PDF (456 KB) - Journal of Obstetrics and Gynaecology Canada

WOMEN’S HEALTH

Process Evaluation of a Task-Shifting Strategy in Hormonal Contraception: Does Training Translate into Practice? Edith R. Guilbert, MD, MSc,1,2 Mélanie Rousseau, MD,2 Alexis C. Guilbert, BA,1 Jean Robitaille, PhD,3 Hélène Gagnon, PhD,4 Diane Morin, PhD5 1

National Institute of Public Health of Quebec, Quebec City QC

2

Department of Obstetrics and Gynecology, Laval University, Quebec City QC

3

Department of Agribusiness and Consumer Sciences, Laval University, Quebec City QC

4

Department of Nursing Sciences, Laval University, Quebec City QC

5

National Institute of Graduate Studies and Research in Care, IUFRS, University of Lausanne, Lausanne, Switzerland

Abstract

Résumé

Objectives: Since 2000, the Province of Quebec has experienced a shortage of physicians and a decrease in access to prescription contraceptives. A task-shifting strategy was launched in 2007 to allow trained nurses, in collaboration with community pharmacists, to start healthy women on hormonal contraception for a six-month period without a medical consultation. This study examined the proportion of trained nurses effectively involved in this innovative practice to determine which factors are associated with it.

Objectifs : Depuis 2000, la province de Québec connaît une pénurie de médecins et une baisse de l’accès aux contraceptifs d’ordonnance. Une stratégie de partage des tâches a été lancée en 2007 pour permettre à des infirmières formées de distribuer, en collaboration avec des pharmaciens communautaires, des contraceptifs hormonaux à des femmes en santé pour une période de six mois, sans passer par une consultation médicale. Cette étude s’est penchée sur la proportion d’infirmières formées participant réellement à cette pratique novatrice, et ce, en vue de déterminer les facteurs qui lui sont associés.

Methods: We performed a cross-sectional study in which all nurses who had been trained in hormonal contraception since 2007, who were registered with the College of Nurses of Quebec, and who were employed as nurses in the Quebec Health System were asked to respond to a postal or electronic survey. Results: A total of 3043 nurses were invited to participate in the study. Fifty-seven percent (57.3%) of 745 respondents were involved in this new practice. The major determinant was the adoption of the Collaborative Agreement in Hormonal Contraception by health organizations. The other influential factors were having been trained before 2011, being a permanent employee, working in a youth clinic of a centre for health and social services, and working in a rural or remote area. Conclusion: Despite a modest response rate, this study provides support for formalizing the training of nurses in hormonal contraception by integrating it into nursing education at all levels, and for implementing it in other health organizations such as family medicine groups, which are widespread in Quebec. J Obstet Gynaecol Can 2013;35(11):1090–1100 Key Words: Nurses, task shifting, contraception, training, practice Competing Interests: None declared. Received on June 25, 2013 Accepted on July 16, 2013

1090 l DECEMBER JOGC DÉCEMBRE 2013

Méthodes : Nous avons mené une étude transversale dans le cadre de laquelle nous avons demandé à toutes les infirmières qui avaient reçu une formation en matière de contraception hormonale depuis 2007, qui faisaient partie des membres en règle de l’Ordre des infirmières et des infirmiers du Québec, et qui occupaient un poste d’infirmière au sein du système de santé québécois de répondre à un sondage par voie postale ou électronique. Résultats : Au total, 3 043 infirmières ont été conviées à participer à l’étude. Cinquante-sept pour cent (57,3 %) des 745 répondantes participaient à cette nouvelle pratique. Le principal facteur déterminant était l’adoption de l’Ordonnance collective de contraception hormonale par les organisations de santé. Parmi les autres facteurs d’influence, on trouvait le fait d’avoir été formée avant 2011, le fait d’être une employée permanente, le fait de travailler dans une clinique jeunesse d’un centre de santé et de services sociaux, et le fait de travailler en région rurale ou éloignée. Conclusion : Malgré un taux de réponse modeste, cette étude s’ajoute aux éléments qui soutiennent l’officialisation de la formation des infirmières dans le domaine de la contraception hormonale, en l’intégrant à la formation en sciences infirmières à tous les niveaux et en la mettant en œuvre dans d’autres organisations de santé (tels que les groupes de médecine familiale, lesquels sont très répandus au Québec).

Process Evaluation of a Task-Shifting Strategy in Hormonal Contraception: Does Training Translate into Practice?

INTRODUCTION

I

n mid-2000, the abortion rate in Quebec was the fourth highest in Canada.1–3 According to the 2008 Quebec Health Survey, 67% of women aged 15 to 49 years who were sexually active reported regular use of contraception in the past year.4 In 2005, approximately 25% of the population did not have a family physician; family physicians are the principal prescribers of hormonal contraceptives.5,6 In order to increase contraceptive use and ultimately reduce abortion rates, strategies to shift or share responsibilities in contraception became highly appealing. Task shifting, a process whereby specific tasks are moved to health workers with shorter training and fewer qualifications, is expected to make more efficient use of existing human resources and ease bottlenecks in service delivery.7 As long ago as 1968, a study showed that nurses were as able as physicians to insert intrauterine devices.8 A vast majority of studies done later in multiple countries demonstrated the safety and efficacy of various health workers (community health workers, nurse assistants, nurses) in providing hormonal contraceptives, prenatal and postnatal care, insertion of IUDs, and deliveries.9–21 In 2002 the Province of Quebec approved Bill 90, allowing task shifting between different health professionals.22 The first practical application of this law was the Quebec model of Collaborative Agreement in Hormonal Contraception (CAHC).23 This model, launched in 2007, is a mechanism by which a trained nurse, in collaboration with a community pharmacist, can prescribe hormonal contraception (i.e., combined oral contraceptives, contraceptive patch and ring, progestinonly pills, or injectable contraceptives) to healthy women of reproductive age for a six-month period without a medical consultation. For example, a 16-year-old in need of hormonal contraception can visit her school nurse, who will evaluate her health, BMI, blood pressure, and risk of pregnancy, and provide counselling on contraceptive methods. If she has no absolute or relative contraindication, the nurse will tailor her counselling to the chosen contraceptive method and give her a prescription-like form (“liaison form”) with the name of the recommended contraceptive. The woman will obtain her contraceptive at the pharmacy of her choice for a period of six months. Within this time, she is required to obtain an individual 12- to 24-month prescription from a physician. Because of various legal constraints and with the aim of promoting interdisciplinary collaboration, the College of Physicians of Quebec requires that physicians of each health organization agree on their own local CAHC. The provincial model serves as a guide that can be adapted locally. A copy of each local CAHC must be sent to the College of Pharmacists of Quebec in order for community

pharmacists to verify that the liaison forms they receive are related to reliable local CAHCs. Since 2007, nurses designated by CAHCs have been trained in hormonal contraception. The traditional training program consisted of a seven-hour course given by two trainers (a physician and a nurse). In 2009, the CAHC model was updated24 according to new eligibility criteria for contraceptive use25 and became a 10-hour accredited e-learning program. When new and innovative models of service delivery are implemented, barriers may arise.26–28 To better understand the challenges faced by nurses who had been trained in hormonal contraception, this process evaluation study had two objectives: (1) to determine the proportion of trained nurses who were actually starting women on hormonal contraception, and (2) to identify the factors associated with this innovative practice. MATERIALS AND METHODS

All nurses who were trained and accredited in hormonal contraception from March 2007 to September 30, 2011, were invited to participate in the study. Eligible nurses were those registered at the College of Nurses of Quebec and currently working in the Quebec health system. With the collaboration of College of Nurses of Quebec, the National Institute of Public Health of Quebec obtained recent postal and/or email addresses of accredited nurses. Nurses were sent email invitations and a web link to access the online consent form and research questionnaire (Lime Survey). When nurses had only a postal address, they were sent a letter with two copies of the consent form, the research questionnaire and a pre-addressed and pre-stamped response envelope. Reminders were sent one week and one month after the first contact. Nurses from the electronic cohort also received the documents by mail two weeks after the second reminder. Postal questionnaires were uploaded twice in Excel data banks by two independent research assistants for validity purposes. The postal and electronic data banks were then merged. The questionnaire contained 27 validated items.29 Eighteen items were multilevel questions related to Roger’s theoretical model of diffusion of innovation.30 The other nine questions dealt with external factors: sociodemographic characteristics of the participants, identification of their organization, sector and region of practice, previous training of nurses, and description of the practice of starting hormonal contraception. The analysis presented here is intentionally restricted to the variables related to external factors. DECEMBER JOGC DÉCEMBRE 2013 l 1091

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Flow chart of the study population 3043 nurses were solicited from November 25, 2011, to March 16, 2012

1st Postal solicitation n = 669

1st Internet solicitation n = 2374

Participants = 39

Participants = 124

Refusal = 18 Non-eligible = 27 Wrong address = 59

Refusal = 18 Non-eligible = 8

2nd Postal solicitation n = 526

2nd Internet solicitation n = 2224

Participants = 73 Participants = 90


Refusal = 20 Non-eligible = 13

Internet participants = 7 Transferred to postal = 14 Internet non-eligible = 2 3rd Postal solicitation, n = 417

3rd Internet solicitation n = 2087

Participants = 42

Participants = 56


Refusal = 19 Non-eligible = 9 Transferred to postal = 6

Internet participants = 1

4th solicitation of Internet participants through mail n = 1997

Internet non-eligible = 1

Participants = 313 Refusal = 57 Non-eligible = 40 Wrong address = 39

Non-eligible = 134/3 043 (4.4%) Refusal = 159/3 043 (5.2%) Wrong address = 104/3 043 (3.4%) Participants = 745/2 805 (26.6%)

Given that more than 3000 nurses received the accreditation in hormonal contraception and with an anticipated response rate of 33% to 45%, we expected to receive 900 to 1350 completed questionnaires.31 Chi-square tests, binomial tests and Spearman correlation tests were used for univariate comparisons. Binary logistic regression models using backward stepwise strategies were estimated to assess which variables were associated with the practice of nurses in hormonal contraception. The best model was judged upon the highest value of the Nagelkerke R2 and the highest percentage of valid predictions of performing or not performing the new practice.32 All statistical 1092 l DECEMBER JOGC DÉCEMBRE 2013

analyses in this study were performed using SPSS v. 20.0.0 (IBM Corp., Armonk, NY). The study was approved by the ethical review board of Laval University, Quebec. RESULTS

Data were collected between November 25, 2011, and March 16, 2012. As shown in the Figure, 3043 nurses were invited to participate in the study. One hundred thirty-four of those invited were not eligible (not a nurse, retired, still


Table 1. Basic characteristics of the participants Characteristics Age, years < 30 30 to 39 40 to 49 50 to 59 ≥ 60 Marital status and living arrangements Married with a spouse Married without a spouse Single with a spouse Single without a spouse Other with a spouse Other without a spouse Level of education College degree University certificate Bachelor degree Master or doctorate degree Working status Part-time job Full-time, temporary status Full-time, permanent status Temporary leave of absence Type of organization where the nurse works Health and Social Services organization (CSSS) Group of family medicine or private clinic or women’s health centre Hospital setting College, university, or private school or youth protection centre Other settings Sector of practice Youth clinic School clinic Outpatient clinic Child and maternal health Family planning clinic Public health Flying squad Other settings (administration, Info-Health, pharmacies, etc.) Region of practice Region 01—Bas-Saint-Laurent Region 02—Saguenay-Lac-Saint-Jean Region 03—Capitale-Nationale (Quebec City) Region 04—Mauricie et Centre-du-Québec Region 05—Estrie Region 06—Montreal Region 07—Outaouais Region 08—Abitibi-Temiscamingue Region 09—Côte-Nord Region 11—Gaspésie-ïles-de-la-Madeleine Region 12—Chaudière-Appalaches Region 13—Laval Region 14—Lanaudière Region 15—Laurentides Region 16—Montérégie Region 10–17–18—Northern regions

n

%

75 182 221 235 32

10.1 24.4 29.7 31.5 4.3

347 8 211 51 49 79

46.6 1.1 28.3 6.8 6.6 10.6

116 107 471 51

15.6 14.4 63.2 6.8

178 63 459 45

23.9 8.5 61.6 6.0

604 42 41 24 34

81.1 5.6 5.5 3.2 4.6

71 184 136 130 60 22 32 110

9.5 24.7 18.3 17.4 8.1 3.0 4.3 14.8

27 40 80 53 30 140 26 28 30 19 57 31 55 15 98 16

3.6 5.4 10.7 7.1 4.0 18.8 3.5 3.8 4.0 2.6 7.7 4.2 7.4 2.0 13.2 2.2

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Table 2. Training characteristics of the participants and context of practice Characteristics

n

%

2007

145

19.5

2008

224

30.1

2009

138

18.5

2010

132

17.7

2011

106

14.2

Traditional with trainers

582

78.1

Online

163

21.9

Practising nurse

702

94.2

Student in nursing or other

43

5.8

Year of training

Type of training

Working status at the time of the training

Adoption of a collaborative agreement where the nurse works Yes

654

87.8

No

91

12.2

Compliance of the collaborative agreement with the provincial model Yes

84

11.3

No

456

61.2

Not applicable*

205

27.5

*Compliance was deemed not applicable when the organization where the nurse works had not been included in the 2010 audit of collaborative agreements of hormonal contraception.

studying) and 159 refused to participate (not offering the practice, having changed practice, on a leave of absence, questionnaire too long). Questionnaires were sent to a wrong address in 101 cases, and three consent forms were not signed. Questionnaires were sent back through regular mail by 475 nurses, while 270 filled out the electronic questionnaire for a total of 745 questionnaires. The total response rate (3043 nurses minus the non-eligible and those who had a wrong address) was 26.6% (745/2805). Under the assumption of quasi-heterogeneity, which reflects the results of this study, the margin of error was estimated to be at ± 3.22% within a 95% confidence interval, 19 times out of 20.33–37

practice than those who were younger and less educated. If nurses worked in a regional health and social service organization (referred to as CSSS, of which there are 94 in the province of Quebec) and in sectors of practice such as youth or school clinics, they were significantly more likely to be involved in this practice than if they worked in other health or educational organizations or other sectors of practice. Working in the urban area around Montreal or in rural areas in the region of Quebec City and having been trained in the first years of implementation significantly increased the probability of adopting this practice. Ninety-eight percent of nurses adopting this practice worked in an organization that had a local CAHC, compared with 74% who did not.

Sociodemographic and training characteristics of the participants as well as their practice and its context are shown in Tables 1, 2, and 3. Fifty-seven percent (57.3%) said they were starting women on hormonal contraception. A small proportion admitted not providing liaison forms (3.6%) or practising out of a CAHC (2.4%). The delay between training and practice was less than two years for most of the nurses, and the average number of women started on hormonal contraception per month was 5.6 (SD 9.5).

Five independent variables were retained in the regression model (Table 5), explaining 40.7% of the variance and correctly predicting 81% of the practice of starting women on hormonal contraception. Nurses working in hospitals were significantly less likely (3.5 times less) to adopt this practice than those working in a CSSS. Nurses working in any sector other than youth clinics were significantly less likely to adopt the practice (4 to 50 times less). As expected, the absence of a local CAHC reduced the likelihood of this practice by more than 12 times. However, working full time with permanent status and having been trained in 2007, 2008, or 2010 increased the likelihood of adopting this new practice.

As shown in Table 4, nurses who were older and had a higher level of education were significantly more involved in this 1094 l DECEMBER JOGC DÉCEMBRE 2013


Table 3. Adoption, rate of adoption and intensity of the new practice Characteristics

n

%

Practice within a collaborative agreement

382

51.3

Practice within a collaborative agreement but without signing liaison form

27

3.6

Practice out of a collaborative agreement

18

2.4

No practice

318

42.7

None

248

58.1

1 year

113

26.5

2 years

35

8.2

Practice of the initiation of hormonal contraception

Delay between training and practice

≥ 3 years

31

7.3

Not applicable

318

42.7

24

5.6

Number of initiations of hormonal contraception per month None 0.01 to < 2

116

27.2

2 to < 5

118

27.6

≥5

169

39.6

Not applicable

318

42.7

Because 45 nurses did not adopt the practice exactly as expected, and because 89.6% of the remaining 700 nurses were in organizations in which a CAHC was adopted, we removed the variable related to the adoption of a CAHC which captured most of the variance. The resulting binary logistic model explained 50.1% of the variance and could correctly predict 77.5% of those who adopted the practice (data not shown). Working in a hospital (OR 0.21), in a college/university/private school/youth protection centre (OR 0.28), or in other settings (OR 0.11), and in any sector other than a youth clinic (OR 0.02 to 0.30) significantly decreased the likelihood of adopting this practice. However, having been trained before 2011 (OR 2.51 to 3.34) and practising either in the rural areas around the region of Quebec City (OR 2.12) or in remote regions (OR 2.57) significantly increased the likelihood of adopting this practice. DISCUSSION

According to this cross-sectional study, more than one in two nurses (57.3%) adopted the expected new practice after receiving training in hormonal contraception, a proportion consistent with that found in our exploratory study in 2010 (61.4%).29 In several domains, training does not always translate into practice.38–43 As shown in Honduras,41 where training in IUD insertion was offered to nurses’ auxiliaries (62% completed the training), a large proportion of those trained did not insert IUDs after

returning to their workplaces, mainly because they did not feel confident in their skills. They also did not conduct community information activities to increase demand for little-known long-term contraceptive methods. In another project in Guatemala,42 follow-up visits showed that onefourth of nurse auxiliaries who completed training were not conducting IUD insertions between 9 and 20 months after the end of the training. In the United Kingdom,43 three years after nurse prescribing was extended in 2001 (e.g., prescription of laxatives, wound care products), an evaluation showed that 8% had not prescribed at all and 56.8% prescribed less than once per week. Considering that our evaluation was done on average 3.2 years (SD 1.3) after the training, the proportion of nurses who were actually starting women on contraception in this study (57.3%) appears to be as expected. The reasons for such a proportion may include the fact that several nurses had retired or changed sector of practice and the fact that students in nursing who accessed the e-learning may not have begun working or may not have been working in sectors where the CAHC applies. Literature reviews44,45 have shown that the ideal way to help clinicians introduce preventive measures into their usual practice is to expose them to efficient interventions, such as tailored office systems with a practice facilitator or multifaceted interventions. Although not as extensive as full multifaceted interventions, the implementation of CAHCs included several of the required elements: DECEMBER JOGC DÉCEMBRE 2013 l 1095

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Table 4. Determinants of the practice of starting women on hormonal contraception Practice of starting women on hormonal contraception Yes (n = 427) n (%)

No (n = 318) n (%)

30 (7)

45 (14)

30 to 39

99 (23)

83 (26)

40 to 49

128 (30)

93 (29)

50 to 59

150 (35)

85 (27)

20 (5)

12 (4)

209 (49)

138 (43)

Characteristics Age, years < 30

≥ 60

0.006

Marital status and living arrangements Married with a spouse Married without a spouse

0.176 2 (1)

6 (2)

118 (28)

93 (29)

Single without a spouse

28 (6)

23 (7)

Other with a spouse

31 (7)

18 (6)

Other without a spouse

39 (9)

40 (13)

College degree

51 (12)

65 (21)

University certificate

58 (14)

49 (15)

Bachelor degree

290 (68)

181 (57)

28 (6)

23 (7)

94 (22)

84 (26)

Single with a spouse

Level of education

Master or doctorate degree

0.006

Working status Part-time job

0.070

Full-time, temporary status

34 (8)

29 (9)

Full-time, permanent status

279 (65)

180 (57)

Temporary leave of absence

20 (5)

25 (8)

Type of organization where the nurse works Health and Social Services organization (CSSS)

P

< 0.001 388 (91)

216 (68)

Group of family medicine or private clinic or women’s health centre

18 (4)

24 (8)

Hospital setting

6 (2)

35 (11)

College, university or private school or youth protection centre

10 (2)

14 (4)

Other settings

5 (1)

29 (9)

Youth clinic

66 (15)

5 (2)

School clinic

153 (36)

31 (9)

Outpatient clinic

67 (16)

69 (22)

Child and maternal health

60 (14)

70 (22)

Family planning clinic

35 (8)

25 (8)

Public health

12 (3)

10 (3)

Sector of practice

< 0.001

Flying squad

11 (3)

21 (7)

Other

23 (5)

87 (27)

Region of practice

0.030

Region of Montreal

78 (18)

62 (19)

Urban area around Montreal

81 (19)

48 (15)

Rural area around Montreal

69 (16)

57 (18)

Region of Quebec City

33 (8)

47 (15)

Areas around the region of Quebec City

110 (26)

67 (21)

Remote areas

56 (13)

37 (12) continued



Table 4. Continued Practice of starting women on hormonal contraception Yes (n = 427) n (%)

No (n = 318) n (%)

2007

95 (22)

50 (16)

2008

142 (33)

82 (26)

2009

77 (18)

61 (19)

2010

78 (19)

54 (17)

2011

35 (8)

71 (22)

Characteristics Year of training

P < 0.001

Type of training

< 0.001

Traditional with trainers

364 (85)

218 (69)

Online

63 (15)

100 (31)

417 (98)

285 (90)

10 (2)

33 (10)

Yes

418 (98)

236 (74)

No

9 (2)

82 (26)

Working status at the time of the training

< 0.001

Practising nurse Student in nursing or others Adoption of a collaborative agreement where the nurse works

< 0.001

Compliance of the collaborative agreement with the provincial model

< 0.001

Yes

50 (12)

34 (11)

No

295 (69)

161 (50)

Not applicable*

82 (19)

123 (39)

*Compliance was deemed not applicable when the organization where the nurse worked had not been included in the 2010 audit of collaborative agreements of hormonal contraception.

educational material, articles on contraception in a provincial nursing journal,46 scientific support provided by regional public health departments and the NIPHQ, and an audit with feedback of CAHCs in 2010.28 However, personal reminders, audit, and feedback of the nurse’s practice per se may have been lacking. The major factor predicting adoption of this practice was the adoption of a CAHC by the organizations in which the nurse worked, a positive finding that showed the support of this practice by physicians. Another strong predictive factor was its successful implementation in CSSS. According to our 2012 implementation data, 89 of 94 CSSS (95%) had adopted a CAHC, while only 49 of 227 GMF (22%) had done so. Although not statistically significant, our analysis showed that nurses in GMF and other private settings were twice as likely to adopt this practice as those in CSSS. Since GMF are well distributed geographically in the province of Quebec, enhancing implementation in these health services would increase access to contraceptive methods among women, especially young adults who cannot find family physicians and who have the highest abortion rates.2,3

The fact that nurses trained in the earlier period of the implementation were more likely to adopt this practice may relate to the fact that they were already providing contraceptive counselling and contraceptive samples. Nurses trained later included younger nurses who were studying at the time of training and were working at that time in settings where they could not put the training into practice (such as in hospitals). In addition, since the data collection was carried out in December 2011 and early 2012, it may be expected that some of the nurses trained during 2011 may not have had time to establish this practice. The analysis also showed that adopting the practice was associated with working full time in a permanent position, a situation more often associated with experienced nurses who have positions in youth clinics and in settings where the CAHC is effective. The adoption of this practice was positively associated with working in rural areas around the region of Quebec City (regions 01, 02, 04, and 12, excluding the region of Quebec City) as well as in remote regions. Although 21.1% of the Canadian population lives in rural, remote, or northern regions, only 16% of family medicine physicians DECEMBER JOGC DÉCEMBRE 2013 l 1097

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Table 5. Likelihood of adopting the practice of initiation of hormonal contraception by selected characteristics, n = 745 Variable

n

Regression coefficient

Standard error

aOR

P

Type of organization where the nurse works Health and social services organization (CSSS)

604

1.00

0.04

Group of family medicine or private clinic or women’s health centre

42

0.759

0.441

2.14

0.09

Hospital setting

41

–1.243

0.573

0.29

0.03

College, university or private school or youth protection centre

24

–0.422

0.623

0.66

0.50

Other settings

34

–0.409

0.674

0.66

0.54

Sector of practice Youth clinic

71

1.00

< 0.001

School clinic

184

–1.432

0.569

0.24

< 0.001

Outpatient clinic

136

–3.033

0.571

0.05

< 0.001

Child and maternal health

130

–3.235

0.567

0.04

< 0.001

Family planning clinic

60

–2.312

0.608

0.10

< 0.001

Public health

22

–2.686

0.708

0.07

< 0.001

Flying squad

32

–3.237

0.681

0.04

< 0.001

Other

110

–3.850

0.594

0.02

< 0.001

1.00

0.06

–0.036

0.364

0.97

0.92

Working status Part-time job

178

Full-time, temporary status

63

Full-time, permanent status

459

0.427

0.218

1.53

0.05

Temporary leave of absence

45

–0.303

0.404

0.74

0.45

2007

145

0.886

0.340

2.43

< 0.01

2008

224

0.758

0.317

2.13

0.02

2009

138

0.567

0.334

1.76

0.09

2010

132

0.339

0.339

2.66

< 0.01

2011

106

1.00

0.04

0.08

< 0.001

Year of training

Adoption of a collaborative agreement where the nurse works No

91

Yes

654

Constant –2 log likelihood = 78.003 Cox and Snell R2 = 0.303 Nagelkerke R2 = 0.407 Hosmer-Lemeshow test = 0.551 Prediction: I start hormonal contraception = 81 Prediction:I do not start hormonal contraception = 66.4 Prediction:Global = 74.8


–2.484

0.484

1.00 2.211

0.611


practise in these areas.47 In 2010–2011,48 the College of Nurses of Quebec reported that 41.6% of registered nurses (approximately 30 000 nurses) worked outside the urban areas of Montreal, Quebec City, and Sherbrooke. The opportunity for nurses to enable women to start on contraception may be welcome to many women living in areas where contraceptive needs are unmet.49,50 This study has several limitations. The response rate was low (26.6%). According to Asch et al.,51 postal questionnaires usually have a response rate around 50%. Other surveys among nurses have shown higher response rates than ours.52–59 Potential factors60–62 explaining this were the plan to collect data during the Christmas period, having a long questionnaire, the lack of a personalized invitation, and the absence of incentives. Other possible limitations were recall bias and social desirability biases. No information is available on the non responders, but it is plausible that they may have failed to respond because they had not implemented the new practice. The participants in this study were similar to the general population of nurses in Quebec in terms of age (35.8% in our study aged more than 50 years vs. 36.6% for all nurses) and geographical distribution.48,63 However, our respondents had much higher education levels than nurses in Quebec in general, this profile being consistent with nurses working in youth clinics, schools, and maternal and child health facilities.48,63 CONCLUSION

Changing clinical practices in health services is a challenge in many ways. Looking ahead, this study provides support for formalizing training in nursing education at all levels, including pre- or postgraduate and continuing education, so that future nursing graduates will be ready to replace more experienced nurses who retire. It also suggests that implementation in settings such as GMF should be accelerated. The update of the provincial model of CAHC launched before the end of 2012 now allows nurses and pharmacists to start women on hormonal contraception and continue for up to one year, and to screen women before IUD insertion. Implementing innovative health care strategies is a never-ending activity that needs to be adaptive to population needs and professionals’ abilities. ACKNOWLEDGEMENTS

This study was funded by the Ministry of Health and Social Services of Quebec, Quebec. Special thanks are addressed to our research assistants Mélissa Lafrenière and Julie Colas and to Mary Richardson for her English language revision.

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