Multiple-case study methodology to inform nurse practitioner role development

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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

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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

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 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

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129 263 122 90-99 - 56 > 9 1482 64 96 69 106

Total number of NPs (acute and primary care) in Canada in 2010 = 2,486

(Total in 2009= 2,374)

(Canadian Institute for Health Information, 2012)

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 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

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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}

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 _{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

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 _{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

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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 Practitioner Psychological

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.

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Data Sources

Source

Time and motion study 108h 53 min

Non-participant observations 17.5 h

Interviews 59 participants

Field notes Daily

Administrative data and document analysis

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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

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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}

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

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

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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

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 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}

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 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}

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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

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Phase 2 of Project Reports on the

Results of a Case Study

FINAL REPORT

Evaluation of Clinic Specialist and Adva Midwife Practitione

(SCAPE)

al Nurse and Midwife nced Nurse and

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Briefing Note Summarizes Key

Points about NP Roles in Canada

20

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Special Edition of NURSING LEADERSHIP

on APN roles in Canada

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Multiple-case study methodology to inform nurse practitioner role development