Advancing the nurse practitioner role in British Columbia
Marjorie MacDonald, RN, PhD, School of Nursing, University of Victoria
Heather Davidson, PhD, British Columbia Ministry of Health Services
Rita Schreiber, RN, DNS, School of Nursing, University of Victoria
Jane Crickmore, RN, MPA, British Columbia Ministry of Health Services
Lesley Moss, MA, Vancouver Island Health Authority
Janet Pinelli, RN, DNS, McMaster University
Sandra Regan, RN, MSN, College of Registered Nurses of British Columbia
Bernadette Pauly, RN, MN, School of Nursing, University of Victoria
This project brought together a team of researchers and decision makers to conduct policy-relevant research to support the introduction of advanced nursing practice roles in British Columbia. All team members, including decision makers, were actively involved in the conceptualization, design, data collection, analysis and interpretation of the study. This level of engagement, coupled with ongoing knowledge translation (KT) activities, led to a majority of the study's recommendations being implemented by stakeholders. The results have since been used to guide legislative and regulatory development, and to design a nurse practitioner education program.
In 2001, the Canadian Health Services Research Foundation (CHSRF) funded us to study the opportunities and challenges for advanced nursing practice (ANP) in British Columbia. Nurses working in ANP roles have been shown to provide appropriate and cost-effective continuity of care.1,2 However, widespread adoption of advanced nursing practice has been hampered by considerable confusion and debate about definitions, roles and functions, as well as the required competencies, practice environments, educational qualifications, credentials, regulations and legislation.3
This project aimed to bring researchers and decision makers together to conduct policy-relevant research that would support the introduction of new ANP roles, including nurse practitioners, in B.C. Our research objectives were to: clarify the understanding of ANP and related roles within the health care system; identify the current status of ANP in B.C.; identify gaps in health care services that might be filled by the expansion/introduction of new nursing roles; explore and describe models of ANP in other jurisdictions; identify barriers to implementing new nursing service delivery models in B.C.; and, on the basis of the above analysis, identify and recommend future policy directions for new nursing roles and models in B.C.
The project team, which was convened by the B.C. Ministry of Health, included researchers, educators, government and health authority decision makers, and nursing regulators. An advisory group, who provided advice and feedback on research methods and findings, included representatives of the public, other health professions (e.g. midwifery, medicine, pharmacy) and other constituencies (e.g. seniors, First Nations and Inuit Health Branch, British Columbia Nurses' Union).
The CHSRF funding strategy required co-funding arrangements, involving both cash and in-kind contributions from a variety of national, provincial and local sources. Our co-funders included the Nursing Research Fund, the B.C. Health Research Foundation, the B.C. Ministry of Health, the Registered Nurses Association of B.C., Capital Health Region in Victoria (now Vancouver Island Health Authority), and the University of Victoria. Some of the funders were also research partners and appointed representatives to the research team.
The KT initiative
All team members, including decision makers, were actively involved in the project throughout the study, from conceptualization and design through to data collection, analysis, and interpretation.
Our study was carried out in three phases, with KT goals incorporated directly into the research process. All team members, including decision makers, were actively involved in the project throughout the study, from conceptualization and design through to data collection, analysis, and interpretation.
In Phase 1, data were gathered through telephone interviews and focus groups with nurses in a variety of roles and settings to determine how they understood ANP and how nurses in ANP roles were deployed in B.C. An email survey was conducted with employers to determine their understanding of ANP and to identify health service priorities, gaps in service, and the potential for introducing new ANP roles in their organizations.
In Phase 2, we conducted five case studies of models of ANP in other jurisdictions to understand the nature and benefits of advanced practice, and to determine the feasibility of various service models for B.C.
Phase 3, which also comprised our major KT activity, was a provincial think tank attended by almost 100 key stakeholders to discuss preliminary research findings and generate policy recommendations. Not only did the think tank provide important data for Phase 3, but it also provided for dissemination of the preliminary findings to a broad stakeholder audience and acted as a mechanism to test the validity and relevance of our results for informing policy recommendations.
Decision maker and researcher team members conducted interviews and observations and actively participated in analyzing and interpreting the data. We learned from other research teams funded in the same CHSRF competition that the full engagement of decision makers at all phases of the research was unusual, and we believe that this level of involvement contributed to the successful use of the research findings.
Decision maker partners also took a leadership role in developing the overall KT plan and strategies that were consistent with the information needs and preferred communication mechanisms of our audiences. Other KT activities included:
- Regular status reports to senior administration in all partner organizations;
- Sharing interim and final reports with multiple audiences, including the Federal/Provincial/Territorial Advisory Committee on Health Human Resources and all partner organizations;
- Creation of a website that included descriptions of the projects, regular updates, project reports, links to other resources and a mechanism for visitor feedback; and
- Presentations by members of the research team to various partner organizations, including Ministry and employer policy rounds.
The project's advisory group was also an important mechanism for KT, through our ongoing communication and their ability to distribute information through their networks. The advisory group also participated in the think tank.
Results of the KT initiative
Our KT strategies resulted in substantial buy-in from stakeholders and facilitated implementation of a majority of the study's recommendations in the following two years. The results were used directly in an instrumental fashion4 to develop nurse practitioner competencies and practice standards, to guide legislative and regulatory development and to inform the development of at least one nurse practitioner education program. Five articles based on the study have been published to date.5-9
Instrumental use of research findings, which is defined as acting on research in specific and direct ways, is reported less frequently in the literature than conceptual or symbolic use.4,10 Although we did not have a formal evaluation plan to assess the KT strategies, we recognized that success indicators would include the actual implementation of study recommendations and this did occur. In addition, the entire team engaged in a reflective exercise on the benefits and challenges of the partnership experience.
Decision makers and researchers operate on very different time frames.
The research partnership was clearly a successful venture. Nonetheless, we had to deal with the challenge of negotiating and mediating our differing interests. Decision makers and researchers operate on very different time frames, with decision makers often under pressure to produce swift results. In the time between writing the original research proposal and getting it funded, the political context changed dramatically and we were under pressure to produce data much more quickly.
Tension between the researchers’ needs to maintain scientific rigour and the decision makers’ needs for information actually created an opportunity for us to understand each other’s approaches.
But the tension between the researchers' needs to maintain scientific rigour and the decision makers' needs for information actually created an opportunity for us to understand each other's approaches, as well as the demands and perspectives of our different work processes. At times, the researcher team members were somewhat frustrated by the demand to speed up study timelines, but through education, negotiation, and prioritizing, we developed strategies (e.g. additional funding provided by government to focus on specific areas of data collection) that met the decision makers' time-sensitive information needs, while maintaining scientific rigour.
Although there were clear research goals, each team member had a somewhat different vision for the project and different reasons for engaging in the research process. These differences added depth to the research, but also needed to be negotiated as they emerged in subtle ways to create tensions and disagreements. Autonomy and academic freedom are core values in universities. The ability to speak openly and freely is both encouraged and expected. In the partner organizations, decision makers operate within a policy context that explicitly and implicitly governs their work and that may, at times, preclude the expression of opinion.
Within the research team, the same data also meant different things to different people and we needed to negotiate how the data were interpreted, reported, and disseminated. To complicate the situation, universities and organizations have differing reward systems, which influenced, more than we anticipated, the direction each of us wanted to take on particular issues, such as the focus and slant of a particular journal article.
Within the research team, the same data also meant different things to different people and we needed to negotiate how the data were interpreted, reported, and disseminated.
Our ability to negotiate and mediate all of these differences was made possible by several team characteristics, including:
- The steadfast commitment of all partners to the research enterprise and the goals of the project;
- The willingness of team members to compromise;
- Trust and respect for each other based on established prior relationships;
- Researchers who had been policy makers and policy makers who had been researchers, with understanding of the values and constraints faced by each partner; and
- Decision maker team members with the authority and accountability to make important decisions, and to make and honour commitments.
Conclusions and implications
Our research experience and our findings have been used extensively by our own organizations to inform policy and program development. The results have also been used outside the original partnership. For example, the Canadian Nurses Association held an invitational forum in the fall of 2005 on advanced nursing practice and some of our published research was used to inform the discussion and debate about the direction of ANP in Canada. Our final report has been used and cited by other nursing education institutions in the development of graduate programs in advanced nursing practice. On a national level, the findings of this research have informed discussions of a Primary Health Care Nurse Practitioner Education task force. Finally, this research provides the starting point of a longer-term program of research that will include many of the original research team.
1 Horrocks, S., E. Anderson, and C. Salisbury. 2002. Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ 324:819-23.
2 Safriet, B. J. 1992. Health care dollars and regulatory sense: the role of advanced practice nursing. Yale J Regul 9:417-88.
3 Bryant-Lukosius, D., A. DiCenso, G. Browne, and J. Pinelli. 2004. Advanced practice nursing roles: Development, implementation and evaluation. J Adv Nurs 48 (5): 519-29.
4 Lavis, J. N., D. Robertson, J. M. Woodside, C. B. MacLeod, J. Abelson, and the Knowledge Transfer Study Group. 2003. How can research organizations more effectively transfer research knowledge to decision makers? Milbank Q 81 (2): 221-48.
5 Schreiber, R. and M. MacDonald. 2003. Nurse anesthesia: The time has come. Can Nurse 99 (6): 20-3.
6 Pauly, B., R. Schreiber, M. MacDonald, H. Davidson, J. Crickmore, L. Moss, J. Pinelli, S. Regan, and C. Hammond. 2004. Dancing to our own tune: Understandings of advanced nursing practice in British Columbia. Can J Nurs Leadersh 17 (2): 47-57.
7 Schreiber, R., M. MacDonald, B. Pauly, H. Davidson, J. Crickmore, L. Moss, J. Pinelli, S. Regan, and C. Hammond. 2005. Singing in different keys: Enactment of advanced nursing practice in British Columbia. CJNL. Online exclusive (June).
8 MacDonald, M., R. Schreiber, H. Davidson, B. Pauly, L. Moss, J. Pinelli, S. Regan, J. Crickmore, and C. Hammond. 2005. Moving towards harmony: Exemplars of advanced nursing practice for British Columbia. CJNL. Online exclusive (June).
9 Schreiber, R., M. MacDonald, B. Pauly, H. Davidson, J. Crickmore, L. Moss, J. Pinelli, and S. Regan. 2005. Singing from the same songbook: The future of advanced nursing practice in British Columbia. CJNL. Online exclusive (June).
10 Weiss, C. H. 1980. Knowledge creep and decision accretion. Knowledge: Creation, Diffusion, Utilization 1 (3): 381-404.
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