Carl-Ardy Dubois

Human resources for health policies: a critical component in health policies.

In the last few years, increasing attention has been paid to the development of health policies. But side by side with the presumed benefits of policy, many analysts share the opinion that a major drawback of health policies is their failure to make room for issues of human resources. Current approaches in human resources suggest a number of weaknesses: a reactive, ad hoc attitude towards problems of human resources; dispersal of accountability within human resources management (HRM); a limited notion of personnel administration that fails to encompass all aspects of HRM; and finally the short-term perspective of HRM.There are three broad arguments for modernizing the ways in which human resources for health are managed:• the central role of the workforce in the health sector;• the various challenges thrown up by health system reforms;• the need to anticipate the effect on the health workforce (and consequently on service provision) arising from various macroscopic social trends impinging on health systems.The absence of appropriate human resources policies is responsible, in many countries, for a chronic imbalance with multifaceted effects on the health workforce: quantitative mismatch, qualitative disparity, unequal distribution and a lack of coordination between HRM actions and health policy needs.Four proposals have been put forward to modernize how the policy process is conducted in the development of human resources for health (HRH):• to move beyond the traditional approach of personnel administration to a more global concept of HRM;• to give more weight to the integrated, interdependent and systemic nature of the different components of HRM when preparing and implementing policy;• to foster a more proactive attitude among human resources (HR) policy-makers and managers;• to promote the full commitment of all professionals and sectors in all phases of the process.The development of explicit human resources policies is a crucial link in health policies and is needed both to address the imbalances of the health workforce and to foster implementation of the health services reforms.

Conceptualizing performance of nursing care as a prerequisite for better measurement: a systematic and interpretive review

BackgroundDespite the critical role of nursing care in determining high-performing healthcare delivery, performance science in this area is still at an early stage of development and nursing’s contribution most often remains invisible to policy-makers and managers. The objectives of this study were: 1) to develop a theoretically based framework to conceptualize nursing care performance; 2) to analyze how the different components of the framework have been operationalized in the literature; and 3) to develop a pool of indicators sensitive to various aspects of nursing care that can be used as a basis for designing a performance measurement system.MethodsWe carried out a systematic review of published literature across three databases (MEDLINE, EMBASE and CINAHL), focusing on literature between 1990 and 2008. Screening of 2,103 papers resulted in final selection of 101 papers. A detailed template was used to extract the data. For the analysis, we used the method of interpretive synthesis, focusing first on 31 papers with theoretical or conceptual frameworks; the remaining 70 articles were used to strengthen and consolidate the findings.ResultsCurrent conceptualizations of nursing care performance mostly reflect a system perspective that builds on system theory, Donabedian’s earlier works on healthcare organization, and Parsons’ theory of social action. Drawing on these foundational works and the evidence collated, the Nursing Care Performance Framework (NCPF) we developed conceptualizes nursing care performance as resulting from three nursing subsystems that operate together to achieve three key functions: (1) acquiring, deploying and maintaining nursing resources, (2) transforming nursing resources into nursing services, and (3) producing changes in patients’ conditions. Based on the literature review, these three functions are operationalized through 14 dimensions that cover 51 variables. The NCPF not only specifies core aspects of nursing performance, it also provides decision-makers with a conceptual tool to serve as a common ground from which to define performance, devise a common and balanced set of performance indicators for a given sector of nursing care, and derive benchmarks for this sector.ConclusionsThe NCPF provides a comprehensive, integrated and theoretically based model that allows performance evaluation of both the overall nursing system and its subsystems. Such an approach widens the view of nursing performance to embrace a multidimensional perspective that encompasses the diverse aspects of nursing care.

Measuring actual scope of nursing practice: a new tool for nurse leaders.

Objective: This project describes the development and testing of the actual scope of nursing practice questionnaire. Background: Underutilization of the skill sets of registered nurses (RNs) is a widespread concern. Cost-effective, safe, and efficient care requires support by management to facilitate the implementation of nursing practice at the full scope. Methods: Literature review, expert consultation, and face validity testing were used in item development. The instrument was tested with 285 nurses in 22 medical units in 11 hospitals in Canada. Results: The 26-item, 6-dimension questionnaire demonstrated validity and reliability. The responses suggest that nurses practice at less than their optimal scope, with key dimensions of professional practice being implemented infrequently. Conclusions: This instrument can help nurse leaders increase the effective use of RN time in carrying out the full scope of their professional practice.

A process-based framework to guide nurse practitioners integration into primary healthcare teams: results from a logic analysis

BackgroundIntegrating Nurse Practitioners into primary care teams is a process that involves significant challenges. To be successful, nurse practitioner integration into primary care teams requires, among other things, a redefinition of professional boundaries, in particular those of medicine and nursing, a coherent model of inter- and intra- professional collaboration, and team-based work processes that make the best use of the subsidiarity principle. There have been numerous studies on nurse practitioner integration, and the literature provides a comprehensive list of barriers to, and facilitators of, integration. However, this literature is much less prolific in discussing the operational level implications of those barriers and facilitators and in offering practical recommendations.MethodsIn the context of a large-scale research project on the introduction of nurse practitioners in Quebec (Canada) we relied on a logic-analysis approach based, on the one hand on a realist review of the literature and, on the other hand, on qualitative case-studies in 6 primary healthcare teams in rural and urban area of Quebec.ResultsFive core themes that need to be taken into account when integrating nurse practitioners into primary care teams were identified. Those themes are: planning, role definition, practice model, collaboration, and team support.The present paper has two objectives: to present the methods used to develop the themes, and to discuss an integrative model of nurse practitioner integration support centered around these themes.ConclusionIt concludes with a discussion of how this framework contributes to existing knowledge and some ideas for future avenues of study.

Cross-national comparisons of human resources for health what can we learn?

After a long period of neglect, the issue of human resources for health (HRH) has recently emerged as a core component on the international health agenda, with policy makers increasingly eager to learn from experience elsewhere. This article investigates systematically the opportunities and challenges associated with the use of cross-national comparisons of HRH policies and practices. It reviews the evidence in favour of using international comparative studies on HRH, discusses emerging opportunities for developing a cross-national research agenda to guide HRH policies in Europe, and highlights obstacles which may hinder the implementation of comparative studies on HRH. While demonstrating many opportunities offered by the comparative approach to improve understanding of human resources processes in the health sector, this article also emphasizes the dangers of simplistic pleas for the transfer of human resource policies without taking into account the context-specific factors and the generative capacity of the social actors in the design and implementation of policy changes.

A taxonomy of nursing care organization models in hospitals

BackgroundOver the last decades, converging forces in hospital care, including cost-containment policies, rising healthcare demands and nursing shortages, have driven the search for new operational models of nursing care delivery that maximize the use of available nursing resources while ensuring safe, high-quality care. Little is known, however, about the distinctive features of these emergent nursing care models. This article contributes to filling this gap by presenting a theoretically and empirically grounded taxonomy of nursing care organization models in the context of acute care units in Quebec and comparing their distinctive features.MethodsThis study was based on a survey of 22 medical units in 11 acute care facilities in Quebec. Data collection methods included questionnaire, interviews, focus groups and administrative data census. The analytical procedures consisted of first generating unit profiles based on qualitative and quantitative data collected at the unit level, then applying hierarchical cluster analysis to the units’ profile data.ResultsThe study identified four models of nursing care organization: two professional models that draw mainly on registered nurses as professionals to deliver nursing services and reflect stronger support to nurses’ professional practice, and two functional models that draw more significantly on licensed practical nurses (LPNs) and assistive staff (orderlies) to deliver nursing services and are characterized by registered nurses’ perceptions that the practice environment is less supportive of their professional work.ConclusionsThis study showed that medical units in acute care hospitals exhibit diverse staff mixes, patterns of skill use, work environment design, and support for innovation. The four models reflect not only distinct approaches to dealing with the numerous constraints in the nursing care environment, but also different degrees of approximations to an “ideal” nursing professional practice model described by some leaders in the contemporary nursing literature. While the two professional models appear closer to this ideal, the two functional models are farther removed.

Role Clarification Processes for Better Integration of Nurse Practitioners into Primary Healthcare Teams: A Multiple-Case Study

Role clarity is a crucial issue for effective interprofessional collaboration. Poorly defined roles can become a source of conflict in clinical teams and reduce the effectiveness of care and services delivered to the population. Our objective in this paper is to outline processes for clarifying professional roles when a new role is introduced into clinical teams, that of the primary healthcare nurse practitioner (PHCNP). To support our empirical analysis we used the Canadian National Interprofessional Competency Framework, which defines the essential components for role clarification among professionals. A qualitative multiple-case study was conducted on six cases in which the PHCNP role was introduced into primary care teams. Data collection included 34 semistructured interviews with key informants involved in the implementation of the PHCNP role. Our results revealed that the best performing primary care teams were those that used a variety of organizational and individual strategies to carry out role clarification processes. From this study, we conclude that role clarification is both an organizational process to be developed and a competency that each member of the primary care team must mobilize to ensure effective interprofessional collaboration.

Implementation of integrated services networks in Quebec and nursing practice transformation: convergence or divergence?

BackgroundEven though nurses are expected to play a key role in implementing integrated services networks, up to now their practice in this regard has received very little research attention. The aim of this study is to describe the extent to which the evolution of nursing practice in Quebec in recent years has converged with the requirements and efforts involved in services integration.MethodsThis descriptive study was carried out with 107 nurses working an integrated network of healthcare services in Quebec in four different care pathways: chronic obstructive pulmonary disease, autonomy support for the elderly, palliative oncology care, and mental health. Development model for integrated care (DMIC) was used, first, to examine the prevalence in each pathway of integrative activities, grouped into nine practice dimensions, and then to position each pathway in relation to the four phases of development for any integration process, as defined by the DMIC.ResultsOnly one pathway had reached Phase 3, which involves expansion and monitoring of integration, whereas the others were still in the preliminary Phases 1 and 2 characterized by initiative and experimentation. Only two dimensions out of nine (‘quality of care’ and ‘interprofessional teamwork’) were prevalent in all the pathways; two others (‘transparent entrepreneurship’ and ‘performance management’) were in none of the pathways, and the remaining five (‘patient–family centered care’, ‘result-focused learning’, ‘delivery system’, ‘commitment’, ‘roles and tasks’) were present to varying degrees.ConclusionsThese results suggest that particular efforts should be made to bridge the significant gap between the pace of nursing practice transformation and the objectives of service integration. These efforts should focus, among other things, on the deployment of organizational, clinical, human, and material resources to support practice renewal and continuing education for nurses to prepare them for the requirements of integration.

Assessing the performance of centralized waiting lists for patients without a regular family physician using clinical-administrative data

BackgroundWith 4.6 million patients who do not have a regular family physician, Canada performs poorly compared to other OECD countries in terms of attachment to a family physician. To address this issue, several provinces have implemented centralized waiting lists to coordinate supply and demand for attachment to a family physician. Although significant resources are invested in these centralized waiting lists, no studies have measured their performance. In this article, we present a performance assessment of centralized waiting lists for unattached patients implemented in Quebec, Canada.MethodsWe based our approach on the Balanced Scorecard method. A committee of decision-makers, managers, healthcare professionals, and researchers selected five indicators for the performance assessment of centralized waiting lists, including both process and outcome indicators. We analyzed and compared clinical-administrative data from 86 centralized waiting lists (GACOs) located in 14 regions in Quebec, from April 1, 2013, to March 31, 2014.ResultsDuring the study period, although over 150,000 patients were attached to a family physician, new requests resulted in a 30% median increase in patients on waiting lists. An inverse correlation of average strength was found between the rates of patients attached to a family physician and the proportion of vulnerable patients attached to a family physician meaning that as more patients became attached to an FP through GACOs, the proportion of vulnerable patients became smaller (r = −0.31, p < 0.005). The results showed very large performance variations both among GACOs of different regions and among those of a same region for all performance indicators.ConclusionsCentralized waiting lists for unattached patients in Quebec seem to be achieving their twofold objective of attaching patients to a family physician and giving priority to vulnerable patients. However, the demand for attachment seems to exceed the supply and there appears to be a tension between giving priority to vulnerable patients and attaching of a large number of patients. Results also showed heterogeneity in the performance of centralized waiting lists across Quebec. Finally, our findings suggest it is critical that similar mechanisms should use available data to identify the best strategies for reducing variations and improving performance.

Associations between level of services integration and nurses’ workplace well-being

BackgroundTo respond better to population needs, in recent years Quebec has invested in improving the integration of services and care pathways. Nurses are on the front lines of these transformation processes, which require them to adopt new clinical practices. This updating of practices can be a source of both satisfaction and stress. The aim of this study was to gain a better understanding of the relationship between the transformation processes underlying services integration and nurses’ workplace well-being.MethodThis study was based on a descriptive cross-sectional correlational design. The target population included all nurses working in four care pathways in a Quebec healthcare establishment: palliative oncology services, mental health services, autonomy support for the elderly, and chronic obstructive pulmonary disease. In all, 107 nurses took part in the study and completed a questionnaire sent to them. Hierarchical linear regression analyses were used to examine the relationship between level of integration, measured using the Development Model for Integrated Care; nurses’ perceptions of organizational change, measured on four dimensions (challenge, responsibility, threat, control); and nurses’ workplace well-being, measured on three dimensions (negative stress, positive stress, satisfaction), as defined by the Flexihealth model.ResultsNurses in the palliative oncology care pathway, which was at a more advanced level of integration, presented a lower negative stress level and a higher positive stress level than did nurses in other care pathways. Their mean satisfaction score was also higher. More advanced integration was associated with nurses’ feeling less threatened, as well as improved workplace well-being. The perception of threat appeared to be a significant mediating variable in the relationship between level of integration and well-being.ConclusionThe association observed between level of services integration and workplace well-being contributes to a better understanding of nurses’ experiences in such situations. These results provide new perspectives on interventions that could be implemented to remedy the potential negative consequences of these types of transformations.