
   •   assessments of team satisfaction with the role

• NPs later introduced into other specialty areas due to a
  shortage of medical residents and lack of continuity of
  care for seriously ill patients
           The Past

• 1993: Ontario Minister of Health and NDP government
  announce new NP Initiative
• 1994: COUPN NP consortium education program
• 2001: CHSRF/CIHR Chair Program in APN
• 2002: Romanow and Kirby Reports
   Across Canada, there has been an increasing emphasis on the role of
   NPs who can take on roles that traditionally have been performed only
   by physicians. This could even include providing NPs with admitting
   privileges to hospitals so that they could refer patients and begin initial
   treatment in hospitals (Romanow 2002: 106)
• 2003: „IBM‟ study --- NP Task Team
             The Past

• 2005: Canadian Nurse Practitioner Initiative (CNPI)
    •   education
    •   regulation
    •   recruitment and retention
    •   professional practice and liability
    •   core competency framework
• 2006: CNA‟s Dialogue on Advanced Nursing Practice
• 2008: CNA‟s Advanced Nursing Practice Framework

Kaasalainen S et al. (in press) An Historical Overview of the Development of
  Advanced Practice Nursing Roles in Canada. Canadian Journal of
  Nursing Leadership
          The Present

• 2009: All provinces and territories have legislation in
  place for the NP role
• Bill 179 passed: prescribing of a broader range of
  drugs, communicating diagnoses, doing more
  procedures, dispensing medications and performing
  and ordering a wider range of investigations
• NPs integrated into various PHC models, LTC, EDs,
  public health
• 26 NP-led clinics funded in Ontario
• Under review: admission, discharge and transfer
          Nurse Practitioner Workforce by Province in Fall 2009



    129                                                                             3
             294     120    75                                  41
                                     1,463                                          96


Canadian NP Total = 2,442

                                   Source: Provincial/Territorial Regulators
 The Present

NPs in Ontario (Nov 2010)*

NP-Adult:                          324
NP-Paediatrics:                    139
NP-Primary Health Care:            1,261

Total:                             1,715

*some NPs are registered in more than 1 category
    The Present
Top 5 Nursing Employers for NPs (CNO 2009):
 Acute Care Hospital:              286 (25.5%)
 Community Health Centre:          236 (21.1%)
 MD's Office/Family Practice Unit: 213 (19.0%)
 Public Health Unit/Department:    41 (3.7%)
 College/University:               39 (3.5%)
 Other employers:                  284 (25.4%)

 307 NPs in Family Health Teams (fall 2010)
  (85% of approved positions filled)
  151 operational FHTs; 50 more have been approved
 The Present

APN Chair Program Mission

– To increase capacity of APN researchers across
  Canada who will conduct research responsive
  to the needs of decision maker partners

– Funded for 10 years (2001-2011) by Canadian
  Health Services Research Foundation (CHSRF)
  & Canadian Institutes of Health Research
               The Present

– 24 graduate students: 6 MSc/16 PhD/2 DNP (13 completed)
–   20 NPs or researching NPs:
    C. McCurdy (2006). Transition from pediatric to adult transplant
      care. Progress in Transplantation, 16(4):309-316.
    F. Donald (2009). NP and MD collaboration in LTC. Canadian
      Journal on Aging, 28(1):77-87.
    K. Lamarche (Case Western) (2009). Canadian NP job
      satisfaction. Canadian Journal of Nursing Leadership, 22(2): 41-
    A. de Guzman (2010). NP role implementation in Ontario public
      health units. Canadian Journal of Public Health, 101(4): 309-
             The Present - completed

J. Opsteen: Measurement properties of NP-MD collaboration

P. Carter-Arrowsmith: Barriers and facilitators to prenatal care
   for Mexican Mennonite women in southern Ontario

J. Burgess (Victoria U): Relevance of collaboration to NP role

K. Kilpatrick (McGill U): Implementation of cardiology ACNP
   roles in Quebec
              The Present – in progress

E. Sangster-Gormley (Dalhousie U): Implementation of the NP
   role in practice settings in Vancouver Island Health Authority

P. Harbman (U of T): Effectiveness of NPs in secondary
   prevention of AMI

S. Kioke (Victoria U): Current model of care for First Nations &
   Inuit women at risk of or living with HIV/AIDS in rural/remote

S. Strickland: Influence of power and interdependence on
   collaboration in a Family Health Team
            The Present – in progress
A. Roots (Victoria U): Evaluating the implementation of the NP
 role in BC

J. Kilbreath (Ottawa U): Introduction of NNPs in secondary level
  NICUs in Ottawa

T. Armstrong (Ottawa U): A case study of the introduction and
  sustainability of an NP-led clinic in Ontario

L. Housden (UBC): Involvement of NPs in group medical visits

R. Heale (Case Western): Evidence-based practice and NPs
    APN Resources

• Participatory Evidence-Based Patient-Focused
  Process for Advanced Practice Nursing Role
  Development, Implementation, and Evaluation
  (PEPPA) Framework
• PEPPA Toolkit
• Graduate Course: “Research Issues Specific to
  the Introduction and Evaluation of APN Roles”
• APN Data Collection Toolkit
• APN Literature Database
    APN Resources

• APN Policy/Practice Briefs
• NP Role Implementation Toolkits
• Oncology APN Canadian Centre of Excellence
• APNs in Long-Term Care
• COUPN-Related Research
• CJNR June 2010 issue on APNs
• Evidence-Informed Decision Making Workshop
       PEPPA Toolkit

• Design appropriate APN role or changes to an existing
  APN role
• Create a business case and budget for an APN role
• Establish a plan to support optimal APN role
• Outline a plan for monitoring and evaluating the role

Freely available on Cancer Care Ontario website:
(look under „Related Resources‟ on the right side of page)
               NUR 706: Research Issues Specific to the
               Introduction and Evaluation of APNs
                           1. Formulating a Research Question

10. Dissemination & Utilization of
     APN Research Findings                                  2. Developing a
                                                           Research Proposal
 Working with Decision-Makers

                                                               3. Conducting a
     9. Economic                                              Needs Assessment
   Evaluation of APN
                                                                      4. Methods for
                                                                  Defining APN Roles
8. Health Care Provider
                                                             5. Methods for Defining
     7. Evaluating Patient                                      & Evaluating APN
                                                              Education Programs
  Outcomes of New APN Roles

                            6. Evaluating APN Practice Patterns
            NUR 706
 Combination of on-site (McMaster) and distance

 March 21 to June 24, 2011

 For more information and permission to take the course, contact Denise
  Bryant-Lukosius at bryantl@mcmaster.ca

 Application due December 17, 2010

 Notification of acceptance by December 31, 2010

APN Data Collection Toolkit

   A compendium of common instruments to
   measure dimensions of APN for policy
   makers, managers, researchers, APNs and
   graduate students involved in APN role
   development, implementation and
APN Literature Database
APN Policy
            NP Role Implementation

CNPI: Implementation and Evaluation Toolkit for
 NPs in Canada (2006)

Winnipeg Regional Health Authority: A Guide to the
 Implementation of the NP Role in Your Health
 Care Setting (2006)

Taranaki District Health Board (New Zealand): NP
  Development Toolkit (2007)
Leadership and Innovation in
Oncology Advanced Practice
  To provide a comprehensive, integrated national
  program with core funding to sustain long-term,
  leading edge initiatives in oncology APN research
  and education

Welcome to the Advanced Practice Nurses in Long-Term
Care website. This site provides information about ongoing
and recent research conducted by our teams regarding
Nurse Practitioners and Clinical Nurse Specialists in long-
term care settings.


      COUPN-Related Research

Led by Pam Baxter, Affiliate Faculty in APN Chair
  – Formative evaluation of the PHCNP program to inform
    NP education best practice guidelines
  – Assessment of NP continuing education needs
  – Examination of consortium structure and process
  – Identification of development needs of professors,
    tutors and preceptors to inform a spring workshop
    (Research booth)
          CJNR June 2010 Issue on
   The Long and Winding Road: Integration of NPs and CNSs into the
    Canadian Health-Care System
    Authors: DiCenso, Bryant-Lukosius

   Will NPs Achieve Full Integration Into the Canadian Health-Care
    Author: Martin-Misener; Commentary: Stevenson, Sawchenko

   The CNS Role in Canada: Forecasting the Future Through Research
    Author: Bryant-Lukosius; Commentary: O'Connor, Ritchie

   Defining the Role of PHCNPs in Rural Nova Scotia
    Authors: Martin-Misener, Reilly, Vollman
          CJNR June 2010 Issue on
   Integration of NPs Into Ontario's Primary Health Care System:
    Variations Across Practice Settings
    Authors: Koren, Mian, Rukholm

   The Transformational Journey of NPs in Acute-Care Settings
    Authors: Rashotte, Jensen

   The Consultation Component of the CNS Role
    Authors: Dias, Chambers-Evans, Reidy

   Resources to Facilitate Research in APN
    Authors: Charbonneau-Smith, McKinlay; Vohra

   Book Reviews
        EIDM Workshop

            Decision Making Workshop
       Sunday May 1st to Friday May 6th, 2011
    Canadian Centre for EBN, McMaster University

APN Group: Advanced practice nurses, educators, administrators, and
policy makers seeking to expand and further their EIDM skills related to the
development, implementation, and evaluation of APN roles
       Decision Support Synthesis

To conduct a review of the literature and stakeholder
  interviews to:
  • Identify and describe distinguishing characteristics of
    CNS and NP role definitions and competencies
  • Identify key barriers and facilitators for effective
    development and utilization of CNS and NP roles
       Decision Support Synthesis

Scoping Review of Literature
  • 468 papers (all Canadian papers of any type or date
    and international review papers 2003-2008)

Key Stakeholder Interviews (81)
  • APNs, government policymakers, nurse administrators,
    regulators, educators, physicians, other health care
    team members

NP roles
  – Legislation exists in all 13 provinces/territories
  – Numbers increasing quickly across Canada
  – Regulatory mechanisms to support expanded scope of
  – Increased integration across various types of practice

CNS roles
  – 40+ year history in Canada
  – Less understanding & awareness especially of clinical
  – Limited access to CNS-specific graduate education
  – Lack of credentialing & role titling makes it difficult to
    accurately assess employment trends

CNS roles
  – Number of CNSs declining especially in B.C. & Ontario
  – Some pockets of higher deployment, but nationally
    stagnant growth in role development or use
  – Lack of a national voice or vision for the role in the
    Canadian health care system
  – Little CNS-focused research in Canada:
 1970 to 2009: 124 primary studies or reviews on NPs and 10 on CNSs
      Effectiveness of APNs

Numerous randomized controlled trials (RCTs) and
systematic reviews have shown that APNs are effective,
safe practitioners who can positively influence patient,
provider and health system outcomes:

    ACNPs:       18 RCTs (11 since 2000)
    PHCNPs:      28 RCTs (18 since 2000)
    CNSs:        32 RCTs (20 since 2000)

    Patient:          Provider:      Health System:

   Health status     Satisfaction   Cost
   Quality of life                  Length of stay
   Quality of care
   Satisfaction
          ACNPs (18 RCTs)
          US: 10, UK: 6; AU: 1, CA: 1

                Health Quality Quality   Patient Provider Cost   Length
                Status of Life of Care   Satis-  Satis-          of Stay
                                         faction faction
Improvement       5                        5        1      2        2

Decline                                                             1

No difference     7       1       7        2        1      2        2
          PHCNPs (28 RCTs)
          US: 15, UK: 8; NE: 2, CA: 3

                Health Quality Quality Patient   Provider Cost   Length
                Status of Life of Care Satis-    Satis-          of Stay
                                       faction   faction
Improvement       7                       6                2        1

Decline                                                    1

No difference    15       2       2       5         1      1
           CNSs (32 RCTs)
           US: 16, UK: 11, CA: 2, Other: 3
                Health Quality Quality Patient Provider Cost   Length
                Status of Life of Care Satis-  Satis-          of Stay
                                       faction faction
Improvement      15      5       2       4               9        5


No difference     8      4               3        1      4        1
     General Facilitators to Role

• Systematic patient-focused planning to guide
  role development including early stakeholder
• Clearly defined APN roles
• Public and health provider awareness
         PHCNPs – Facilitators and
   • Government legislation and regulation
   • Government funding for NP positions
   • Emphasis on interprofessional collaboration facilitated by a
     shift away from FFS physician reimbursement model

   • Working out relationship between two autonomous clinicians
     (NPs and GPs) with substantial overlap in scope of practice
   • Inconsistencies in educational preparation across Canada
         Adult/Paediatrics NPs –
         Facilitators and Challenges
  • Support from medical & nursing administrators within
  • Support from physician colleagues who appreciate help with
    heavy patient care demands

  • Difficulty implementing non-clinical dimensions of the role
  • Limitations to scope of practice due to hospital restrictions on
    NPs‟ autonomous ordering and prescribing
  • Inconsistent team acceptance
  • Funding of role
         CNSs – Facilitators and

   • Support of health administrators
   • Increased emphasis on promoting evidence-based practice

   • Lack of a common vision and understanding of the CNS role
   • Limited access to CNS-specific graduate education programs
   • Lack of title protection or credentialing
        CHSRF Roundtable
        April 2009
 Representatives:
   • Policy makers, nursing and medical professional
     leaders, regulators, administrators, practitioners,
 Mandate:
   • To develop recommendations for policy, practice &

• Create a vision statement that clearly articulates
  the value-added role of APNs across settings.

• Establish a pan-Canadian multidisciplinary task
  force involving key stakeholder groups to
  facilitate the implementation of APN roles.

• Consider advanced practice nursing as part of
  health human resources planning based
  strategically on population healthcare needs.

• Standardize APN regulatory and educational
  standards, requirements and processes across
  the country.

• Include components that address inter-
  professionalism in undergraduate and post-
  graduate health professional training programs.

• Develop a communications strategy to
  disseminate to a wide readership the positive
  contributions of advanced practice nursing.

• Protect funding support for APN positions and
  education to ensure stability and sustainability.

• Conduct further research on:
   • the „value-added‟ of APN roles
   • their impact on healthcare costs
   • the CNS role

• CHSRF website (Commissioned Research Reports):
   Clinical Nurse Specialists and Nurse Practitioners
   In Canada: A Decision Support Synthesis

• Researcher-on-Call Webinar:
   Integrating Advanced Practice Nurses

• CHSRF Mythbuster:

    Special Issue of Canadian Journal of Nursing
     Leadership, November 2010
1. Advanced Practice Nursing in Canada: Overview of a Decision Support Synthesis
2. An Historical Overview of the Development of APN Roles in Canada
3. Education of APNs in Canada
4. CNSs and NPs: Title Confusion and Lack of Role Clarity
5. The Primary Health Care NP Role in Canada
6. The Acute Care NP Role in Canada
7. The CNS Role in Canada
8. The Role of Nursing Leadership in Integrating CNSs and NPs in Healthcare Delivery
    in Canada.
9. Factors Enabling APN Role Integration in Canada
10. Utilization of NPs to Increase Patient Access to Primary Healthcare in Canada –
    Thinking Outside the Box
     OECD Working Paper
     (July 2010)
Nurses in Advanced Roles: A Description and
 Evaluation of Experiences in 12 Developed
  Australia                    Belgium
  Canada                       Cyprus
  Czech Republic               England
  Finland                      France
  Ireland                      Japan
  Poland                       United States

    OECD Working Paper
    (July 2010)

• Focus on NP role in Primary Health Care
• Objectives:
  • Review factors motivating the development of APN
  • Describe state of development of the role
  • Review results of evaluations of APN roles on care
    and cost
  • Examine main factors that have hindered or
    facilitated the development of APN roles and how
    barriers have been overcome
    The Future

• Collaboration with CNA and Office of Nursing
  Policy to mount a forum of key stakeholders to
  move forward on implementation of
• Completion of systematic review on
  effectiveness of APNs – patient, provider, health
  system outcomes
• NP-Physician Assistant synthesis - BC
    The Future

• Evaluation of new models of care provision
  (e.g., NP-led clinics, Family Health Teams)
• Nurse-Anesthetist role
• Payment-for-Performance (incentives)
• CNS practice patterns
• Follow-up on CNPI recommendation
     Continuing Challenges

• Professional interests/monopolies
• Absence of an HHR strategy
• Interprofessional collaboration
          Professional Interests

• Professional interests/monopolies
• Baerlocher and Detsky (2009) describe „turf battles‟
  between and within professions when they compete to
  perform the same task.
• Reliance on self-governing professional bodies to
  determine appropriate work boundaries is problematic
  as they may have no reason to cooperate with one
• Requires successful negotiation that keeps the public‟s
  rather than the profession‟s interest in mind.
  (Baerlocher, M. and A. Detsky. 2009. “Professional Monopolies in Medicine.” JAMA 301(8): 858-60.)
      Absence of a Health Human
      Resource Strategy
• Results in knee-jerk reactions
• In Ontario, shortage of physicians has led to dramatic
  increase in number of medical students being trained
  and introduction of physician assistants
• Team based care has made family medicine more
  attractive increasing the number of medical students
  who choose family medicine
• What will the future hold when there are sufficient
  numbers of physicians?
• In 2004, the prime minister and premiers of Canada
  set an objective that 50% of Canadians would have
  24/7 access to multidisciplinary primary healthcare
  teams by 2011
• Learning in silos does not facilitate interprofessional
  collaboration – need shift to interprofessional
• Who leads the team?
   • “the move toward collaborative and team-based approaches
     to care requires a culture shift that will be especially
     challenging for physicians who are accustomed to being the
     undisputed team leader.”
     (Hutchison, B. 2008. “A Long Time Coming: Primary Healthcare Renewal in Canada.” Healthcare
     Papers 8(2): 10-24.)
“Here is Edward Bear,coming
downstairs now, bump, bump, bump,
on the back of his head, behind
Christopher Robin. It is, as far as
he knows, the only way of coming
downstairs, but sometimes he feels
that there really is another way, if only
he could stop bumping for a moment
and think of it”
                                  A.A. Milne 1926

                   Illustration E.H.Shepard 192614
Thank you!

• Jane Sanders, Executive Director, NPAO
• All of you for your active participation in NP-
  related research studies

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