Download Advanced Practice Roles

New Ways of Working
A Provincial Strategy for Advanced
Practice Roles In Cancer Care
Summary Strategy Document
July 2006
Background
Ontario’s health care system has a strong and highly skilled workforce, consisting of more
than 350,000 regulated and unregulated providers. 1 A number of these workers play vital
roles in the delivery of cancer services to patients across the province. However, like other
areas of the health care system, Ontario’s cancer care system faces significant challenges in
the area of health human resources, and the resulting pressures on service are wellrecognized. The province does not have sufficient numbers of appropriately trained health
care providers to meet present and future needs, in both hospital and community settings.
Health human resources issues in the cancer system are critical, given:
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Increased demand for cancer services
Continuing expansion of cancer services to meet public expectations and government
targets
Shortages of specialized staff in cancer-related disciplines (e.g. pathology, radiology,
anesthesiology, radiation therapy, nursing)
Workforce aging and retirement of staff, over the next 10 years, in all cancer-related
professions and supporting disciplines
Difficulty in attracting and retaining staff
Lack of approved funding for new positions
Lack of candidates to fill vacancies
Inadequate supply of trainees in cancer-related disciplines
Technical advances requiring highly specialized staff
The drive for continuous improvement in the delivery of cancer prevention, diagnosis
and treatment services
In response to these challenges, and given its mandate to drive innovation, Cancer Care
Ontario (“CCO) is proposing a strategic initiative to explore, develop and implement
advanced practice roles in cancer care. This initiative follows up on specific commitments
made in the Ontario Cancer Plan 2005-2008, and reaffirmed in the 2005 Progress Report.
The balance of this document provides a brief overview of advanced practice roles, and sets
out a preliminary provincial strategy for moving forward with a coordinated, strategic,
systemic and interdisciplinary approach to the planning, development and implementation of
advanced practice roles in cancer care in Ontario.
Benefits and Opportunities
The concept of “advanced practice roles” is not new to the Ontario cancer system. Ontario’s
cancer system currently utilizes the skills of a number of advanced practice nurses, and we
are making the first forays into advanced practice in other health disciplines, such as
1
Government of Ontario, Laying the Foundation for Change: A Progress Report on Ontario’s Health Human Resources
Initiatives, December 2005, at p.3.
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radiation therapy. Many initiatives to introduce advanced practice nurses have been
implemented on an ad hoc basis, and not as part of a systematic and evidence-based strategy.
CCO is interested in exploring additional opportunities to further expand advanced practice
in disciplines such as nursing, and to introduce advanced practice roles in new areas such as
radiation therapy, pathology, pharmacy, anesthesia and others. These roles can cover the
spectrum of services, including prevention, screening, diagnosis, surgery, systemic and
radiation treatments, supportive and palliative care.
Experience with advanced practice roles demonstrates clearly that these roles can improve
the quality and efficiency of patient services, address critical health human resource issues,
address key gaps in service delivery in Ontario’s cancer system, and increase patient and
provider satisfaction. Benefits of advanced practice roles include:
For Patients. . .
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Improved patient care
Improved health outcomes
Faster access to more focused services or specialized care
Continuity of service provider
Flexible services designed around population needs
For Services. . .
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Positive impact on recruitment and retention
Enhanced continuity and coordination of care
Better utilization of staff skills and expertise and, as a consequence, more targeted use
of the skills of other professions
Cost-effective method of delivering high-quality services
Improved team work and interdisciplinary collaboration
More appropriate skill-mix within clinical teams
Facilitates increased emphasis on prevention, education and health promotion
Increase patient and family satisfaction with services
For Health Professionals. . .
• Opportunities to increase and utilize knowledge, skills and competencies
• Increased job satisfaction
• Improved accountability and responsibility
• Leadership opportunities
• Expanded career pathway with increased job options
Opportunities to implement advanced practice roles
Advanced practice roles provide the opportunity to improve the quality and efficiency of
patient care, and to address potential and actual gaps in service delivery in Ontario’s cancer
system. Implementation of advanced practice roles in cancer care can be explored across all
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disciplines that have, or may have, a role to play in delivering cancer services, based on
comprehensive service and needs assessments. While not the focus of the present report,
expanded roles may also play an important part in efforts to meet patient care and health
human resource objectives. The following list, while not exhaustive, identifies some
potential opportunities to implement both advanced practice roles and expanded roles in
cancer care in Ontario.
Advanced Practice Roles
1.
Advanced Practice Nurses
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2.
Nurse Practitioners
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Advanced Practice Radiation Therapists
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4.
Advanced Practice Pharmacists
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Acute Care Nurse Practitioners
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in anesthesia care
6.
Advanced Practice Social Workers
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offering therapeutic counseling to patients and families
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Advanced Practice Dietitians
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in pain and symptom management, in disease site-focused roles
in family practice areas, or community clinics offering prevention,
screening to clients and surveillance follow-up to cancer patients
in disease-site focused roles
Pharm. D. practitioners managing complex pharmaceutical care on
inpatient units (i.e., change prescriptions, order drugs, dependent on
lab/other results)
in independent practice counseling patients and families on nutrition
management and offering interventions to manage eating, swallowing
problems
Expanded Practice Roles
1.
Registered Nurses
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performing a flexible sigmoidoscopy screening role
2.
Radiation Therapists
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performing dosimetry
3.
Pathology Assistants
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Radiology Assistants
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working alongside Radiologist doing preliminary 'read' of imaging
5.
Pharmacy Technicians
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in chemotherapy admixtures
6.
Respiratory Therapists
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working as Anesthesia Assistants
working alongside the Pathologist doing preliminary 'read' of
specimens
Goal
To maximize the contribution of advanced practice roles and support appropriate and
sustained integration of advanced practice roles in Ontario’s cancer system through a
provincial, systematic, coordinated and interdisciplinary approach to planning, development,
implementation and evaluation of advanced practice roles in cancer care across the spectrum
of services.
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Approach
The proposed approach to planning, development, implementation and evaluation of
advanced practice roles is characterized by the following features:
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Province- and system-wide
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Interdisciplinary
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Patient-centered
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Coordinated and efficient
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Needs- and evidence-based
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Transformative
These features distinguish the proposed advanced practice roles initiative from earlier ad hoc
efforts to introduce individual advanced practice roles in cancer care.
Guiding Principles
The following principles will guide any initiative directed at planning, developing and
implementing advanced practice roles in cancer care:
(a) Introduction of advanced practice roles must be predicated on better meeting patient
care needs
While effective implementation of an advanced practice strategy has the potential to
offer many benefits – including improved service delivery, recruitment, retention and
provider satisfaction – the development and introduction of advanced practice roles must
be predicated on better meeting patient care needs. The clinical team – and the roles of
its members – should be shaped around patient and care requirements, and the skills and
experience of health professionals, as opposed to professional boundaries. 2 When
assessing and evaluating opportunities for new roles and new models of care,
consideration should be given to areas of greatest need from the patient perspective (e.g.
high-risk, high-cost, heavy user, most vulnerable, and underserved patient populations). 3
(b) Measures to support cultural change are fundamental to effective implementation and
integration of advanced practice roles
A concerted effort will be made to support the cultural change(s) that must occur for
successful implementation and integration of advanced practice roles. These efforts may
include such things as an increased emphasis on collaborative team, flexible and
evolving approaches to care in undergraduate and continuing education programs for
health providers, workplace programs and inter-professional education programs that
support more interdisciplinary and team-oriented models of care, and measures that
2
NHS, Radiography skills mix: A report on the four-tier service delivery model, June 2003 at p. 6.
Bryant-Lukosius, Denise, “Evidence-based Strategies for Determining the Need for Advanced Nursing Services”,
Presentation to the CCO Advanced Practice Symposium, February 23, 2006.
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demonstrate executive and administrative support for the new roles and new models of
care.
(c) To the extent possible, advanced practice roles will be implemented in a consistent and
coordinated manner
Appropriate and viable new advanced practice roles that are identified following service
and needs assessment will be planned, implemented and evaluated in a consistent and
coordinated manner. The use of a common framework, and the provision of common
assessment, implementation and evaluation tools, will assist in achieving consistency and
coordination. This approach offers a number of benefits, including efficiencies in
planning, implementation and evaluation. Consistency of approach and conformance to
established guidelines may also enhance the reliability of research results.
(d) Any new advanced practice role must be clearly and succinctly defined and described
Effective planning, implementation and evaluation requires a clear description of roles
and responsibilities, the patient needs that the advanced practitioner is expected to meet,
the technical, clinical and other skills that are required for the role, the relationship to
other members of the multi-disciplinary team, and the accountability structure. Where
possible, the title, definition and description should conform to existing terms and
definitions used for the same or substantially similar roles in other jurisdictions.
(e) Appropriate education and training for advanced practice roles is vital
Health professionals assuming an advanced practice role must have access to appropriate
education and training that will allow them to meet the role’s responsibilities
competently. They must be intellectually, academically and clinically prepared to take
on new roles. In order to accomplish this, an advanced practice agenda must involve
effective coordination with the post-secondary education system, and the advanced
education sector.
(f) Utilize a consistent conceptual framework
Strive for consistency of agendas for individual advanced practice roles, and develop a
consistent planning, implementation and evaluation framework that can be applied across
new advanced practice roles.
(g) Use a coordinated process for legislative change
Because a number of regulatory issues cut across professions, to the extent possible an
advanced practice roles agenda should utilize a coordinated process to ensure the
efficient, orderly and consistent development of changes to legislation and regulations
that are necessary to implement new advanced practice roles.
(h) Outcomes research documenting the value of the advanced practice role is critical
It is critically important to conduct studies to validate the need for and impact of
advanced practice roles in cancer care. CCO can facilitate documentation of outcomes
of advanced practice roles in cancer care by publishing guidelines for outcomes
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documentation, including reliable tools and a description of a process that can be applied
to a variety of advanced practice roles in diverse practice settings. This information will
support effective workforce and service planning and reform, and assist efforts to
demonstrate the value and impact of an advanced practice role.
(i) Advanced practice initiatives will align with CCO and regional priorities and positions
Advanced practice role initiatives will be consistent with other priorities and positions
for cancer system and the health care system at large. Areas demanding continued
alignment include government’s health transformation agenda, health human resources
strategies and approaches, regional and CCO innovation agendas, approach to regulated
health professions and interdisciplinary practice, and commitments contained in the
Ontario Cancer Plan.
(j) Long-term strategic direction / incremental change
While new roles can be introduced in a phased process, changes should be guided by a
longer-term strategic view of advanced practice roles.
Strategic Alignment
Consideration of advanced practice roles is taking place at a critical juncture for health care
and cancer care in Ontario, and in other parts of the country. Advanced practice initiatives
are consistent with local, provincial, national and international reforms to health care policy
and practice. Among other things, the advanced practice roles agenda outlined in this
document is consistent with:
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Ontario government’s major policy directions for health care transformation
Ontario’s Healthy Workforce blueprint
CCO innovation agendas
Emphasis on interdisciplinary collaboration, eliminating professional territorialism, and
maximizing scopes of practice for regulated health professions
National and international interest in matters relating to advanced and expanded practice
roles
Key recommendations set out in the Ontario Cancer Plan and reaffirmed in the 2005
Progress Report
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