impact of a framework and toolkit on apn role introduction...
TRANSCRIPT
Impact of a Framework and
Toolkit on APN Role
Introduction for Underserviced
Patients with Cancer
PONR Rounds January 17, 2011
Denise Bryant-Lukosius, Debra Bakker, Esther Green, Mike Conlon,
Jennifer Wiernikowski, Pam Baxter, Nancy Carter, Alba DiCenso,
Project Background
Improved patient, provider & health system outcomes
are associated with well designed APN roles
Increasing demand for APN roles in cancer control
Several studies identified significant gaps & challenges
to the effective use of oncology APN roles in Ontario
Poor access to APN services across the cancer continuum
Several groups of high incidence/high need & under-serviced
cancer patient populations who could benefit from APN care
Multiple systemic barriers to role integration
Poor APN job satisfaction
Difficulty recruiting & retaining highly qualified oncology APNs
Project Background
• Barriers to effective APN role implementation in Canada & internationally are not unique to cancer control
– Stakeholder confusion about the purpose & scope of APN roles
– Lack of clearly defined goals & role expectations
– Role emphasis on MD replacement & support
– Under use of the full scope & range of ANP role domains
– Limited use of evidence to guide role development
(DiCenso, Bryant-Lukosius et al, 2010; Bryant-Lukosius et al., 2004)
Project Background
• Many implementation barriers could be
avoided or minimized through improved role
planning and better stakeholder
understanding of APN roles
• Two Ontario consensus meetings identified
stakeholder needs for tools and resources to
support oncology APN role implementation(Cancer Care Ontario, 2006 & 2008)
Overall Project Goals
• To develop and evaluate tools and resources to support
APN role implementation
• To establish clearly defined APN roles and role outcomes
through the use of a systematic, population based, patient
centred approach (PEPPA Framework)
• To create practice environments that support APN roles in
new models of care delivery through the use of
collaborative, interprofessional and intersectoral strategies.
Evaluation Framework
Structures Processes Outcomes
Structures
Characteristics of 2 cases• Northern cancer centre
• Southern cancer centre
Description of current care models• GI Team
• Palliative Team
Characteristics of the APN Teams
PEPPA Framework & Toolkit
Facilitator
Processes
How did PEPPA effect:
• Stakeholder involvement & team function?
• Decision-making & achieved activities?
How helpful was the Toolkit in assisting teams to
implement the PEPPA Framework?
What was the role of the facilitator in assisting
team to implement the PEPPA Framework?
Outcomes
APN job description
APN hired
New care delivery model
Team dynamics & structure
Finalized APN Role Implementation Toolkit
Focus of the Evaluation
• Multiple case study design to examine:– The use and impact of the Oncology APN Role
Implementation Toolkit
– How the PEPPA Framework and facilitator
influenced organization and health care team
planning and decision-making in developing
and implementing new APN roles
Case Selection
Two Cases that varied in terms of:
• Experience in introducing APN roles
• Geographic location and size
• Population density & demands for cancer services
• Organizational structures
• Nursing leadership
• Academic mission
• Patient population to be the focus of a new APN role
Characteristics of
Health Care Teams
Case #1 – Southern Site
- 33 individuals
- Multidisciplinary
- 88% felt knowledgeable
about APN roles
- 76% had worked previously
with an APN
Case #2 – Northern site
- 22 individuals
- Multidisciplinary
- 62% felt knowledgeable
about APN roles
- 50% had worked
previously with an APN
Data Collection
Variety of data collection strategies
• Self-report questionnaires
• Team Climate Inventory (Kivimaki & Elovainio, 1999)
• Interviews of key stakeholders
• Focus groups
• Key documents
Data were collected from key informants on completion
of selected stages of the PEPPA Framework
Toolkit Development
• Initial drafts developed using:– Results of previous APN & oncology APN research
– Survey of Ontario cancer care administrators
– Input from an Expert Panel & National Advisory Committee
– “Real-time” needs & issues of the health care team & practice setting in each Case
• Toolkit revisions made based on:– Evaluation data from health care teams
– Project team
– Expert panel
Evaluation Findings
• Findings are organized using the following
four categories:
– PEPPA Framework or process
– Toolkit
– Facilitator
– Health Care Team
PEPPA Framework
Allowed teams to use a systematic process to:
• Examine current health provider roles & models of care
• Identify care gaps
• Assess the need for an advanced practice role related to a
specific group of cancer patients
• Design a new or enhanced model of interdisciplinary care
• Develop an APN role description
• Provide a good case/rationale for the role to key decision-
makers
• Introduced/hired an APN for the position (1 of 2 teams)
PEPPA Framework
The high level of team & stakeholder involvement promoted support & acceptance of the new APN role
Differences between cases
• Time to work through the PEPPA steps due to system issues:– Size & complexity of clinical teams & patient needs
– Availability of existing needs assessment data
– System readiness for change/competition with other change activities
– Level of senior administrator participation in the process
– Expertise & allocated time for team members to lead/complete activities
• Hiring of an APN– Changes in funding
– HR policies
– Availability of APNs with role requirements
Oncology APN Role
Implementation Toolkit
Viewed by both teams as:
• An essential “roadmap” for guiding the process and
“keeping the team on track”
• A useful manual or checklist at every meeting
• Providing resources/activities in each step that aided the
collection of data for group decision-making
Oncology APN Role
Implementation Toolkit• “Real time” participant use and feedback on toolkit
facilitated resource improvements and further tool
development
– Readability & format
– Time saving tools & worksheets
– Stakeholder engagement
– Conducting needs assessments
– Decision making
– Priority setting
– Business case & budgets
Facilitator
• Structure of facilitation was different at each site
– Onsite facilitator versus facilitator at a distance
• Challenge with teleconference but “reality of the times”
– Team member became the site group leader
• Teams at both sites reported
– Knowledge and experience of their facilitator “made a real
difference” in moving the process along
– Role of the facilitator was an added value
– “Real practice examples” helped to see how the PEPPA process
could be applied to their practice settings and patient populations
Team Dynamics
• Structure of teams differed in roles and decision-making responsibilities– Case #1- working team provided recommendations to
overall site team
– Case #2- working team had final decision-making responsibilities
• Structure of teams differed in presence and support of organizational administration and community stakeholders
Team Dynamics
• Processes:– High level of interdisciplinary collaboration/participation
from: physicians, nurses, social workers, middle/senior administrators
– Diversity of participants facilitated completion of activities and decision making
– Improved team function and positive group dynamics developed over time
– The consistent presence of a senior organization administrator and community stakeholders as active team members indicated “buy in”
Concluding Remarks
• Teams at both sites were able to:
– Move through the PEPPA process to accomplish their goal
– Design a new model of care and produce an APN job
description to meet the needs of a specific patient
population
• Engagement of diverse target users and key APN
stakeholders in toolkit design and evaluation:
– Promoted the development of a relevant, practical and
resource rich toolkit
– May promote the uptake of toolkit use
Concluding Remarks
• Framework and toolkit use can be adapted to meet
the varied needs and characteristics of different
practice settings and teams
• The evaluation component and case study
approach allowed examination across oncology
settings of the:
– Application of the PEPPA Framework
– Use of a Toolkit and facilitator
– Interprofessional collaboration and organizational support
Concluding Remarks
Findings about the utility of the PEPPA Framework are consistent with other studies– APN Roles in Long-term care
(Donald, 2007; Donald & Martin-Misener, 2007; McAiney et al., 2008)
– Oncology APN roles(Bryant-Lukosius et al., 2007; Carter, 2008; Martelli-Reid, 2007)
– Cardiology APN role (McNamara et al, 2009)
– Advanced physiotherapist role in joint replacement(Robarts et al., 2008)
Framework Benefits
• Helps to plan & anticipate important steps in role planning, implementation and evaluation
• Promotes role clarity and agreement about role priorities
• Promotes role understanding, acceptance and support through stakeholder engagement
• Promotes improved coordination & patient satisfaction with care through patient input in role design
• Helps to identify strategies for minimizing barriers and maximizing facilitators for role implementation
(McAiney et al., 2008; McNamara et al., 2009; Robarts et al. 2008)
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