Danielle D’Amour

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.

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.

Validación de un instrumento de medida de la intensidad de la colaboración entre los profesionales de la salud traducido al español

Objetivo. Establecer la fiabilidad y validez de una version espanola del cuestionario Intensite de la Collaboration Interprofessionnelle de Sicotte et al. Metodo. Tras una primera etapa de traduccion al espanol y de adaptacion, el instrumento se ha distribuido a una muestra de 123 enfermeras de un hospital universitario espanol. La segunda etapa ha consistido en la determinacion de: 1) la validez estructural; 2) la validez convergente, y 3) la consistencia interna de la version espanola del instrumento. Resultados. El analisis factorial en componentes principales y con rotacion Promax sugiere la existencia de 4 factores que explican el 61,47% de la varianza total. Por otro lado, el coeficiente de correlacion de Pearson entre el instrumento a estudio y otro instrumento que mide el mismo fenomeno es de 0,718. Por ultimo, el analisis de la coherencia interna del instrumento ha mostrado un * de Cronbach de 0,907. Conclusion. Se puede concluir que la escala Intensidad de la colaboracion entre los profesionales de la salud (ICPS) posee un buen grado de validez y fiabilidad para medir la colaboracion que hay entre los profesionales de la salud en los equipos interprofesionales.

Indicators for Evaluating the Performance and Quality of Care of Ambulatory Care Nurses

The quality and safety of nursing care vary from one service to another. We have only very limited information on the quality and safety of nursing care in outpatient settings, an expanding area of practice. Our aim in this study was to make available, from the scientific literature, indicators potentially sensitive to nursing that can be used to evaluate the performance of nursing care in outpatient settings and to integrate those indicators into the theoretical framework of Dubois et al. (2013). We conducted a scoping review in three databases (CINAHL, MEDLINE, and EMBASE) and the bibliographies of selected articles. From a total of 116 articles, we selected 22. The results of our study not only enable that framework to be extended to ambulatory nursing care but also enhance it with the addition of five new indicators. Our work offers nurses and managers in ambulatory nursing units indicators potentially sensitive to nursing that can be used to evaluate performance. For researchers, it presents the current state of knowledge on this construct and a framework with theoretical foundations for future research in ambulatory settings. This work opens an unexplored field for further research.

Nursing practice in primary care and patients’ experience of care

Purpose: Nurses are identified as a key provider in the management of patients in primary care. The objective of this study was to evaluate patients’ experience of care in primary care as it pertained to the nursing role. The aim was to test the hypothesis that, in primary health care organizations (PHCOs) where patients are systematically followed by a nurse, and where nursing competencies are therefore optimally used, patients’ experience of care is better. Method: Based on a cross-sectional analysis combining organizational and experience of care surveys, we built 2 groups of PHCOs. The first group of PHCOs reported having a nurse who systematically followed patients. The second group had a nurse who performed a variety of activities but did not systematically follow patients. Five indicators of care were constructed based on patient questionnaires. Bivariate and multivariate linear mixed models with random intercepts and with patients nested within were used to analyze the experience of care indicators in both groups. Results: Bivariate analyses revealed a better patient experience of care in PHCOs where a nurse systematically followed patients than in those where a nurse performed other activities. In multivariate analyses that included adjustment variables related to PHCOs and patients, the accessibility indicator was found to be higher. Conclusion: Results indicated that systematic follow-up of patients by nurses improved patients’ experience of care in terms of accessibility. Using nurses’ scope of practice to its full potential is a promising avenue for enhancing both patients’ experience of care and health services efficiency.

Développement d’un système de gestion de la performance des soins dans un centre hospitalier universitaire suisse

Studies show high variability in the quality of care and a significant incidence of adverse events. The care management direction of a university hospital center (CHU) has developed a care performance measuring system. The aim of the article is to present the different development stages of this system. The authors used Mays Normalization Process Theory, which focuses on factors influencing the engagement of individuals, groups, and organizations in sustaining change.The CHUs approach led to the following results : 1) reaching a consensus on performance concept and identifying five areas of performance, 2) selection of 12 priority indicators to assess performance, 3) measures development, 4) setting up the method of collecting information 5) creation of a mechanism for analyzing the results by care teams and 6) dissemination of results via dashboards.The approach focuses on strategies for mobilizing managers and health care teams. Specific recommendations relate to the need to provide expert resources, review clinical guidance and ensure accountability of health care providers.