Available online 30 March 2024, 151625

Author links open overlay panel, , , , , AbstractObjectives

Internationally, there is limited evidence about the role and impact of nurse practitioners (NPs) in complex malignant hematology (CMH). In one Canadian CMH program, NPs have existed for 20 years but not been evaluated. This study aimed to understand stakeholder perceptions of CMH NP role structures, processes, and outcomes and the extent to which the role meets patient and health service needs.

Methods

A qualitative descriptive study was conducted, guided by the PEPPA-Plus framework. Purposive sampling was used to recruit stakeholders who participated in focus groups and interviews. Content analysis was used to analyze the data.

Results

Participants included patients (n = 8) and healthcare professionals (n = 27). Themes about structures related to evolution of the CMH Program, model of care, and need for strategic vision. Process themes related to provision of accessible, comprehensive, and holistic care and NP workload. Positive and negative outcomes and lack of outcome measurement were identified.

Conclusion

Structures related to patient and NP characteristics, organizational change, staffing, and how NP work is organized impacts on NP role implementation and outcomes. Organizational structures can be strengthened to improve the model of care and NP role implementation and workload. Value-added NP contributions related to providing comprehensive care with attention to safety and social determinants of health. Research is needed to evaluate NP role outcomes in CMH.

Implications for Nursing Practice

The results can inform role design and organization policies and strategies to promote the recruitment, retention, and optimization of NP roles in CMH settings. Priorities for future research are also identified.

Section snippetsCMH and the Nurse Practitioner Role

Internationally, cancer programs are introducing innovative models of care to address rapidly evolving changes in treatments and rising demands for CMH care.3,7, 8, 9 Reports from a Canadian provincial cancer agency outline service needs1 and recommendations10 to reduce wait times, increase access, and improve the quality of CMH care by establishing multidisciplinary team-based models of care, expanding the workforce, and optimizing scopes of practice. Within new models of CMH care, NPs were

Implementing and Evaluating NP Roles in CMH

Like other CMH programs in Canada, one Ontario program has undergone significant expansion from 2008 to 2023 to increase access to care and introduce new treatments like CAR T-cell therapy. The number of NPs increased from 4 to 14, and their roles have evolved in response to program expansion. However, the extent to which NP role activities meet patient and program needs has not been examined. Challenges in recruiting and retaining NPs and persistent workload issues suggest a mismatch between

Conceptual Framework

The PEPPA Framework is a participatory, evidence-based, patient-focused process for improving advanced practice nursing role development, implementation, and evaluation.31 This framework has been used in 27 countries, with application to oncology.32, 33, 34 PEPPA-Plus guides evaluation at three role stages: introduction, implementation, and long-term sustainability.28 The frameworks informed study methods, emphasizing stakeholder engagement and assessment of role structures, processes, and

Purpose

To optimize role implementation and promote long-term role sustainability and effectiveness, the study addressed this research question: What are stakeholder perceptions of NP role structures, processes, and outcomes, and extent to which the role meets patient and health service needs in the CMH program?

Study Design

A qualitative descriptive study was conducted. Qualitative descriptive studies are effective for generating new information to inform practical solutions for improving the quality of care in practice settings.35,36 This study has been reported using the COnsolidate criteria for REporting Qualitative research (COREQ) checklist (Supplemental Data 1).37

Setting and Participants

The study occurred in a CMH program within a tertiary hospital and regional cancer center in Ontario, Canada. The CMH program has 56 inpatient

Study Participants

Thirty-five people participated, including 27 healthcare professionals (Table 1) and eight patients (Table 2). We exceeded recruitment estimates to achieve data saturation. Healthcare professionals included nurses, AHPs, physicians, managers, and NPs with considerable work experience and experience in the CMH program. Patients had varied demographic and socioeconomic backgrounds and different diagnoses and treatment experiences. However, more patients had acute myeloid leukemia and were

Discussion

This study aimed to inform optimal implementation of the NP role in a CMH program by examining stakeholder perceptions of the role and extent to which it was meeting patient and program needs. Application of the PEPPA31 and PEPPA-Plus28 frameworks, advocating for examination of NP role structures, processes, and outcomes proved valuable for discerning factors that influenced role implementation and outcomes. Participants’ detailed descriptions illustrating the connections between NP role

Study Strengths and Limitations

To the best of our knowledge, this is the first study to examine NP role structures, processes, and outcomes in a CMH program. A study strength is the participation of diverse patients and healthcare professionals providing new insights on the NP role and its evolution. We only examined perceived CMH NP outcomes. Future studies are needed to measure and provide predictive evidence about outcomes. This study was conducted at a single site, which may limit the transferability of the results to

Conclusion

There was stakeholder consensus that NPs are highly valued and essential healthcare team members within the CMH program. Establishing a critical mass of NPs has enabled program expansion and responsiveness to meet growing demands for CMH care and provides a model for developing CMH programs. In addition to their medical expertise, study results highlight the unique value-added contributions of NPs in delivering holistic, comprehensive, coordinated, and patient/family-centered care with

CRediT authorship contribution statement

Margaret F. Forbes: Conceptualization, Methodology, Formal analysis, Validation, Visualization, Writing – original draft, Writing – review & editing. Nancy Carter: Methodology, Investigation, Formal analysis, Validation, Writing – original draft, Writing – review & editing. Kristi L. MacKenzie: Conceptualization, Funding acquisition, Writing – review & editing. C. Tom Kouroukis: Conceptualization, Methodology, Writing – review & editing. Kerry S. Balonjan: Investigation, Data curation, Formal

Declaration of competing interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Denise Bryant-Lukosius reports financial support was provided by Complex Malignant Hematology Program, Juravinski Hospital, Hamilton Health Sciences. Denise Bryant-Lukosius was a Guest Editor for the Advanced Practice Nursing Special Issue of Seminars in Oncology Nursing. As an author of this article, she did not participate in any editorial process or

Author Contributions

Margaret F. Forbes was responsible for conceptualization, methodology, formal analysis, validation, visualization, writing - original draft, writing - review & editing. Nancy M. Carter was responsible for methodology, investigation, formal analysis, validation, writing - original draft, writing - review & editing. Kristi L. MacKenzie was responsible for conceptualization, funding acquisition, writing - review & editing. C. Tom Kouroukis was responsible for conceptualization, methodology,

Ethical Statement

This study received ethical approval from the Hamilton Integrated Research Ethics Board (project number 15352) and was conducted in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for research involving humans.

Acknowledgement

The authors would like to express their deep appreciation to each of the participants for their important contributions to this study and to improving understanding of the NP role in CMH. The authors would also like to acknowledge the preliminary work by Alyssa Stewart, CMH NP Fellow that led to the development of this study.

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