About the Project

This project is funded by the Ontario Ministry of Health and Long-Term Care and seeks to optimize patient panel size for Nurse Practitioners (NPs) in Primary Healthcare (PHC) and inform planning and future evaluations of team performance in Ontario by improving understanding of how organizational, NP and patient characteristics influence NP activities in PHC settings and the barriers and facilitators to optimizing NP patient panel size.

Optimizing the patient panel size of NPs in PHC is important for effective interprofessional team functioning, human resource planning and timely access to high quality patient care. No studies have directly measured NP activities in PHC settings.

[Optimizing NP Patient Panel Size Project summary]

Project Objectives

A conceptual framework developed from our NP patient panel size scoping review guides this study. Click here to view the framework. This is a descriptive, multiple case study using mixed methods.  The case settings were selected to examine factors that may influence NP panel size (e.g., geographic location, practice size, years of NP experience). Eight cases studies within each of four PHC practice models in Ontario - Family Health Teams, NP-Led Clinics, Aboriginal Health Access Centres, and Community Health Centres were conducted.

Objectives

1. Update the scoping review regarding NP patient panel size and determine the relevance and applicability of scoping review findings for the Ontario context. [View scoping review report]
2. Identify and compare organizational and NP factors influencing NP time spent in patient care and other work-related activities across a range of geographic locations and delivery models in Ontario.
3. In these same settings, measure the time NPs spend in patient care and other work-related activities.
4. For those patients cared for by the NP, determine patient factors that influence NP activities and panel size.
5. Identify perceptions of barriers and facilitators to optimizing NP patient panel size in Ontario.
6. Integrate findings to identify implications for optimizing NP activity and panel size.
7. Build capacity in conducting research that informs optimal health human resource (HHR) planning and the effective use of PHC NP roles in Ontario. To increase research capacity we will sponsor one Ontario-based postdoctoral fellow and a graduate student to participate in and conduct specific components of the study.

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Applied Health Research Questions

Applied Heath Research Questions forming 3 smaller research projects in relation to NP panel size with a focus on health system performance and sustainability and nursing research were also developed, listed below. The projects involved the Nurse Practitioner Association of Ontario, Association of Family Health Teams, and Association of Ontario Health Centres as primary knowledge users.

1) What are the outcomes of NP-PHC care in Ontario primary healthcare settings? How are NPs in Ontario performing related to the primary care performance measures domains of a high quality health system?

2)  Does the Nurse Practitioner Reporting System (NPAR) accurately reflect nurse practitioner patient care activities in participating family health teams?

3) What patient, provider, and organizational factors influence Ontario's nurse practitioner activities and patient panel size in primary healthcare settings?

 

Project Team

Faith Donald

• Associate Professor, Daphne Cockwell School of Nursing, Ryerson University
• Affiliate Faculty Member, School of Nursing, McMaster University
• Member, Canadian Centre for APN Research (CCAPNR)

Faith Donald, NP-PHC, Ph.D also holds an Ontario Training Centre Graduate Diploma in Health Services and Policy Research and completed a two-year Canadian Health Services Research Foundation Postdoctoral Award.

An Associate Professor in the Daphne Cockwell School of Nursing, Ryerson University in Toronto, Canada, she is a primary health care nurse practitioner with a background in acute, long-term, and primary health care. Faith has extensive experience with curriculum design and evaluation, as well as teaching nurse practitioners at the post-diploma, post-baccalaureate, graduate, and post-masters levels.

Faith is an Affiliate Faculty member with the Canadian Centre for Advanced Practice Nursing Research. Her research interests primarily focus on advanced practice nursing (nurse practitioners and clinical nurse specialists) in primary and long-term care and nurse practitioner education. Faith continues her clinical practice as a primary health care nurse practitioner on a locum/casual basis. She has served two terms as a Director on the board of Health Quality Ontario and Faith completed two terms on the Board of Directors for Central West Specialized Developmental Services and chaired the Quality Improvement Committee.

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Ruth Martin-Misener

• Professor, School of Nursing, Dalhousie University
• Affiliate Faculty Member, School of Nursing, McMaster University
• Co-Director, Canadian Centre for APN Research (CCAPNR)
• Chair, Nurse Practitioner Committee, College of Registered Nurses of Nova Scotia

Ruth Martin-Misener, DOPN, BScN, MN, PhD has a career focused on primary health care. After practicing in the Canadian North she was invited to return to Dalhousie School of Nursing to teach in the Outpost Nursing Program from which she received her diploma in 1986. The Dalhousie Outpost Nursing Program (DOPN) was essentially Canada’s first nurse practitioner (NP) program and in the late 1990s Martin-Misener played a key role in transitioning the DOPN to a Primary Health Care Nurse Practitioner (NP) Program. Dr. Martin-Misener has been a key player in the development and implementation of the NP role in Nova Scotia and nationally. She has worked closely with the College of Registered Nurses of Nova Scotia to develop NP regulatory policies and processes and was a central figure in the Strengthening Primary Care initiative in Nova Scotia, and the Canadian Nurse Practitioner Initiative.

After completing her PhD at the University of Calgary in 2006, Martin-Misener completed a strategic fellowship in TUTOR-PHC, a CIHR-funded training initiative that aims to build a critical mass of researchers through student and faculty development and increase interdisciplinary focus in primary health care research. In 2009 she was invited to join the TUTOR-PHC team as a co-investigator and mentor. Dr. Martin-Misener’s research has focused on the implementation and evaluation of multi-disciplinary innovative models of care in primary and long-term care. For example, the rural primary health care delivered collaboratively by NPs, paramedics and family physicians on Long and Briar Islands.

Dr. Martin-Misener was profoundly influenced and inspired by Dr. Alba DiCenso’s research mentorship offered through her Advanced Practice Nursing Chair at McMaster University. When the Chair program ended, Martin-Misener played a key role in the evolution to the Canadian Center for Advanced Practice Nursing Research for which she now is co-Director. Over the past decade this group has been highly productive completing several influential studies including a CHSRF-commissioned Decision Support Synthesis on Clinical Nurse Specialists and Nurse Practitioners in Canada leading to a peer-reviewed special issue of Canadian Journal of Nursing Leadership consisting of 10 papers and a systematic review of the cost effectiveness of advanced practice nurse roles. In recognition of her many contributions, she received a Centennial Award of Distinction from the College of Registered Nurses of Nova Scotia in 2009.

Dr. Martin-Misener’s health services research uses mixed methods to examine optimal integration of nurse practitioner and other roles in innovative team-based models of care that enable improved accessibility to quality healthcare in community-based primary and long-term care settings. She teaches and supervises students in the Master’s and PhD programs.

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Kelly Kilpatrick

• Researcher, Centre de recherche de l’Hôpital Maisonneuve Rosemont
• Assistant Professor, Faculté des sciences infirmières, Université de Montréal
• Affiliate Faculty Member, School of Nursing, McMaster University
• Member, Canadian Centre for APN Research (CCAPNR)

Kelley Kilpatrick, RN., PhD is an Assistant Professor with the Faculty of Nursing at the Université de Montréal, and a researcher with the Maisonneuve-Rosemont Hospital Research Center and the Canadian Centre for Advanced Practice Nursing Research at McMaster University. Kelley received a Junior researcher award from the Fonds de recherche du Québec-Santé (2013-2017). She completed a PhD in Nursing at McGill University (2010) and a postdoctoral fellowship at McMaster University (2011). Her research interests include nurse practitioner and clinical nurse specialist roles, boundary work activities, perceptions of team effectiveness, acute and primary care, and the effects of healthcare service delivery on patients and families. Kelley has used different approaches including mixed methods, case study, surveys, systematic reviews, and qualitative description to answer her research questions.

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Denise Bryant-Lukosius

• Associate Professor, School of Nursing, McMaster University
• Associate Member, Department of Oncology, McMaster University
• Co-Director, Canadian Centre for APN Research (CCAPNR)
• Director, Canadian Centre for Excellence in Oncology Advanced Practice Nursing (OAPN)

Denise Bryant-Lukosius, RN, CON(C), BScN, MScN, PhD is an associate professor in the School of Nursing and the Department of Oncology and is the co-Director for The Canadian Centre for Advanced Practice Nursing Research (CCAPNR) at McMaster University. She holds a cross appointment with the Juravinski Hospital and Cancer Centre as a Clinician Scientist and Director of the Canadian Centre of Excellence in Oncology Advanced Practice Nursing (OAPN)  which provides a unique a program of research, education, mentorship and knowledge translation activities to support the development of generalist, specialized and advanced nursing roles in cancer control.

From 1993 to 1999, Denise was the founding Chair of the Adult Oncology Nursing Program at McMaster which provided an innovative model for degree-linked, post-basic specialty education in Canada. Between 2007 and 2013, Denise has led the development, evaluation and expansion of the Ontario Oncology Nursing e-Mentorship Program – a provincial program funded by the Ministry of Health and Long-Term Care and the de Souza Institute to promote the career and professional development of specialized and advanced oncology nurses. Nationally, she has received two awards of recognition for excellence in education and research from the Canadian Association of Nurses in Oncology. In addition to her education and research roles, Denise has national certification in oncology nursing and over 25 years of experience as a Clinical Nurse Specialist in Hematology/Oncology and urological cancers.

As a health services researcher, Denise has expertise in qualitative, quantitative, mixed method and participatory action research. She developed the PEPPA Framework which is recognized internationally as a best practice approach for the effective development, implementation and evaluation of advanced practice nursing and other health provider roles. She is involved in numerous knowledge translation, research, policy and consultation activities designed to improve  access and quality of care and health outcomes for patients with a chronic health conditions though optimal utilization of specialized and advanced nursing roles.

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Nancy Carter

• Assistant Professor, School of Nursing, McMaster University
• Member, Canadian Centre for APN Research (CCAPNR)

Nancy Carter, RN, PhD is an assistant professor in the School of Nursing at McMaster University in Hamilton, Ontario, Canada and teaches in the undergraduate, graduate and nurse practitioner programs. She is a researcher in the Canadian Centre for Advanced Practice Nursing Research (CCAPNR). Nancy's research interests include knowledge translation, focusing on the dissemination and uptake of evidence on Clinical Nurse Specialists and Nurse Practitioners by administrators and decision makers, as well as the development of new nursing roles in oncology and community settings. Dr. Carter has many years of experience working with stakeholders on research projects (integrated KT), and also end-of-grant KT activities. Additionally she has done some pilot work related to KT Science, focussing on knowledge needs and dissemination preferences of nursing leaders about Advanced Practice Nursing. Dr. Carter’s research expertise is in APN, Knowledge Translation and Exchange, Nursing Leadership, and qualitative methods.

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Noori Akhtar-Danesh

Dr. Akhtar-Danesh began his career at McMaster in 2003 and is currently an Associate Professor with the School of Nursing.  He is an Associate Member, Department of Clinical Epidemiology & Biostatistics, Department of Mathematics & Statistics. Dr. Akhtar-Danesh is also a Member, Nursing Health Services Research Unit (NHSRU). He has a Bachelor of Science in Statistics from Ferdowsi University, a Master of Science in Biostatistics from Shiraz University, and a Doctor of Philosophy (PhD) in Medical Statistics from the University of Newcastle upon Tyne.

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Ivy Lyn Bourgeault, Ph.D

CIHR Chair in Gender, Work and Health Human Resources

For more information, please visit: Ivy Lynn Bourgeault's website

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Rick Glazier

Senior Core Scientist/Program Lead, ICES

For more information, please visit: Rick Glazier's page on ICES website

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Postdoctoral Fellow

Jennifer Rayner

Postdoctoral Fellow, Canadian Centre for APN Research (CCAPNR), Daphne Cockwell School of Nursing, Ryerson University

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Graduate Students

Nicole Bennewies

Master of Nursing Yr 2 Student, Daphne Cockwell School of Nursing, Ryerson University

Erin Ziegler

Erin Ziegler holds a master's in nursing and primary health care nurse practitioner from Ryerson University. She is a doctoral student in the School of Nursing at McMaster University. In addition, she is a nurse practitioner at Wise Elephant family health team and a sessional instructor at Ryerson University.

 

Knowledge Transfer

As of January, 2016, we have updated a previous scoping review entitled "Benchmarking for Nurse Practitioner Patient Panel Size and Comparative Analysis of Nurse Practitioner Pay Scales". The updated 2015 report can be found below.

Data collection for case studies at all 8 sites: 2 diverse sites for each model (NP-led clinic, Community Health Centre, Aboriginal Health Access Centre and Family Health Team) has been completed including healthcare provider interviews (the NPs observed, receptionist, MD at each site, administrator) at each of the case study sites.

In terms of next steps, our goal is to complete data analysis (patient and provider surveys, and interviews) by March, 2016.

Relevant Documents Generated from the Study

• Scoping Review Report: Benchmarking for Nurse Practitioner Patient Panel Size and Comparative Analysis of Nurse Practitioner Pay Scales
• Briefing Note Short Version: Measuring Factors that Influence Nurse Practitioner (NP)Activites and Implications for Optimizing NP Patient Panel Size in Primary Healthcare
• Briefing Note Long Version: Measuring Factors that Influence Nurse Practitioner (NP)Activites and Implications for Optimizing NP Patient Panel Size in Primary Healthcare

Bibliography of Included Articles in the Scoping Review "Benchmarking For Nurse Practitioner (NP) Patient Panel Size and Comparative Analysis of NP Pay Scales".

• Abood, S. A. (2005). Analysis of the compensation arrangements experienced by primary care nurse practitioners in the managed care environment. (Unpublished doctoral dissertation). George Mason University, Fairfax, Virginia. 
• Altschuler, J., Margolius, D., Bodenheimer,T., & Grumbach, K. (2012). Estimating a reasonable patient panel size for primary care physicians with team-based task delegation. Annals of Family Medicine, 10, 396-400.
• American Association of Nurse Practitioners. (2011). National nurse practitioner compensation survey 2011. Retrieved from 2011 AANP National NP Compensation Survey.
• American Association of Nurse Practitioners. (2011). NP fact sheet. Retrieved from NP Fact Sheet.
• Australian College of Nurse Practitioners. (2012). Nurse practitioners in primary care: Benefits for your practice. Retrieved from Australian College of Nurse Practitioners (ACNP) website.
• Barkauskas, V.H., Pohl, J.M., Benkert, R., & Wells, M.A. (2009). Measuring quality in nurse-managed centers using HEDIS measures. Journal for Healthcare Quality, 27, 4-14.
• Bonsall, K. & Cheater, F. M. (2008). What is the impact of advanced primary care nursing roles on patients, nurses and their colleagues? A literature review. International Journal of Nursing Studies, 45, 1090-1102.
• Brown, J., Hart, A. M., & Burman, M. E. (2009). A day in the life of RURAL advanced practice nurses. The Journal for Nurse Practitioners, 5, 108-114.
• Canadian Federation of Nurses. (2011). Overview of key nursing contract provisions. Retrieved from 2011 Overview of Key Nursing Contract Provisions.
• Chapados, C. (2013).  L’évaluation de la santé par les infirmières praticiennes spécialisées: Des IPS témoignent. Perspectives Infirmières, 10, 26-30.
• Charland, S. Personal communication received March 2, 2013.
• Chumbler, N. R., Geller, J. M., & Weier, A. W. (2000). The effects of clinical decision making on nurse practitioners' clinical productivity. Evaluation & the Health Professions, 23, 284-305.
• Clendon, J.M. (2003). Nurse-managed clinics: issues in evaluation. Journal of Advanced Nursing, 44, 558–565.
• College of Family Physicians of Canada. (2012). Best advice: Panel size. Retrieved from Best Advice Panel Size 2012.
• Counsell, S. R., Callahan, C. M., Buttar, A. B., Clark, D. O., & Frank, K. I. (2006). Geriatric resources for assessment and care of elders (GRACE): A new model of primary care for low-income seniors. Journal of the American Geriatrics Society, 54, 1136-1141.
• Dahrouge, S., Hogg, W.E., et al. (2013). NAPCRG abstract for presentation. Author.
• Dahrouge, S., Muldoon, L., Ward, N., Hogg, W., Russell, G., & Taylor-Sussex, R. (2014). Roles of nurse practitioners and family physicians in community health centres. Canadian Family Physician, 60, 1020-1027.
• Deshefy-Longhi, T., Swartz, M. K., & Grey, M. (2008). Characterizing nurse practitioner practice by sampling patient encounters: An APRNet study. Journal of the American Academy of Nurse Practitioners, 20, 281-287.
• DiCenso, A., Bourgeault, I., Abelson, J., Martin-Misener, R., Kaasalainen, S., Carter, … Kilpatrick, K. (2010). Utilization of nurse practitioners to increase patient access to primary healthcare in Canada--thinking outside the box. Nursing Leadership, 23(Special Issue), 239-259. Nursing Leadership.
• Dierick-van Daele, A., Steuten, L. M., Romeijn, A., Derckx, E. W., & Vrijhoef, H. J. (2011). Is it economically viable to employ the nurse practitioner in general practice? Journal of Clinical Nursing, 20(3), 518-529.
• Dierick-van Daele, A. T., Metsemakers, J. F., Derckx, E. W., Spreeuwenberg, C., & Vrijhoef, H. J. (2009). Nurse practitioners substituting for general practitioners: Randomized controlled trial. Journal of Advanced Nursing, 65, 391-401.
• Dierick-van Daele, A. T., Steuten, L. M., Metsemakers, J. F., Derckx, E. W., Spreeuwenberg, C., & Vrijhoef, H. J. (2010). Economic evaluation of nurse practitioners versus GPs in treating common conditions. British Journal of General Practice, 60 (570), e28-35.
• Donald, F., Martin-Misener, R., Bryant-Lukosius, D., Kilpatrick, K., Kaasalainen, S., Carter, N., . . . DiCenso, A. (2010). The primary healthcare nurse practitioner role in Canada. Nursing Leadership, 23(Special Issue), 88-113. http://www.longwoods.com/content/22271
• Donelan, K., DesRoches, C.M., Dittus, R.S., & Buerhaus, P. (2013). Perspectives of physicians and nurse practitioners on primary care practice. New England Journal of Medicine, 368, 1898-906.
• Department of Veterans Affairs, Veteran Health Administration. (2014). Patient aligned care team (PACT) handbook.
• Department of Veterans Affairs, Veteran Health Administration. (2009). Primary care management module (PCMM): VHA handbook 1101.02. Veterans Health Administration Transmittal Sheet. Retrieved from Patient aligned care team (PACT) handbook
• Duck, E., DeLia, D., & Cantor, J. C. (2001). Primary care productivity and the health care safety net in New York City. Journal of Ambulatory Care Management, 24, 1-14.
• Fédération interprofessionnelle de la santé du Québec (FIQ) (Union). (2010). Titres d'emploi, libellés, échelles et suppléments (Employment titles and pay scales). Retrieved from Titres d'emploi, libellés, échelles et suppléments.  
• Gambino, K., Planavsky, L., & Gaudette, H. (2009). Transition toward a nurse practitioner-managed clinic. Journal of Cardiovascular Nursing, 24, 132-139.
• Glazier, R.H., Zagorski, B.M., & Rayner, J. (2012). Comparison of primary care models in Ontario by demographics, case mix and emergency department use, 2008/09 to 2009/10. ICES Investigative Report. Toronto: Institute for Clinical Evaluative Sciences. Retrieved from Comparison of Primary Care Models in Ontario by Demographics, Case Mix and Emergency Department Use, 2008/09 to 2009/10.
• Guey-Chi Chen, P., Mehrotra, A., & Auerbach, D.I. (2014). Response: Effectiveness in primary care is paramount, but need not come at the expense of efficiency. Medical Care, 52(2): 99-100.
• Haber, J., Strasser, S., Lloyd, M., Dorsen, C., Knapp, R., Auerhahn, C., . . . Fulmer, T. (2009). The oral-systemic connection in primary care. The Nurse Practitioner, 34, 43-48.
• Hay Group Health Care Consulting. (2011). Hay report: Compensation consulting services. Author.
• Hayes, E. F. (2007). Embattled and embittered or empowered and evolving: Nurse practitioner attitudes toward managed care. Journal of the American Academy of Nurse Practitioners, 19(3), 143-151.
• Health Services Restructuring Committee. (1999). Primary health care strategy. Advice and recommendations to the Honourable Elizabeth Witmer, Minister of Health.
• Hing, E., & Hooker, R. S. (2011). Community health centers: Providers, patients, and content of care. NCHS Data Brief, 65, 1-8.
• Hing, E., Hooker, R. S., & Ashman, J. J. (2011). Primary health care in community health centers and comparison with office-based practice. Journal of Community Health, 36(3), 406-413.
• Holcomb, L. O. (2000). A Delphi survey to identify activities of nurse practitioners in primary care. Clinical Excellence for Nurse Practitioners, 4, 163-172.
• Hollinghurst, S., Horrocks, S., Anderson, E., & Salisbury, C. (2006). Comparing the cost of nurse practitioners and GPs in primary care: Modelling economic data from randomized trials. British Journal of General Practice, 56, 530-535.
• Hooker, R. S. (2006). Physician assistants and nurse practitioners: The United States experience. Medical Journal of Australia, 185, 4-7.
• Hooker, R. S., & Berlin, L. E. (2002). Trends in the supply of physician assistants and nurse practitioners in the United States. Health Affairs (Project Hope), 21, 174-181.
• Horizon Health Network (New Brunswick) Policy and Procedure Manual. (2012). Nurse practitioner accountability guidelines for community health centres, health centres and collaborative practice settings. Author.
• Huang, P. Y., Yano, E. M., Lee, M. L., Chang, B. L., & Rubenstein, L. V. (2004). Variations in nurse practitioner use in Veterans Affairs primary care practices. Health Services Research, 39(4 Pt 1), 887-904.
• Humbert, J., Legault, F., Dahrouge, S., Halabisky, B., Boyce, G., Hogg, W., & Amos, S. (2007). Integration of nurse practitioners into a Family Health Network. Canadian Nurse, 103, 30-34.
• Johnson, R. (2005). Shifting patterns of practice: Nurse practitioners in a managed care environment. Research & Theory for Nursing Practice, 19, 323-340.
• Kaissi, A., Kralewski, J., & Dowd, B. (2003). Financial and organizational factors affecting the employment of nurse practitioners and physician assistants in medical group practices. Journal of Ambulatory Care Management, 26, 209-216.
• Kernick, D. & Scott, A. (2002). Economic approaches to doctor/nurse skill mix: Problems, pitfalls, and partial solutions. British Journal of General Practice, 52, 42-46.
• Kinnersley, P., Anderson, E., Parry, K., Clement, J., Archard, L., Turton, P., & Rogers, C. (2000). Randomised controlled trial of nurse practitioner versus general practitioner care for patients requesting "same day" consultations in primary care. BMJ, 320(7241), 1043-1048.
• Klein, S. (2010). Quality matters in focus: Using pharmacists, social workers, and nurses to improve the reach and quality of primary care. The Commonwealth Fund Newsletter August-September 2010.
• Knapp, K. K., & Hardwick, K. (2000). The availability and distribution of dentists in rural ZIP codes and primary care health professional shortage areas (PC-HPSA) ZIP codes: Comparison with primary care providers. Journal of Public Health Dentistry, 60, 43-48.
• Koren, I., Mian, O., & Rukholm, E. (2010). Integration of nurse practitioners into Ontario's primary health care system: Variations across practice settings. Canadian Journal of Nursing Research, 42, 48-69.
• Koren, I., Mian, O., & Rukholm, E. (2010). Primary health care nurse practitioners in rural locations of Ontario: Demographic and practice profile. Centre for Rural and Northern Health Research, Laurentian University, Sudbury, Ontario.
• Larson, E. H., Palazzo, L., Berkowitz, B., Pirani, M. J., & Hart, L. G. (2003). The contribution of nurse practitioners and physician assistants to generalist care in Washington State. Health Services Research, 38, 1033-1050.
• Liu, N., & D'Aunno, T. (2012). The productivity and cost-efficiency of models for involving nurse practitioners in primary care: A perspective from queueing analysis. Health Services Research, 47, 594-613.
• Lui, N., Finkelstein, S., & Poghosyan, L. (2012). A new model for nurse practitioner utilization in primary care: Increased efficiency and implications. Forthcoming in Healthcare Management Review.
• Lui, N., Ozen, A., & Balasubramanian, H., J. (2013). Primary care practice design under case mix: Joint consideration of access to care and continuity of care. Retrieved from http://www.columbia.edu/~nl2320/
• Manitoba Finance. (2013). Year 3 salary schedule; March 24, 2012 to March 22, 2013. Retrieved from HEALTH COMPONENT YEAR 3 SALARY SCHEDULE.
• Manitoba Health. (2012). Primary care interprofessional team toolkit.
• Martin, K. E. (2000). Nurse practitioners: A comparison of rural-urban practice patterns and willingness to serve in underserved areas. Journal of the American Academy of Nurse Practitioners, 12, 491-496.
• Martin Misener, R., Crawford, T., DiCenso, A., Akhtar-Danesh, N., Donald, F., Bryant-Lukosius, D., & Kaasalainen, S. (2010). A survey of the practice patterns of nurse practitioners in primary health care in Nova Scotia. College of Registered Nurses of Nova Scotia and Dalhousie University School of Nursing, Halifax, NS.
• McIntosh, B., & Sheppy, B. (2013). Skill maximisation: The future of healthcare. British Journal of Healthcare Management, 19(3): 118-122.
• Mian,O., & Koren, I. (2011). Primary healthcare nurse practitioner tracking study: The 2010 survey report. Centre for Rural and Northern Health Research, Laurentian University, Sudbury, Ontario.
• Mian, O., Lacarte, S., & Koren, I. (2012). 2012 NursepPractitioner workforcetTracking study. Centre for Rural and Northern Health Research, Laurentian University.
• Miller, D., Zantop, V., Hammer, H., Faust, S., & Grumbach, K. (2004). Group medical visits for low-income women with chronic disease: A feasibility study. Journal of Women's Health, 13, 217-225.
• Muldoon, L., Dahrouge, S., Russell, G., Hogg, W., & Ward, N. (2012). How many patients should a family physician have? Factors to consider in answering a deceptively simple question. Healthcare Policy, 7, 26-34.
• Muldoon, L., Rayner, J., & Dahrouge, S. (2013). Patient poverty and workload in primary care. Canadian Family Physician, 59, 384-90. 
• Mundell., B.F., Friedberg, M.W., Eibner, C., & Mundell, W.C. (2013). US military primary care: Problems, solutions, and implications for civilian medicine. Health Affairs, 32 (11): 1949-1955.
• Naylor, M. D., & Kurtzman, E. T. (2010). The role of nurse practitioners in reinventing primary care. Health Affairs, 29, 893-899.
• Nurse Practitioners’ Association of Ontario. (2012a). Think tank report 2012. Nurse Practitioners’ Association of Ontario, Toronto, Ontario.
• Nurse Practitioner’s Association of Ontario. (2012b). From the initial vision to present day reality for Sue Leddy.
• Nurse Practitioners’ Association of Ontario. (2013). Pan-Canadian Nurse Practitioner Salary Table. Nurse Practitioners’ Association of Ontario, Toronto, Ontario.
• Offredy, M., & Townsend, J. (2000). Nurse practitioners in primary care. Family Practice, 17, 564-569.
• Ontario Ministry of Health and Long Term Care. (2005). Report on the integration of primary health care nurse practitioners into the province of Ontario.
• Ontario Ministry of Health and Long Term Care. (2010). Interprofessional provider compensation, version 2.1; nurse practitioner-led clinics.
• Ortiz, J., Wan, T. T., Meemon, N., Paek, S. C., & Agiro, A. (2010). Contextual correlates of rural health clinics' efficiency: Analysis of nurse practitioners' contributions. Nursing Economics, 28, 237-244.
• Parker, R., Forrest, L.E., Desborough, J., McRae, I.,  & Boyland, T. (2011). Independent evaluation of the nurse-led ACT health walk-in centre. Australian Primary Health Care Research Institute.
• Phillips, R.L., Jr.,  Bazemore, A.M., & Peterson, L.E. (2014). Effectiveness over efficiency underestimating the primary care physician shortage. Medical Care, 52:97-98.
• Plexus Medical Recruitment. Nursing (NP) Salaries Australia and New Zealand.
• Poghosyan, L., Lucero, R., Rauch, L., & Berkowitz, B. (2012). Nurse Practitioner Workforce: A Substantial Supply of Primary Care Providers. Nursing Economics, 30, 268-274.
• Poghosyan, L., Nannini, A., & Clarke, S. (2013). Organizational climate in primary care settings: Implications for nurse practitioner practice. Journal of the American Association of Nurse Practitioners, 25, 134–140. 
• Pohl, J.M., Breer, M.L., Tanner, C., Barkaiskas, V.H., Bleich, M., Bomar, P., Fiandt, K., Jenkins, M., Lundeen, S., Mackey, T.A., Nagelkerk, J., & Werner, K. (2006) National consensus on data elements for nurse managed health centres. Nursing Outlook, 54, 81-84.
• Pohl, J.M., Tanner, C., Barkauskas, V.H., Gans, D.N., Nagelkerk, J., & Fiandt, K. (2010). Towards a national nurse-managed health centre data set: Findings and lessons learned over 3 years. Nursing Outlook, 58, 97-103.
• Potts, B., Adams, R., & Spadin, M. (2011). Sustaining primary care practice: A model to calculate disease burden and adjust panel size. Permanente Journal, 15, 53-56.
• Prince Albert Parkland Regional Health Authority. (2008). 2007-2008 Annual report to the Ministry.
• Rayner, J. (2013). Measuring client complexity and creating a risk adjusted target panel size for CHCs in
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• Reay, T., Patterson, E. M., Halma, L., & Steed, W. B. (2006). Introducing a nurse practitioner: Experiences in a rural Alberta family practice clinic. Canadian Journal of Rural Medicine 11, 101-107.
• Rhoads, J., Ferguson, L. A., & Langford, C. A. (2006). Measuring nurse practitioner productivity. Dermatology Nursing, 18, 32-34.
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