SUU, Alm.del - 2015-16 - Bilag 511: Opfølgende materiale fra Dansk Sygeplejeråds foretræde den 19. april 2016 om det nære og sammenhængende sundhedsvæsen og handleplan for den ældre medicinske patient

Sundheds- og Ældreudvalget 2015-16
SUU Alm.del Bilag 511
Offentligt

ICN Policy Brief

Advanced Practice Nursing:

An Essential Component of Country Level Human Resources for Health

Authors

Denise Bryant-Lukosius, RN, CON(C), PhD and Ruth Martin-Misener, NP, PhD

Purpose

Globally, there is high demand and interest in advanced practice nursing (APN) roles as an

essential vehicle for innovation and healthcare reform to provide more effective and sustainable

models of healthcare.

This paper outlines important implications for integrating APN roles in

country level human resources for health (HRH) by summarising the evidence on: i) facilitators

and evidence-based strategies for effective APN role implementation; ii) the contribution of

APN roles for improving health and health system outcomes; and iii) the alignment of APN roles

with the World Health Organization's (WHO) Global Strategy on Human Resources for Health

and with the United Nation's

Sustainable Development Goals.

This paper should be read in relation to the zero draft of the “Health Workforce 2030: A Global

Strategy on Human Resources for Health”.

Background

Defining the advanced practice nurse and types of APN roles.

According to the International

Council of Nurses (ICN), an advanced practice nurse is a "registered nurse who has acquired

the expert knowledge base, complex decision-making skills and clinical competencies for

expanded practice, the characteristics of which are shaped by the context and/or country in

which s/he is credentialed to practice. A master's degree is recommended for entry level."

(2008, p.7). Clinical practice is a defining feature of APN roles. However,

what makes the roles

advanced and the means through which healthcare reform and innovation can be achieved,

the integration of clinical practice with responsibilities for education, organisational leadership,

professional development, evidence-based practice and research.

5,6,7

The two most common types of APN roles, the Clinical Nurse Specialist (CNS) and the Nurse

Practitioner (NP)

8,9

are the focus of this paper. How CNSs and NPs enact their roles is highly

variable in response to population health and practice setting needs. This fluidity makes CNSs

and NPs assets for addressing dynamic healthcare system needs, but can also contribute to

role confusion. CNSs often have greater responsibilities for non-clinical activities such as

education or quality improvement. NPs tend to have greater involvement in clinical care. NPs

ICN • CIE • CII

3, place Jean-Marteau, 1201 Ginebra- Suiza - Tfno.: +41 22 908 01 00

Fax: +41 22 908 01 01 – c. elect.:

[email protected]

- Web: www.icn.ch

SUU, Alm.del - 2015-16 - Bilag 511: Opfølgende materiale fra Dansk Sygeplejeråds foretræde den 19. april 2016 om det nære og sammenhængende sundhedsvæsen og handleplan for den ældre medicinske patient

also have an expanded scope of clinical practice which gives them the authority to

autonomously order diagnostic tests, make diagnoses, and prescribe treatments and

medications. In contrast, CNSs have the same scope of practice as a registered nurse. These

role differences have important implications for legislation, regulation and education.

Determining the types of APN roles that best fit country needs for improving health and health

system outcomes is essential for effective role implementation.

CNSs and NPs work in a broad

range of practice settings including hospitals (acute and ambulatory care), primary healthcare

(general and specialised), homes, community agencies and outreach programmes, and in long-

term care.

APN role deployment.

Countries are in different stages of developing APN roles as part of their

nursing workforce. Over 70 countries have or are interested in introducing APN roles.

established APN roles are found in higher income countries but there is documented need for

and the growing introduction of APN roles in low and middle income countries.

1,11,12

NPs have

been introduced most often to increase access to essential primary healthcare in underserviced

rural and remote communities and to address disparities in access to care for vulnerable

populations with high needs as a result of their economic, social, cultural, educational or health

circumstances in urban settings. CNSs have been introduced to provide highly complex and

specialised care, develop nursing practice and support nurses at the point-of-care, and lead

quality improvement and evidence-based practice initiatives in response to research advances

in treatment and technology. A more recent driver for the introduction of APN roles has been

healthcare reform and the need to improve the quality of healthcare and provide more

sustainable models of healthcare delivery. Aging populations and increasing demands for care

of the elderly, chronic disease management, health promotion and chronic disease prevention

and healthcare provider shortages are associated with needs for different healthcare delivery

solutions that are amenable to APN roles. The introduction of APN roles is also identified as an

important HRH strategy to improve nursing recruitment and retention and to provide

opportunities for career advancement.

APN role integration into healthcare systems.

There is limited access to current international

data examining APN role integration within health systems. Existing data indicates that APN role

integration, even for countries where the roles have been established for well over 60 years, is

quite limited. The ideal ratio of advanced practice nurses to the number of registered nurses in a

country is not known, but provides a crude measure of role integration or the extent to which

APN roles make up the nursing workforce and contribute to healthcare delivery. The United

States may have the greatest extent of health systems integration with NPs making up 6.5%

and CNSs 2.5% of the nursing workforce, followed by Ireland where NPs account for 2% of all

registered nurses.

In most other OECD countries with established APN roles, CNSs and NPs

each make up less than 1% of the nursing workforce. Thus, tremendous potential remains for

APN roles globally to improve health and health systems outcomes.

The integration of APN roles into healthcare organisations and systems is challenging,

contextual and evolves iteratively over time. In most countries, APN roles are introduced in an

ad-hoc manner. As a result, formal policies and practices necessary to support optimal APN role

implementation such as legislation, regulation, competencies and education, lag substantially

behind the informal introduction of the roles. Many of the challenges encountered occur

because APN role implementation stimulates changes and makes evident the need for further

change at macro, meso and micro levels. Ireland is one country that successfully utilised a

ICN • CIE • CII

3, place Jean-Marteau, 1201 Ginebra- Suiza - Tfno.: +41 22 908 01 00

Fax: +41 22 908 01 01 – c. elect.:

[email protected]

- Web: www.icn.ch

systematic approach to APN role implementation.

However, such an approach may be more

challenging to employ in larger countries and those with less centralised models of nursing

regulation and healthcare system governance.

At the country and organisation level, the successful introduction of an APN role is facilitated by

a goal and outcome orientated approach beginning with an assessment of patient and

community needs and early engagement of key stakeholders such as physicians and other

healthcare providers, administrators and patients. It is important to discuss and agree on the

gaps in the current model of healthcare, define the changes needed and identify the APN role

required to achieve identified goals, and how this role will interface and collaborate with other

members of the healthcare team. Alignment of APN roles with healthcare quality improvement

goals is critical for success. Country level enablers of role development include high quality

education programmes with standardised requirements and legislation and regulation that

support scope of practice expectations for the role.

Once developed, APN role implementation is facilitated by factors such as recruitment and

retention strategies, public awareness of the APN role and national and healthcare setting

leadership support. Addressing healthcare funding arrangements is essential to the introduction

and long-term sustainability of APN roles. Countries providing dedicated role funding or funding

arrangements that align with healthcare priorities and areas of demonstrated need will have

greater success in introducing and expanding the reach of APN roles within healthcare

systems.

8,11,13,14,15

To promote effective collaboration between advanced practice nurses and

physicians, it is important to ensure the introduction of APN roles does not negatively impact on

physician income and that physician concerns about liability are addressed. Role clarity is a key

enabler during both role development and implementation stages and is intertwined with inter

and intra professional relations. For NPs, particularly community-based NPs, role clarity

challenges are with physicians whereas for CNSs, role clarity challenges are often with other

registered nurses or NPs.

APN role outcomes.

APN roles contribute to achieving better care for individuals, better health

for populations and lower healthcare costs. Alignment of APN roles with patient and population

health needs is essential for realising healthcare improvements and efficiencies.

Evaluations of

APN roles focus on their effectiveness in achieving patient, provider and health system

outcomes. Systematic reviews of APN roles consistently show that their outcomes are as good,

or better, than their comparators, usually physicians.

16,17,18,19,20

Just as importantly, patients

consistently report high levels of satisfaction with care provided by advance practice nurses.

Some examples of key outcomes of CNS-provided care are: 1) improved access to supportive

care through case management to assess and manage risks and complications, plan and

coordinate care, monitor and evaluate, and to advocate for health and social services that best

meet patient/client needs; 2) improved quality of life, increased survival rates, lower

complication rates, and improved physical, functional, and psychological well-being of patients

with acute or chronic conditions; 3) improved health promotion practices such as immunisation

rates, weight management, and participation in cancer screening; 4) improved recruitment and

retention by mentoring, educating, and supporting nurses at the front-line of care; and 5)

reduced hospital admissions and visits to the emergency department, shortened hospital

lengths of stay and decreased use of unnecessary diagnostic tests, through improved case

management of patients with high risk and complex conditions.

21,22,23,24,25

ICN • CIE • CII

3, place Jean-Marteau, 1201 Ginebra- Suiza - Tfno.: +41 22 908 01 00

Fax: +41 22 908 01 01 – c. elect.:

[email protected]

- Web: www.icn.ch

Some examples of key outcomes of NP-provided care are: 1) increased access to primary

healthcare for at risk isolated groups, people living in rural and remote regions, and Indigenous

Peoples; 2) increased access to high quality care in primary healthcare clinics, reduced wait

times in emergency departments and increased timeliness of care in nursing homes; 3)

improved health outcomes of high risk patient populations in units such as neonatology,

cardiology, neurosurgery, and intensive care; 4) improved quality of disease management and

health outcomes for people with chronic diseases such as diabetes and hypertension; and 5)

reduced costs in the care of general practice patients and specific patient populations such as

those with diabetes, eczema, and those who live in rural areas.

22,24,26,27,28

Connection to WHO Global Strategy on HRH

APN role contributions to and policy implications for addressing objectives of the WHO's

strategy on HRH are outline below.

Objective #1:

Implement evidence-based HRH policies to optimise impact of the current health

workforces, ensuring healthy lives, effective Universal Health Coverage (UHC), and contributing

to global health security. Achieving UHC is reliant on financing, the costs of which are a

challenge for every country as a result of burgeoning healthcare budgets. The WHO

estimates

that 20% to 40% of all healthcare spending is currently wasted through inefficiency and points to

ten areas where better policies and practices could reduce expenditures. As indicated in the

above summary on outcomes, APN roles are effective for addressing at least five of these ten

areas related to overuse of healthcare services, inappropriate and costly staff mix and

unmotivated workers, inappropriate hospitalisation and length of stay, errors and suboptimal

quality of care, and inefficient mix or level of healthcare interventions. Expanding the

introduction of APN roles and strengthening role integration within health systems to reduce

inefficiency will result in cost savings that can be re-invested to achieve country goals for UHC.

Similarly, alignment of APN roles to address priority unmet health needs and access to care will

lead to improved health outcomes and quality of life especially for vulnerable, complex, high risk

and hard to reach populations.

Objective #2:

Align HRH investment frameworks at national and global levels. There is now

clear evidence that how APN roles are introduced substantially influences how well they will be

implemented, and in turn, how well they are implemented influences their ability to achieve

desired goals and outcomes. A fundamental principle of successful APN role development,

introduction and implementation is that the roles must align with the current and projected needs

of the healthcare system in which they are situated. The PEPPA framework, a participatory

evidence-based and patient-centred process for designing, implementing and evaluating

advanced practice nursing roles, was designed to guide effective APN role introduction,

implementation and sustainability

to achieve this alignment. Now a little more than a decade

after its introduction the PEPPA framework is recognised as a best practice for healthcare

redesign. It has been implemented in at least 16 countries, translated into several languages,

and demonstrated wide applicability to diverse provider roles, models of care, practice settings

and patient populations.

30,31

Quality graduate education is critical to the success of APN roles. The return on this investment

is the recruitment and retention of highly skilled nurses who want to advance their education

and careers by staying in clinical practice. Without such opportunities, nurses seek

ICN • CIE • CII

3, place Jean-Marteau, 1201 Ginebra- Suiza - Tfno.: +41 22 908 01 00

Fax: +41 22 908 01 01 – c. elect.:

[email protected]

- Web: www.icn.ch

advancement outside of clinical practice, for example, in managerial and administrative

positions that do not take full advantage of their expert clinical knowledge and skills to advance

healthcare for people and populations.

Objective #3:

Build the capacity of national and international institutions for an effective

leadership and governances of HRH actions. Leadership is a core competency of advanced

practice nurses who are educated to apply concepts of participatory and transformational

leadership to facilitate and manage change. Advanced practice nurses exercise their capacity

for leadership within practice settings and organisations by working with healthcare teams to

develop effective collaborative team processes to benefit patients. They understand the

importance of and have the capabilities needed to build strategic partnerships and alliances

within and outside the health sector to improve the health of communities and populations. They

are educated to appraise and apply evidence in local contexts and to enable others to develop

these capacities. Their orientation to quality improvement, intersectoral collaboration and

community involvement creates synergies that promote healthcare innovation and enable the

achievement of outcomes that would otherwise not be possible. As APN roles evolve, they are

also assuming formal leadership roles within healthcare organisations and governments.

Objective #4:

To ensure that reliable, harmonised and up-to-date HRH data, evidence and

knowledge underpin monitoring and accountability of HRH efforts at national and global levels.

As a result of their clinical and evidence-based practice expertise and collaboration with

stakeholders (e.g. patients, providers) and decision-makers (e.g. administrators, policy-makers,

funders, regulators) at multiple levels within the health system, advanced practice nurses inform

and lead the development of policies and practices relevant to HRH. They support effective

HRH efforts through research to collect data and generate new knowledge and to synthesise

and translate research evidence for uptake into policies and practice. Advanced practice nurses

also lead quality improvement and education initiatives that support healthy workplace

environments for nurses and other healthcare providers.

Despite the availability of substantive synthesised evidence about the safety and effectiveness

of APN roles, a major barrier to effective HRH planning is that healthcare decision-makers are

often not aware of this evidence, have difficulty translating the evidence for their particular

context, and in general lack a good understanding of these roles in relation to other nursing and

health provider roles.

32,33

At country and global levels, knowledge translation tools (e.g. briefing

notes, role implementation toolkits, algorithms, policy statements) are needed to improve the

use of research evidence related to APN roles and HRH planning. Ongoing evaluation of APN

role integration is also required to inform HRH planning about the appropriate supply,

deployment and needs for role supports. A generic evaluation framework has recently been

developed to provide guidance and to address country specific needs for collecting contextually

relevant data about the effective use of APN roles.

Contributions to meeting SDGs

Advance practice nurses can contribute to the following six Sustainable Development Goals.

SDG 1 - No poverty:

Advanced practice nurses improve access to healthcare for at-risk hard to

reach populations such as those who live in inner cities as well as those who live in rural and

remote communities. Access to health promotion and preventive health services as well as

ICN • CIE • CII

3, place Jean-Marteau, 1201 Ginebra- Suiza - Tfno.: +41 22 908 01 00

Fax: +41 22 908 01 01 – c. elect.:

[email protected]

- Web: www.icn.ch

treatment of illness and injury enables people to participate in opportunities for self and paid

employment.

SDG 3 -: Good health and wellbeing:

Advanced practice nurses improve access to healthcare

for at-risk, hard to reach populations such as those who live in inner cities as well as those who

live in rural and remote communities. Access to health promotion and preventive health services

as well as treatment of illness and injury enables people to gain or regain their health. In turn,

this enables opportunities for their participation in social and economic systems.

SDG 4 - Quality education:

The opportunity to participate in graduate education is especially

important for women who, in many countries, have not had access to higher level education.

Advanced practice nurses contribute to the education of other nurses as clinical faculty and

preceptors for Schools of Nursing and through education, coaching and mentorship provided to

nurses at the point-of care.

SDG 5 - Gender equality:

APN education and employment opportunities empower women with

the knowledge, skills, confidence and capabilities to assume clinical leadership positions within

a country’s healthcare system. These opportunities enable great social and economic security

and wellbeing for women thereby reducing gender inequalities.

SDG 8 - Decent work and economic growth:

APN is a satisfying and fulfilling career opportunity

for women. It builds on their knowledge and skills as nurses to enable them to apply their

advanced knowledge and skills in new and challenging healthcare settings. Advanced practice

nurses, in turn, are of benefit to the country’s people and communities. Achieving a healthier

population is important for economic growth.

SDG 10 - Reduce inequalities:

Developing APN roles in a country reduces inequalities by

improving the social and economic wellbeing and status of women and by improving access to

healthcare and the potential for a healthier life to some of the most vulnerable populations within

countries.

SDG 17 - Partnerships for the goals:

APN roles are being implemented in low, middle and high

income countries around the world to address country-specific health needs and goals. Within

countries, advanced practice nurses are well positioned to develop inter-sectoral partnerships to

achieve health, education and economic goals.

Key messages to policy makers

Advanced practice nursing roles, such as the CNS and NP, are a powerful instrument for

healthcare innovation and reform because they achieve policy priorities related to:



Improving health outcomes for disadvantaged, complex, and hard to reach patient

populations (e.g. indigenous people, homeless, immigrants, elderly, mentally disabled, at

risk children and youth and those living in rural, northern and remote communities) by

increasing access to specialised, acute and general primary healthcare services.



Reducing the burden of chronic illness by achieving a better balance in the delivery of

health promotion and chronic disease prevention services.



Achieving efficiencies through the appropriate mix of providers, reduced complications,

decreased acute care service use and the more appropriate use of community and

homecare services that best meet patient needs.

ICN • CIE • CII

3, place Jean-Marteau, 1201 Ginebra- Suiza - Tfno.: +41 22 908 01 00

Fax: +41 22 908 01 01 – c. elect.:

[email protected]

- Web: www.icn.ch



Improving the quality of healthcare services through the development and uptake of best

practices by patients and providers.

Improving patient healthcare experiences and satisfaction with care through enhanced

healthcare team functioning, continuity of care, care coordination and system navigation.

Strengthening the nursing profession through increased access to graduate education,

leadership and career laddering opportunities.

Improving the recruitment and retention of nurses through education, coaching and

mentorship at the point-of-care.

Recommendations for National Nursing Associations (NNAs)

NNA leadership is essential for the development, implementation and sustainability of APN

roles. The leadership challenge for NNAs at all levels is to create the organisational and health

system conditions for APN roles to improve the health status of people in countries around the

world. Even though APN roles may take on functions traditionally provided by physicians,

emphasising the advanced nursing contributions of these roles will increase the likelihood that

implementation efforts are met with success and will generate less resistance than an emphasis

on role substitution. It is also important to appreciate that while autonomy is a hallmark of APN

roles, realising its full achievement requires supportive legislative and regulatory changes. Such

changes are not easily achieved and require significant time, effort and resources. Change is

usually slow, incremental and hard-won. It is facilitated when the goals of NNAs and other

stakeholders are aligned to identify policy windows of opportunity. Collaboration with

intersectoral stakeholders at the national and international levels is central to this effort.

At the international level NNA leaders can collaborate across countries to:



Leverage existing resources for APN education, practice and policy.



Explore the possibilities for resource sharing across countries.



Achieve greater consensus on role definitions and terminology to promote APN role

clarity.



Implement policies to prevent “brain drain” of nursing leaders, educators, researchers

and advanced practice nurses in countries where APN roles are just getting started.



Ensure open access to resources for APN role development.

At the country level NNA leaders can collaborate across sectors to:



Advocate for systematic and evidence based approaches to role development,

implementation and evaluation.



Connect with key stakeholders around shared policy concerns to create conditions for

healthcare organisation and system transformational change.



Build leadership skills and consensus among healthcare stakeholders on health systems

solutions that utilise APN roles.



Advocate for dedicated funding to support APN education and practice.



Promote role clarity by establishing clearly defined APN roles with consensus on

standards of care and role competencies.



Establish a national knowledge translation plan to promote understanding and

awareness of APN roles, reduce barriers to role uptake, and educate APN stakeholders

and healthcare decision-makers about the benefits of the role.

ICN • CIE • CII

3, place Jean-Marteau, 1201 Ginebra- Suiza - Tfno.: +41 22 908 01 00

Fax: +41 22 908 01 01 – c. elect.:

[email protected]

- Web: www.icn.ch



Advocate for the effective increase in use of information technology to increase access

to education through distance learning.

Create networks of communities of practice to develop advanced practice nurses.

About ICN

The

International Council of Nurses (ICN)

is a federation of more than 130 national nurses

associations representing the millions of nurses worldwide. Operated by nurses and leading

nursing internationally, ICN works to ensure quality nursing care for all and sound health

policies globally.

About the Authors

Denise Bryant-Lukosius is an Associate Professor in the School of Nursing and Department of

Oncology at McMaster University where she is the co-director of the Canadian Centre for

Advanced Practice Nursing Research (CCAPNR). She is also a Clinician Scientist and Director

of the Canadian Centre of Excellence in Oncology Advanced Practice Nursing at the Juravinski

Hospital and Cancer Centre.

Ruth Martin-Misener is a Professor in the School of Nursing at Dalhousie University and co-

director of CCAPNR at McMaster University. She is also the co-lead for Collaborative Research

in Primary Health Care (CoR-PHC) at Dalhousie University and member of the Nova Scotia

Primary and Integrated Health Care Innovations Network.

ICN • CIE • CII

3, place Jean-Marteau, 1201 Ginebra- Suiza - Tfno.: +41 22 908 01 00

Fax: +41 22 908 01 01 – c. elect.:

[email protected]

- Web: www.icn.ch

References

1. Bryant-Lukosius, D. (2014).

Back to the Future: Advancing the Global Evolution of Advanced Practice

Nursing.

Keynote address. International Council of Nurses, Nurse Practitioner/Advanced Practice

Nurse Network Conference. Helsinki.

2. United Nations General Assembly (2015)

Transforming Our World: The 2030 Agenda for Sustainable

Development.

Retrieved from

www.un.org/ga/search/view_doc.asp?symbol=A/70/L.1&Lang=E

3. World Health Organization. (2015).

Health Workforce 2030: A Global Strategy on Human Resources

for Health.

Geneva: WHO.

Retrieved from

http://www.who.int/hrh/resources/glob-strat-

hrh_workforce2030.pdf?ua=1

4. International Council of Nurses. (2008).

The Scope of Practice, Standards and Competencies of the

Advanced Practice Nurse.

ICN Regulatory Series. Geneva: ICN.

5. Bryant-Lukosius, D. & DiCenso, A. (2004). A framework for the introduction and evaluation of

advanced practice nursing roles.

Journal of Advanced Nursing,

48(5), 530-540.

6. Mantzoukas, S., & Watkinson, S. (2007). Review of advanced nursing practice: The international

literature and developing the generic features.

Journal of Clinical Nursing,

16, 28-37.

7. Dowling, M., Beauchesne, M., Farrelly, F., & Murphy, K. (2013). Advanced practice nursing: A

concept analysis.

International Journal of Nursing Practice,

19, 131-140.

8. Delamaire, M.L., & Lafortune, G. (2010).

Nurses in Advanced Roles: Description and Evaluation of

Practices in 13 Developed Countries.

Geneva: OECD.

9. Schober, M. (2013). Global perspectives on advanced nursing practice. In L. Joel (Ed),

Advanced

Practice Nursing: Essentials for Role Development,

3rd Edition (p 71-104). Philadelphia: F.A. Davis.

10. International Council of Nurses. (2015).

The Most Frequently Asked Questions of the ICN

International Nurse Practitioner/Advanced Practice Nursing Network.

Geneva: ICN. Retrieved from

http://international.aanp.org/Home/FAQ

11. National Nursing Centres Consortium. (2014).

International Advanced Practice Nursing Symposium.

Philadelphia: NNCC. Retrieved from

http://www.nncc.us/images_specific/pdf/GlobalAPNSymposiumFINAL.pdf

12. Pan American Health Organization (PAHO) and School of Nursing, McMaster University. (2015).

Universal Access to Health and Universal Health Coverage: Advanced Practice Nursing Summit.

Hamilton:

McMaster.

Retrieved

from

https://www.salud.gob.sv/archivos/enfermeria/PAHO_Advanced_Practice_Nursing_Summit_Hamilton

_CA.pdf

13. Begley, C., Murphy, K., Higgins, A., Elliott, N., Lalor, J., Sheerin, F., Coyne, I., MacNeela, P. (2010).

Evaluation of Clinical Nurse and Midwife Specialist and Advanced Nurse and Midwife Practitioner

Roles in Ireland (SCAPE) Final Report.

Dublin: National Council for the Professional Development of

Nursing and Midwifery. Retrieved from

https://nursing-midwifery.tcd.ie/assets/research/pdf/SCAPE_Final_Report_13th_May.pdf

ICN • CIE • CII

3, place Jean-Marteau, 1201 Ginebra- Suiza - Tfno.: +41 22 908 01 00

Fax: +41 22 908 01 01 – c. elect.:

[email protected]

- Web: www.icn.ch

14. DiCenso, A., Bryant-Lukosius, D., Martin-Misener, R., Donald, F., Abelson, J., Bourgeault, I.,

Kilpatrick, K., Harbman, P. (2010). Factors enabling advanced practice nursing role integration in

Canada. Canadian Journal of Nursing Leadership, 23(special edition), 211-338.

15. Seymour, J., Clark, D., Hughes, P., Bath, P., Beech, N., Corner, J., Douglas, H.R., Webb, T. (2002).

Clinical nurse specialists in palliative care. Part 3. Issues for the MacMillan Nurse caseload.

Palliative

Medicine,

16(5), 386-96.

16. Donald, F., Martin-Misener, R., Carter, N., Donald, E., Kaasalainen, S., Wickson-Griffiths, A., Lloyd,

M., DiCenso, A. (2013) A systematic review of the effectiveness of advanced practice nurses in long-

term care.

Journal of Advanced Nursing, 69(10),

2148-2161. doi: 10.1111/jan.12140. Open access

retrieved from

http://onlinelibrary.wiley.com/doi/10.1111/jan.12140/pdf

17. Donald, F., Kilpatrick, K., Reid, K., Carter, N., Martin-Misener, R., Bryant-Lukosius, D., Harbman. P.,

DiCenso, A. (2014). A systematic review of the cost-effectiveness of clinical nurse specialists and

nurse practitioners: What is the quality of the evidence?

Nursing Research & Practice.

vol. 2014,

Article ID 896587, 28 pages, doi:10.1155/2014/896587

18. Horrocks S, Anderson E, & Salisbury C. (2002). Systematic review of whether nurse practitioners

working in primary care can provide equivalent care to doctors. BMJ, 324 (7341), 819-823.

19. Morilla-Herrera, J. C., Garcia-Mayor, S., Martín-Santos, F.J., Kaknani Uttumchandani, S., Leon

Campos, Á., Caro Bautista, J., & Morales-Asencio, J. M. (2015). A systematic review of the

effectiveness and roles of advanced practice nursing in older people.

International Journal of Nursing

Studies.

doi: 10.1016/j.ijnurstu.2015.10.010. [Epub ahead of print]

20. Newhouse, R. P., Stanik-Hutt, J., White, K. M., et al. (2011). Advanced practice nurse outcomes

1990-2008: a systematic review. Nurse Economics, 29 (5), 230-250.

21. Bryant-Lukosius, D., Carter, N., Reid, K., Donald, F., Martin-Misener, R., Kilpatrick, K., Harbman, P.,

DiCenso, A. (2015a). The clinical effectiveness and cost-effectiveness of clinical nurse specialist-led

hospital to home transitional care: A systematic review.

Journal of Evaluation of Clinical Practice,

21,

763-781.

22. Bryant-Lukosius, D. Cosby, R., Bakker, D., Earle, C., & Burkoski, V. (2015b).

Practice

Guideline on the Effective Use of Advanced Practice Nurses in the Delivery of Adult Cancer

Services in Ontario.

Toronto: Cancer Care Ontario. Retrieved from

https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=340702

23. Canadian Centre for Advanced Practice Nursing Research (CCAPNR), (2012a).

The Clinical Nurse

Specialist: Getting a good return on healthcare investment.

McMaster University, Hamilton, ON:

Author. Retrieved from

http://fhs.mcmaster.ca/ccapnr/documents/onp_project/CNS_Brief_final.pdf

24. Kilpatrick, K., Reid, K., Carter, N., Donald, F., Bryant-Lukosius, D., Martin-Misener, R., Kaasalainen,

S., Marshall, D.A., Charbonneau-Smith, R., & DiCenso, A. (In-press). A systematic review of the cost

effectiveness of clinical nurse specialists and nurse practitioners in inpatient roles.

Canadian Journal

of Nursing Leadership.

25. Kilpatrick, K., Kaasalainen,S., Donald, F., Reid, K., Carter, N., Bryant-Lukosius, D., Martin-Misener,

R., DiCenso, A. (2014). The effectiveness and cost effectiveness of clinical nurse specialists in

outpatient roles: A systematic review.

Journal of Evaluation in Clinical Practice.

July 5, doi:

10.1111/jep.12219.

ICN • CIE • CII

3, place Jean-Marteau, 1201 Ginebra- Suiza - Tfno.: +41 22 908 01 00

Fax: +41 22 908 01 01 – c. elect.:

[email protected]

- Web: www.icn.ch

26. Canadian Centre for Advanced Practice Nursing Research (CCAPNR), (2012b). The Nurse

Practitioner: A strategy for healthcare system improvement. McMaster University, Hamilton, ON:

Author. Retrieved from

http://fhs.mcmaster.ca/ccapnr/documents/onp_project/NP_Brief_final.pdf

27. Donald, F., Kilpatrick, K., Carter, N., Bryant-Lukosius, D., Martin-Misener, R., Kaasalainen, S.,

Harbman, P., Marshall, D., Reid, K., & DiCenso, A. (2015). Hospital to community transitional care by

nurse practitioners: A systematic review of cost-effectiveness.

International Journal of Nursing

Studies.

Jan;52(1):436-451. doi: 10.1016/j.ijnurstu.2014.07.011.

28. Martin-Misener, R., Harbman, P., Donald, F., Reid, K., Kilpatrick, K., Carter, N., Bryant-Lukosius, D.,

DiCenso, A. (2015). Cost-effectiveness of nurse practitioners in ambulatory care: systematic review.

BMJ

Open

5:e007167

doi:10.1136/bmjopen-2014-007167

Retrieved

from

http://bmjopen.bmj.com/cgi/content/full/bmjopen-2014-007167?ijkey=uzaooKIc7lMSWrv&keytype=ref

29. Chisholm, D., & Evans, D.B. (2010).

Improving Health System Efficiency As A Means of Moving

Towards Universal Coverage. World Health Report.

Background Paper, 28. Geneva: WHO. Retrieved

from

http://www.who.int/healthsystems/topics/financing/healthreport/28UCefficiency.pdf

30. Boyko, J., Carter, N., & Bryant-Lukosius, D. (submitted). Assessing the spread and uptake of a

framework for introducing and evaluating advanced practice nursing roles.

Worldviews on Evidence-

Based Nursing.

Manuscript ID WVN-15-142.

31. Bryant-Lukosius, D., Israr, S., & DiCenso, A. (2013). Resources to facilitate APN outcome research.

Chapter in R. Kleinpell (ed.).

Outcome Assessment in Advanced Practice Nursing, (3rd ed).

New

York: Springer Publishing Company

32. Carter, N., Martin-Misener, R., Kilpatrick, K., Kaasalainen, S., Donald, F., Bryant-Lukosius, D.,

Harbman, P., & DiCenso, A. (2010). The role of nursing leadership in integrating clinical nurse

specialists and nurse practitioners in healthcare delivery in Canada.

Canadian Journal of Nursing

Leadership,

23(special issue), 167-188.

33. Kilpatrick, K., Carter, N., Bryant-Lukosius, D., Charbonneau-Smith, R., & DiCenso, A. (2015).

Development of evidence briefs to transfer knowledge above advanced practice nursing roles in

providers, policy-makers and administrators.

Canadian Journal of Nursing Leadership,

28(1), 11-23.

34. Bryant-Lukosius, D., Spichiger, E., Martin, J., Stoll, H., Degen Kellerhals, S. Fliedner, M., Grossman,

F., De Geest, S. (submitted). Framework for evaluating the impact of advanced practice nursing roles.

Journal of Nursing Scholarship.

ICN • CIE • CII

3, place Jean-Marteau, 1201 Ginebra- Suiza - Tfno.: +41 22 908 01 00

Fax: +41 22 908 01 01 – c. elect.:

[email protected]

- Web: www.icn.ch