Christina Hurlock-Chorostecki

The role of nurse practitioners in hospital settings: implications for interprofessional practice.

Expansion of the nurse practitioner (NP) role worldwide indicates a need to understand how the role functions in interprofessional healthcare teams. Through the adoption of a mixed methods approach that gathered on-site tracking and observation, self-recorded logs of consultations and focus group interviews of team members and NPs, we describe the extent of role activity and the nature of interprofessional practices of 46 NPs and their team members in nine hospital sites across the province of Ontario, Canada. Findings outline the nature of the NP role activities, which largely focused on providing clinical care, with the support of their team, to a range of patients across the study settings. We discuss how ‘embedding’ the NP in this way appears to contribute to utilization of expertise of all professions as well as enabling team members to promote evidence-based practices. We argue that the use of NPs augments interprofessional role utilization through their desire to consult with a range of professionals and the capacity to perform holistic care for patients that is not limited to traditional nursing boundaries.

The value of the hospital-based nurse practitioner role: development of a team perspective framework

Abstract There is a need to understand nurse practitioner (NP) interprofessional practice within hospital teams to inform effective role integration and evolution. To begin this understanding a supplementary analysis of 30 hospital team member focus groups was carried out using constructivist grounded theory methodology. This conceptual rendering of the team members’ shared perspective of NP actions provides insight into the meaning and importance of the NP role. Participants emphasized three hospital-based (HB) NP practice foci as the meaning of role value; easing others’ workload, holding patient care together and evolving practice. Trust emerged as a pre-requisite condition for HB NP role efficacy. A team member perspective framework of HB NP practice is presented as the first stage in developing a model of HB NP interprofessional practice within hospitals. The framework provides multiple perspectives to the meaning and value of the HB NP role beyond basic role description. The framework may be used by healthcare professionals, operational leaders, academia and HB NPs to enhance role respect and understanding.

Impact of the opening of a specialized cardiac surgery recovery unit on postoperative outcomes in an academic health sciences centre.

PurposeIt is controversial as to whether cardiac surgery patients are optimally managed in a mixed medical-surgical intensive care unit (ICU) or in a specialized postoperative unit. We conducted a prospective cohort study in an academic health sciences centre to compare outcomes before and following the opening of a specialized cardiac surgery recovery unit (CSRU) in April 2005.MethodsThe study cohort included 2,599 consecutive patients undergoing coronary artery bypass grafting (CABG), valve and combined CABG-valve procedures from April 2004 to March 2006. From April 2004 to March 2005 (year 1) all patients received postoperative care in mixed medical-surgical ICUs at two different sites staffed by critical care consultants, fellows and residents. From April 2005 until March 2006 (year 2) patients were cared for in a newly-established CSRU on one site staffed by cardiac anesthesiology fellows, a nurse practitioner and consultants in critical care, cardiac anesthesiology and cardiac surgery. The effect of this change on in-hospital mortality, the incidence of ten major postoperative complications, postoperative ventilation hours, readmission rates and case cancellations due to a lack of capacity was assessed using Chi-square or Wilcoxon tests, where appropriate.ResultsCoronary artery bypass grafting, valve and combined CABG-valve mortality rates were similar in years 1 and 2. There was a significant reduction in the composite major complication rate (16.3% to 13.0%,P = 0.02) and in median postoperative ventilation hours (8.8vs 8.0 hr,P = 0.005) from year 1 to 2. On multivariable logistic regression analysis, the pre-merger interval (year 1) was a significant independent predictor of the occurrence of death or major complications.ConclusionA specialized CSRU with a multi-disciplinary consultant model was associated with stable or improved outcomes postoperatively, when compared to a mixed medical-surgical ICU model of cardiac surgical care.RésuméObjectifLa question de savoir si les patients de chirurgie cardiaque sont traités de façon optimale dans une unité de soins intensifs mixte, c’est-à-dire médico-chirurgicale, ou dans une unité postopératoire spécialisée, demeure controversée. Nous avons mené une étude de cohorte prospective dans un centre de santé universitaire afin de comparer les devenirs avant et après l’ouverture d’une unité spécialisée de rétablissement après chirurgie cardiaque (CSRU) en avril 2005.MéthodeLa cohorte de l’étude a été constituée de 2 599 patients consécutifs subissant une chirurgie de revascularisation coronarienne, un remplacement valvulaire, et des chirurgies combinant les deux procédures entre avril 2004 et mars 2006. D’avril 2004 à mars 2005 (1ère année), tous les patients ont été traités dans des unités de soins intensifs mixtes dans deux différents sites employant des consultants en soins intensifs, des fellows et des résidents. D’avril 2005 à mars 2006 (2ème année), les patients ont été pris en charge dans une nouvelle unité CSRU dans un seul site, dont le personnel se composait de fellows en anesthésie cardiaque, d’un infirmier praticien et de consultants en soins intensifs, en anesthésie cardiaque et en chirurgie cardiaque. L’effet de ce changement sur la mortalité à l’hôpital, l’incidence de dix complications postopératoires majeures, le nombre d’heures de ventilation postopératoire, les taux de réadmission et les annulations de cas par manque de capacité, ont été évalués à l’aide des tests du chi-carré et de Wilcoxon, lorsqu’ils étaient adaptés.RésultatsLes tauxde mortalité pourlespontages aortocoronariens, les remplacements valvulaires et les chirurgies combinées étaient similaires la première et la deuxième année. Il y a eu une réduction significative dans le taux composite de complications majeures (de 16,3% à 13,0 %,P = 0,02) et dans la moyenne du nombre d’heures de ventilation postopératoire (8,8 vs 8,0 hres, P = 0,005) entre la première et la deuxième année. Dans l’analyse multivariée de régression logistique, l’intervalle avant la fusion (1ère année) a constitué un prédicteur indépendant significatif de l’incidence de décès ou de complications majeures.ConclusionUn modèle d’unité CSRU spécialisée avec des consultants pluridisciplinaires a été associé à des devenirs postopératoires stables ou meilleurs par rapport à un modèle d’unité de soins intensifs mixte médico-chirurgical pour les soins post-chirurgie cardiaque.

Labour saver or building a cohesive interprofessional team? The role of the nurse practitioner within hospitals

Abstract Nurse practitioners (NP) are employed within hospital interprofessional (IP) teams in several countries worldwide. There have been some efforts to describe the nature of the NP role within IP teams largely focussing on how the role may augment care processes. Here, using a constructivist grounded theory approach, the perceptions of NPs about their role were compared and integrated into a previously published team perspective as the second phase of a larger study. Seventeen hospital-based (HB) NPs across Ontario, Canada, participated in group and individual interviews. The NP perspective substantiated and expanded the previously reported team perspective, resulting in an IP perspective. The three practice foci illustrating role value meaning of this perspective became: evolve NP role and advance the specialty, focus on team working, and hold patient care together. The IP perspective, juxtaposed with an existing contingency approach, revealed that NPs were promoting IP work, predominantly at the collaboration and teamwork levels, and aiding IP team transitions to appropriate forms of IP work. The practice, “focus on team working”’ was strongly related to promoting IP work. The findings were consistent with HB NPs enacting a role in building IP team cohesiveness rather than merely acting as a labour saver. This is the first study to align NP and team understanding of HB NP role value using an IP framework.

Exploring Differences in Patient-Centered Practices among Healthcare Professionals in Acute Care Settings

ABSTRACT There is limited evidence of the extent to which Healthcare professionals implement patient-centered care (PCC) and of the factors influencing their PCC practices in acute care organizations. This study aimed to (1) examine the practices reported by health professionals (physicians, nurses, social workers, other healthcare providers) in relation to three PCC components (holistic, collaborative, and responsive care), and (2) explore the association of professionals’ characteristics (gender, work experience) and a contextual factor (caseload), with the professionals’ PCC practices. Data were obtained from a large scale cross-sectional study, conducted in 18 hospitals in Ontario, Canada. Consenting professionals (n = 382) completed a self-report instrument assessing the three PCC components and responded to standard questions inquiring about their characteristics and workload. Small differences were found in the PCC practices across professional groups: (1) physicians reported higher levels of enacting the holistic care component; (2) physicians, other healthcare providers, and social workers reported implementing higher levels of the collaborative care component; and (3) physicians, nurses, and other healthcare providers reported higher levels of providing responsive care. Caseload influenced holistic care practices. Interprofessional education and training strategies are needed to clarify and address professional differences in valuing and practicing PCC components. Clinical guidelines can be revised to enable professionals to engage patients in care-related decisions, customize patient care, and promote interprofessional collaboration in planning and implementing PCC. Additional research is warranted to determine the influence of professional, patient, and other contextual factors on professionals’ PCC practices in acute care hospitals.

A survey of interprofessional activity of acute and long-term care employed nurse practitioners

Purpose:To describe activities of interprofessional (IP) care, a key aspect of high‐quality care, performed by nurse practitioners (NPs) employed in acute and long‐term care institutions. Data sources:We developed and tested a new theory‐driven process tool to quantify NP everyday activities of IP care. We then invited NPs in acute and long‐term care to complete the IP self‐assessment tool (IPSAT). Conclusions:The IPSAT is a validated tool shown to be reliable for use with NPs. Testing with other healthcare professionals is suggested. More than 50% of NPs engage in all activities of IP care. Many engage in shared decision making, professional relationship, communication, and partnership or collaboration activities on most work days. Less‐common activities were interdependence and collective problem solving including efforts to create role clarity. Implications for practice:It is important to evaluate the everyday use of activities that enhance high‐quality care. Awareness and enhanced knowledge of IP care activities such as promoting interdependence, collective problem solving, and ensuring role clarity will improve care quality. The tool results are valuable for practicing NPs and their educators to reflect on practice and advance knowledge to influence purposeful engagement in interprofessional care.

Initial refeeding with a soft diet was better than a clear liquid diet for length of hospital stay in mild acute pancreatitisCommentary

E Sathiaraj Ms E Sathiaraj, Asian Institute of Gastroenterology, Hyderabad, India; esther.sathiaraj@gmail.com In patients with mild acute pancreatitis, is resumption of oral feeding with a soft diet better than a clear liquid diet for reducing length of hospital stay? ### Design: randomised controlled trial. ### Allocation: {concealed}.* ### Blinding: blinded {patients and data analysts}.* ### Follow-up period: until hospital discharge. ### Setting: Asian Institute of Gastroenterology, India. ### Patients: 101 patients (mean age 38 y, 82% men) who had mild acute pancreatitis (absence of pancreatic necrosis, abscess and pseudocyst, organ dysfunction, hypotension [systolic blood pressure 3 times the upper limit of normal …