Multiple-case study methodology to inform nurse practitioner role development Kelley Kilpatrick, RN, PhD Assistant Professor, Université de Montréal Researcher, Research Center Hôpital Maisonneuve-Rosemont and Canadian Centre for Advanced Practice Nursing Research-McMaster University Belfast, Ireland, UK March 21 2013
Acknowledgements All those who participated in the study Thesis Committee members Mélanie Lavoie-Tremblay, RN, PhD, McGill University, Director Judith A. Ritchie, RN, PhD, McGill University Health Center, Co-director Lise Lamothe, PhD, Université de Montréal Diane Doran, RN., PhD, University of Toronto Suzanne Lanctôt, RN., MSc(N), CSSS Jeanne Mance Participating organizations: Centre hospitalier de l Université de Montréal S.M.B. Davis Jewish General Hospital Institut Universitaire de Cardiologie et de Pneumologie de Québec Financial support: FERASI Center, Research Institute of the MUHC, FRSQ, CHSRF/CIHR Chair Program in Advanced Practice Nursing
Background Nurse practitioner (NP) in acute care in Canada introduced in the mid-80s Are graduate-prepared nurses Assume medical and nursing care of patients and families with complex acute or chronic conditions NPs introduced in Quebec (Can) in 2006 Contradictory findings of how NP roles affect processes (e.g., communication, coordination) in healthcare teams
Total number of NPs (acute and primary care) in Canada in 2010 = 2,486 (Total in 2009= 2,374) - 56 129 263 122 90-99 1482 64 96 > 9 106 69 (Canadian Institute for Health Information, 2012) 4
Case Study Intensive examination of one or more cases for a specific purpose Explain relationships Explore a phenomenon in-depth Describe a phenomenon within its context Build theory Design of choice to answer how or why questions Greatest challenge is defining the case
Descriptive Multiple-Case Study Reference theory or model directs/supports all phases of case study Review existing frameworks Develop or adapt a conceptual framework Essential to structure the analysis and report!! Findings from multiple-case studies are more robust Multiple experiments 6
Exemplar Introduction of cardiology NPs in two healthcare teams in Quebec (Kilpatrick, 2010) The study aimed to: Describe cardiology NP role components Describe cardiology NP role enactment Explore how NP role enactment and boundary work activities of team members affect the team s perceptions of team effectiveness
Building Theory Adaptation of the Conceptual Framework to Evaluate the Acute Care NP Role (Sidani & Irvine, 1999) Additions: Bi-directional arrows to clarify the reciprocal relationships between the dimensions and concepts 3 team-level structures 7 team-level processes
Example: Proposed Conceptual Framework Structure Process Outcome Patient-level ACNP Scope of Practice Quality Demographics Role Components Role Enactment Clinical Illness/health Complications Resources Research Physician extender Functional Educator Expanded nursing role Knowledge ACNP-level Administrator Satisfaction Professional Psychological Practitioner Organizational-level Health Care Team Type of setting Scope of Practice Cost Role formalization Patient Practice model Role Enactment Perceptions of Institution Receptivity of role Intra- and inter- Team Effectiveness Health care Role authority professional Decision-making system role boundaries Communication Team-level Cohesion Type of team Coordination Size Problem-solving Rewards Patient/family focus Figure 1. Conceptual Framework to Evaluate the Acute Care Nurse Practitioner Role and Perceptions of Team Effectiveness. Adaptation of Sidani, S., & Irvine, D. (1999). A conceptual framework for evaluating the nurse practitioner role in acute care settings. Journal of Advanced Nursing, 30(1), 58-66.
Data Sources Source Time and motion study Non-participant observations Interviews Field notes Administrative data and document analysis 108h 53 min 17.5 h 59 participants Daily 535 documents
Within-Case Analysis Parallel mixed method analysis strategy Consistent formatting of case study data Used concepts of proposed framework Quantitative data analysis Descriptive statistics of NP role components and communication Qualitative data analysis Content analysis Case-ordered matrices
Cross-Case Analysis Important element to build theory Pattern-matching was used the most Variable-oriented strategies used to identify similarities and differences across the cases Concepts were added or removed from the proposed framework to find the best fit
Key Findings of Multiple-Case Study First study to identify how system level imperatives filter down to the local level How NP roles are enacted is affected by 5 layers of structural dimensions and interacting team processes Influence of specific organizational structures
Case study Kilpatrick, K., Lavoie-Tremblay, M., Lamothe, L., Ritchie, J.A., &, Doran, D. (2012). Conceptual framework of acute care nurse practitioner role enactment, boundary work and perceptions of team effectiveness. Journal of Advanced Nursing, 69(1), 205-217. DOI: 10.1111/j.1365-2648.2012.06046.x/pdf
Implications Examine complex phenomena in their specific context Examine the relationships between concepts that have been studied disparately Conceptual and paradigmatic clarity Inductive and deductive reasoning to build theory Qualitative and quantitative data sources Moving from variables to concepts
Future Research Future work using case study methodology Test the conceptual framework in different settings and clinical specialties Identify outcomes sensitive to NP and other provider care Identify team-level outcomes of care
A few resources
International Perspective of APN Roles Please cite this paper as: Delamaire, M. and G. Lafortune (2010), Nurses in Advanced Roles: A Description and Evaluation of Experiences in 12 Developed Countries, OECD Health Working Papers, No. 54, OECD Publishing. doi: 10.1787/5kmbrcfms5g7-en OECD Health Working Papers No. 54 Nurses in Advanced Roles A DESCRIPTION AND EVALUATION OF EXPERIENCES IN 12 DEVELOPED COUNTRIES Marie-Laure Delamaire, Gaetan Lafortune
Phase 2 of Project Reports on the Results of a Case Study Evaluation of Clinic a l Nurse and Midwife Specialist and Adva nced Nurse and Midwife Practitione r Roles in Ireland (SCAPE) FINAL REPORT
Briefing Note Summarizes Key Points about NP Roles in Canada 20 Available at :http://www.apnnursingchair.mcmaster.ca/documents/np.pdf
Special Edition of NURSING LEADERSHIP on APN roles in Canada Available at :http://www.longwoods.com/publications/nursing-leadership/22240 21
Some Useful References Appleton, J.V. (2002). Critiquing approaches to a case study design for a constructivist inquiry. Qualitative Research Journal, 2(2), 80-97. Eisenhardt K.M. (1989) Building theories from case study research. The Academy of Management Review, 14, 532-550. Luck L., Jackson D. & Usher, K. (2006) Case study: A bridge across the paradigms. Nursing Inquiry, 13, 103-109. Parkhe A. (1993) Messy research, methodological predispositions and theory development in international joint ventures. The Academy of Management Review, 18, 227-268. Plowright, D. (2011). Using Mixed Methods: Frameworks for an Integrated Methodology. London, UK: Sage. Ross Baker, G. (2011). The contribution of case study research to knowledge of how to improve quality of care. BMJ Quality and Safety, 20(Suppl 1), i30-i35. Sandelowski, M. (2011). «Casing» the research case study. Research in Nursing and Health, 34, 153-159. Stake, R.E. (1995). The art of case study research. Thousand Oaks, CA: Sage. Yin R.K. (2009) Case Study Research Design and Methods, 4th ed. Thousand Oaks, Sage.
Thank you! Questions or comments? You can reach me at: kelley.kilpatrick@umontreal.ca