Impact of a Framework and Impact of a Framework and Toolkit on APN Role Toolkit on APN Role

Introduction for Underserviced Introduction for Underserviced Patients with CancerPatients with Cancer

CANO Conference 2010 – Edmonton, AlbertaCANO Conference 2010 – Edmonton, Alberta

Denise Bryant-Lukosius, Debra Bakker, Esther Green, Mike Conlon, Jennifer Wiernikowski, Pam Baxter, Nancy Carter, Alba DiCenso,

Project BackgroundProject 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 Evaluation Framework

Structures Processes Outcomes

StructuresCharacteristics 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

ProcessesHow 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?

OutcomesAPN 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 SelectionTwo 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 CollectionVariety of data collection strategies• Self-report questionnaires• 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 FrameworkAllowed 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 FrameworkThe 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

• 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 the design and evaluation of the toolkit:– 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 RemarksFindings 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)