Faith Donald & Ruth Martin-Misener. Submitted: June 30, 2011

Transcription

1 UNDERSTANDING THE INDIVIDUAL, ORGANIZATIONAL, AND SYSTEM FACTORS INFLUENCING THE INTEGRATION OF THE NURSE PRACTITIONER ROLE IN LONG-TERM CARE SETTINGS IN CANADA Faith Donald & Ruth Martin-Misener Submitted: June 30, 2011 Revised: August 26, 2011

2 Research Team Co-Primary Investigators Faith Donald 1 & Ruth Martin-Misener 2 Mentorship Team Jenny Ploeg, 3 Alba DiCenso 3 & Kevin Brazil 3 Co-Investigators Sharon Kaasalainen, 3 Nancy Carter, 3 Lori Schindel Martin, 1 Carrie McAiney, 3 Denise Bryant-Lukosius, 3 Noori Ahktar-Danesh, 3 Paul Stollee, 4 Alan Taniguchi, 3 Esther Sangster-Gormley 5 & Maureen Dobbins 3 1 Ryerson University, Toronto, Ontario, Canada; 2 Dalhousie University, Halifax, Nova Scotia, Canada; 3 McMaster University, Hamilton, Ontario, Canada; 4 University of Waterloo, Waterloo, Ontario, Canada; 5 University of Victoria, Victoria, British Columbia, Canada Decision-Maker Partners* Paul Bond, Assistant Deputy Minister, Chief Nurse Executive, British Columbia Ministry of Health Services Vanessa Burkoski, Chief Nursing Officer, Ontario Ministry of Health and Long-Term Care Brenda Canitz, Chief Nurse Executive and Executive Director, British Columbia Ministry of Health Services Heather Davidson, Assistant Deputy Minister, Health Authorities Division, British Columbia Ministry of Health Services Donna Denney, Executive Director, College of Registered Nurses of Nova Scotia; Formerly Nursing Policy Advisor, Nova Scotia Department of Health** Gulrose Jiwani, Executive Director, Nursing Directorate, British Columbia Ministry of Health Services Laurianne Jodouin, Director, Health Human Resources Planning Branch, British Columbia Ministry of Health Services** 2 of 99

3 Norm Robertson, Senior Program Consultant, Performance and Compliance Branch, Ontario Ministry of Health and Long Term Care** Rebecca Scott, Senior Policy Analyst, Ontario Ministry of Health and Long-Term Care Sharon Stewart, Nursing Directorate, British Columbia Ministry of Health Services Janet Simm, Director, Policy, Planning & Decision Support, Health Association of Nova Scotia Valerie St. John, Assistant Deputy Minister, British Columbia Health Human Resources Division Alice Thériault, Chief Nursing Officer & Nursing Resources Advisor, Planning and Medicare Services Division, New Brunswick Department of Health Sharen Wilson-Carr, Vice President, Quality Management, Revera Inc.** * All Decision-Maker Partners participating in a component of the study are listed ** Indicates Decision-Maker Partner participation for the entire study period Acknowledgements We thank the NPs, administrators, directors of care, residents, family members, physicians and staff from all participating LTC settings. We also thank the many professional nursing associations and colleges, provincial/territorial/regional government departments and decision-maker partners that assisted us with identifying NPs in LTC. The co-principal investigators of the report recognize and appreciate the invaluable contributions from the co-investigators, mentorship team, and decision-maker partners involved in this study. We are grateful for the assistance from the CHSRF/CIHR Advanced Practice Nursing (APN) Chair Program staff, and to James McKinlay, in particular, for his assistance with data analysis, to Abigail Wickson-Griffiths for her many contributions as project coordinator, and to Teresa D Elia, and Clare Parks who assisted with coordination of case studies, data collection and coding. We thank the Canadian Institutes of Health Research: Partnerships for Health Systems Improvement, Nova Scotia Health Research Foundation and the British Columbia Ministry of Health Services for providing generous funding for the study. 3 of 99

4 Table of Contents List of Exhibits... 6 Executive Summary Introduction Policy Context Literature Review Approach and Analytic Process Theoretical Framework Phase One: Survey Design and Sampling Methods Nurse Practitioner Questionnaire Administrator and Director of Care Questionnaire Participant Identification Phase Two: Case Study Methods Participant Identification Nurse Practitioner Survey Response Rate and Demographics Nurse Practitioner Demographic Information Funding Source and Accountabilities of Nurse Practitioners Working 75% in LTC Administrator and Director of Care Survey Response Rate and Demographics Administrator and Director of Care Demographic Information Case Descriptions Roles and Practice Patterns of Nurse Practitioners 75% in LTC Practicing to Full Scope of Practice Nurse Practitioner Confidence ENPRAS Scale Practice Pattern Results Collaboration Activities with Physicians Roles and Activities of Case Study NPs Satisfaction of Nurse Practitioners 75% in LTC Physician Collaboration Salary Misener Job Satisfaction Results Resources and Supports Satisfaction of Nurse Practitioners in Case Studies of 99

5 10. Facilitators and Barriers to Integration of Nurse Practitioners in Long-Term Care Nurse Practitioner Role Acceptance and Support Other Barriers and Facilitators Perceived Impacts of the Integration of Nurse Practitioners in Long-Term Care Current and Ideal Integration of Nurse Practitioners in Long-Term Care Discussion of Findings Strengths and Limitations of the Study Conclusions and Recommendations References Appendix A: Nurse Practitioner Survey Appendix B: Administrator & Director of Care Survey Appendix C: Interview Guides LPN/RPN/HCA/PSW Interview Guide Nurse Practitioner In-Depth Interview Guide Multidisciplinary Interview Guide Nurse Manager Interview Guide Administrator & Director of Care Interview Guide Telephone Interview Guide: Administrator at LTC Setting Where Unable to Recruit/Retain the Nurse Practitioner Nurse Practitioner No Longer Working in LTC Interview Guide Physician & Medical Director Interview Guide Telephone Interview Guide: Funder Resident/Family Member Focus Group Interview Guide Registered Nurse (Charge Nurse) Interview Guide Appendix D: NP Confidence Scores: Prior to Being Hired in NP Role and Current Appendix E: ENPRAS Scale Results of 99

6 List of Exhibits Exhibit 1: Respondents to NP Survey: 75% and <75% Full Time Equivalent in LTC Exhibit 2: NP Sex, Age and Education: 75%, Single Compared with Multiple Settings, and <75% in LTC Exhibit 3: Practice Experience of NPs Working 75% in LTC Exhibit 4: Practice Experience of NPs Working 75% in LTC: Single Compared with Multiple Settings Exhibit 5: Practice Setting Characteristics: NPs Working 75% in LTC Exhibit 6: Respondents to Administrator and DOC Survey Exhibit 7: Administrator and DOC Specific Roles and Responsibilities Exhibit 8: Description of Case Settings Exhibit 9: NP Confidence Level: Total and Single versus Multiple Setting Exhibit 10: Ten Most Frequently Performed Activities Reported by NPs Working 75% in LTC Exhibit 11: Most Common Resident Conditions for Which NPs Provided Care: Reported by NPs Exhibit 12: Reasons for NP and Physician Collaboration: NPs Working in Single versus Multiple Settings Exhibit 13: Satisfaction with Collaborative Relationship with Physician: Nurse Practitioners Working 75% in LTC Exhibit 14: Nurse Practitioners Working 75% in LTC Satisfaction with Salary Exhibit 15: Misener Nurse Practitioner Job Satisfaction. NPs working 75% in LTC: Total and Single versus Multiple Settings Exhibit 16: Misener NP Job Satisfaction Scale: Total and Subscales Exhibit 17: Satisfaction with Resources and Supports: NPs Working 75% Exhibit 18: Satisfaction with Individual Resources and Supports. Single versus Multiple Sites: NPs Working 75% in LTC Exhibit 19: A Comparison of the Top Three NP Role Facilitation Factors Exhibit 20: A Comparison of the Top Three Barriers to NP Role Integration 6 of 99

7 Executive Summary The focus of the study has been to explore the integration of the nurse practitioner (NP) role in Canadian long term care (LTC) settings so the full potential of this role can be realized and timely access to quality care ensured for a growing population of LTC residents. Research questions addressed by this study were: 1) What are the roles and practice patterns of NPs in LTC settings in Canada? 2) What are the perceptions of NPs and stakeholders regarding current and ideal integration of NPs in Canadian LTC settings? 3) What individual, organizational, and system factors (facilitators and barriers) influence the integration and job satisfaction of NPs in Canadian LTC settings? The study used a sequential two-phase mixed methods design including surveys of NPs and their Administrators and Directors of Care (DOCs) and case studies involving a total of 150 participants in individual or focus group interviews. Main Findings We surveyed 23 NPs who are full-time ( 75%) in single or multiple LTC settings (focus of this report) and 63 administrators and directors of care (DOC). More than 90% of NPs indicated they are working to their full scope of practice. The most frequently performed activities that NPs perform are assessing residents, managing chronic and acute illness, collaborating with nursing staff, and communicating with families, residents and staff. NPs are well integrated in their organizations and perceived by stakeholders to improve the accessibility, timeliness, comprehensiveness and quality of resident and family care. NPs are accepted by the health care team, residents and families. NPs are satisfied with their roles and responsibilities, relationships with collaborative physicians and the resources and supports available to them. NPs support and assist nursing staff to learn new knowledge and skills and thereby enable LTC organizations to increase their capacity to admit and care for residents with more complex behavioural and physical challenges and needs. The main barriers preventing integration of NPs in LTC are insufficient funding, resistance from some physicians, lack of awareness of the NP role within LTC organizations and the general public, legislative restrictions to NP practice and limitations of NP education programs. Conclusions and Recommendations The integration of NPs in LTC is an innovation that offers considerable promise to enable LTC organizations and health care systems to meet the current and coming challenges within the LTC sector. We make the recommendations to address a number of the barriers to integration, which, in turn, will enable the full potential of NPs in LTC to be realized. 1. Federal/ provincial/territorial (FPT) governments to develop funding and human resource strategies to support and plan for the integration of the NP role in LTC settings. 2. FPT governments in collaboration with national and provincial/territorial nursing and NP organizations to develop and disseminate public information about the NP role in LTC. 3. FPT governments in collaboration with national and provincial/territorial nursing and NP organizations to collaborate to remove legislative barriers to the scope of practice of NPs in LTC. 4. LTC organizations, including all key stakeholders, to identify the gaps in service that the NP role is intended to address when planning for implementation of the role in LTC settings. 5. Canadian Association of Schools of Nursing in collaboration with educational institutions providing NP education to review NP curricula to include more geriatric theory and clinical experience. 7 of 99

8 1. Introduction The focus of the Understanding the Individual, Organizational, and System Factors Influencing the Integration of the Nurse Practitioner Role in Long Term Care Settings in Canada Study has been to fully explore the integration of the nurse practitioner (NP) role in Canadian long term care (LTC) settings so the full potential of this role can be realized and timely access to quality care ensured for a growing population of LTC residents. The research questions addressed by this study were: What are the roles and practice patterns of NPs in LTC settings in Canada? What are the perceptions of NPs and stakeholders regarding current and ideal integration of NPs in Canadian LTC settings? What individual, organizational, and system factors (facilitators and barriers) influence the integration and job satisfaction of NPs in Canadian LTC settings? This study used a sequential two-phase mixed methods design. 1 In Phase One we surveyed NPs working in LTC across Canada with an investigator-developed questionnaire that included two psychometrically tested scales. 2,3 Using a separate questionnaire, we surveyed the Administrators and Directors of Care (DOC) from the NPs practice settings. In Phase Two, we conducted four case studies in LTC settings. The NPs in these settings held full-time positions meaning that 75% of their time was devoted to the LTC setting. The four case study sites were located in western, central and eastern regions of the country and involved a total of 150 participants in individual or focus group interviews. In addition, we conducted individual interviews with NPs (n=3) who had left a position in LTC and an Administrator (n=1) challenged by retention or recruitment of NPs in a LTC setting(s). 2. Policy Context It is estimated that by 2021, 29% of Canadian seniors will be in the year age group and 13% will be 85 and over. 4 People in these age groups are at increased risk of chronic health problems and physical and cognitive impairments that often require housing and healthcare in LTC settings. Providing comprehensive, coordinated primary healthcare to LTC residents is more difficult as access to traditional physician-led services declines. 5,6 The National Advisory Council on Aging has called for action to increase the supply of health professionals to care for seniors. 7 Exploring evidence-based care models that will address the evolving primary healthcare needs of LTC residents is a national and provincial concern 7-9. NPs are well positioned to become members of innovative health service models with legislation now in place for the role in all Canadian provinces and territories. The initial priority of governments when introducing NPs was to improve access to primary healthcare, especially in remote communities and areas with physician shortages. 10 Currently, managers and policy makers in Canada are interested in the potential of the NP role in settings that have not traditionally hired NPs, such as LTC. 11,12 3. Literature Review The 21st century has brought renewed support for the NP role in concert with an emphasis on improving the organization and delivery of primary healthcare. 13,14 The first randomized controlled trial of NPs was conducted in Burlington, Ontario in the 1970s. 15 Patients were randomized to NP or 8 of 99

9 physician care and after one year, the groups did not differ in mortality; physical, social or emotional function; quality of care; or patient satisfaction. Since that time several randomized trials have been conducted worldwide and, in 2002, Horrocks et al. published a systematic review in which they identified 11 randomized trials and 23 observational studies that compared NPs and MDs providing primary care. 16 Their meta-analyses indicated that patients who received NP care had higher satisfaction and better quality of care than those who received MD care, with no difference in patient health outcomes. NPs have provided services in LTC settings in the United States for several decades where they have been shown to improve access to primary care and reduce hospital admissions and emergency department use, and costs In Canada, NPs were introduced into LTC settings in the late 1990s to help support the ever increasing complex care needs of the elderly residential population. 21,22 When we began the study available data indicated there were 1,026 licensed NPs in Canada, 35 of whom practiced in geriatrics/long term care. 23 By the conclusion of the study, there were 2,048 licensed NPs, 93 of whom indicated their place of work was geriatrics/ long term care. 24 During this time a few Canadian studies were published providing some data about NPs in LTC settings and their impact. 22,25-30 NPs had a positive impact on medication use, 30 geriatric assessment, education, and use of specialized geriatric services, 22 engaged in a wide variety of pain management activities such as assessing, advocating and educating to help manage residents pain, 26 were effective in assessment and treatment of new wounds and follow-up wound care, 22,28 and improved communication and acted as advocates for staff, residents and families. 22,28 Physicians were satisfied with their collaboration with NPs 25 and staff valued NPs expert knowledge. 26,27 In addition to their impact on residents and families, NPs improved staff capacity with wound care through informal education. 22,28 Some studies, all of which had methodological limitations, indicated NPs were effective in reducing transfers to emergency departments, 27,28,30 but another did not find this effect. 29 The main facilitators to NP integration include a clearly delineated scope for practice for NPs, an optimal resident caseload for NPs, and organizational support. 22 Nevertheless, despite evidence about the benefits of the NP role in LTC settings, there are barriers to successful role implementation and integration, including lack of role awareness and role clarity, poor implementation planning, and inadequate administrative support The 2002 interim evaluation of NPs in LTC settings in Ontario by Stolee et al. found that NPs were involved in a wide variety of activities, pulled in many directions, and at risk for burnout. 31 This evaluation, involving interviews with 12 NPs in one focus group and three site visits, found that the NPs carried a heavy workload, often working in excess of 40 hours per week and on weekends to complete paperwork and prepare for educational and community outreach activities. This workload interfered with NPs ability to engage in collaboration with other LTC staff and to perform activities and services other than direct care to residents. NPs reported that the specialized and complex needs of LTC residents required an expertise beyond what was currently addressed in their NP program. Furthermore, these excessive workloads and inadequate delineation of the NP role led to difficulties with retaining NPs in LTC (C. Crane, Project Coordinator, Primary Health Care Nurse Practitioners and Long-Term Care, MoHLTC, personal communication, June 27, 2003). Resistance from physicians is another barrier to role integration. In part, it is due to a lack of knowledge about the NP role and scope of practice, as well as concerns about reimbursement. A nation-wide study of Canadian LTC medical directors confirmed the uncertainty this group of physicians has about the value of the NP role as a strategy to alleviate the MD shortage in LTC. 34 When role confusion exists, it interferes with collaboration between NPs and physicians of 99

10 At the organizational level, barriers include NPs being required to work at multiple LTC sites, lack of planning for collaboration, lack of expectation for collaboration and resistance to change. 25 System level barriers include restrictions on the legislated scope of practice for NPs; for instance, not being able to admit patients to or discharge them from hospitals, or provide care to inpatients Approach and Analytic Process Theoretical Framework The Participatory Evidence-Based Patient-Focused Process for Advanced Practice Nursing Role Development, Implementation, and Evaluation (PEPPA) framework 35 is the theoretical guide for the study and was developed by two research team members (DBL & AD). The framework recommends formative evaluations examining the structures and processes of new NP roles to monitor progress in achieving role goals and to identify and address barriers to role implementation. Structures refer to: role resources; the physical and organizational environment; characteristics of NPs, patients/residents, and the health care team; and model of care delivery. Access to educational programs, regulatory mechanisms, and funding policies are system structures within the framework that impact on NP role integration. Within the PEPPA framework, processes refer to the work or characteristics of what the NP does in the role. We examined NP job satisfaction as an outcome that is important for monitoring the early stages of role implementation and integration Phase One: Survey Design and Sampling Methods Two questionnaires were created, one for NPs and one for LTC setting Administrators and DOCs from the NPs practice settings. The questionnaire development was based on the literature review, existing survey instruments 2,3,36 and collaboration with the research team. The questionnaires were predominately designed as closed-ended instruments. The majority of questions were closed-ended with open-ended questions to explore integration factors and features of the NP role in each setting. The two questionnaires were pretested prior to mailing to the NPs, Administrators and DOCs. Mail-in surveys historically have low response rates, approximately 30-35%. To encourage response, participants were mailed up to two reminder questionnaires and were given a gift card for a national coffee shop as a token of appreciation for completion. 37 Nurse Practitioner Questionnaire The questionnaire included 54 questions, in addition to space provided to share additional information or expand on responses (See Appendix A). The questionnaire took approximately one hour to complete. Administrator and Director of Care Questionnaire The questionnaire included 25 questions, in addition to space for comments (See Appendix B). The survey took approximately 20 minutes to complete. Participant Identification Potential NP participants were identified through a number of strategies including: 10 of 99

11 Co-PIs prior knowledge and contact with NPs Communication with decision-maker partners, directors of primary care, ministry/health department personnel (e.g., provincial nursing officers), professional colleges/associations, regional/district health authority ethics boards, LTC settings, and academic institution personnel Advertisement through national and provincial NP listservs Authors of publications. The NPs were contacted via , either through the research coordinator or provincial liaison, and provided with an invitation to participate in the study. They were also asked to provide the names and addresses of the Administrators and DOCs with whom they work. In cases where the NP did not provide these names, the research coordinator contacted the LTC setting(s) directly, to obtain that information. No NPs were certified in primary care in Quebec at the time of participant identification and we were unable to identify any NPs in LTC in Prince Edward Island or the three territories. Through our research we learned there are several models in which NPs in LTC are being used. A number of NPs have full-time positions in a community-based primary healthcare setting and also devote less than a half day per week to a LTC setting. A few NPs focus primarily on admission and annual histories and physical examinations, rather than providing the full scope of primary care services. Some NPs working in independent practice continue to care for their patients from the community when they are subsequently admitted to LTC. Various outreach-focussed models exist in which NPs are on-call to a number of LTC settings and respond when needed to assess and manage residents and, when possible, prevent visits to emergency departments. Some of these outreach models include an expectation for NPs to provide formal and/or informal education for staff. While these NP positions and models of care did not meet the inclusion criteria for this study, we believe it is important to document that these innovations in LTC exist. Phase Two: Case Study Methods Participant Identification Following preliminary analysis of Phase One data, the research team identified the following criteria to determine site selection. NPs working in single and multiple settings Rural and urban settings For-profit and not-for-profit settings NP experience differences Administrator & DOC ratings of NP integration, NP/MD collaboration, NP satisfaction rating of collaborative relationship with physician Four NP cases were selected: one representing western Canada, two representing central Canada, and one representing eastern Canada. Unfortunately, we were unable to pursue a rural setting initially selected due to changes in health care providers in the setting. An alternate site that met site selection criteria was selected by the team. Data collection methods included: 1) individual and focus group interviews with health care providers (NPs, physicians, regulated and unregulated nursing staff, allied health professionals for example, pharmacists, physiotherapists, social workers, dietitians, hospice nurses, recreational therapists, 11 of 99

12 Administrators, DOCs, residents and family members; 2) document analysis; 3) site visit observations and 4) field notes. See Appendix C. 5. Nurse Practitioner Survey Response Rate and Demographics Survey data were collected from July 2009 until September Obtaining clearance from multiple ethics boards across the country extended the survey data collection process. Surveys were mailed to 48 NPs. A total of 82% (n=37) of NPs responded to the survey, 3 were excluded who did not meet survey inclusion criteria. 38 The data were sub-divided into survey results from NPs practicing 75% of their time in a LTC setting(s) (n=23) (the focus of this report), and those practicing <75% of their time in LTC settings (n=14) (Exhibit 1). The response rate was 88% (n=23) for NPs working 75% in LTC setting(s) and 74% (n=14) for NPs working <75%, but at least 4 hours per week in a LTC setting(s). Exhibit 1: Respondents to Nurse Practitioner Survey: 75% and <75% Full Time Equivalent in LTC Total NP Sample (n=45)* NPs Practicing 75% in LTC* (n=26) NPs Practicing <75% in LTC (n=19)* Survey Respondents (n=23) Missing Respondents (n=3) Survey Respondents (n=14)* Missing Respondents (n=5) * 48 surveys were mailed, 22 were sent to NPs working <75% in LTC. Of these 22, 17 NPs responded, 3 NPs did not meet inclusion criteria. Nurse Practitioner Demographic Information The demographic data of NPs practicing 75% and those who practice <75% of their time in LTC settings are presented in Exhibit 2. Of the 23 NPs working at least 75% in LTC, 14 are working in a single setting and 9 are working in multiple settings. All respondents were female and most were greater than 45 years of age. In both groups NPs most frequently reported having attained a baccalaureate education (n=12). The majority of NPs practicing 75% (n=17) specified that they obtained their NP education through a Post-RN or Post-Baccalaureate NP program, whereas fewer (n=4) had completed a Masters or Post Masters NP program. This was similar in the <75% in LTC NP group. 12 of 99

13 Exhibit 2: Nurse Practitioner Sex, Age and Education: 75%, Single Compared with Multiple Settings and <75% in LTC Characteristics Participants working 75% in LTC in a single setting Participants working 75% in LTC in multiple settings Participants working <75% in a LTC setting(s) Sex (n=14) (n=9) (n=14) Female 100% (n=14) 100% (n=9) 85.7% (n=12) Male 14.3% (n=2) Age (n=14) (n=9) (n=14) % (n=1) 0% (n=0) 7.1% (n=1) % (n=7) 11.1% (n=1) 28.6% (n=4) % (n=5) 33.3% (n=3) 50% (n=7) 55 and over 7.1% (n=1) 55.6% (n=5) 14.3% (n=2) Highest Level of Education (n=14) (n=9) (n=14) Diploma 14.3% (n=2) 0% (n=0) 14.3% (n=2) Baccalaureate 42.9% (n=6) 66.7% (n=6) 42.9% (n=6) Masters 42.9% (n=6) 33.3% (n=3) 42.9% (n=6) NP Education (n=14) (n=9) (n=14) Post RN or Post- 64.3% (n=9) 88.9% (n=8) 71.4% (n=10) Baccalaureate Masters or Post Masters 35.7% (n=5) 11.1% (n=1) 28.6% (n=4) Specific Geriatric Education* (n=14) (n=9) (n=14) Courses with geriatric theory 57.1% (n=8) 55.6% (n=5) 50% (n=7) Clinical experience with 57.1% (n=8) 55.6% (n=5) 71.4% (n=10) geriatric population in NP program CNA geriatrics certification 28.6% (n=4) 55.6% (n=5) 0% (n=0) Other 14.3% (n=2) 33.3% (n=3) 0% (n=0) None 7.1% (n=1) 11.1% (n=1) 14.3% (n=2) * Participants could select more than one answer NPs 75% in LTC practiced a mean of 5 years as an NP in LTC, however, the variance within the sample was considerable with some practicing less than one year and some more than 9 years (Exhibit 3). Only 39% (n=9) had prior RN experience working in the same setting where they were now an NP. All NPs 75% in LTC (n=23) have practiced in the same setting since beginning their work in the LTC sector. The mean number of years in the NPs current position was 4 years in single settings and 7 years in multiple settings (Exhibit 4). 13 of 99

14 Exhibit 3: Practice Experience of Nurse Practitioners Working 75% in LTC Characteristic Respondents Min Max Mean SD Years practiced as an RN (n=23) Years practiced as an RN in LTC before NP designation (n=23) Years practiced as NP in total (n=23) Years practiced in LTC as NP (n=23) Years in current NP position (n=23) SD= standard deviation Exhibit 4: Practice Experience of Nurse Practitioners Working 75% in LTC: Single Compared with Multiple Settings Characteristic Respondents Min Max Mean SD Single Setting NPs: Years practiced as an RN (n=14) Multiple Settings NPs: Years practiced as an RN (n=9) Single Setting NPs: Years practiced as an RN in LTC before NP designation Multiple Settings NPs: Years practiced as an RN in LTC before NP designation (n=14) (n=9) Single Setting NPs: Years practiced as NP in total (n=14) Multiple Settings NPs: Years practiced as NP in total (n=9) Single Setting NPs: Years practiced in LTC as NP (n=14) Multiple Settings NPs: Years practiced in LTC as NP (n=9) Single Setting NPs: Years in current NP position (n=14) Multiple Settings NPs: Years in current NP position (n=9) SD= standard deviation The majority of NPs 75% in LTC reported working full-time in LTC setting(s) (n=19), between 31 and 40 hours per week (Exhibit 5). All but three NPs were employed solely in a LTC setting. The remaining three spent a small portion of their time in another setting such as primary healthcare. Union membership was almost evenly split, with 52% of NPs 75% in LTC indicating union membership. Eleven of the 14 NPs (79%) who worked in a single setting were members of a union compared to only one of the 9 (11%) who worked in multiple settings. Exhibit 5 displays the characteristics of the settings in which the NPs practice who work 75% in LTC. Almost half (n=11) of the NPs practice in central Canada (ON), while 6 NPs practice in western (BC, AB, 14 of 99

15 SK, MB) and 6 in eastern Canada (NL, NB, NS). The majority (n=14) practice in a single LTC setting. Those who practice in multiple settings (n=9), work in 2 to 4 sites. Most NPs worked in urban or suburban settings (n=17) and in not-for-profit settings (n=18). Where NPs were working in multiple sites, it was unclear if all settings were under the same administrative or corporate management. Exhibit 5: Practice Setting Characteristics: Nurse Practitioners Working 75% in LTC Characteristics Total Respondents Percentage LTC Setting Location (n=23) Western Canada % Central Canada % Eastern Canada % Number of Settings NP Practices (n=23) Single home % Multiple homes % Geographic Location* (n=23) Urban or suburban % Rural or remote % Both urban or suburban and rural and remote 2 8.7% Funding Model* (n=23) Not-for-profit setting(s) % For-profit % Both not-for-profit and for-profit settings % * Participants could select more than 1 response Funding Source and Accountabilities of Nurse Practitioners Working 75% in LTC The majority of NPs (n=16) indicated that their role is funded by an external source to the LTC setting such as the provincial government, district or regional health authority, county, etc. Three NPs reported an internal funding source from the LTC organization. Four NPs indicated the funding for their role is from a combination of external and internal sources. In addition to their salary, most NPs reported receiving funding to support continuing education, most often for conference registration and tuition (n=16) and paid leave (n=14). The majority of NPs indicated that the DOC (65%) or Administrator (35%) was their direct supervisor. Over 50% (n=12) of the NPs indicated they have never had a performance appraisal. However, over 70% (n=17) reported that they meet at least yearly with their direct supervisor to discuss their role performance. Having an annual meeting with the supervisor was reported by 86% of the NPs working in a single setting and 55% of the NPs working in multiple settings. 15 of 99

16 6. Administrator and Director of Care Survey Response Rate and Demographics Survey data were collected from July 2009 until September A total of 108 Administrators and DOCs were sent surveys by mail and 90 completed surveys were returned. The data were sub-divided into surveys from Administrators and DOCs in LTC settings where an NP practiced 75% of their time (n=63) (focus of report), and those where an NP practiced <75% in LTC settings (n=23) (See Exhibit 6). The total response rate for the survey was 83%, and for Administrators and DOCs in settings with NPs working 75% the response rate was 86%. Exhibit 6: Respondents to Administrator and Director of Care Survey Total Administrator and DOC Sample (n=104)* Administrator or DOC where NP practicing 75% in LTC (n=73) Administrator or DOC where NP practicing <75% in LTC (n=35)* Survey respondents (n=63) Missing respondents (n=10) Survey respondents (n=23)* Missing respondents (n=8) * 4 survey responses were excluded because the corresponding NP (3) did not meet inclusion criteria. Administrator and Director of Care Demographic Information The final sample of Administrators and DOCs working in settings where an NP is practicing 75% of their time was 63. Of these, 37 indicated they were a DOC and 26 were Administrators. The majority of respondents were female (89%) and most (85%) were between 40 to 59 years of age. Forty-eight percent (n=30) of Administrators and DOCs reported a diploma or certificate as their highest level of education and were registered nurses. More Administrators had graduate education (23%) than did DOCs (14%). Although participants indicated a substantial range in job experience, a 7 year mean was calculated for their current position. Administrators and DOCs were asked to indicate their specific roles and responsibilities (Exhibit 7). Thirty-five percent of respondents indicated they were responsible for the supervision of the NP role compared to 70% who indicated responsibility for supervision of nursing staff. 16 of 99

17 Exhibit 7: Administrator and Director of Care Specific Roles and Responsibilities 100 Percentage of "Yes" Responses (n=63) Roles and Responsibilites 7. Case Descriptions The five LTC settings (one case had two sites) that participated as cases in Phase Two of the study were located in western, central and eastern regions of Canada and were selected related to their diverse characteristics (Exhibit 8). All interviews were audio-taped, transcribed and coded in NVIVO Because there are a small number of NPs practising 75% in LTC settings, we have taken precautions to protect the confidentiality of each case by avoiding presentation of specific details. Equal numbers of for-profit and not-for-profit LTC settings were represented. In Case One, the NP role was funded by government and the NP had been in the setting for more than 5 years. The NP practised in multiple sites in rural and suburban locations, provided care to 400 plus residents and collaborated with four to six physicians. In Case Two, the NP role was funded by a mix of government and LTC setting funding and the NP had been in the setting 2-5 years. The NP practised in an urban setting, provided care to 200 plus residents and collaborated with more than 6 physicians. In Case Three, the NP role was funded by the LTC setting and the NP had been in the setting for more than 5 years. The NP practised in a suburban setting, provided care to 200 plus residents and collaborated with 1-3 physicians. In Case Four, the NP role was funded by a mix of government and LTC setting funding and the NP had been in the setting less than 2 years. The NP practised in an urban setting, provided care to about a third of the 200 plus residents and collaborated with 1-3 physicians. 17 of 99

18 Exhibit 8: Description of Case Settings Characteristics Case One Case Two Case Three Case Four Funding Model for LTC Setting For-profit Not-for-profit For-profit Not-for-profit Funding Source for NP Role Government Mixed government/ltc setting LTC setting Mixed government/ltc setting Setting Location Rural/suburban Urban Suburban Urban Number of Sites in Setting Setting s Bed Capacity Proportion of Residents for whom NP Provides Care Years NP in Position Number of Collaborating Physicians Multiple Single Single Single 400 plus 200 plus 200 plus 200 plus 100% 100% 100% 25-35% > 5 years 2-5 years > 5 years < 2 years 4-6 > Main Reason (s) NP Introduced* Quality of care Quality of care Physician support Physician support Accessibility Quality of care *Three of the settings began as pilots 8. Roles and Practice Patterns of Nurse Practitioners 75% in LTC We examined the roles and practice patterns of NPs working in LTC 75% using investigator-developed survey questions as well as the Evercare Nurse Practitioner Role and Activity Scale, 2 a psychometrically tested instrument developed in the United States and modified slightly for the Canadian context. We present this data first, followed by relevant data from the case study component of the study. 18 of 99

19 Practicing to Full Scope of Practice Ninety-one percent of NPs indicated they worked to their full scope of practice. Two NPs working in single settings identified they were not working to their full scope of practice. Their narrative comments indicated they believed their skill was greater than their current legislated scope of practice allowed them to work; for example, they thought they should be able to prescribe narcotics and admit and provide care for residents in hospital. Nurse Practitioner Confidence NPs were asked to rate 20 items related to their confidence on a four point Likert scale. An example includes, How confident do you feel with geriatric physical health problems? Responses ranged from (1) Not at all Confident to (4) Very Confident. NPs rated their confidence level at two points in time, requiring them to recall their confidence level immediately prior to being hired in their NP role, and to reflect on their current level of confidence. Their scores were summed and compared for each time frame (minimum score= 20, maximum score=80) (Exhibit 9). Scores for individual scale items can be found in Appendix D. The total confidence score increased from an overall mean of 52 prior to being hired, to a current overall mean of 68 and the difference is statistically significant. Exhibit 9: Nurse Practitioner Confidence Level: Total and Single versus Multiple Setting Characteristics Respondents Prior Mean Prior SD Prior Min Prior Max p value a Current Mean Current SD Current Min Current Max Overall (n=23) p<0.001* Working in a single setting (n=14) p=0.001* Working in multiple settings (n=9) a Wilcoxon Signed Ranks Test * p significant <0.05 SD=standard deviation p<0.01* ENPRAS Scale Practice Pattern Results An adapted version of the Evercare Nurse Practitioner Role and Activity Scale 2 was used to measure the practice patterns of the NPs. This tool is designed to measure the frequency of NP activities. NPs were asked to indicate on a Likert scale, how often they performed each of the 108 activities in the scale. Their options ranged from "never" (0 times per year), once every three months (4 times per year), once a month (12 times per year), once a week (52 times per year), 3-4 times per week (172 times per year), once a day (365 times per year) and more than once a day (730 times per year). Frequency was analyzed and reported as the number of times the NP performs each activity per year. The 108 items were also categorized into the following subscale roles "collaborator" (7 items), "clinician" (54 items), "care manager" (7 items), "communicator" (23 items), "coach/ educator" (14 items) and "counsellor" (3 items). When items appropriate to the Canadian context were added to the scale, they were analyzed in the appropriate subscale. 19 of 99

20 The most frequently performed NP activities included 1) assessing residents, 2) managing chronic and acute illness, 3) clinical decision-making, 4) collaborating with nursing staff and 5) communicating with and building rapport with families, residents and staff (Exhibit 10 ). NPs working in a single setting indicated they collaborate with other NPs to discuss residents and treatment plans more frequently (mean 35.8 vs. 2.0 times per year) than NPs working in multiple settings. NPs working in multiple settings indicated they put in place standing orders for their residents more frequently (mean vs times per year) than NPs working in a single home. Itemized ENPRAS scale results are presented in Appendix E. Exhibit 10: Ten Most Frequently Performed Activities Reported by Nurse Practitioners Working 75% in LTC Activity Category N Mean SD MIN MAX Incorporate my nursing knowledge into my clinical decisions and orders Clinician Collaborate with nursing staff Collaborator Build rapport with residents, families, & staff built on honesty, frequent communication, & response Coach/ Educator Collaborate with licensed practical nurses/ registered practical nurses Clinician Encourage families, residents, & staff to ask questions Provide cost efficient care to my resident Coach/ Educator Care Manager Assess resident whenever concerns brought to my attention by staff Clinician Conduct physical assessment of my resident Clinician Management of chronic and acute illnesses for my residents Clinician Write medical orders including orders for Clinician laboratory tests, medications, therapy, consults, routine orders Mean= mean number of times activity was performed during a year SD= standard deviation In addition to completing the ENPRAS scale, NPs were asked to indicate the three most common resident conditions for which they provide care (Exhibit 11). NPs reported they most commonly provide 20 of 99

21 care for chronic conditions, especially cardiac and diabetes, followed by infections (e.g., urinary tract, pneumonia) and mental health conditions (e.g., dementia). Exhibit 11: Most Common Resident Conditions for Which Nurse Practitioners Provided Care: Reported by Nurse Practitioners Condition Total (Responses/ Participants) Single Setting (Responses/ Participants) Multiple Settings (Responses/ Participants) Chronic conditions (31/14) (22/10) (9/4) Cardiac (CHF, CAD, HTN, Atrial Fib) (11/10) (7/6) (4/4) Diabetes (8/8) (6/6) (2/2) Respiratory (6/6) (4/4) (2/2) Pain management (2/2) (1/1) (1/1) Arthritis (1/1) (1/1) Constipation (1/1) (1/1) Hypothyroidism (1/1) (1/1) Renal failure (1/1) (1/1) Infections (19/12) (10/8) (9/4) Urinary tract (9/9) (6/6) (3/3) Pneumonia (4/4) (2/2) (2/2) Respiratory (3/3) (1/1) (2/2) Unspecified infections (3/3) (1/1) (2/2) Mental health (15/13) (12/10) (3/3) Dementia (11/11) (8/8) (3/3) Neuro/mental health (2/2) (2/2) Depression (1/1) (1/1) Delusions (1/1) (1/1) Integumentary (11/9) (4/3) (7/6) Wound care (6/6) (1/1) (5/5) Dermatological issues (4/4) (2/2) (2/2) Cellulitis (1/1) (1/1) (1/1) Acute conditions (5/5) (1/1) (4/4) Acute conditions (4/4) (4/4) Falls/injury (1/1) (1/1) Palliative care (3/3) (2/2) (1/1) Total behaviour challenges (2/2) (1/1) (1/1) Total health promotion (1/1) (1/1) 21 of 99

22 Collaboration Activities with Physicians On the questionnaire, NPs were asked to select reasons for collaborating with physicians. Responses were similar for NPs in single and multiple settings (Exhibit 12). All NPs (n=23) indicated they collaborate with physicians regarding LTC resident needs. They also spend time collaborating with physicians about family needs (n=20) and changes in organizational practice (n=14). Other responses included: cosigning for narcotics or other medications outside of NPs scope of practice, co-signing for assistive devices or insurance forms, and discussing the latest evidence or new research (n=4). Exhibit 12: Reasons for Nurse Practitioner and Physician Collaboration: Nurse Practitioners Working in Single versus Multiple Settings Percentage of Respondents 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Single Setting (n=14) Multiple Settings (n=9) * Participants selected all that applied NPs were asked to indicate the methods they use to communicate with physicians. In-person (n=23) and by telephone (n=22) were the most common responses. One NP recorded in the other category that she communicates with the charge nurse who relays the information to the physician. 22 of 99

23 Roles and Activities of Case Study NPs The roles and activities performed by the NPs in the case studies fall into five major groupings: 1) direct clinical care for residents; 2) collaboration, consultation and referral; 3) teaching and coaching; 4) communication and counselling; and 5) leadership activities such as program planning and practice improvement initiatives. Most of the comments from participants in all four cases described the NPs direct clinical care role with residents and families. Many participants indicated the NPs completed extremely comprehensive admission assessments and assessed, managed and followed-up residents with a variety of chronic conditions as well as acute conditions such as eye, throat, chest and urinary tract infections. They also performed procedures such as suturing and ear syringing when needed. The NPs practices were characterized by collaboration, consultation, and referral. Participants indicated the NPs collaborated and consulted with physicians, the nursing staff and interprofessional team within the LTC setting as well as with external resources. Nursing and interprofessional participants indicated the NP provided consultation regarding resident care issues and the NP also sought consultation from others when needed. Participants indicated initially when NPs were new graduates and in the facility, NPs worked quite closely with We had a resident who developed symptoms of pneumonia. So NP did an assessment and she had a chest x-ray ordered. She was treated for pneumonia. Her chest x-ray also showed some infiltrates which were a little unusual, and at that point, with her first diagnosis, she was referred to the physio for chest physio and she was referred to the dietitian because we were querying whether her pneumonia was related to aspiration. So the dietitian assessed her. She also saw a respiratory therapist regarding oxygen. So there were many disciplines involved. We were in touch with the physician. On her second chest x-ray, they were querying whether she might have markings of a possibility of tuberculosis. So at that point, Public Health and our infection control nurse was involved and the respiratory specialist. There was a referral made to a respiratory specialist. It turned out she didn't have TB and her outcome was good. She's done extremely well. [Nurse Practitioner] physicians; however, as the NP gained experience and collaborative practice patterns were established the amount of time needed for collaboration was less and more situation-specific. Teaching and coaching of nursing staff in particular was an important role performed by all NPs in our case studies. Much of this was done on an informal day by day basis described as on the spot and little tidbits, all the time. Many health care providers and family members discussed the importance of the NPs communication and counselling role with residents and families as well as the health care team. Leadership activities included participating on committees within and external to the LTC settings, involvement in developing and implementing practice innovations, and program planning. I guess the ultimate thing that I appreciated most about having the nurse practitioner here was at the time of my mother's apparent about to die situation where we sat together and made the decision about whether or not to continue treatment. I felt such support and confidence in having her perspective on what was going on, because I'm sure you all know, that is a difficult decision to make, and the nurse practitioner really was tremendously helpful and very, very present with me at that time. [Family Member] 23 of 99

24 9. Satisfaction of Nurse Practitioners 75% in LTC We examined the satisfaction of NPs working in LTC 75% using investigator-developed questions on the NP survey as well as a previously developed resource satisfaction scale 36 and the Misener NP Job Satisfaction Scale, 3 a psychometrically tested instrument developed in the United States and modified slightly for the Canadian context. We present this data first, followed by relevant data from the case study component of the study. Physician Collaboration NPs were asked to rate on a 6-point Likert scale, (1) very dissatisfied to (6) very satisfied, their satisfaction with their collaborative relationship with the physician. All of the NPs (n=23) indicated a positive satisfaction rating (score of 3.5) with their collaborative relationship; however, NPs in single settings expressed a somewhat higher level of satisfaction with physician collaboration than did those who work in multiple homes (Exhibit 13). More than 70% of Administrators and DOCs indicated NPs and physicians collaborate well to extremely well in their LTC setting. Exhibit 13: Satisfaction with Collaborative Relationship with Physician: Nurse Practitioners Working 75% in LTC Percentage of Nurse Practitioners 80% 70% 60% 50% 40% 30% 20% 10% 0% Single Setting (n=14) Multiple Settings (n=9) Satisfaction Rating Salary NPs were also asked to rate their satisfaction with their salary on a 6-point Likert scale. Most NPs (n=20) indicated satisfaction with their salary (score of 3.5 out of 6) (Exhibit 14). The annual salaries reported by just over half of the NPs (n=12) were between $80,000 and $99, of 99

25 Exhibit 14: Nurse Practitioners Working 75% in LTC Satisfaction with Salary Percentage of Respondents 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Single Setting (n=14) Multiple Settings (n=8)* Nurse Practitioner Satisfaction Rating *One missing response (valid response indicated) Misener Job Satisfaction Results NPs were asked to complete the Misener NP Job Satisfaction Scale 3, containing 44 items. They rated their satisfaction with each item on a 6-point Likert scale, ranging from (1) very dissatisfied to (6) very satisfied. For analysis, the items were divided in to six subscales, including: Benefits; Time; Professional Growth; Professional, Social, and Community Interaction; Challenge and Autonomy; and Intrapractice Partnership/ Collegiality. As shown in Exhibit 15, NPs (n=22) indicated satisfaction with their job as interpreted by an overall mean score of 3.5 or greater. The Mann-Whitney U (nonparametric) test was used to determine statistical differences between NPs working in single and multiple settings. There was a statistically significant difference (p<0.02) between NPs working in a single setting, who rated their satisfaction lower (mean of 4.2/6) than NPs working in multiple settings (mean of 5.0/6) on the Benefits subscale (Exhibit 16). In addition, there was a statistically significant difference (p=0.05) on the Intrapractice Partnership/Collegiality subscale, where NPs working in a single setting rated their satisfaction lower (mean of 3.9/6) than NPs working in multiple settings (mean of 4.4/6). 25 of 99

26 Exhibit 15: Misener Nurse Practitioner Job Satisfaction. Nurse Practitioners working 75% in Long-Term Care: Total and Single versus Multiple Settings Misener Satisfaction Scale Comparisons of Nurse Practitioners Number of Respondents Mean SD Frequency of Satisfaction (score Average level of satisfaction of 3.5) Total (n=23) % (n=22) Working in a single setting Working in multiple settings (n=14) % (n=13) (n=9) % (n=9) Average level of satisfaction- Benefits Subscale Average level of satisfaction- Time Subscale Average level of satisfaction- Professional Growth Subscale Total (n=23) % (n=18) Working in a single setting Working in multiple settings (n=14) % (n=9) (n=9) % (n=9) Total (n=23) % (n=22) Working in a single setting Working in multiple settings (n=14) % (n=14) (n=9) % (n=8) Total (n=23) % (n=19) Working in a single setting Working in multiple settings (n=14) % (n=10) (n=9) % (n=9) Average level of satisfaction- Professional, Social, and Community Interaction Subscale NPs working more than 75% in LTC Working in a single setting Working in multiple settings (n=23) % (n=22) (n=14) % (n=13) (n=9) % (n=9) 26 of 99

27 Misener Satisfaction Scale Comparisons of Nurse Practitioners Number of Respondents Mean SD Frequency of Satisfaction (score of 3.5) Average level of satisfaction- Challenge/Autonomy Subscale Average level of satisfaction- Intrapractice partnership/ Collegiality Subscale NPs working more than 75% in LTC Working in a single setting Working in multiple settings NPs working more than 75% in LTC Working in a single setting Working in multiple settings (n=23) % (n=23) (n=14) % (n=14) (n=9) % (n=9) (n=23) % (n=18) (n=14) % (n=9) (n=9) % (n=9) Exhibit 16: Misener Nurse Practitioner Job Satisfaction Scale: Total and Subscales Test Total Benefits Time Professional Growth Professional, Social, and Community Challenge/ Autonomy Mann- Whitney U Interaction Exact Sig..141 a.013 a.477 a.124 a.926 a.403 a.053 a [2*(1- tailed Sig.)] a. Not corrected for ties. Intrapractice / Collegiality Resources and Supports NPs were asked to complete a satisfaction scale, composed of 20 items focused on resources and supports 36. They were asked to rate their satisfaction with each item on a 6-point Likert scale, ranging from (1) very dissatisfied to (6) very satisfied. 27 of 99

28 Generally, NPs (n=20) reported satisfaction with their resources and supports as indicated by a mean score of 3.5. Except for clerical and data management support, NPs positively rated each of the items on the resources and supports scale (Exhibit 17). Exhibit 17: Satisfaction with Resources and Supports: Nurse Practitioners Working 75% Resource and Support Items Respondents Mean SD Office space (n=23) Clinical examination (n=23) Communication technology (fax, telephone, computer, pager) (n=23) Clerical support (n=23) Computer technology (n=23) Data management support (e.g., access to databases, analysts and (n=23) statisticians) Policies that support full implementation of the NP role as an advanced (n=23) practice nursing role Adequate orientation time (n=22) Supervisor availability or regular contact and support (n=22) Policies necessary for the NP role (n=22) Introduction to key stakeholders and health care providers (n=22) Facilitation of NP involvement in quarterly and annual resident review (n=22) team meetings Clear expectations for collaboration between team members, (n=22) physicians, and NPs Introduction to other advanced practice nurses (n=20) Participation on organizational committees (n=22) Facilitation of NP involvement in research (n=22) Mentorship from experts (n=21) Leadership opportunities (n=22) Supervisors support with conflict resolution (n=22) Support to attain hospital privileges (n=15) SD= Standard deviation There was no difference in overall mean satisfaction with resources and supports between NPs working in single and multiple settings. However, there was a significant difference between NPs working in single and multiple settings for 5 of the 20 items (Exhibit 18). NPs working in a single setting rated their satisfaction with the following resource and support items significantly lower than those working in multiple settings: communication technology (fax, telephone, computer, pager), policies that support full implementation of the NP role as an advanced practice nursing role, computer technology, introduction to key stakeholders and health care providers, and support to attain hospital privileges. However, only introduction to key stakeholders and health care providers, and support to attain hospital privileges are significant when the analysis corrects for ties. 28 of 99

29 Exhibit 18: Satisfaction with Individual Resources and Supports. Single versus Multiple Sites: Nurse Practitioners Working 75% in LTC Individual Items of Satisfaction with Support and Resources Respondents Mann- Whitney U Asymp. Sig. (2- Exact Sig. [2*1- tailed Sig.)] Communication technology (fax, telephone, computer, pager) SS (n=14) MS (n=9) tailed) a Policies that support full implementation of the NP role as an advanced practice nursing role Computer technology Introduction to key stakeholders and health care providers Support to attain hospital privileges a. Not corrected for ties. b. SS=single site; MS=Multiple Sites SS (n=13) MS (n=9) SS (n=14) MS (n=9) SS (n=13) MS (n=9) SS (n=10) MS(n=5) a a a a Satisfaction of Nurse Practitioners in Case Studies The NPs in all four case studies reported being very satisfied with their roles most of the time. Funding uncertainties created some anxiety that affected satisfaction and in some cases the NP did not have a clear sense of belonging within the nursing or medical domains of the organization. NPs reported working long hours, taking work home with them and being on-call in specific situations. To prevent burn out and maintain satisfaction they described various processes they had implemented to improve their time management. One of the NPs strategies was to continuously enable nursing staff to develop new knowledge, skills and confidence to complete assessments and make decisions independently rather than developing an over reliance on the NP. 10. Facilitators and Barriers to Integration of Nurse Practitioners in Long-Term Care Nurse Practitioner Role Acceptance and Support NPs were asked to rate on a 6-point Likert scale, (1) not accepted to (6) extremely well accepted, how well 13 groups of people had accepted their role. A rating of 3.5 was interpreted to mean positive role acceptance. NPs indicated they perceived positive acceptance of their role by residents, residents families, family physicians/ general practitioners, medical directors, specialist physicians, registered nurses, licensed practical/ registered practical nurses, health care aides/ personal support/continuing care workers, clinical nurse specialists, pharmacists, social workers, physiotherapists, and registered dietitians. Almost 90% of Administrators and DOCs also reported high levels of acceptance of the NP role by residents, families, medical directors, and the health care team. 29 of 99

30 NPs were asked to consider how supportive four groups of health care professionals were toward their role and rate the perceived support on a 6-point Likert scale, (1) not supportive to (6) extremely supportive. A rating of 3.5 was interpreted to mean a positive support rating. NPs rated all four groups as being predominantly supportive of their role. More than 70% of Administrators and DOCs reported having a job description for the NP and indicated NP involvement in its development. Fifty percent indicated physician involvement in the development of the NP job description. Administrator and DOC responses were varied as to their knowledge regarding the provision of orientation about the NP role to both physicians and health care team members. Less than one third of respondents indicated there was good attendance for orientation to the NP role for these groups. Many Administrators and DOCs (49%) indicated first learning about the NP role through documents from their professional association or college. Other ways Administrators and DOCs learned about the NP role included being involved with developing the proposal for the NP position/pilot project, being informed about the role by a physician, and working with NP students and/or NPs. Other Barriers and Facilitators On the survey, NPs were asked to identify the top three factors that facilitated and the top three factors that created barriers for their integration into the LTC setting. The most common facilitators by frequency of response were: 1) medical staff support or involvement with the role (responses=15); 2) the NP s personal attributes (responses=15); and 3) supportive and accepting LTC staff (responses=13). The most common barriers by frequency of response were: 1) the lack of medical staff support or involvement with the NP role (responses=11); 2) a lack of knowledge about the NP role at the organizational level (responses=11); and 3) lack of support for NP role by LTC staff (responses=10). From the case studies we learned the main facilitators to NP integration occurred at the individual and organizational levels. These were: 1) a positive perception of the NP & NP role, particularly NPs knowledge, confidence and experience and their approachability and respect for staff; 2) strategies initiated by the NP such as developing clear communication mechanisms and building relationships; 3) support from physicians, nursing & allied health staff; and 4) orientation and education about the NP s role. In contrast, we learned the main barriers to NP integration occurred at the organizational and systems levels. These were: 1) the structure of the model of care particularly if the model spread the NP too thin or diminished the full potential of the role; 2) lack of role clarity; 3) inadequate funding; 4) legislation and regulation; and 5) limitations of NP education in relation to geriatric content. See Exhibits 19 and 20 for a comparison of the factors serving as facilitators and barriers to NP integration. I just think that they [NPs] are a great asset. I think that long term care, this is the last that we are going to be able to do for these people [residents], and we are all going to reach it one day and I hope that there is going to be somebody there that is going to be caring and able to help me at the end. I think that long term care is under-funded and I think that we need to do more. [Licensed/Registered Practical Nurse] 30 of 99

31 Exhibit 19: A Comparison of the Top Three Nurse Practitioner Role Facilitation Factors NP Survey Administrator and DOC Survey Case Studies 1 Medical staff supportive/ involved in NP Role Medical staff supportive/ involved in NP role Positive perception of NP & NP role 2 Personal attributes of NP Supportive/accepting LTC Staff Strategies initiated by the NP such as developing clear communication mechanisms and building relationships 3 Supportive/accepting LTC Staff Need for NP role/expertise in LTC setting Support from physicians, nursing & allied health staff Exhibit 20: A Comparison of the Top Three Barriers to Nurse Practitioner Role Integration NP Survey Administrator and DOC Survey Case Studies 1 Lack of Medical staff support or involvement with the NP role Lack of medical staff support or Involvement with the NP Role The structure of the model of care (NP spread too thin ) 2 Lack of knowledge about the NP role at the organizational level 3 Lack of support for NP role by LTC staff Sustainable funding NP role in multiple settings Lack of role clarity Inadequate funding 11. Perceived Impacts of the Integration of Nurse Practitioners in Long- Term Care On the survey, NPs were asked to indicate, in order of importance the top three contributions they make to: a) residents and families, b) the LTC setting, and c) the health care system. The top three contributions NPs perceive they make to residents and families are: 1. assessing, managing and following-up residents care (13 responses from 11 participants), 2. improved timeliness of care (13 responses from 11 participants); and 3. NP as teacher and coach (8 responses from 8 participants). The top contributions NPs perceive they make to the LTC setting are: 1. staff development (8 responses from 7 participants), 2. improved quality of resident care (7 responses from 7 participants), 3. NP as an innovator and leader (7 responses from 7 participants), and NP as a teacher and coach (7 responses from 7 participants). 31 of 99

32 The top contributions NPs perceive they make to the health care system are: 1. decreased transfers to emergency departments (EDs) (19 responses from 15 participants), 2. cost efficient care (7 responses from 5 participants), 3. improved timeliness of care (6 responses from 6 participants), less demand on physician (6 responses from 6 participants), and improved quality of resident care (6 responses from 6 participants). Many participants in the case studies talked about the benefits of the NP role and identified how these benefits facilitated the integration of the role. Participants were emphatic that the benefits of the NP role needed to be disseminated. From the case studies we learned the main benefits of the NP role were: Improved quality of care for residents Improved accessibility Improved continuity of care Improved support for families Benefits for physicians Improved organizational capacity to care for complex residents Improved coordination across levels of care Reduced ED transfers We definitely wouldn't be able to accept or admit some residents that we do. We are able to take residents with higher care needs because she's here. She, in the past, has educated the staff on... say it's a complex open area or something like that, we are able to take those people because she's here and she can educate our staff. So therefore we can meet their needs. [Manager] 12. Current and Ideal Integration of Nurse Practitioners in Long-Term Care Eighty percent of Administrators and DOCs indicated the NP was well to extremely well integrated in LTC. Data from three of our four case study sites support this finding. The fourth site had only fairly recently implemented the NP role and, while implementation was going well and the NP was beginning to become integrated, an expectation of full integration was premature. Even though case study sites had well integrated NP roles they identified several factors that would enable ideal integration. In sites where the NP serves a larger resident population, a smaller NP caseload is preferred. Three case sites indicated dedicated external funding would enable ideal integration, facilitate strategic planning in the organization and relieve the NPs uncertainties about their positions. Where an NP is shared across sites, the site s preference is for one NP per site. Finally, three of the four sites indicated NPs should be part of the on-call schedule on evenings and weekends to achieve ideal integration. Staff and NPs shared examples of when the NPs are contacted during the night and on weekends, particularly for residents who are dying; however, this access to the NP has not been formally acknowledged and has not been incorporated into the NP job description or organizational structure. She fits. She's part of it. It's like she completes the circle of our care. It just wouldn't be the same without her there. [Staff Nurse Leader] The nurse practitioner is such an important integral part of this institution. [Family Member] I would say we are all puzzle pieces staff, families, managers, friends, volunteers, she's [NP] like the glue that puts it all together. [Manager] 32 of 99

33 13. Discussion of Findings This is the first national study to explore the integration of the NP role in LTC settings. The release of our study findings comes at a time when the full impact of what an aging population will mean for the LTC sector is garnering the attention of governments at all levels. Not only will the number of older adults requiring residential LTC increase, improved home support programs will mean that when they are admitted to a LTC facility they are more likely to be older and have multiple chronic conditions including dementia. 9,40 In doing this study, our purpose was to enable realization of the full potential of the NP role to contribute to the innovative strategies needed to ensure timely access to quality care for LTC residents, one of society s most vulnerable populations. To that end, we set out to address three research questions: 1. What are the roles and practice patterns of NPs in LTC settings in Canada? 2. What are the perceptions of NPs and stakeholders regarding current and ideal integration of NPs in Canadian LTC settings? 3. What individual, organizational, and system factors (facilitators and barriers) influence the integration and job satisfaction of NPs in Canadian LTC settings? The findings from our study indicate that NPs are beginning to be implemented in LTC in almost every province. Although the number of NPs in LTC is slowly growing, it is somewhat surprising that in all of Canada there are fewer than 50 NPs in LTC, an indication of the earliness of the stage of adoption of this innovation. Ontario has the greatest number of NPs in LTC. This is not surprising given that it is also the province with the longest experience with the NP role generally, having had legislation and regulation for NPs in primary healthcare for more than 15 years. 10 In some other jurisdictions, the introduction of the NP role is much more recent. While significant progress has been made toward the integration of NPs in primary healthcare in Canada, barriers to their full integration exist at systemic and organizational levels We found that most NPs in LTC are practicing in models where they are employed full-time (more than 75%) in one or multiple LTC settings. While not the focus of our study, through our recruitment processes we learned that there are other models in which NPs in LTC are being used. For example, there are a number of NPs in several provinces who have a full-time position in a community-based primary healthcare setting and who also devote at least a half day per week to a LTC setting. In Ontario, there are also outreach focussed models. In some of these, NPs are on-call to a set of LTC settings traveling there when needed to assess and manage residents and, when possible, prevent visits to emergency departments. There are also outreach models in which NPs have an education focus. This diversity of models reflects a degree of experimentation with using NPs in LTC to meet local needs and should be the focus of future research. Our study findings show that overall NPs who work 75% or more in LTC are well integrated in their organizations and perceived by stakeholders to improve the accessibility, timeliness, comprehensiveness and quality of care. They are accepted by the healthcare team, residents and families, and are satisfied with their roles and responsibilities, collaborative relationship with physicians and the resources and supports available to them. Integration is a process that occurs over time and begins with successful implementation of the role. NPs are providing a broad range of services and supports in LTC settings. Consistent with studies of NPs in LTC in the United States, they spend the majority of their time providing direct care to residents and families and have an important role educating and supporting staff. 44 NPs support and assist nursing 33 of 99

34 staff to learn new knowledge and skills and thereby enable LTC organizations to increase their capacity to admit and care for residents with more complex behavioural and physical challenges and needs. Importantly, regulated and unregulated nursing staff report feeling supported by the NPs actions and approach, and ultimately feel more satisfied. This is an important consideration as provinces and territories develop plans to address the growing numbers of older adults who at some point in their lives will require residential care as well as concerns about the declining morale of staff in these settings. 9 We found that NPs in multiple LTC settings were more satisfied than those in single LTC settings on some sub-scale measures of satisfaction. This contrasts with previous research conducted soon after NPs were introduced in Ontario that found NPs working in multiple LTC settings experienced considerable stress and challenges meeting the demands of their workload. 22,31 It is possible that these differences in satisfaction ratings may be related to regional differences in salaries and benefits for NPs. However, our findings suggest another alternative explanation. The NPs working in multiple settings, almost all of whom are in Ontario and have not changed positions, are now a more experienced group of NPs who have learned how to manage their time and organize their workloads. Overtime these NPs and their organizations seem to have learned how to clarify role expectations and implement strategies to foster the development of other staff to work to their full scope of practice thereby reducing the need to contact the NP for so many concerns. Organizations deciding to employ NPs in multiple LTC sites need to consider that the adaptation curve for both the NP and the organization may be longer and steeper than in a single LTC site and therefore may require more time and implementation supports to realize the full benefits of role integration. There are several significant barriers that prevent the full integration of NPs into the LTC sector. Funding has not kept pace with the expanding expectations being placed on the LTC sector 9 and so it is not surprising that one of the main barriers identified by stakeholders is the insufficient level of fiscal investment from healthcare systems to support NP roles. Early adopter organizations who recognized the benefit of having an NP in their setting are struggling to find the means to support NPs from within their existing budgets. When they are required to support an NP from their existing nursing envelope they do so at the cost of forgoing other valuable nursing roles. The uncertainty generated by unstable funding limits the strategic planning of LTC organizations and creates anxiety for NPs that threatens their job satisfaction. Funding challenges are an issue preventing the integration of all NP roles in Canada and there is an increasing recognition that pan-canadian solutions are needed. 45,46 As has been found in other studies, 40,41,45,46 physician support is an important enabler of NP integration in LTC, when present, and, when absent, it is a significant barrier. While NPs in our survey were satisfied with their collaborative relationships with the physicians with whom they collaborate most, almost half the NPs identified lack of physician support as a barrier to role implementation. We found a similar pattern in our case studies in that the relationship between NPs and physicians with whom they worked was positive; however, stakeholders identified that other physicians in the LTC setting and in the broader community were resistant and even opposed to the NP role in LTC. These inter-professional issues are similar to those experienced by NPs in primary healthcare and acute care settings and require organization and systems-based resolutions. 41,45,46 Other barriers to NP integration were lack of awareness of the NP role, legislative restrictions to NP practice, and limitations of NP education programs. Finally, our study revealed that stakeholders perceive there are many beneficial impacts associated with having an NP in a LTC setting. Investments in the integration of NPs in LTC may be quite attractive, if LTC settings are able to realize improvements in the accessibility, quality and continuity of care for residents 34 of 99

35 and support for families. These are important considerations as the LTC sector struggles to keep up with the increasing numbers of older adults requiring residential care as well as their expanding expectations for quality and choice in care. 9 Just as important to LTC organizations and the broader system are the perceptions of stakeholders that the integration of NPs in LTC results in improvements in the organizational capacity of LTC settings to care for complex residents, better coordination across levels of care, and reductions in ED transfers. 14. Strengths and Limitations of the Study This cross-canada study used mixed methods thereby enabling triangulation of data sources. It involved a large cross- jurisdictional research team composed of investigators and decision makers with a broad range and depth of experience relevant to our study aims. Since there was no available central data source to tell us who the NPs in LTC were, we used multiple approaches to enable us to identify NPs and their administrators and DOCs. Although we are reasonably confident we were able to identify most of the NPs in LTC it is possible we may have missed some potential participants. The response rates of the NP and administrator and DOC surveys were excellent thereby giving us confidence that our results represent national perspectives. Our case studies involved many diverse stakeholders including residents, families, administrators, managers, NPs, physicians, allied health professionals and regulated and unregulated nursing staff. When arranging the site visits and before each interview, we explained that we welcomed all perspectives about NP integration, positive, and negative. In spite of these efforts, it is possible that participants who held less favourable views about NPs may not have participated in the interviews or may not have volunteered their perspectives creating a potential response bias. Lastly, in all of the case studies integration of the NP role was good to excellent and our findings may have been different had we been able to recruit a site where there were more challenges with integration. 15. Conclusions and Recommendations The integration of NPs in LTC is an innovation that offers considerable promise to enable LTC organizations and health care systems to meet the current and coming challenges within the LTC sector. The impact of the NP role occurs not only by the direct interventions of the NP with residents and families but also by the impact of the NP on the organization as a whole, particularly in respect to capacity development with nursing staff. NPs practice in single and multiple LTC settings as well as other models. There is variability in how they divide their time between direct clinical care, for example, doing comprehensive admission assessments and providing chronic and episodic acute care, and other activities, such as family support, collaboration and consultation, teaching staff, and leading practice innovations. NPs mix of activities should reflect and respond to the needs of residents, families and the LTC organization. We offer the following recommendations to enable broader integration of NPs into the health care system so that NPs in LTC in Canada may become, as one of our case study participants said, the usual, not the exception : 1. Federal/ provincial/territorial (FPT) governments to develop funding and human resource strategies to support and plan for the integration of the NP role in LTC settings. 35 of 99

36 2. FPT governments in collaboration with national and provincial/territorial nursing and NP organizations to develop and disseminate public information about the NP role in LTC. 3. FPT governments in collaboration with national and provincial/territorial nursing and NP organizations to collaborate to remove legislative barriers to the scope of practice of NPs in LTC. 4. LTC organizations, including all key stakeholders, to identify the gaps in service that the NP role is intended to address when planning for implementation of the role in LTC settings. 5. Canadian Association of Schools of Nursing in collaboration with educational institutions providing NP education to review NP curricula for geriatric theory and clinical experience. It's [NP role] a respected and accepted and expected even part of the multidisciplinary team. So it's receiving referrals from the physio and from the dietitian and from the physician. And it's [NP] giving referrals back to them. So it's a constant flow of working with each other as part of a team, looking at what the resident really needs and how we can best as a team provide that. So it's like the usual, not the exception. [Nurse Practitioner] 36 of 99

37 References 1. Tashakkori, A., & Teddlie, C. (2003). The past and future of mixed methods research: From data triangulation to mixed model designs (pp ). In: A. Tashakkori & C.Teddlie (Eds). Handbook of mixed methods in social & behavioral research. California: Sage Thousand Oaks 2. Abdallah, L., Fawcett, J., Kane, R.L., Dick, K., & Chen, J. (2005). Development and psychometric testing of the EverCare Nurse Practitioner Role and Activity Scale (ENPRAS). Journal of the American Academy of Nurse Practitioners, 17(1), Misener, T.R., & Cox, D.L. (2001). Development of the Misener Nurse Practitioner Job Satisfaction Scale. Journal of Nursing Management, 9(1), Golant, S.M. (2001). Assisted living: A potential solution to Canada's long-term care crisis. Retrieved from, 5. College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada (2005). National physician survey 2004: Results for family physicians. Retrieved from, df 6. Chan, B.T.B. (2002). From perceived surplus to perceived shortage: What happened to Canada's physician workforce in the 1990's? Ottawa, ON, Canadian Institutes for Health Information. 7. National Advisory Council on Aging. (2003). Interim report card: Seniors in Canada Retrieved from, 8. Special Senate Committee on Aging. (2009). Canada s aging population: Seizing the opportunity. Retrieved from, 9. Conference Board of Canada (2011). Elements of an effective innovation strategy for long term care in Ontario. Retrieved from, Kaasalainen, S., Martin-Misener, R., Kilpatrick, K., Harbman, P., Bryant-Lukosius, D., Donald, F., & DiCenso, A. (2010). An historical overview of the development of advanced practice nursing roles in Canada. Canadian Journal of Nursing Leadership, 23(SI), Donald, F., Martin-Misener, R., Bryant-Lukosius, D., Kilpatrick, K., Kaasalainen, S., Kioke, S., & DiCenso, A. (2010). The primary healthcare nurse practitioner role in Canada. Canadian Journal of Nursing Leadership, 23(SI), of 99

38 12. DiCenso, A., Auffrey, L., Bryant-Lukosius, D., Donald, F., Martin-Misener, R., Matthews, S., & Opsteen, J. (2007). Primary health care nurse practitioners in Canada. Contemporary Nurse, 26(1), Marriott, J., & Mabel, A. (2000). A review of international literature on primary health care reform and models. Ottawa, ON, Minister of Public Works and Government Services Canada. 14. Romanow, R.J. (2002). Building on values: The future of health care in Canada. Retrieved from, Spitzer, W.O., Sackett, D.L., Sibley, J.C., Roberts, R.S., Gent, M., Kergin, D.J. et al. (1974). The Burlington randomized trial of the nurse practitioner. New England Journal of Medicine, 290(5), Horrocks, S., Anderson, E., & Salisbury, C. (2002). Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal, 324(7341), Intrator, O., Zinn, J., & Mor, V. (2004). Nursing home characteristics and potentially preventable hospitalizations of long-stay residents. Journal of the American Geriatrics Society, 52(10), Rosenfeld, P., Kobayashi, M., Barber, P., & Mezey, M. (2004). Utilization of nurse practitioners in long-term care: Findings and implications of a national survey. Journal of the American Medical Directors Association, 5(1), Kane, R.L., Garrard, J., Buchanan, J.L., Rosenfeld, A., Skay, C., & McDermott, S. (1991). Improving primary care in nursing homes. Journal of the American Geriatrics Society, 39(4), Kane, R.L., Keckhafer, G., Flood, S., Bershadsky, B., & Siadaty S. (2003). The effect of Evercare on hospital use. Journal of the American Geriatrics Society, 51(10), Kaasalainen, S., Martin Misener, R., Carter, N., DiCenso, A., Donald, F., & Baxter, P. (2010). The nurse practitioner role in pain management in long-term care. Journal of Advanced Nursing, 66(3), Stolee, P., Hillier, L., Esbaugh, J., Griffiths, N., & Borrie, M. (2006). Examining the nurse practitioner role in long-term care. Journal of Gerontological Nursing, 32, Canadian Institute for Health Information, Canadian Nurses Association. (2006). The regulation and supply of nurse practitioners in Canada: 2006 update. Retrieved from, Canadian Institute for Health Information. (2010). Regulated nurses: Canadian trends, Retrieved from, 38 of 99

39 25. Donald, F., Mohide, A., DiCenso, A., Brazil, K., Stephenson, M., & Akhtar-Danesh, N. (2009). Nurse practitioner and physician collaboration in long-term care homes: Survey results. Canadian Journal on Aging, 28(1), Kaasalainen, S., Martin Misener, R., Carter, N., DiCenso, A., Donald, F., & Baxter, P. (2010). The nurse practitioner role in pain management in long-term care. Journal of Advanced Nursing, 66(3), Kaasalainen, S., DiCenso, A., Donald, F., & Staples, E. (2007). Optimizing the role of the nurse practitioner to improve pain management in long-term care. Canadian Journal of Nursing Research, 39(2), McAiney, C., Haughton, D., Jennings, J., Farr, D., Hillier, L., & Morden, P. (2008). A unique practice model for nurse practitioners in long-term care homes. Journal of Advanced Nursing, 62(5), McCloskey, R., Jarret, P., Knudson, C., Quinn, S. & Stewart, C. (2009). Exploring the role of the nurse practitioner in long-term care. Canadian Journal of Geriatrics, 12(4): Klaasen, K., Lamont, L., & Krishnan, P. (2009). Setting a new standard of care in nursing homes. Canadian Nurse, 105(9), Stolee, P., Hillier, L.M., & æstima research. (2002). The Ontario nurse practitioner in long-term care facilities pilot project: Interim evaluation final report. Retrieved from, ml 32. DiCenso, A., Paech, G., & IBM Corporation. (2003). Report on the integration of primary health care nurse practitioners into the province of Ontario: Final report June 30, Retrieved from, DiCenso, A., Bryant-Lukosius, D., Bourgeault, I., Martin-Misener, R., Donald, F., Abelson, J.,... & Harbman, P. (2010). Clinical nurse specialists and nurse practitioners in Canada: A decision support synthesis. Retrieved from, aa57-2b81c aspx 34. Frank, C., Seguin, M.A., Haber, S., Godwin, M., & Stewart, G.I. (2006). Medical directors of long-term care facilities: Preventing another physician shortage? Canadian Family Physician, 52(6), 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, Green E, Fitch M, et al. (2007). A survey of oncology advanced practice nurses in Ontario: Profile and predictors of job satisfaction. Canadian Journal of Nursing Leadership, 20(2), Edwards, P., Roberts, I., Clarke, M., et al. (2002). Increasing response rates to postal questionnaires: Systematic review. British Medical Journal, 324, of 99

40 38. Hidiroglou, M. A., Drew, J. D., & Gray, G. B. (1993). A framework for measuring and reducing nonresponse in surveys. Survey Methodology, 19(1), QSR International Pty Ltd. (2010). NVIVO 9. QSR International Pty Ltd. 40. International Collaborative Research Strategy for Alzheimer s Disease of the Canadian Institutes of Health Research. (2010). Turning the tide: A Canadian strategy for international leadership in the prevention and early treatment of Alzheimer s disease and related dementias. Retrieved from, Donald, F., Martin-Misener, R., Bryant-Lukosius, D., Kilpatrick, K., Kaasalainen, S., Kioke, S.,... & DiCenso, A. (2010). The primary healthcare nurse practitioner role in Canada. Canadian Journal of Nursing Leadership, 23(SI), DiCenso, A., Bryant-Lukosius, D., Martin-Misener, R., Donald, F., Abelson, J., Bourgeault, I.,... & Kioke, S. (2010). Factors enabling advanced practice nursing role integration in Canada. Canadian Journal of Nursing Leadership, 23(SI), Martin-Misener, R. (2010). Will nurse practitioners achieve full integration in the Canadian healthcare system? Canadian Journal of Nursing Research, 42(2), Abdallah,L. M. (2005). EverCare nurse practitioner practice activities: similarities and differences across five sites. Journal of the American Academy of Nurse Practitioners, 17(9), DiCenso, A., Martin-Misener, R., Bryant-Lukosius, D., Bourgeault, I., Kilpatrick, K., Donald, F.,... & Charbonneau-Smith, R. (2010). Advanced practice nursing in Canada: Overview of a decision support synthesis. Canadian Journal of Nursing Leadership, 23(SI), DiCenso, A., Bryant-Lukosius, D., Bourgeault, I., Martin-Misener, R., Donald, F., Abelson, J.,... & Harbman, P. (2010). Clinical nurse specialists and nurse practitioners in Canada: A decision support synthesis. Retrieved from, aa57-2b81c aspx 40 of 99

41 Appendix A: Nurse Practitioner Survey Integration of Nurse Practitioners in Long-Term Care Settings in Canada Questionnaire for Nurse Practitioners Faith Donald, RN(EC), PHC-NP, PhD Associate Professor Daphne Cockwell School of Nursing Ryerson University Ruth Martin-Misener, RN-NP, PhD Associate Professor School of Nursing Dalhousie University 350 Victoria Street 5869 University Ave Toronto, ON M5B 2K3 Halifax, NS B3H 3J5 (416) , ext (902) of 99

42 Part A Nurse Practitioner (NP) Demographics 1. What is your highest nursing educational background? (Check ONE only) Nursing Diploma Baccalaureate Master s Doctorate 2. What is your licensed NP designation? (Check ALL that apply) Family/ Primary Health Care/ All Ages NP Specialty/ Acute Care NP Not licensed as an NP 3. How did you obtain your NP education? (Check ONE only) Post-RN or Post-Baccalaureate Master s or Post-Master s NP program Doctorate in Nursing Practice Other 4. What specific education or certifications related to geriatrics do you have? (Check ALL that apply) Course(s) with geriatric theory Clinical experience with geriatric population in my NP program CNA geriatrics certification Other None 5. What is your age in years? years 6. What is your sex? Female Male 7. How long have you practiced as a Registered Nurse, including as an NP? years months 8. How many years did you practice as a Registered Nurse in LTC, prior to becoming an NP? years as a Registered Nurse in LTC 9. How long have you practiced as an NP in total? years months 42 of 99

43 10. How long have you worked in LTC as an NP? years months 11. How long have you worked in your current position as an NP? years months 12. What is your employment status? Full-time in a LTC setting (e.g., nursing home) Full-time in primary healthcare and LTC % LTC setting % Community/ Primary Healthcare Part-time in a LTC setting hours per week Other Adapted from Bryant Lukosius (2006). The first Ontario questionnaire of oncology APNs; Donald, F.C. (2007) Collaborative Practice by Nurse Practitioners and Physicians in Long-Term Care Settings; and IBM (2005) Integration of Nurse Practitioners in Ontario. Questions 13 & 14 consider the impact of your educational and work experience in your NP role. Please check the one best answer for each question below. 13. Immediately prior to being hired into your current NP role in LTC, how confident did you feel with each of the following: a. Geriatric physical health problems 1 Not at all confident 2 Somewhat confident 3 Confident 4 Very confident b. Geriatric mental health problems c. Diagnostic skills for a geriatric population d. Technical skills and procedures, e.g., suturing e. Prescribing medications for a geriatric population f. Interventions for geriatric behavioural issues g. Legal and ethical issues relevant to geriatrics h. Working with families i. Palliative care interventions j. Collaborative practice skills k. Autonomy and independent practice l. Teaching nursing staff m. Application of research findings to clinical practice n. Implementing best-practices in an organization 43 of 99

44 13. Immediately prior to being hired into your current NP role in LTC, how confident did you feel with each of the following: o. Research skills 1 Not at all confident 2 Somewhat confident 3 Confident 4 Very confident p. Organization leadership skills q. Change management skills r. Conflict management skills s. Time management t. Establishing priorities 14. Now that you have been in your NP role, how confident do you feel with each of the following: 1 Not at all confident 2 Somewhat confident 3 Confident 4 Very confident a. Geriatric physical health problems b. Geriatric mental health problems c. Diagnostic skills for a geriatric population d. Technical skills and procedures, e.g., suturing e. Prescribing medications for a geriatric population f. Interventions for geriatric behavioural issues g. Legal and ethical issues relevant to geriatrics h. Working with families i. Palliative care interventions j. Collaborative practice skills k. Autonomy and independent practice l. Teaching nursing staff m. Application of research findings to clinical practice n. Implementing best-practices in an organization o. Research skills p. Organization leadership skills q. Change management skills r. Conflict management skills s. Time management 44 of 99

45 13. Immediately prior to being hired into your current NP role in LTC, how confident did you feel with each of the following: 1 Not at all confident 2 Somewhat confident 3 Confident 4 Very confident t. Establishing priorities Part B Characteristics of Residents and Long-Term Care Settings 15. In what province do you work? 16. How would you classify your LTC work location(s)? (Check ALL that apply) Remote Rural Suburban Urban 17. Within how many LTC setting do you work? Number of for-profit settings Number of not-for-profit settings 18. Please provide the name of each LTC site where you work. For each site identify the total number of beds, the number of physicians with whom you work on a regular basis, your average number of hours on-site per week, and the average number of resident contacts that you provide per week. Name of LTC site Total # of beds # of physicians Average # of hours on-site per week Average # of resident contacts per week of 99

46 Adapted from Bryant Lukosis (2006). The first Ontario questionnaire of oncology APNs. Used with permission. For all remaining questions: If you practice in more than one facility or setting, please answer the questions based on the one LTC facility where you work the most hours as an NP, unless otherwise indicated. 46 of 99

47 19. Overall, how well do you feel that residents have accepted your NP role? (Circle ONE number) a. Overall, how well do you feel that residents families have accepted your NP role? (Circle ONE number) 20. How many hours per week do you get paid to work as an NP in LTC? a. How many overtime hours per week do you work in LTC? b. How many hours of on-call time do you work per month? c. How many weeks per year of paid vacation do you receive? Not Minimally Somewhat Fairly Accepted Extremely accepted accepted accepted well well accepted accepted Not Minimally Somewhat Fairly Accepted Extremely accepted accepted accepted well well accepted accepted Regular hours per week Paid overtime hours per week (average) Unpaid overtime hours per week (average) Paid on-call hours per month (average) Unpaid on-call hours per month (average) Weeks per year of paid vacation 21. What financial support does your employer provide for you to participate in continuing education opportunities? (Check ALL that apply) Conference registration/tuition Travel and hotel Texts/ On-line resources Paid educational leave days/year Other None 22. In your current position, are you a member of a union? a. Has union membership affected your NP role? Yes (go to 22a, b and c) No (go to question 23) Yes (go to 22b and c) No (go to question 23) b. If yes, what has the effect been? Generally positive Generally negative c. Please comment; if more comment space is needed, please use the blank pages at the end and specify question #22c 47 of 99

48 23. What is the primary source of funding for your salary? (Check ONE only) Provincial government District or regional health authority or LHIN LTC organization Family Health Team/ Primary Care Network Physician Nursing budget Other (specify) Do not know 24. What is your gross base and overtime income? Annual gross base $ Annual gross overtime $ 25. How satisfied are you with your salary? (Circle ONE number) Very Dissatisfied Minimally Minimally Satisfied Very dissatisfied dissatisfied satisfied satisfied Adapted from IBM (2005) Integration of nurse practitioners in Ontario; Donald, F.C. (2007) Collaborative Practice by Nurse Practitioners and Physicians in Long-Term Care Settings. 26. Who is your direct supervisor? (Check ALL that apply) Administrator Physician Nursing Director Other 27. If you have a performance appraisal, please specify how often it is done and who does the performance appraisal. 28. At time other than your performance appraisal, on average, how often do you meet with your supervisor to discuss role performance? Annually (Title of person) Every few years (Title of person) I have never had a performance appraisal Weekly Monthly Quarterly Yearly Never 48 of 99

49 Part C - NP Role Definition 29. Do you have a written position description specific to your NP role? 30. Were you or another NP involved in developing your NP position description? Yes No Do not know Yes No Do not know 31. How well is your NP role defined? (Check ONE only) 32. Are you expected to achieve specific goals or outcomes related to your role? (Check ONE only) Well defined Somewhat defined Yes (go to question 32a) No (go to question 33) Not sure (go to question 33) Poorly defined Not defined at all a. Please list the goals or outcomes you are expected to achieve. (If more space is needed, use the blank pages at the end and specify question 32a) Adapted from Bryant Lukosius (2006). The first Ontario questionnaire of oncology APNs; Donald, F.C. (2007) Collaborative Practice by Nurse Practitioners and Physicians in Long-Term Care Settings; IBM (2005) Integration of Nurse Practitioners in Ontario. Part D- Characteristics of and Relationships with Health Care Team, Resident and Family 33. How are the majority of physicians with whom you practice paid for their work in LTC? (Check ONE only) Fee-for-service Capitation Salary Do not know Combination of fee-for-service and salary Other (specify) 34. For NPs who work in primary care and LTC, do the same physicians collaborate with you in your office practice and in the LTC setting? Yes Some yes, some no No N/A 49 of 99

50 Please consider the one physician with whom you collaborate with most frequently in LTC when answering questions How many hours PER MONTH do you collaborate with this physician? 36. Which of the following do you spend the most time on when collaborating with this physician? Please rank in order of frequency or write N/A, if not applicable. (1 indicating most frequent) # of hours Resident needs Family needs Quality assurance Changes in organizational practice Program development Other (specify) 37. Which of the following methods of communication do you use when you collaborate with this physician? Please rank in order of frequency or write N/A, if not applicable. (1 indicating most frequent) In person Telephone Communication book Other (specify): Text messaging Fax Health records 38. How satisfied are you with the collaborative relationship with this physician? (Circle ONE number) Very Dissatisfied Minimally Minimally Satisfied Very dissatisfied dissatisfied satisfied satisfied 39. How supportive of your NP role are the following people? (Check the ONE best answer) 1 Not supportive 2 Minimally supportive 3 Somewhat supportive 4 Fairly well supportive 5 Supportive 6 Extremely well supportive a. Administrator or DOC b. Medical Director c. Majority of physicians d. Majority of charge nurses 40. Was there an orientation of physicians and other health care providers to your role prior to your arrival? a. Physicians Yes No Do not know b. Health care providers Yes No Do not know 50 of 99

51 41. Overall, how well have the following people accepted your NP role? (Check the ONE best answer. Write N/A if not applicable.) 1 Not accepted 2 Minimally accepted 3 Somewhat accepted 4 Fairly well accepted 5 Accepted 6 Extremely well accepted a. Family Physicians/ General Practitioners b. Medical Directors c. Specialist Physicians d. Registered Nurses e. Licensed Practical Nurses/ Registered Practical Nurses f. Health Care Aides/ Personal Support Workers g. Clinical Nurses Specialists h. Pharmacists i. Social Workers j. Physiotherapists k. Registered Dietitians Part E - NP Job Satisfaction 42. Please indicate your level of satisfaction in your current job as an NP. There may be items that do not pertain to you; however, please answer them based on the employer s policy, i.e. if you needed it, would it be there? (Check the ONE best answer) 1 Very dissatisfied 2 dissatisfied 3 Minimally dissatisfied 4 Minimally satisfied 5 Satisfied 6 Very satisfied a. Vacation/leave policy b. Benefit package c. Retirement plan d. Time allotted for answering messages e. Time allotted for review of lab and other test results f. Your immediate supervisor g. Percentage of time spent in direct resident care h. Time allocation for seeing patients (e.g.) amount of time allocated to see patients 51 of 99

52 i. Amount of administrative support j. Quality of assistive personnel k. Patient scheduling policies and practices (e.g., practices regarding scheduling of residents) l. Resident mix m. Sense of accomplishment n. Social contact at work o. Status in the community p. Social contact with colleagues after work q. Professional interaction with other disciplines/ providers r. Support for continuing education (time and money) s. Opportunity for professional growth t. Time to serve on professional committees u. Amount of involvement in research v. Opportunity to expand your scope of practice w. Interaction with other NPs, including faculty x. Consideration given to your opinion and suggestions for change in the work setting or office space y. Input into organizational policy z. Freedom to question decisions and practices 2a. Expanding skill level/procedures within your scope of practice b. Ability to deliver quality care c. Opportunities to expand your scope of practice and time to seek advanced education d. Recognition of your work from superiors e. Recognition of your work from peers f. Level of autonomy g. Evaluation process and policy h. Reward distribution 52 of 99

53 i. Sense of value for what you do j. Challenge in work k. Opportunity to develop and implement ideas l. Process used in conflict resolution m. Amount of consideration given to your personal needs n. Flexibility in practice protocols o. Monetary bonuses that are available in addition to your salary p. Opportunity to receive compensation for services performed outside of your normal duties q. Respect for your opinion r. Acceptance and attitudes of physicians outside of your practice (such as specialists you refer residents to) Misener NP Job Satisfaction Scale, Copyright All rights reserved. Used with permission from Deanna L. Cox. Adapted for LTC. 43. What is your level of satisfaction with these resources and supports for your NP role in LTC? (Check the ONE best answer. Write N/A if not applicable.) 1 Very dissatisfied 2 Dissatisfied 3 Minimally dissatisfied 4 Minimally satisfied 5 Satisfied 6 Very satisfied a. Office space b. Clinical examination c. Communication technology (fax, telephone, computer, pager) d. Clerical support e. Computer technology f. Data management support (e.g., access to databases, analysts and statisticians) g. Policies that support full implementation of the NP role as an advanced practice nursing role h. Adequate orientation time i. Supervisor availability or regular contact and support j. Policies necessary for the NP role k. Introduction to key stakeholders and health care providers 53 of 99

54 43. What is your level of satisfaction with these resources and supports for your NP role in LTC? (CONTINUED) l. Facilitation of NP involvement in quarterly and annual resident review team meetings m. Clear expectations for collaboration between team members, physicians, and NPs 1 Very dissatisfied 2 Dissatisfied 3 Minimally dissatisfied 4 Minimally satisfied 5 Satisfied 6 Very satisfied n. Introduction to other advanced practice nurses o. Participation on organizational committees p. Facilitation of NP involvement in research q. Mentorship from experts r. Leadership opportunities s. Supervisors support with conflict resolution t. Support to attain hospital privileges Adapted from Bryant Lukosius (2006). The first Ontario questionnaire of oncology APNs. Adapted for LTC. 44. Do you work to the full scope of NP practice? Yes No Comments 45. What are the three (3) most common resident conditions for which you provide care? Consider the amount of time you spend on each of these activities in an AVERAGE WEEK in LTC. Rank order them, with 1 indicating most time spent and 8 indicating least time spent. Write N/A, if not applicable. Wellness care/health promotion (health screenings/ immunizations) Episodic care for minor acute illness/injury (e.g. flu, falls, UTI, pneumonia) Management and monitoring of chronic conditions (e.g. CHF, diabetes, HT, asthma) Wound care management Episodic care for major acute illness (unstable angina, acute abdominal pain) Management and monitoring of mental health concerns (e.g. depression, anxiety, stress) Palliative care (e.g. some cancers, some degenerative conditions) 54 of 99

55 Community outreach (e.g. senior s complexes) (specify) Other (please specify) 47. What are the three (3) most important contributions of your role for residents and their families? (Please list according to importance, with #1 being the most important) What are the three (3) most important contributions of your NP role to the LTC organization (Please list according to importance with #1 being the most important) What are the three (3) most important contributions of your NP role to the health care system? (Please list according to importance with #1 being the most important) of 99

56 50. Please complete the scale by placing a check in the one box that best indicates the frequency with which you perform each activity listed below. Write N/A if not applicable. Never Once every 3 months Once a month Once a week 3-4 times a week Once a day More than once a day a. Collaborate with physician b. Collaborate with nursing staff c. Call physician with resident status changes d. Keep everyone on same page (team members) e. Call family with resident status changes f. Keep everyone up to date (team members) g. Collaborate with physician for diagnosis, management of resident (chronic conditions) h. Collaborate with physician for diagnosis, management of resident (acute conditions) i. Collaborate with speech therapist j. Collaborate with dietitian k. Collaborate with physical therapist l. Collaborate with personal support worker m. Collaborate with social worker n. Collaborate with nursing administration o. Collaborate with occupational therapy p. Collaborate with pharmacist q. Collaborate with licensed practical nurses/ registered practical nurses r. Collaborate with family to incorporate their wishes into plan of care s. Develop plan of care in synch with resident, family, physician, and other staff recommendations t. Collaborate with resident to incorporate their wishes into plan of care. If resident unable, collaborate with family u. Collaborate with psychiatric services v. Conduct rounds on resident with physician w. Collaborate with other NPs to discuss residents and treatment plan 56 of 99

57 50. Please complete the scale by placing a check in the one box that best indicates the frequency with which you perform each activity listed below. Write N/A if not applicable. x. Collaborate with charge nurse/director of care to discuss residents and treatment plan, or other issues Never Once every 3 months Once a month Once a week 3-4 times a week Once a day More than once a day y. Collaborate with activity staff z. Diagnosis of chronic and acute illness for my residents 2a. Management of chronic and acute illnesses for my residents b. Develop a treatment plan for management of chronic and acute illnesses for my resident c. Conduct physical assessment of my resident d. Conduct diagnostic workup on my resident e. Develop a plan of care for my resident f. Promote quality of life in care that I provide g. Maximize the functional ability of my resident h. Incorporate my nursing knowledge into my clinical decisions and orders i. Maintain continuing education/keep current in latest research related to geriatric resident care j. Conduct monthly assessments on all residents k. Aware of subtle changes in resident s condition which may be significant to health status l. Check resident s weight for changes m. Check resident s dietary intake for changes n. Check resident for mild behaviour changes o. Conduct overview of resident s health records every month p. Assess resident whenever concerns brought to my attention by staff q. Stay on top of residents with fluctuating chronic conditions r. Order therapy evaluations on residents 57 of 99

58 50. Please complete the scale by placing a check in the one box that best indicates the frequency with which you perform each activity listed below. Write N/A if not applicable. s. Interpret diagnostic testing done on my resident t. Conduct a complete physical examination on my resident u. Revise treatment plan on my resident as needed v. Provide primary care management of each resident w. If medical plan fails, find out why through communication with nursing staff and physician x. Titrate medications of resident to lowest amount with greatest effect y. Write nursing intervention orders (e.g., hydration, turn & reposition, wound care, etc.) z. Assist nursing staff in implementing care of my residents 3a. Conduct functional health assessment for Never Once every 3 months Once a month Once a week 3-4 times a week Once a day More than once a day my resident b. Conduct mental status evaluation for my resident c. Conduct medication review for my resident d. Review advanced directives for my resident e. Conduct monthly routine physical examination of my resident f. Develop a problem list and medication list for my resident g. Assess skin condition of my resident h. Put in place routine labs/orders for my residents i. Focus on disease management and health promotion when developing resident plan of care j. Order nursing procedures/guidelines for skilled services (VS, O 2 sat, VS parameter for medications, etc.) k. Write medical orders including orders for laboratory tests, medications, therapy, consults, routine orders l. Act as the person responsible for continuity of care of resident by providers m. Educate nursing staff about diagnostic workup and why conducting it 58 of 99

59 50. Please complete the scale by placing a check in the one box that best indicates the frequency with which you perform each activity listed below. Write N/A if not applicable. n. Educate nursing staff about treatment plan and plan of care o. Educate families about diagnostic workup and why doing it p. Educate families about resident disease state and progression q. Educate resident about disease state & progression, if resident is able to comprehend information r. Educate resident about diagnostic workup why doing it, if resident is able to comprehend information s. Educate resident about treatment plan, plan of care, and why important to follow it t. Consult with appropriate discipline specialist, when needed, about resident s condition changes u. Evaluate all services resident receives, determine and order those services that provide the most resident benefit v. Function as a gateway to the care the resident receives w. Approve and disapprove therapy orders and other treatments for my resident x. Act as a leader of the care management team who provide care for my resident y. Initiate communication with all interested parties (including resident and family) to share information and make decisions z. Review advanced directives with family and resident (if able to comprehend information) and make changes as needed 4a. Provide cost efficient care to my resident Never Once every 3 months Once a month Once a week 3-4 times a week Once a day More than once a day b. Educate nursing staff about specific diseases of my resident c. Educate family about care options for my resident d. Educate family about advanced directives e. Discuss advanced directives with nursing staff f. Discuss advanced directives with physician g. Conduct formal inservice education for staff of nursing home h. Coach nursing staff to enhance their ability to recognize changes in my resident s condition 59 of 99

60 50. Please complete the scale by placing a check in the one box that best indicates the frequency with which you perform each activity listed below. Write N/A if not applicable. i. Coach nursing staff to seek out specific teaching opportunities of the NP j. Interact with nursing staff to update them on current geriatric care practices k. Educate nursing staff on proper approach for residents with dementia, agitation, and other psychiatric-mental health issues l. Meet personal educational needs of nursing staff daily through informal education m. Educate and talk informally with other NPs and coach them through issues n. Percept new NPs and NP students Never Once every 3 months Once a month Once a week 3-4 times a week o. Share literature with nursing staff about different condition (e.g., wound care journal) p. Support nursing staff who are dealing with resident with difficult behaviours q. Coach nursing staff about nursing practice activities (e.g. auscultation of lungs) r. Support families as they deal with acute illness and status changes of resident s. Provide families with cell phone number or voice mail to contact me t. Encourage families to contact me directly if issues/concerns arise u. Counsel families in preparation for endstage disease progression v. Listen to families & provide time for them to express their losses/sadness/anger/grief w. Give access to cell phone or telephone number to all disciplines & physician x. Notify staff & families of my time away & how to contact appropriate coverage y. Communicate information to physician via fax transmissions z. Communicate resident plan of care using face-to-face contact with team members 5a. Communicate plan of care for resident using written plan in chart/health record b. Communicate plan of care for resident using telephone contact with team members c. Encourage families, residents, & staff to ask questions d. Build rapport with residents, families, & staff built on honesty, frequent communication, & response Adapted from Abdallah, Fawcett, Kane, Dick, & Chen, (2005). Development and psychometric testing of the EverCare nurse practitioner role and activity scale ENPRAS) Once a day More than once a day 60 of 99

61 51. What were the (3) THREE most important factors, in order of importance that facilitated your NP integration into the LTC setting? Please use the blank pages at the end of the questionnaire and specify question 51, if more space is needed. 52. What were the (3) THREE most important barriers, in order of importance, that hindered your NP integration into the LTC setting? Please use the blank pages at the end of the questionnaire and specify question 52, if more is needed. 53. If you work in multiple LTC settings, how has this influenced your role and integration? Please use the blank pages at the end of the questionnaire and specify question 53, if more space is needed. 54. What (3) THREE recommendations would you make to improve NP integration in LTC settings? Please use the blank pages at the end of the questionnaire and specify question 54, if more space is needed. Please use the following pages to share any additional information. If the information relates to a specific question, please indicate the question number. 61 of 99

62 Thank you! Your input will inform the effective integration of the NP role in LTC settings across Canada. 62 of 99

63 Appendix B: Administrator & Director of Care Survey Integration of Nurse Practitioners in Long-Term Care Settings in Canada Questionnaire for Administrators and Nursing Directors Faith Donald, RN(EC), PHC-NP, PhD Ruth Martin-Misener, RN-NP, PhD Associate Professor Daphne Cockwell School of Nursing Ryerson University Associate Professor School of Nursing Dalhousie University 350 Victoria Street 5869 University Ave Toronto, ON M5B 2K3 Halifax NS B3H 3J5 (416) , ext (902) of 99

64 1. What is your role in the LTC setting where you are employed? Executive Director/ Administrator Nursing Director/ Director of Care Other (specify) 2. What is your age in years? Over 60 years What is your sex? Female Male 4. In total, how long have you been in your current position? years months 5. Are you a Registered Nurse? Yes No 6. What is your education? Diploma/ Certificate Baccalaureate Masters Doctorate Other (specify) 7. What responsibilities do you have in your role? (Check ALL that apply) Supervision of NP Supervision of nursing staff Supervision of allied health professionals Human resources Budget Educational planning Quality assurance Policy development Policy approval Facilitation of interdisciplinary collaboration Internal communication (e.g., staff, residents, families) External communication (e.g., governments) Other (specify) 8. How would you classify the location of your LTC setting? 9. In what type of LTC setting do you work and what is the maximum number of residents? Remote Rural Suburban Urban Not-for-profit max. number of residents For profit max. number of residents 10. What is the number of NPs (actual number and FTE) that work in your LTC setting? actual # of NPs # of NP FTEs 64 of 99

65 11. Is there a written job description for the NP role in your LTC setting? a. Was there an NP involved in developing the NP job description in your LTC setting? b. Was the medical director or another physician involved in developing the NP job description in your LTC setting? 12. Is the NP expected to achieve specific goals or outcomes in your LTC setting? a. If you checked yes in #12 above, please list the goals or outcomes the NP is expected to achieve in your LTC setting. Yes (go to 11a and b) No (go to question 12) Do not know (go to question 12) Yes No Do not know Yes No Do not know Yes (go to question 12a and b) No (go to question 13) Do not know (go to questions 13) b. What are the tools you use to measure the NP outcomes? 13. What is the primary source of funding for the NP s salary in the LTC setting? (Check ONE only) MDS-RAI Satisfaction surveys Audit health record Other- please specify None Provincial government District or regional health authority/lhin LTC organization Family Health Team/ Primary Care Network Physician Nursing budget Other (specify) Do not know 65 of 99

66 14. How many NPs will you likely need in your LTC setting over the next 5 years? 15. Are there other types of care providers that may be hired in the next 5 years to provide primary care to residents in your setting? 16. How did you first learn about NPs and their scope of practice? (Check the ONE best answer) # in your setting Yes No Do not know If yes, please specify Documents from Nursing College or Association Discussion with NP faculty Documents from the Canadian Nurse Practitioner Initiative Discussions with the NP in my LTC setting Research reports or articles Other (specify) Please circle the one best answer for questions 17 to 18c, as applicable to your LTC setting 17. How well do the NP and Medical Director in your LTC setting collaborate? 18. Overall, how well have residents accepted the NP role? a. Overall, how well has the Medical Director accepted the NP role? b. Overall, how well have residents families accepted the NP role? c. Overall, how well has the health care team accepted the NP role? 19. Was there an orientation for Yes, good attendance Do not know other health care providers to Yes, minimal attendance No the NP role? 20. Was there an orientation for Yes, good attendance Do not know physicians to the NP role? Yes, minimal attendance No Do Collaborate Collaborate Collaborate Collaborate Collaborate Not Minimally Somewhat Fairly Well Extremely Collaborate Well Well Not Minimally Somewhat Fairly Accepted Extremely Accepted Accepted Accepted Well Well Accepted Accepted Not Minimally Somewhat Fairly Accepted Extremely Accepted Accepted Accepted Well Well Accepted Accepted Not Minimally Somewhat Fairly Accepted Extremely Accepted Accepted Accepted Well Well Accepted Accepted Not Minimally Somewhat Fairly Accepted Extremely Accepted Accepted Accepted Well Well Accepted Accepted 21. Overall, how well has the NP role been integrated into your LTC setting? (Circle ONE number only) Not Minimally Somewhat Fairly Integrated Extremely Integrated Integrated Integrated Well Well Integrated Integrated 66 of 99

67 22. What are the three (3) most important factors that facilitated the integration of the NP role into your LTC setting? 23. What are the three (3) most important barriers to the integration of the NP role into your LTC setting? 24. What three (3) recommendations would you make to improve NP role integration in LTC settings? 67 of 99

68 25. List the three (3) most important contributions the NP role has made to resident and/or family care/ team functioning at your LTC setting. Please use the following lines to share any additional information. If the information relates to a specific question, please indicate the question number. Thank you! Your input will inform the effective integration of the NP role in LTC settings across Canada. 68 of 99

69 Appendix C: Interview Guides LPN/RPN/HCA/PSW Interview Guide Setting the Stage Introduce the topic area to be explored: e.g., today we re going to talk about integration of the NP role into the Long-Term Care setting. The interview will be approximately 40 minutes in length. Confidentiality Reminder e.g., To ensure confidentiality, please use pretend names if you refer to specific resident or staff names. The information that you share during this interview is confidential. Your individual answers will not be identified and shared with your employer, or colleagues. Permission to audio record e.g. I would now like to ask your permission to turn on the audio recorder. 1. Think back to when the role of the NP was first introduced into this Long-Term Care (LTC) setting. At that time, what did you expect that the NP would do? a. What did you think it would look like? b. What did you think they would be doing? 2. As you gained more experience with the NP, did he/she meet your initial expectations? a. Why/Why not? b. What s that like for you as a (LPN/RPN/HCA/PSW)? 3. Can you talk about how the NP role was introduced to you and the staff in the LTC home? a. What were the expectations of others with respect to the NP role in your best estimation? b. Were there chances to discuss the NP role and how it could fit your practice (work) and responsibilities? c. Prior to implementation, after implementation or both? Were there specific plans made to assist the NP to gain entry into the culture of the home? To meet the staff and team members? d. Were there specific supports put in place to assist the NP to become part of the team? What supports were you able to offer to the NP? 4. The purpose of this study is to understand the factors related to integration of the NP role into the context of the LTC setting. Please explain what the term integration means to you. How does your definition of integration influence how you relate to/collaborate with the NP? a. What does it mean to have the NP integrated into the healthcare team? b. What does integration look like? c. What would happen if the NP position was no longer available at (insert name of LTC organization)? 69 of 99

70 5. How well integrated is the NP at this time? a. What is working well and why? b. What is not working well and why? c. Please describe some examples that help us to understand. 6. Describe the ideal situation where you would see the role of the NP fully integrated into the LTC setting? a. How would this look in terms of the NP working relationship with various members of the care team in the LTC setting, including yourself? (e.g., front-line nurse, case managers, physician, administrative staff, external consultants, mental health practitioners, geriatricians, pharmacists, nutritionists, front-line staff, others?) b. What resources would be made available to the NP? c. How would various members of the team support the NP? d. How would the various members of the team, and you as the LPN/RPN/PSW/HCA, best utilize the skills of the NP? e. How is the ideal situation different than what currently exists? 7. Thinking back over the past 3 months, please describe a clinical situation that illustrates a team/personal collaboration involving the NP that went well. Probe: a. What went well? Why? 8. Thinking back over the past 3 months, please describe a clinical situation that illustrates a team/personal collaboration involving the NP that did not go so well. a. What did not go well? Why? b. What could have been done to improve the situation? 9. Describe how you and/or the team work with the NP. a. What requests do you ask of the NP? b. What NP skills do you find valuable? Of benefit to the team? c. How often do you work with the NP? d. What impact has the NP had on the care of the residents? On your practice? 10. What has helped the NP role to work well? 11. What has prevented the NP role from working? 12. What can be done to help the NP role be better integrated here? 13. What recommendations would you have to enhance full integration of the NP role in the LTC sector? In your organization? a. Would advice would you give a colleague who called you to say "we are getting a NP, what do I need to know"? Summary At the end of the interview the interviewer will conclude with a summary of the discussion points made by the participant. The interviewer will then give the participant the opportunity to verify and clarify their perceptions. 70 of 99

71 Nurse Practitioner Interview Guide Setting the Stage Introduce the topic area to be explored: e.g., today we re going to talk about integration of the NP role into this Long-Term Care setting. The interview will be approximately 90 minutes in length. Confidentiality Reminder e.g., To ensure confidentiality, please use pretend names if you refer to specific resident or staff names. The information that you share during this interview is confidential. Your individual answers will not be identified and shared with your employer, or colleagues. Permission to audio record e.g. I would now like to ask your permission to turn on the audio recorder. 1. Think back to when you first began your role as a nurse practitioner in Long-Term Care (LTC). At that time, what were your expectations for the role? a) How did you envision it? b) What did you think it would look like? c) What were your concerns? 2. As your experiences with the role evolved, did they meet your initial expectations? a) Why/Why not? b) What s that like for you? c) What does that feel like for you? 3. Can you talk about how prepared you felt to work in LTC? a) Training in geriatrics, geriatric mental health b) Experience/understanding of LTC c) Experience with collaborating with other health professionals 4. Can you talk about how the NP role was introduced to the physicians and staff in the LTC home? a) What were their expectations of your role? b) Were there opportunities to discuss the NP role with the physicians and/or staff of the LTC home? c) Were there specific plans made to introduce you to the team members that you consider to be central to the implementation of your role? Please identify who those team members are in your practice: (For example, Physicians, Pharmacists, Director of Care, Nurse managers, Front-line nurses, Dietitians, LPNs/RPNs, HCAs/PSWs, Administrative staff, other?) Plans to introduce you to Residents, Families? Plans to initiate the role and how the various team members could work collaboratively with you? d) Were there specific supports put in place to assist you to become part of the team? 71 of 99

72 5. What kinds of support do you find most useful for your role integration in LTC? a) From whom specifically? Anyone else? b) What about NP colleagues, is there a supportive network that you rely on? c) What about the administrative/clinical teams in the LTC facility? d) What about the physician? e) What types of supports just mentioned are most helpful and why? f) What additional supports would be helpful to you and why? 6. The purpose of this study is to understand the factors related to integration of the NP role into the context of the LTC setting. Please explain what the term integration means to you. How does your definition of integration influence how you approach your NP role? 7. Please describe your perceptions of the current integration of your NP role in your LTC setting. a) What is working well and why? b) What is not working well and why? 8. Thinking back over the past 3 months, please describe a clinical situation or a LTC interaction that best illustrates a team collaboration that went well. a) What went well? Why? 9. Thinking back over the past 3 months, please describe a clinical situation or LTC interaction that best illustrates a team collaboration that did not go as well as you had hoped. a) What did not go well? Why? b) What could have been done to improve the situation? c) What made this situation different from the positive one? 10. Describe your main activities during a typical day, week (time unit to be discussed here)? a) What do you concentrate your time on is it direct practice, consultation, capacity building? What else? b) Is this how you think you should be spending your time? If no, how do you think your time would best be spent? c) Who decides what you will concentrate on? d) How often do you work with the health care team in the setting? e) Who is your main customer group? RN? LPN/RPN? PSW? Resident? Family? f) How have you tried to build capacity in the LTC team? What works well? Why/Why not? g) Are there specific educational or team consultation models that you have identified and applied in enacting your role? Why does this work/not work? If you work in more than one LTC home.. h) How much time do you spend at each home? How is this determined (e.g. scheduled days for each site)? How do you handle urgent situations? i) In what ways do you think being involved in multiple sites affects NP role integration? 72 of 99

73 11. What factors influence the integration of your role in the LTC setting? What is it about the LTC setting that influences integration of your role? In this particular setting? a) Facilitators: factors, organizational factors, relationship factors, human resource factors, support structures, infrastructure, others? b) Barriers: System factors, organizational factors, relationship factors, human resource factors, support structures, infrastructure, others? b) Recommendation to reduce or eliminate barriers? 12. What factors influence your job satisfaction as an NP in a LTC setting: a) Individual, organizational, system factors? 13. What recommendations would you have to enhance full integration of the NP role in the LTC sector? In your organization? 14. Describe the ideal situation where you would see the role of the NP fully integrated into the LTC setting? a) How would this look in terms of the NP working relationship with the various members of the care team in the LTC setting you previously identified? What would this look like in terms of the NP working relationship with external consultants such as geriatricians, external mental health practitioners, others? b) What resources would be available to you? c) How would various members of the team support you? d) How would various members of the team best utilize your skills as an NP? e) How is the ideal situation different than what currently exists? 15. Is this the first NP that you have hired? Have you had challenges in hiring or retaining NPs in the past? What changes have you made as a result of these challenges? Summary At the end of the interview the interviewer will conclude with a summary of the discussion points made by the participant. The interviewer will then give the participant the opportunity to verify and clarify their perceptions. 73 of 99

74 Multidisciplinary Interview Guide Setting the Stage Introduce the topic area to be explored: e.g., today we re going to talk about integration of the NP role into this Long-Term Care setting. The interview will be approximately 40 minutes in length. Confidentiality Reminder e.g., To ensure confidentiality, please use pretend names if you refer to specific resident or staff names. The information that you share during this interview is confidential. Your individual answers will not be identified and shared with your employer, or colleagues. Permission to audio record e.g. I would now like to ask your permission to turn on the audio recorder. 1. Think back to when the role of the NP was first introduced into this Long-Term Care (LTC) setting. At that time, what were your expectations for the role? a) How did you envision it? b) What did you think it would look like? 2. As your experiences with the NP role evolved, did they meet your initial expectations? a) Why/Why not? b) What s that like for you as a (Pharmacist)? 3. Can you talk about how the NP role was introduced to you and the staff in the LTC home? a) What were the expectations of others with respect to the NP role in your best estimation? b) Were there opportunities to discuss the NP role and how it could fit with your practice and responsibilities as a pharmacist in the LTC home? c) Were there specific plans made to introduce the NP to you and your team members? Physicians, Residents, Families? To initiative the role and how the various team members could work collaboratively with the NP? d) Were there specific supports put in place to assist the NP to become part of the team? What supports were you able to offer to the NP? 4. The purpose of this study is to understand the factors related to integration of the NP role into the context of the LTC setting. Please explain what the term integration means to you. How does your definition of integration influence how you relate to/collaborate with the NP? a. What does integration look like? b. What would happen if the NP position was no longer available at (insert name of LTC organization)? 5. Please describe your perceptions of the current integration of the NP role in your LTC setting: a) What is working well and why? b) What is not working well and why? c) Would advice would you give a colleague who called you to say "we are getting a NP, what do I need to know"? 74 of 99

75 Summary At the end of the interview the interviewer will conclude with a summary of the discussion points made by the participant. The interviewer will then give the participant the opportunity to verify and clarify their perceptions. 75 of 99

76 Nurse Manager Interview Guide Setting the Stage Introduce the topic area to be explored: e.g., today we re going to talk about integration of the NP role into this Long-Term Care setting. The interview will be approximately 40 minutes in length. Confidentiality Reminder e.g., To ensure confidentiality, please use pretend names if you refer to specific resident or staff names. The information that you share during this interview is confidential. Your individual answers will not be identified and shared with your employer, or colleagues. Permission to audio record e.g. I would now like to ask your permission to turn on the audio recorder. 1. Think back to when the role of the NP was first introduced into this Long-Term Care (LTC) setting. At that time, what were your expectations for the role? a) How did you envision it? b) What did you think it would look like? 2. As your experiences with the NP role evolved, did they meet your initial expectations? a) Why/Why not? b) What s that like for you as a (Nurse Manager/Team Leader)? 3. Can you talk about how the NP role was introduced to you and the staff in the LTC home? a) What were the expectations of others with respect to the NP role in your best estimation? b) Were there opportunities to discuss the NP role and how it could fit with your practice and responsibilities as a nurse manager of the LTC home? c) Were there specific plans made to introduce the NP to you and your team members? Physicians, Residents, Families? To initiative the role and how the various team members could work collaboratively with the NP? d) Were there specific supports put in place to assist the NP to become part of the team? What supports were you able to offer to the NP? 4. The purpose of this study is to understand the factors related to integration of the NP role into the context of the LTC setting. Please explain what the term integration means to you. How does your definition of integration influence how you relate to/collaborate with the NP? a. What does integration look like? b. What would happen if the NP position was no longer available at (insert name of LTC organization)? 5. Please describe your perceptions of the current integration of the NP role in your LTC setting: a) What is working well and why? b) What is not working well and why? 6. Describe the ideal situation where you would see the role of the NP fully integrated into the LTC setting? 76 of 99

77 a) How would this look in terms of the NP working relationship with various members of the care team in the LTC setting, including yourself? (e.g., front-line nurse, case managers, physician, administrative staff, external consultants, mental health practitioners, geriatricians, pharmacists, nutritionists, front-line staff, others?) b) What resources would be made available to the NP? c) How would various members of the team support the NP? d) How would the various members of the team, and you as the nurse manager, best utilize the skills of the NP? e) How is the ideal situation different than what currently exists? 7. Thinking back over the past 3 months, please describe a clinical situation or a LTC interaction that best illustrates a team/personal collaboration involving the NP that went well. a) What went well? Why? 8. Thinking back over the past 3 months, please describe a clinical situation or LTC interaction that best illustrates a team/personal collaboration involving the NP that did not go so well. a) What did not go well? Why? b) What could have been done to improve the situation? c) What made this situation different from the positive one? 9. Describe how you and/or the team work with the NP. a) What requests do you ask of the NP? b) What NP skills do you find valuable? Of benefit to the team? c) How often do you work with the NP? d) What impact has the NP had on the care of the residents? On your practice? 10. What factors influence the integration of the NP role in the LTC setting? What is it about the LTC setting that influences integration of the NP role? In this particular setting? a) Facilitators and barriers: System factors, organizational factors, relationship factors, human resource factors, support structures, infrastructure, others? b) Recommendation to reduce or eliminate barriers? 11. What recommendations would you have to enhance full integration of the NP role in the LTC sector? In your organization? a. Would advice would you give a colleague who called you to say "we are getting a NP, what do I need to know"? Summary At the end of the interview the interviewer will conclude with a summary of the discussion points made by the participant. The interviewer will then give the participant the opportunity to verify and clarify their perceptions. 77 of 99

78 Administrator & Director of Care Interview Guide Setting the Stage Introduce the topic area to be explored: e.g., today we re going to talk about integration of the NP role into this Long-Term Care setting. The interview will be approximately 40 minutes in length. Confidentiality Reminder e.g., To ensure confidentiality, please use pretend names if you refer to specific resident or staff names. The information that you share during this interview is confidential. Your individual answers will not be identified and shared with your employer, or colleagues. Permission to audio record e.g. I would now like to ask your permission to turn on the audio recorder. 1. Think back to when the role of the NP was first introduced into this Long-Term Care (LTC) setting. At that time, what were your expectations for the role? a) How did you identify the needs in the home and decide an NP would be the best role to meet the needs? b) How did you envision the NP role? c) What did you think it would look like? 2. As your experiences with the NP role evolved, did they meet your initial expectations? a) Why/Why not? b) What s that like for you as the (Administrator/Director of Care)? 3. Can you talk about how the NP role was introduced to the physicians and staff in the LTC home? a) What were their expectations of your role? b) Were there opportunities to discuss the NP role with the physicians and/or staff of the LTC home? Prior to implementation, after implementation or both? c) Were there specific plans made to introduce the NP to the team members, Physicians, Pharmacists, Residents, Families? To initiate the role and how the various team members could work collaboratively with the NP? d) Were there specific supports put in place to assist the NP to become part of the team? What supports were you able to offer the NP? 4. The purpose of this study is to understand the factors related to integration of the NP role into the context of the LTC setting. Please explain what the term integration means to you. How does your definition of integration influence how you relate to/collaborate with the NP? a. What does integration look like? b. What would happen if the NP position was no longer available at (insert name of LTC organization)? 5. Please describe your perceptions of the current integration of the NP role in your LTC setting. a) What is working well and why? 78 of 99

79 b) What is not working well and why? 6. Describe the ideal situation where you would see the role of the NP fully integrated into the LTC setting? What would this look like? a) How would this look in terms of the NP working relationship with various members of the care team in the LTC setting? (e.g., front-line nurse, case managers, physician, administrative staff, external consultants, mental health practitioners, geriatricians, pharmacists, nutritionists, front-line staff, others?) b) What resources would be made available to the NP? c) How would various members of the team support the NP? d) How would various members of the team best utilize the skills of the NP? e) How is the ideal situation different than what currently exists? 7. Thinking back over the past 3 months, please describe a situation or a LTC interaction that best illustrates a team collaboration involving the NP that went well. a) What went well? Why? 8. Thinking back over the past 3 months, please describe a clinical situation or LTC interaction that best illustrates a team collaboration involving the NP that did not go so well. a) What did not go well? Why? b) What could have been done to improve the situation? c) What made this situation different from the positive one? 9. Describe how you and/or the team work with the NP. a) What requests do you/the team ask of the NP? b) How do you/the team make a referral? c) What skills do you/the team find valuable? Of benefit to the team? d) How often do you/the team work with the NP? e) What impact has the NP had on the care of residents? On your/your team s practice? 10. What factors influence the integration of the NP role in the LTC setting? What is it about the LTC setting that influences integration of the NP role? In this particular setting? a) Facilitators and barriers: System factors, organizational factors, relationship factors, human resource factors, support structures, infrastructure, others? b) Recommendation to reduce or eliminate barriers? 11. What recommendations would you have to enhance full integration of the NP role in the LTC sector? In your organization? a. Would advice would you give a colleague who called you to say "we are getting a NP, what do I need to know"? Summary 79 of 99

80 At the end of the interview the interviewer will conclude with a summary of the discussion points made by the participant. The interviewer will then give the participant the opportunity to verify and clarify their perceptions. 80 of 99

81 Telephone Interview Guide: Administrator at LTC Setting Where Unable to Recruit/Retain the Nurse Practitioner Setting the Stage Introduce the topic area to be explored: e.g., today we re going to talk about integration of the NP role into this Long-Term Care setting. The interview will be approximately minutes in length. Confidentiality Reminder e.g., To ensure confidentiality, please use pretend names if you refer to specific resident or staff names. The information that you share during this interview is confidential. Your individual answers will not be identified and shared with your employer, or colleagues. Permission to audio record e.g. I would now like to ask your permission to turn on the audio recorder. 1. Think back to when the role of the NP was first planned for and/or introduced into the Long-Term Care (LTC) setting. At this time, what were your expectations for the role? a. How did you identify the needs in the home and decide an NP would be the best role to meet the needs? b. How did you envision the NP role? c. What did you think it would look like? 2. If you were able to hire an NP, as your experiences with the NP role evolved, did they meet your initial expectations? Probe: a. Why/Why not? 3. How did you plan for the NP role? a. Was an NP involved in planning for the role? b. What members of the health care team were involved in planning for the NP role? 4. How did you recruit for the NP role? a. What would you do differently next time? b. Are there policies or other supports that are needed to help recruit NPs to LTC settings? 5. If you were able to hire an NP, was the NP involved in planning for the role? a. Why/Why Not? b. In what aspects of role planning was the NP involved? 6. If you were able to hire an NP, can you talk about how the NP role was introduced to the physicians and staff in the LTC home? a. What were their expectations of your role? 81 of 99

82 b. Were there opportunities to discuss the NP role with the physicians and/or staff of the LTC home? Prior implementation, after implementation, or both? c. Were there specific plan made to introduce the NP to the team members, physicians, pharmacists and/ or families? To initiate the role and how the various team members could work collaboratively with the NP? d. Were there specific supports put in place to assist the NP to become part of the team? What supports were you able to offer the NP? 7. The purpose of this study is to understand the factors related to integration of the NP role into the context of the LTC setting. Please explain what the term integration means to you? How does your definition of integration influence how you related to/collaborated with the NP? 8. If you were able to hire an NP, please describe your perceptions of the integration of the NP role that occurred in your LTC setting. a. What worked will and why? b. What did not work well and why? 9. Describe the ideal situation where you would see the role of the NP fully integrated into the LTC setting? What would this look like? a. How would this look in terms of the NP working relationship with various members of the care team in the LTC setting? (e.g. front-line nurse, case managers, physicians, administrative staff, external consultants, mental health practitioners, geriatricians, pharmacists, nutritionists, front-line staff, others?) b. What resources would be made available to the NP? c. How would various members of the team support the NP? d. How would various members of the team best utilize the skills of the NP? e. How is the ideal situation different than what currently exists? 10. If you were able to hire an NP, describe how you and/or the team worked with the NP. a. What requests did you/the team ask of the NP? b. How did you/the team make a referral? c. What skills did you/the team find valuable? Of benefit to the team? d. How often did you/the team work with the NP? e. What impact did the NP have on the care of residents? On your/your team s practice? 11. What is it about the LTC setting that influences integration of the NP role? What factors influenced the integration of the NP role in your LTC setting? a. Facilitators and barriers: system factors, organizational factors, relationship factors, human resource factors, support structures, infrastructure, others? b. Recommendation to reduce or eliminate barriers? 12. What recommendations would you make to enhance full integration of the NP role in the LTC sector? In your organization? a. What would you do the same to integrate the NP role? b. What would you do differently to integrate the NP role? 13. If you had difficulty retaining the NP in your LTC setting, describe the factors contributing to this? What could be done to improve retention of NPs in your LTC setting? 82 of 99

83 Summary At the end of the interview the interviewer will conclude with a summary of the discussion points made by the participant. The interviewer will then give the participant the opportunity to verify and clarify their perceptions. 83 of 99

84 Nurse Practitioner No Longer Working in LTC Interview Guide Setting the Stage Introduce the topic area to be explored: e.g., today we re going to talk about integration of the NP role into this Long-Term Care setting. The interview will be approximately 90 minutes in length. Confidentiality Reminder e.g., To ensure confidentiality, please use pretend names if you refer to specific resident or staff names. The information that you share during this interview is confidential. Your individual answers will not be identified and shared with your employer, or colleagues. Permission to audio record e.g. I would now like to ask your permission to turn on the audio recorder. 1. Think back to when you first began your role as a nurse practitioner in Long-Term Care (LTC). At that time, what were your expectations for the role? a) How did you envision it? b) What did you think it would look like? 2. As your experiences with the role evolved, did they meet your initial expectations? a) Why/Why not? b) What s that like for you? c) What does that feel like for you? 3. Can you talk about how prepared you felt to work in LTC? a) Training in geriatrics, geriatric mental health b) Experience/understanding of LTC c) Experience with collaborating with other health professionals 4. Can you talk about how the NP role was introduced to the physicians and staff in the LTC home? a) What were their expectations of your role? b) Were there specific supports put in place to assist you to become part of the team? 5. The purpose of this study is to understand the factors related to integration of the NP role into the context of the LTC setting. Please explain what the term integration means to you. How does your definition of integration influence how you approached your NP role? 6. Describe the ideal situation where you would see the role of the NP fully integrated into the LTC setting? a) How would this look in terms of the NP working relationship with the various members of the care team in the LTC setting you previously identified? What would this look like in terms of 84 of 99

85 the NP working relationship with external consultants such as geriatricians, external mental health practitioners, others? b) What resources would be available to you? c) How would various members of the team support you? d) How would various members of the team best utilize your skills as an NP? e) How is the ideal situation different than what currently exists? 7. What kinds of support did you find most useful? a) From whom specifically? Anyone else? b) What about NP colleagues, is there a supportive network that you rely on? c) What about the administrative/clinical teams in the LTC facility? d) What about the physician? e) What types of supports just mentioned are most helpful and why? f) What additional supports would be helpful to you and why? 8. What factors influenced the integration of your role in the LTC setting? What is it about the LTC setting that influences integration of your role? In this particular setting? a) Facilitators and barriers: System factors, organizational factors, relationship factors, human resource factors, support structures, infrastructure, others? b) Recommendation to reduce or eliminate barriers? 9. What factors influenced your job satisfaction as an NP in a LTC setting: a) Individual, organizational, system factors? 10. What were your reasons for leaving the long term setting? 11. What is your current job position? Are you still working with geriatric patients? 12. What would attract you to working in a long term care setting? 13. What recommendations would you have to enhance full integration of the NP role in the LTC sector? Summary At the end of the interview the interviewer will conclude with a summary of the discussion points made by the participant. The interviewer will then give the participant the opportunity to verify and clarify their perceptions. 85 of 99

86 Physician & Medical Director Interview Guide Setting the Stage Introduce the topic area to be explored: e.g., today we re going to talk about integration of the NP role into this Long-Term Care setting. The interview will be approximately 40 minutes in length. Confidentiality Reminder e.g., To ensure confidentiality, please use pretend names if you refer to specific resident or staff names. The information that you share during this interview is confidential. Your individual answers will not be identified and shared with your employer, or colleagues. Permission to audio record e.g. I would now like to ask your permission to turn on the audio recorder. 1. Think back to when the role of the NP was first introduced into this Long-Term Care (LTC) setting. At that time, what were your expectations for the role? a) How did you envision it? b) What did you think it would look like? c) What were your hopes for the role? d) What were your concerns for the role? 2. As your experiences with the NP role evolved, did they meet your initial expectations? a) Why/Why not? b) What s that like for you as a (Physician/Medical Director)? 3. Can you talk about how the NP role was introduced to you and the staff in the LTC home? a) What were the expectations of others with respect to the NP role in your best estimation? b) Were there opportunities to discuss the NP role and how it could fit with your practice and responsibilities as a physician/medical director of the LTC home? Prior to implementation, after implementation or both? c) Were there specific plans made to introduce the NP to you and the other team members? Residents, Families? To initiate the role and how the various team members could work collaboratively with the NP? d) Were there specific supports put in place to assist the NP to become part of the team? What supports were you able to offer to the NP? 4. The purpose of this study is to understand the factors related to integration of the NP role into the context of the LTC setting. Please explain what the term integration means to you. How does your definition of integration influence how you relate to/collaborate with the NP? a) What does integration look like? b) What would happen if the NP position was no longer available at (insert name of LTC organization)? 5. Please describe your perceptions of the current integration of the NP role in your LTC setting. 86 of 99

87 a) What is working well and why? b) What is not working well and why? 6. Thinking back over the past 3 months, please describe a clinical situation or a LTC interaction that best illustrates a team/personal collaboration involving the NP that went well. a) What went well? Why? 7. Thinking back over the past 3 months, please describe a clinical situation or LTC interaction that best illustrates a team/personal collaboration involving the NP that did not go so well. a) What did not go well? Why? b) What could have been done to improve the situation? c) What made this situation different from the positive one? 8. Describe how you and/or the team work with the NP. a) What requests do you ask of the NP? b) What NP skills do you find valuable? Of benefit to the team? c) How often do you work with the NP? d) What impact has the NP had on the care of the residents? On your practice? 9. What factors influence the integration of the NP role in the LTC setting? What is it about the LTC setting that influences integration of the NP role? In this particular setting? a) Facilitators and barriers: System factors, organizational factors, relationship factors, human resource factors, support structures, infrastructure, others? b) Recommendation to reduce or eliminate barriers? 10. What recommendations would you have to enhance full integration of the NP role in the LTC sector? In your organization? a) Would advice would you give a colleague who called you to say "we are getting a NP, what do I need to know"? Summary At the end of the interview the interviewer will conclude with a summary of the discussion points made by the participant. The interviewer will then give the participant the opportunity to verify and clarify their perceptions. 87 of 99

88 Telephone Interview Guide: Funder Setting the Stage Introduce the topic area to be explored: e.g., today we re going to talk about integration of the NP role into this Long-Term Care setting. The interview will be approximately 30 minutes in length. Confidentiality Reminder e.g., To ensure confidentiality, please use pretend names if you refer to specific resident or staff names. The information that you share during this interview is confidential. Your individual answers will not be identified and shared with your employer, or colleagues. Permission to audio record e.g. I would now like to ask your permission to turn on the audio recorder. 1. What are your roles and responsibilities related to the NP role in your region/province? 2. Think back to when the role of the NP was first conceived. At that time, what were your expectations for the role? a) How did you identify that there was a need for NPs in LTC settings? b) How did you envision the NP role? c) What did you think it would look like? 3. As your experiences with the NP role evolved, did they meet your initial expectations? a) Why/Why not? b) What s that like for you as the Funder? 4. Can you talk about your perception of the planning and development for the NP role? a) What policies were needed? b) Were there policies that needed to be revised to facilitate the NP role? c) Were there specific policies or plans made to introduce and orient the NP, administrator, director of nursing care, and medical director to the NP role? d) Were there specific supports put in place to assist the NP to become part of the team? What supports were you able to offer the NP? 5. The purpose of this study is to understand the factors related to integration of the NP role into the context of the LTC setting. Please explain what the term integration means to you. How does your definition of integration influence how the NP role was funded and implemented? a) What does integration look like? b) What would happen if the NP position was no longer available at (insert name of LTC organization)? 6. Please describe your perceptions of the implementation and integration of the NP role that has occurred. a) What is working well and why? 88 of 99

89 b) What is not working well and why? 7. Describe the ideal situation where you would see the role of the NP fully integrated into LTC settings? What would this look like? a) How would this look in terms of the NP working relationship with residents, families, and various members of the care team in the LTC setting? b) What resources would be made available to the NP? c) How is the ideal situation different than what currently exists? 8. What factors influenced the integration of the NP role in the LTC setting(s)? What is it about the LTC setting that influences integration of the NP role? In your particular region/province? a) Facilitators and barriers: System factors, organizational factors, relationship factors, human resource factors, support structures, infrastructure, others? b) Recommendation to reduce or eliminate barriers? 9. What recommendations would you have to enhance full integration of the NP role in the LTC sector? In your region/province? a) What would do the same to integrate the NP role? b) What would you do differently to integrate the NP role? c) What further policy changes need to occur to integrate the NP role d) Would advice would you give a colleague who called you to say "we are getting a NP, what do I need to know"? 10. Given that there have been difficulties in recruiting NPs into LTC, please describe any incentive mechanisms that funders could consider implementing. Summary At the end of the interview the interviewer will conclude with a summary of the discussion points made by the participant. The interviewer will then give the participant the opportunity to verify and clarify their perceptions. 89 of 99

90 Resident/Family Member Focus Group Interview Guide Setting the Stage Introduce the topic area to be explored: e.g., today we re going to talk about integration of the NP role into this Long Term Care setting. This focus group will be approximately 90 minutes in length. Confidentiality Reminder e.g., To ensure confidentiality, please use pretend names if you refer to specific resident or staff names. The information that you share during this interview is confidential. Your individual answers will not be identified and shared with your employer, or colleagues. Permission to audio record e.g. I would now like to ask your permission to turn on the audio recorder. Questions 1. Perhaps we can start by asking if anyone knows what a nurse practitioner, or NP is? Please describe. 2. Have you had any contact with nurse practitioners prior to coming to this home? a) In hospital?, at your family physician s office?, at a clinic? b) What were these experiences like? *** At this point, show the picture of the NP (picture provided by the NP). Ensure that everyone knows the NP. 3. How did you first hear and learn about the nurse practitioner working in this long term care facility? Probe: a) Was it a good way, or is there a better way to learn about the NP role 4. What do you think that the NP does in this facility? 5. How comfortable did you feel about the NP being involved in your care/family member s care when the NP role started? How comfortable do you feel now? 6. How satisfied are you with the care of the NP? What makes you satisfied or not? 7. What has been good about the NP taking care of you/your family member? a) Has having an NP here in this setting meant that you received care here for an illness or injury instead of having to go to the hospital? b) Has the NP been available within a reasonable time when you/your family member needed her care? 8. What could be improved about the NP taking care of you/your family member? 90 of 99

91 Summary At the end of the focus group discussion the facilitator will conclude with a summary of the discussion points made by the participants. The interviewer will then give the participants the opportunity to verify and clarify their perceptions. 91 of 99

92 Registered Nurse (Charge Nurse) Interview Guide Setting the Stage Introduce the topic area to be explored: e.g., today we re going to talk about integration of the NP role into this Long Term Care practice setting. The interview will be approximately 40 minutes in length. Confidentiality Reminder e.g., To ensure confidentiality, please use pretend names if you refer to specific resident or staff names. The information that you share during this interview is confidential. Your individual answers will not be identified and shared with your employer, or colleagues. Permission to audio record e.g. I would now like to ask your permission to turn on the audio recorder. 1. Think back to when the role of the NP was first introduced into this Long Term Care (LTC) setting. At that time, what were your expectations for the role? a) How did you envision it? b) What did you think it would look like? 2. As your experiences with the NP role evolved, did they meet your initial expectations? a) Why/Why not? b) What s that like for you as a (Nurse Manager/Team Leader)? 3. Can you talk about how the NP role was introduced to you and the staff in the LTC home? a) What were the expectations of others with respect to the NP role in your best estimation? b) Were there opportunities to discuss the NP role and how it could fit with your practice and responsibilities as a nurse manager of the LTC home? c) Were there specific plans made to introduce the NP to you and your team members? Physicians, Residents, Families? To initiative the role and how the various team members could work collaboratively with the NP? d) Were there specific supports put in place to assist the NP to become part of the team? What supports were you able to offer to the NP? 4. The purpose of this study is to explicate and understand the factors related to integration of the NP role into the context of the LTC setting. Please explain what the term integration means to you. How does your definition of integration influence how you relate to/collaborate with the NP? a) What does integration look like? b) What would happen if the NP position was no longer available at (insert name of LTC organization)? 5. Please describe your perceptions of the current integration of the NP role in your LTC setting: a) What is working well and why? 92 of 99

93 b) What is not working well and why? 6. Describe the ideal situation where you would see the role of the NP fully integrated into the LTC setting? a) How would this look in terms of the NP working relationship with various members of the care team in the LTC setting, including yourself? (e.g., front-line nurse, case managers, physician, administrative staff, external consultants, mental health practitioners, geriatricians, pharmacists, nutritionists, front-line staff, others?) b) What resources would be made available to the NP? c) How would various members of the team support the NP? d) How would the various members of the team, and you as the nurse manager, best utilize the skills of the NP? e) How is the ideal situation different than what currently exists? 7. Thinking back over the past x months, please describe a clinical situation or a LTC interaction that best illustrates a team/personal collaboration involving the NP that went well. a) What went well? Why? 8. Thinking back over the past x months, please describe a clinical situation or LTC interaction that best illustrates a team/personal collaboration involving the NP that did not go so well. a) What did not go well? Why? b) What could have been done to improve the situation? c) What made this situation different from the positive one? 9. Describe how you and/or the team work with the NP. a) What requests do you ask of the NP? b) What NP skills do you find valuable? Of benefit to the team? c) How often do you work with the NP? d) What impact has the NP had on the care of the residents? On your practice? 10. What factors influence the integration of the NP role in the LTC setting? What is it about the LTC setting that influences integration of the NP role? In this particular setting? a) Facilitators and barriers: System factors, organizational factors, relationship factors, human resource factors, support structures, infrastructure, others? 11. What recommendations would you have to enhance full integration of the NP role in the LTC sector? In your organization? a) Would advice would you give a colleague who called you to say "we are getting a NP, what do I need to know"? Summary At the end of the interview the interviewer will conclude with a summary of the discussion points made by the participant. The interviewer will then give the participant the opportunity to verify and clarify their perceptions. 93 of 99

94 Appendix D: NP Confidence Scores - Prior to Being Hired in NP Role and Current Items Prior Not At All Current Confident Geriatric physical health problems Somewhat Confident Confident Very Confident 4.3% (n=1) 43.5% (n=10) 52.2% (n=12) 0% (n=0) 0% (n=0) 0% (n=0) 39.1% (n=9) 60.9% (n=14) Geriatric mental health problems Diagnostic skills for a geriatric population Technical skills and procedures, e.g., suturing* Prescribing medications for a geriatric population Interventions for geriatric behavioural issues Legal and ethical issues relevant to geriatrics 21.7% (n=5) 60.9% (n=14) 13% (n=3) 4.3% (n-1) 0% (n=0) 8.7% (n=2) 47.8% (n=11) 43.5% (n=10) 4.3% (n=1) 60.9% (n=14) 34.8% (n=8) 0% (n=0) 0% (n=0) 4.3% (n=1) 52.2% (n=12) 43.5% (n=10) 43.5% (n=10) 30.4% (n=7) 17.4% (n=4) 8.7% (n=2) 4.8% (n=1) 23.8% (n=5) 33.3% (n=7) 38.1% (n=8) 17.4% (n=4) 69.6% (n=16) 13.0% (n=3) 0% (n=0) 0% (n=0) 4.3% (n=1) 47.8% (n=11) 47.8% (n=11) 47.8% (n=11) 34.8% (n=8) 8.7% (n=2) 8.7% (n=2) 0% (n=0) 8.7% (n=2) 65.2% (n=15) 26.1% (n=6) 21.7% (n=5) 52.2% (n=12) 17.4% (n=4) 8.7% (n=2) 0% (n=0) 30.4% (n=7) 26.1% (n=6) 43.5% (n=10) Working with families 0% (n=0) 21.7% (n=5) 43.5% (n=10) 34.8% (n=8) 0% (n=0) 0% (n=0) 21.7% (n=5) 78.3% (n=18) Palliative care interventions 13.0% (n=3) 26.1% (n=6) 52.2% (n=12) 8.7% (n=2) 0% (n=0) 0% (n=0) 30.4% (n=7) 69.6 (n=16) Collaborative practice skills 0% (n=0) 13.0% (n=3) 43.5% (n=10) 43.5% (n=10) 0% (n=0) 0% (n=0) 21.7% (n=5) 78.3% (n=18) Autonomy and independent practice 4.3% (n=1) 30.4% (n=7) 43.5% (n=10) 21.7% (n=5) 0% (n=0) 0% (n=0) 30.4% (n=7) 69.6% (n=16) Teaching nursing staff 0% (n=0) 8.7% (n=2) 52.2% (n=12) 39.1% (n=9) 0% (n=0) 0% (n=0) 26.1% (n=6) 73.9% (n=17) Application of research findings to clinical practice 4.3% (n=1) 34.8% (n=8) 56.5% (n=13) 4.3% (n=1) 0% (n=0) 17.4% (n=4) 52.2% (n=12) 30.4% (n=7) 94 of 99

95 Implementing best-practices in an organization 4.3% (n=1) 52.2% (n=12) 26.1% (n=6) 17.4% (n=4) 0% (n=0) 17.4% (n=4) 43.5% (n=10) 39.1 (n=9) Research skills 21.7% (n=5) 52.2% (n=12) 21.7% (n=5) 4.3% (n=1) 0% (n=0) 39.1% (n=9) 43.5% (n=10) 17.4% (n=4) Organization leadership skills 0% (n=0) 21.7% (n=5) 56.5% (n=13) 21.7% (n=5) 0% (n=0) 4.3% (n=1) 60.9% (n=14) 34.8% (n=8) Change management skills 4.3% (n=1) 34.8% (n=8) 43.5% (n=10) 17.4% (n=4) 0% (n=0) 4.3% (n=1) 60.9% (n=14) 34.8% (n=8) Conflict management skills 4.3% (n=1) 39.1% (n=9) 39.1% (n=9) 17.4% (n=4) 4.3% (n=1) 56.5% (n=13) 39.1% (n=9) Time management 0% (n=0) 13.0% (n=3) 52.2% (n=12) 34.8% (n=8) 0% (n=0) 4.3% (n=1) 43.5% (n=10) 52.2% (n=12) Establishing priorities** 0% (n=0) 4.3% (n=1) 56.5% (n=13) 39.1% (n=9) 0% (n=0) 0% (n=0) 31.8% (n=7) 68.2% (n=15) * Two missing responses from current (valid percentage indicated) ** One missing response from current (valid percentage indicated) Highlight indicates most frequent response 95 of 99

96 Appendix E: ENPRAS Scale Results Activity N Mean SD Clinician Incorporate my nursing knowledge into my clinical decisions and orders Collaborate with licensed practical nurses/ registered practical nurses Assess resident whenever concerns brought to my attention by staff Conduct physical assessment of my resident Management of chronic and acute illnesses for my residents Write medical orders including orders for laboratory tests, medications, therapy, consults, routine orders Promote quality of life in care that I provide Maximize the functional ability of my resident Develop a treatment plan for management of chronic and acute illnesses for my resident Diagnosis of chronic and acute illness for my residents Develop a plan of care for my resident Act as the person responsible for continuity of care of resident by providers Conduct diagnostic workup on my resident Collaborate with personal support worker Stay on top of residents with fluctuating chronic conditions Aware of subtle changes in resident s condition which may be significant to health status Educate resident about diagnostic workup why doing it, if resident is able to comprehend information Act as a leader of the care management team who provide care for my resident Focus on disease management and health promotion when developing resident plan of care Provide primary care management of each resident Revise treatment plan on my resident as needed Collaborate with resident to incorporate their wishes into plan of care. If resident unable, collaborate with family Assist nursing staff in implementing care of my residents Approve and disapprove therapy orders and other treatments for my resident Interpret diagnostic testing done on my resident Titrate medications of resident to lowest amount with greatest effect If medical plan fails, find out why through communication with nursing staff and physician Write nursing intervention orders (e.g., hydration, turn & reposition, wound care, etc.) Order nursing procedures/guidelines for skilled services (VS, O2 sat, VS parameter for medications, etc.) Educate family about care options for my resident Develop plan of care in synch with resident, family, physician, and other staff recommendations Check resident for mild behaviour changes Order therapy evaluations on residents of 99

97 Activity N Mean SD Consult with appropriate discipline specialist, when needed, about resident s condition changes Collaborate with charge nurse/director of care to discuss residents and treatment plan, or other issues Put in place routine labs/orders for my residents Assess skin condition of my resident Conduct medication review for my resident Collaborate with pharmacist Conduct functional health assessment for my resident Develop a problem list and medication list for my resident Maintain continuing education/keep current in latest research related to geriatric resident care Conduct mental status evaluation for my resident Check resident s dietary intake for changes Conduct a complete physical examination on my resident Review advanced directives for my resident Collaborate with physical therapist Check resident s weight for changes Conduct overview of resident s health records every month Discuss advanced directives with physician Conduct monthly assessments on all residents Conduct monthly routine physical examination of my resident Collaborate with other NPs to discuss residents and treatment plan Collaborator Collaborate with nursing staff Collaborate with physician Call physician with resident status changes Collaborate with physician for diagnosis, management of resident (acute conditions) Collaborate with physician for diagnosis, management of resident (chronic conditions) Communicate information to physician via fax transmissions Collaborate with psychiatric services Conduct rounds on resident with physician Coach/ Cheerleader Build rapport with residents, families, & staff built on honesty, frequent communication, & response Encourage families, residents, & staff to ask questions Communicate plan of care for resident using written plan in chart/health record Keep everyone on same page (team members) Keep everyone up to date (team members) Communicate resident plan of care using face-to-face contact with team members Educate resident about treatment plan, plan of care, and why important to follow it of 99

98 Activity N Mean SD Educate resident about disease state & progression, if resident is able to comprehend information Initiate communication with all interested parties (including resident and family) to share information and make decisions Give access to cell phone or telephone number to all disciplines & physician Educate families about diagnostic workup and why doing it Educate families about resident disease state and progression Encourage families to contact me directly if issues/concerns arise Collaborate with family to incorporate their wishes into plan of care Communicate plan of care for resident using telephone contact with team members Provide families with cell phone number or voice mail to contact me Call family with resident status changes Collaborate with nursing administration Notify staff & families of my time away & how to contact appropriate coverage Discuss advanced directives with nursing staff Educate family about advanced directives Collaborate with social worker Review advanced directives with family and resident (if able to comprehend information) and make changes as needed Care Manager Provide cost efficient care to my resident Function as a gateway to the care the resident receives Evaluate all services resident receives, determine and order those services that provide the most resident benefit Collaborate with occupational therapy Collaborate with dietitian Collaborate with activity staff Collaborate with speech therapist Coach/ Educator Educate nursing staff about treatment plan and plan of care Educate nursing staff about diagnostic workup and why conducting it Meet personal educational needs of nursing staff daily through informal education Educate nursing staff about specific diseases of my resident Support nursing staff who are dealing with resident with difficult behaviours Coach nursing staff to enhance their ability to recognize changes in my resident s condition Interact with nursing staff to update them on current geriatric care practices Educate nursing staff on proper approach for residents with dementia, agitation, and other psychiatric-mental health issues Coach nursing staff to seek out specific teaching opportunities of the NP Coach nursing staff about nursing practice activities (e.g. auscultation of lungs) Share literature with nursing staff about different condition (e.g., wound care journal) of 99

99 Activity N Mean SD Percept new NPs and NP students Educate and talk informally with other NPs and coach them through issues Conduct formal inservice education for staff of nursing home N=Number of Respondents SD= Standard deviation 99 of 99