Feasibility Study of Nurse-Provided Well Child Care in Family Health Team in Ontario, Canada

This study will deploy a mixed-methods convergent parallel design19, using quantitative methods as well as qualitative data gathering and analyses. To test the acceptability and satisfaction of the care received, interviews with patients and health care team members will investigate attitudes and experiences of patients and care providers. To explore the effectiveness and efficiency of nurse-led WCC, interviews and chart audits will assess the quality of care provided, and costs in terms of time and team resources involved. These two methods will occur simultaneously and the results will be integrated and reported together to give an overall view of the feasibility of nurse-provided WCC within the Bruyere/Primrose FHT.

Sample: There will be 2 cohorts of participants. The first cohort will consist of the health care professionals involved, namely the family physicians and nurses from the Bruyere/Primrose FHT who agree to participate and whose patients will be invited to join the research study. The second cohort of participants will consist of parents of well children who will be asked to have a nurse provide WCC during the pilot project. The eligibility criteria will include:

• Most responsible provider agrees to appropriateness for inclusion
• born at term and from uncomplicated pregnancy and birth
• normal physical growth and development to date
• no parental post-partum depression
• aged between 6 weeks and 4 years of age
• due for WCC visits in the study period Recruitment: The appointment schedules and panels of participating FHT physicians will be reviewed to identify eligible children due or scheduled for a visit. The potential participants will be contacted by phone 1-4 weeks prior to their visit, by the research assistant, and have the project explained to them with an invitation to participate or continue with their usual care. If a parent agrees, verbal informed consent over the phone will be obtained. Consenting patients will be offered the nurse intervention on arrival for their scheduled appointment, with the option of seeing their family physician afterwards. They will sign an informed consent form prior to the visit, which will also ask for interest in participating in follow-up interviews.

Intervention: A proposed work-flow model for nurse-led WCC will be developed, informed by both the literature review and competency-mapping exercise as well as with discussions with the participating FHT physicians and nurses to ensure feasibility and buy-in. It is very likely that the nurses will use the Rourke Baby Record, a standardized and validated template for well child visits, endorsed for use by the College of Family Physicians of Canada20, and used by many physicians at the Bruyere/Primrose clinics. FHT team members of all disciplines will be asked to review the work-flow model during a consultation session to provide feedback, buy-in, and validation. The plan will then be tested with a selected cohort of infants and children and adjustments will be made according to feedback and previously unanticipated issues. The pilot project will then commence and run for a 9-month period to allow for multiple visits with the same patients, recall of patients requiring specific WCC tasks and possibly alternating visits with the nurse and the family physician. The goal is to perform 50 nurse WCC visits within the study period.

Data collection: To address our secondary research question, semi-structured interviews will explore the acceptability of nurse-provided WCC for parents, nurses and physicians at the Bruyere/Primrose FHT, focusing on potential facilitators and barriers to the introduction of such a model of care. Interviews will be held with the provider cohort before and after the intervention phase, and with patients after the nurse WCC visit. Interviews will stopped when theme saturation is achieved or 10 providers and 20 patients have been interviewed, which ever comes first. The interview guide will be developed by the research team using information from the literature review, the competency mapping-exercise and the consultations with the FHT members around recruitment and work-flow planning (see Appendix B for potential interview questions). To further assess the acceptability and feasibility of nurse led WCC, the investigators will compile initial participation rates (percentage of patients contacted who accepted the nurse WCC) and continuation rates (percentage of participants who were eligible for additional visits and who agree to at another nurse-led WCC visit within the study period).