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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: y y y y y y y y y y 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. 1 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. . . • • • • • 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. . . • • • • • • • • 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 2 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 • 2. Nurse Practitioners • 3. Advanced Practice Radiation Therapists • 4. Advanced Practice Pharmacists • 5. Acute Care Nurse Practitioners • in anesthesia care 6. Advanced Practice Social Workers • offering therapeutic counseling to patients and families 7. Advanced Practice Dietitians • 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 • performing a flexible sigmoidoscopy screening role 2. Radiation Therapists • performing dosimetry 3. Pathology Assistants • 4. Radiology Assistants • working alongside Radiologist doing preliminary 'read' of imaging 5. Pharmacy Technicians • in chemotherapy admixtures 6. Respiratory Therapists • 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. 3 Approach The proposed approach to planning, development, implementation and evaluation of advanced practice roles is characterized by the following features: • Province- and system-wide • Interdisciplinary • Patient-centered • Coordinated and efficient • Needs- and evidence-based • 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. 3 4 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 5 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: y y y y y y 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 6