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 1
WHAT ARE ANP ROLE TITLES IN QUEBEC? ANP NP CNS Quebec Neonatology Cardiology Nephrology Primary Care Infection prevention and control Mental Heath 5 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. 6 3
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 7 This global trend also touched Canada Although the first efforts to formally introduce APN roles in 1967 partially ceased in 1975, they reappeared across Canada from 2002. (legislation) 1967-1975 2006 2008 2003 2005 2004 2002 2009 Neonatology Legislation Primary Cardiology Legislation Health Nephro. Care role Nephrology Primary Cardio. in practice Roles Health Neonato. in Care practice 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. 8 4
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. 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 9 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 5
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 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. 11 To support the implementation process Bryant-Lukosius, DiCenso (2004) indicated that it is important: 1-to conduct continuous and rigorous analysis of the process; and 12 6
2-to use research and evidence-based approaches. 1-d'en faire une analyse continue et rigoureuse 13 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. 14 7
Intergrated theoretical framework BASED ON THIS PREMISE: 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. 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. 15 Intergrated theoretical framework: Rogers (2003) and (Meleis, 2010). 16 8
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? 17 Approach Our research intends to integrate the knowledge of: Illustration (Ducharme, 2006) Défis et réalités, Liban, 4-5-6 mai 18 9
Phase 1 Interviews and NVivo codifications Quebec Experts N=5 Region :1 Cases Case #1 N=6 Case #2 N=6 Case #3 N=4 Nursing Professional Corporation (OIIQ) Medical Professional Corporation (CMQ) Doctor s Association (FMOQ) Nurse Practitioner s Association (AIPSQ) Data collection and analysis Quebec Ministry of Health (MSSS) Regional Implementation Comity n=2 Local implementation comity n=3 Local Implementation Comity n=2 Medical Director PHCNP MD PHCNP 1 MD 2 Local Implementation Comity n=2 PHCNP MD PHCNP MD Phase 2 of interviews Preliminary results Multiple case-study research Case #1 Emmanuelle Jean, Johanne Synthèse Case #3 Gagnon, Hélène Sylvain, Amélie Trépanier Phase 3 Validation of preliminary results Case #1 Case #2 Centre 1 Case #2 Centre 2 Case #3 Cross-Case analysis Cross-case analysis and validation Preliminary results: - Brief overview of the case; - Transitions; - Participant recommendations. Case #2 Centre #1 Case #2 Centre #2 General Patient Questionnaires 19 Case #1: 1 PHCNP integrated into 2 centres Family medicine unit Primarily dedicated to the training of medical residents Failed 30 km How can we explain this difference? Local community service centre Success Mission is to provide primary health care services to the population of the territory they serve. 20 10
Transitions 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! 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? 21 Transitions Physicians: double transition Role within the implementation process: 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? 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? 22 11
Transitions PHCNP : multiple transitions Simultaneously PHCNP must: 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; In Quebec, PHCNP usually start to work 4 months before they receive their full official work permit. 3-come to know 1 and often 2 new teams and organizations; -This may be particular in remote rural areas 4-while also having the mandate to implement a change within theses teams and organizations, (the role of PHCNP). 23 Transitions Organization : Reinvention 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. 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. 24 12
Use of evidence-based approaches to guide the implementation process? little to none. 25 But, using their experiential knowledge, participants of case # 1 were able to make recommendations to improve the implementation process. 26 13
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. It is to understand who does what, when, how and why. 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. " 27 Participants suggested "It's just like a board game, you can read the rules, but it's by playing that you learn how to play! " 28 14
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: PEPPA Framework: Bryant- Lukosius, D., & DiCenso, A. (2004). Canadian Nurse Practitioner Initiative Implementation and Evaluation Toolkit for Nurse Practitioners in Canada: CNA-AIIC (2006) 29 What are the next steps? 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. 30 15
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. 31 Thank you! Questions 16