3. Determine gaps and need for new model. 4. Identify priority gaps and goals to improve model of care with NP

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2 Acknowledgements This Toolkit was adapted from three landmark papers on the development and implementation of the NP role in Canada: Implementation and Evaluation Toolkit for Nurse Practitioners in Canada (CNPI, 2006), A Framework for the Introduction and Evaluation of Advanced Practice Nursing Roles (Bryant-Lukosius & DiCenso, 2004) and Framework for Evaluating the Impact of Advanced Nursing Roles (Bryant-Lukosius et al., 2016). The BCNPA would like to acknowledge that this Toolkit was developed, trialled, and modified over the course of several months in the Provincial Health Services Authority and the BC Children s and Women s Hospital and Health Centre.

3 NP Role Development Key Stakeholders: PEPPA Steps ACTIONS 1. Current model of care Current Model of Care: Identified Patient Population: 2. Identify stakeholders Key Stakeholders: 3. Determine gaps and need for new model of care with NP Gaps in Current Model of Care and Goals to Improve Model of Care with NP Role: Current Strengths: Current Limitations: 4. Identify priority gaps and goals to improve model of care with NP Priority Gaps: Goals to Improve Model of Care: 5. Define new model of care and NP Role ensure a fit between gaps, goals and NP role Proposed new model: Clinical (Activities, Hours) Leadership Education Agent of Change Research Proposed Activity Level for the NP (Visits, Caseload): A Day in the Life of the NP:

4 PEPPA Steps ACTIONS 6. Plan implementation strategies for new model and NP role- see NP Role Development and Implementation Checklist Implementation Plan: Anticipated Barriers and Plan to Address Them: Non-Salary Support (CME, Admin Support, IT, Office etc.): Identified Evaluation Outcomes: Ongoing Role Development: Communication Strategy: 7. Initiate NP role implementation plan- see NP Role Development and Implementation Checklist Work Plan: 8. Evaluation plan for NP role and new model of care- see Logic Model Evaluation Plan (include how): Quantitative - Qualitative - 9. Long term monitoring of NP role and model of care. Working group recommended. Sustainability Plan for NP Role: Adapted from: Bryant Lukosius, D., & DiCenso, A. (2004). A framework for the introduction and evaluation of advanced practice nursing roles. Journal of Advanced Nursing, 48(5),

5 NP Role Development and Implementation Checklist Step One: PREPARING FOR IMPLEMENTATION Complete PEPPA Framework PEPPA Proposal (sample attached) Understand Legal, Professional, & Regulatory Environment for NPs Review Scope of Practice Document for NPs: Establish Process to Oversee NP Role Implementation Develop Working Group of Stakeholders (NP, Operations, PPO, MD, Other) Use PEPPA to: o Determine Model of Care o Determine Population, Flow and Role Responsibilities/Reporting o Identify Barriers o Develop Engagement Strategy- consider outside groups o Develop Action Plan Consider Logic Model development (see sample) Develop Recruitment Strategies Include HR Determine Advertising Strategies Step Two: IMPLEMENTATION Structure the Role Confirm Reimbursement Ensure budget includes non-salary support What supports are necessary- technology, office space, computer Clerical Support Interview NP Candidates Discuss clinical and leadership expectations Consider key stakeholders for the interview panel (working group) Negotiate Job with NP Consider orientation and learning plan requirements and timelines Discuss hours, expectations, start time Announce NP Hire Develop 1 month orientation plan- operations and professional practice (see orientation manual attached) Step Three: IMPLEMENTATION - Organizational Change Establish Supportive Policies- Working Group (add new hire): Revisit Model of Care and Role Clarity (see sample for role clarity) Revisit barriers and develop plan for each one Meet with Performance Management about Encounter Codes Develop evaluation plan- refine logic model- (see sample) Add NP to Working Group

6 Create Supportive Environment Continue Engagement Strategy o Role and Reporting Expectations Continue Communication Strategy Formal orientation plan for NP beyond one month Consider assigning a mentor Ensure professional practice support is available Develop Learning Plan Develop Communication Strategy Input on the Model of Care from key stakeholders Present on Model of Care once finalized to stakeholder groups Send memo to rest of stakeholders Step Four: SUSTAINING IMPLEMENTATION Building the Team- working group continues with NP- bi-weekly meetings to start Consider team building exercises Establish a shared understanding and approach to care Providing Educational Opportunities Ensure NP is linked to Community of Practice Meetings Provide other educational opportunities Establish Networks for Role Evolution Ensure understanding of NP Scope of Practice Foster relationship with community stakeholders Step Five: MONITOR IMPLEMENTATION Monitor NP Implementation Refine logic model Determine how expected outcomes data will be collected and reported on Revisit Learning Plan- Discuss Career Laddering Decrease frequency of Working Group Meetings to monthly Monitor Challenges/Barriers Review barriers and action plan Revisit communications and engagement strategy

7 Nurse Practitioner Logic Model Framework (Template) Integrating Nurse Practitioner Providers within the Context (Situation) Value Add NPs capacity within the core medical team NP skills & competencies meet the clinical care needs of the patients NPs increase the capacity within the multidisciplinary team NP allows for a focus and improvement of continuity of care NP provider bridges medicine and nursing more current multi-disciplinary care model NP scope contributes to organization & unit quality & safety NP leadership role supports RN capacity building at the point of care Model of Care Guiding Principles Provide high quality health outcomes and better value for patients- Triple Aim Provide access to high quality sub-specialty NP care with a focus on continuity of care & coordinating/facilitating interprofessional roles and relationships Contribute to a sustainable health care system by maximizing provider skill set within the existing care model Address any potential gaps in current healthcare service Introduce an advanced nursing practice role with unique patients and integrate a core body of knowledge in health promotion, preventing illness and restoring health.

8 Nurse Practitioner Logic Model Framework (Template) Inputs Activities Outcomes Service Delivery Oriented Short-term (0-12 Months) Long-term (12+ months) Human Resources Partnerships /Supports CRNBC/MOH NP Professional Practice Lead NP Community of Practice NP Mentor Academic Appointments Physical Infrastructure Workspace IMIT PC/BBRY/Pager Education/Training Funding for research activities/support NP participates in collaborative research projects Clinical Care Leadership and Academic Role Coordinate and facilitate interprofessional roles & relationships Lead or participate in committee/task groups related to program and advanced practice Work with decision makers re: NP practice and policy Involvement in national/international networks Education Patient education Teach nurses, residents, allied health, community partners Participate in multidisciplinary rounds and journal club Preceptor/Mentor students & new staff Agent of Change Identify system gaps and lead change activities Identify best practices & apply to setting Research Critique, interpret, apply and disseminate evidence-informed findings Participate in collaborative practice based research Lead collaborative QA/QI initiatives Contributes to advancing nursing practice/care delivery NP will establish NP practice Increased team capacity Improved early detection of changes in health status continuity of care Use of Provincial Clinical Guidelines Introduce specific nursing practice standards/ guidelines patient education Support transitions Improve utilization of services Potential for case management NP supports knowledge translation activities Participates in collaborative practice based research Participates in NP practice/policy work Embeds self-directed learning consistency of provider/patient interaction time patients wait to access clinical team Improve multidisciplinary collaborations & team functioning Prevention of secondary/tertiary complications from illness Improved quality of care Improved PHC prevention/health promotion care Improve transfer and transition care to appropriate PCPs as needed Advance expertise in nursing with RNs Leads knowledge translation within team/learners Identifies best practices Indicators Clinical Care NP encounter codes for baseline data # of patients seen per location # of subspecialty consults # of clinical guidelines/ pathways utilized PHC screening age appropriate intervention # invasive Procedures CRNBC registration (ANP/PNP/FNP) Leadership Patient satisfaction Team satisfaction Committee membership/leadership Education Number of students mentor/preceptor # of in-services/education activities Agent of Change # of new clinical guidelines/pathways developed Leads/participates in system change initiatives Research NP led projects NP conference presentations NP publications NP participation in QA/QI, evaluation NP participation in collaborative practice based research projects Informs subspecialty education/practice standards

9 Specialist MD The Most Responsible Provider Admits and discharges patients in collaboration with the NP and core clinical team Directs and coordinates the medical care of admitted patients NP Is Advanced Practice Nurse in Clinical assessment, diagnosis and treatment of patients Collaborates with RN, MRP, and Fellows and Residents Makes admission and discharge recommendations to MRP Provides nursing leadership role Can also be the Most Responsible Provider Role Clarity CNS Fellow & Resident Is Advanced Practice Nurse in Provides nursing leadership Leads best practice and standards of care in Learners in the Assesses, diagnoses and manages medical needs of the patient from admission to discharge Hospitalist Can also be the Most Responsible Provider Admits and discharges patients in collaboration with the NP and core clinical team Directs and coordinates the medical care of admitted patients Registered Nurse Assesses and develops treatment plan in collaboration with NP, Fellow, Resident, Hospitalist or Medical Specialist Assessment and management of psychosocial impact of treatment decisions and coordinator of care

10 Frequently Asked Questions Why are Nurse Practitioners being added to the team model? What is a Nurse Practitioner (NP)? NPs are Master s and Doctoral prepared advanced practice nurses who diagnose and treat diseases and health conditions. NPs also educate and support patients who have health issues that range from simple to complex as well as acute to chronic. NPs practice independently and in collaboration with all other healthcare professionals. A key part of their role is to act in a clinical leadership capacity looking at system change and required policy development to improve care delivery. What will be the role of NPs on the care team? Can Nurse Practitioners prescribe and/or order? NPs can prescribe all medications with the exception of a few. NPs can order all routine diagnostic tests. Will you evaluate the impact of NPs joining the team? Yes, ongoing monitoring and evaluating of this new care model to assess will be performed and adjusted where necessary. How are NPs regulated and licensed? NP practice is regulated by the College of Registered Nurses of BC (CRNBC). In British Columbia, the majority of NPs are employees of Health Authorities. How are the competencies and skills of the NP evaluated? Like any health professional, NPs have quality assurance requirements to maintain their license including peer chart reviews and required continuing education. In addition to this, NPs are audited within their first year of practice by the CRNBC, which does an in-depth chart review and evaluation of the NPs practice. Do Nurse Practitioners carry liability insurance? All BC NPs carry liability insurance administered through CRNBC. This is a requirement for all NPs, and NP liability insurance is similar to the insurance physicians carry.

11 Nurse Practitioners Create Positive Change in the Health of all British Columbians. NPs are advanced practice nurses who have enhanced university education and training. We must meet specific requirements to register as NPs, and use the NP title. NPs are educated at least to a Master s level. 1 There are over NPs in BC. In BC, NPs work in hospitals, acute care, emergency departments, wards, clinics, family practice clinics, nursing care homes, palliative care, and hospice services. NPs must complete annual licensing requirements and the credentialing process administered by the College of Registered Nurses of BC. NP must also carry liability insurance administered by the Canadian Nurses Protective Society. NPs work with vulnerable populations, Aboriginal communities, adults, older adults, and children. We re committed to working with all patients and their families! NPs can: Assess, diagnose, and treat health issues. Order medical imaging, bloodwork, and specialized tests. Prescribe medical and psychosocial treatments. Prescribe medications and write orders to be carried out by other healthcare providers (e.g. dietary orders, oxygen therapy, physical therapy, etc.) Complete health and extended benefits forms. Work autonomously with healthcare teams in acute, primary, and residential settings. Sources: It is still a challenge to access an NP. This is partly due to the number of NPs in BC and funding. Generally, NPs are funded through a health authority or hospital. Unlike physicians, NP's cannot directly bill the BC Medical Service Plan for consultations and patient care visits. BCNPA is working with the Ministry of Health to strategize on maximizing the NP role in the health system. 1. College of Registered Nurses of BC (CRNBC) website ( 2. Includes practicing and provisional NPs as of Nov Provided by CRNBC. Photo used with permission from BCNPA member Jennie Woo.

12 References Bryant Lukosius, D., & DiCenso, A. (2004). A framework for the introduction and evaluation of advanced practice nursing roles. Journal of Advanced Nursing, 48(5), Bryant Lukosius, D., Spichiger, E., Martin, J., Stoll, H., Kellerhals, S. D., Fliedner, M.,... & Schwendimann, R. (2016). Framework for evaluating the impact of advanced practice nursing roles. Journal of Nursing Scholarship, 48(2), Canadian Nurse Practitioner Initiative. (2006). Implementation and evaluation toolkit for nurse practitioners in Canada. Ottawa, ON: Canadian Nurses Association.