the implementation process of the primary health care nurse ...€¦ · emmanuelle jean, johanne...

2013-10-17

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Preliminary Results of a Multiple Case Study Research

The Implementation Process of the Primary Health Care Nurse Practitioner (PHCNP) Role in a

Remote Rural Area of Quebec, Canada.

Emmanuelle Jean, Johanne Gagnon, Hélène Sylvain et Amélie Trépanier

10/17/2013 2

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Quebec

Emmanuelle Jean, Johanne Gagnon, Hélène Sylvain, Amélie Trépanier 5

ANP

NP CNS

Infection prevention

and control

Mental Heath

Neonatology Cardiology Nephrology Primary Care

WHAT ARE ANP ROLE TITLES IN QUEBEC?

Why conduct a research on the implantation process of PHCNP roles in

remote rural areas of Quebec?

1-APN roles have become recognized as an important growing trend among healthcare systems worldwide.

Sheer, B., & Wong, F. K. Y. (2008). The development of advanced nursing practice globally. Journal of Nursing Scholarship, 40(3), 204-211.

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According to the ICN INP/APN Network, it has been estimated that approximately 70 countries have established NP/APN roles or are exploring the possibility of introducing

these roles. http://66.219.50.180/INP+APN+Network/FAQ.htm

This global trend also touched Canada

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Although the first efforts to formally introduce APN roles in 1967 partially ceased in 1975, they reappeared across Canada from 2002. (legislation)

1967-1975 2002 2003

Legislation Nephro. Cardio.

Neonato.

2004 2005

Legislation Primary

Health Care

2006

Neonatology Cardiology Nephrology Roles in practice

2008

Primary Health Care

role in practice

2009

Kaasalainen, S., Martin-Misener, R., Kilpatrick, K., Harbman, P., Bryant-Lukosius, D., Donald, F., . . . DiCenso, A. (2010). A Historical Overview of the Development of Advanced Practice Nursing Roles in Canada. Nursing Leadership, 23(Special Issue), 35-60. DiCenso, A., Bryant-Lukosius, D., Martin-Misener, R., Donald, F., Abelson, J.,

Bourgeault, I., . . . Harbman, P. (2010). Factors Enabling Advanced Practice Nursing Role Integration in Canada. Nursing Leadership, 23(Special Issue), 211-238. Kilpatrick, K. (2012). Potentialise-t-on la contribution des infirmières aux soins de santé?...Non. Paper presented at the Colloque en sciences infrimières de l'UQAC: De la

théorie à la pratique: Affirmer son expertise!, Chicoutimi.

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Ordre des infirmières et infirmiers du Québec [OIIQ]. (2012). Le Québec rattrapera-t-il son retard sur les autres provinces canadiennes? Bulletin Infostats, 4(2), 4-5. Retrieved from http://www.oiiq.org/uploads/periodiques/infostats/vol04n02/index.htm

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This global and Canadian trend also touched Quebec

In May 2012, Quebec counted almost 100 PHCNP and 130 others were studying to

become PHCNP.

Although the gap with some other Canadian Provinces has yet to be filled.

2-Despite this worldwide trend, according to the experience and knowledge of other countries and of the rest of Canada, the implementation of ANP roles can be a complex process that can certainly be daunting for the people who are involved. 10

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In 2009, people from three rural and remote areas of eastern Quebec mentioned that guiding the implementation of PHCNP role was a true challenge for them.

In fact, people involved with the implementation process said they consider the Quebec context to be especially difficult. Ordre des infirmières et infirmiers du Québec [OIIQ]. (2009). Les infirmières praticiennes spécialisées: un rôle à propulser, une intégration à accélérer. Retrieved from http://www.oiiq.org/sites/default/files/247-IPS.pdf

To support the implementation process Bryant-Lukosius, DiCenso (2004) indicated that it is important:

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1-to conduct continuous and rigorous analysis of the process; and

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1-d'en faire une analyse continue et rigoureuse

2-to use research and evidence-based approaches.

Goals


1- Understand the implementation process of the PHCNP role in a remote rural area of Quebec.

2- Analyse the use of knowledge, research and evidence-based approaches, by the people involved with the implementation process.

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Diffusion of innovations Theory: An innovation is an idea, practice, or object perceived as new by an individual or other unit of adoption.

Rogers, E. M. (2003). Diffusion of innovations (5 ed.). New York: Free Press.


Intergrated theoretical framework BASED ON THIS PREMISE:

The PHCNP role is an innovation for the Quebec Health Care System that implies transitions for the organizations and people involved.

Transitions Theory: Transitions are a central concept in nursing, that are instigated by changes and require to move from one state of certainty to another, through an interval of uncertainty. Meleis, A. I. (2010). Transitions theory Middle-range and situation-specific theories in nursing research. New York: Springer publishing company.

Intergrated theoretical framework:

Rogers (2003) and (Meleis, 2010).


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Research questions


• How does the implementation process take place in remote rural areas of Quebec?

• What are the transitions experienced by organizations and people? (Meleis)

• Is existing knowledge relevant and useful to the Quebec remote rural context?

• Is existing knowledge used by the people involved? • Could existing knowledge be improved upon? • How can we facilitate the use of existing knowledge?

18 Illustration (Ducharme, 2006) Défis et réalités, Liban, 4-5-6 mai

Our research intends to integrate the knowledge of:

Approach

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Emmanuelle Jean, Johanne Gagnon, Hélène Sylvain, Amélie

Trépanier 19

Data collection and analysis

Multiple case-study research

Phase 1 Interviews and NVivo codifications

Quebec

Region :1

Experts

N=5

Nursing Professional Corporation (OIIQ)

Medical Professional Corporation (CMQ)

Doctor’s Association (FMOQ)

Quebec Ministry of Health (MSSS)

Nurse Practitioner’s Association (AIPSQ)

Regional Implementation Comity n=2

Cases

Case #1 N=6

Local implementation comity n=3

Medical Director

PHCNP

MD

PHCNP

Case #3 N=4

Local Implementation Comity n=2

PHCNP

MD

Case #2 N=6

Loca

l Im

plem

enta

tion

Com

ity n

=2

1 MD

2

MD

PHCNP

Synthesis of interviews Preliminary results

Phase 2 Synthesis

Synthesis

Synthesis

Synthesis

Synthesis

Synthesis

Synthesis Case #1

Synthesis

Synthesis

Synthesis

Synthesis

Synthesis

Synthèse

Synthesis

Synthesis Case #3

Validation of preliminary results Cross-case analysis and validation

Phase 3

General Synthesis

Patient Questionnaires

Case #1

Case #2

Centre 1

Case #2

Centre 2

Case #3

Cro

ss-C

ase

anal

ysis

Synthesis

Synthesis

Synthesis

Synthesis

Synthesis Case #2

Centre #2

Synthesis Case #2

Centre #1 Synthesis

Preliminary results: - Brief overview of the case; - Transitions; - Participant recommendations.

Case #1: 1 PHCNP integrated into 2 centres

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Family medicine unit

Local community service centre

Primarily dedicated to the training of medical residents

Mission is to provide primary

health care services to the

population of the territory they

serve.

30 km

Failed Success

How can we explain this difference?

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Transitions

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Administrators: Steep learning curve!

Simultaneously: • Understand a new nursing role; • explain it to others (and be convincing!) ; • while contributing to manage change. A participant said (translated*): “I was trying to understand it and at the same time I had to talk about it!”

Emmanuelle Jean, Johanne Gagnon, Hélène Sylvain, Amélie Trépanier

In this research, PHCNP had a higher academic degree than Nursing Administrators involved. -This may be particular in remote rural areas

One Nursing Administrator said, “I try to push everyone to achieve their full potential. How will I do that with a PHCNP?”

Transitions

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Physicians: double transition

Physicians participating in this research were unclear about their role within the implementation process. “Am I responsible for that [referring to the process]?”, “Do I have to take that in charge with all the rest of the things I have to do?”

Role within the implementation process:

Collaboration: Physicians also have to learn to work with a type of health care professional that they haven’t seen during their training and with whom they have never worked. They also have to move from supervision to collaboration. One participant said, “The PHCNP is talking to me be about a patient, do I have to go check? Do I have to sign? Who’s responsible?”

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Transitions

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PHCNP : multiple transitions

1-Integrate a new role; Requires that they move from a status of “expert” nurse to “novice” PHCNP.

2-move from a status of supervised candidate to a professional with autonomy and responsibility;

3-come to know 1 and often 2 new teams and organizations; -This may be particular in remote rural areas


In Quebec, PHCNP usually start to work 4 months before they receive their full official work permit.

4-while also having the mandate to implement a change within theses teams and organizations, (the role of PHCNP).

Simultaneously PHCNP must:

Transitions

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To describe this one participant said: “…While respecting legislation and guidelines, I would say that about 50% stayed the same and we had to make the other 50% evolve so that it would be a better fit for everyone.”

Organization : Reinvention


Implementation of innovation in an organization amounts to mutual adaptation in which both the innovation and the organization change in important ways. Rogers, E. M. (2003). Diffusion of innovations (5 ed.). New York: Free Press.

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Use of evidence-based approaches to guide the

implementation process? … little to none.

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But, using their experiential knowledge, participants of case # 1 were able to make recommendations to improve

the implementation process.

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Participants suggested


“If there was one thing that I could start over, it would be to identify our needs. We bought into the idea without really knowing why"

"Having a team to support implementation is a good idea."

Goes beyond knowing about the formal definition and guidelines.

Participants generally spoke of an “indefinable job," "grey zone”. “In family medicine it’s rarely black or white, it's all grey. I think the PHCNP, it is even worse. “ "We had meetings where we got explanations, but we were unable to remember what the PHCNP would do exactly. "

It is to understand who does what, when, how and why.


"It's just like a board game, you can read the rules, but it's by playing that

you learn how to play! "

Participants suggested

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Preliminary discussion:

Although participants from a remote rural area of Quebec did not use evidence-based approaches, their experiential knowledge led them to make recommendations that are, for the most part, supported by evidence.

Particularly by:

Canadian Nurse Practitioner Initiative Implementation and Evaluation Toolkit for Nurse Practitioners in Canada: CNA-AIIC (2006)

PEPPA Framework: Bryant-Lukosius, D., & DiCenso, A. (2004).

These preliminary results lead us to believe that: 1. It is imperative that researchers continue to document the

implementation process, including transitions and the use of knowledge;

2. It seems that some existing knowledge could be relevant and useful to the Quebec remote rural context; the question is

As Mrs Stilwell beautifully put it in her keynote presentation yesterday, “How can we bring global knowledge to local solutions?”

3. It is essential that researchers work towards facilitating the use of existing knowledge to support the implementation process and the transitions of the organizations and the people involved.


What are the next steps?

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What are our next steps?

• We will therefore continue to analyse the results associated with cases 2 and 3 and then cross case analyse.

To contribute to answer Mrs Stilwell’s question: • We are currently working, with the people

involved, on a interactive repertoire of the steps, tools and evidence as a way of facilitating the use of evidence.

Thank you!

Questions

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