impact of a framework and toolkit on apn role introduction...
TRANSCRIPT
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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,
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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
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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)
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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)
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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.
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Evaluation Framework
Structures Processes Outcomes
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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
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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?
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Outcomes
APN job description
APN hired
New care delivery model
Team dynamics & structure
Finalized APN Role Implementation Toolkit
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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
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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
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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
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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
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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
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Evaluation Findings
• Findings are organized using the following
four categories:
– PEPPA Framework or process
– Toolkit
– Facilitator
– Health Care Team
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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)
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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
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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
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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
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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
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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
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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”
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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
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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
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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)
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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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To download presentation slides go
to:
http://oapn.mcmaster.ca
and click on the
PONR Rounds 2011 button