The facility under study has had a traditional postpartum and nursery, with different nurses for the mother and baby. A decision was made to change the care model to couplet-care (CC). CC is an evidence-based care model that promotes newborn care at the mother's bedside. Establishing an education and implementation plan is important to the success of the transition. The purpose of this project was to develop an evidence-based education and implementation plan for CC implementation and to provide for staff barriers and pushback to change. The goals of the study were to identify an approach to implement evidence-based practice education that is efficient and sustainable. There is a paucity of literature available that describes how to plan and implement CC. However, Mercer's maternal role attainment provides ample evidence to support the nursing care model of CC. A survey was developed to determine the gaps in current knowledge of couplet-care. The survey was returned by 54% of the 67 staff nurses from the mother-baby unit. and revealed the need for definitions of CC, Family Centered Care, and the need to integrate role-playing into the education plan. Transformation theory is used to identify attitudes and biases to practice change that interfere with implementation. Reflective discussion was built into the education plan to assist with overcoming barriers to practice change. Using an evidence-based program plan for a nursing care model change may ease the transition of other mother-baby units to CC. CC provides an environment that supports healthy newborn attachment and subsequent healthy lifestyle.

This study explores the meanings that people attributed to their involvement in a participatory on-farm practice change project. Three techniques of discourse analysis were used. The first two identify the diversity among narratives of the participants and explores the origin of these differences. The third technique examined differences and tensions within and across the narratives to identify the discourses that were operating. Participation was found to be mediated through discourse as agents created and reproduced some discourses through their many social acts. For example, some participants recalled incidences of feeling excluded when they presented an alternative understanding of the project. As a result, these people tended to reduced their involvement rather than explore the differences. The project's discourses therefore routinised the participatory experience and tended to lock the narrative in time despite over two decades of rapid social change. Thi s meant the project discourse mediated a favoured type of participation, one that met a symbolic character rather than the particular farming practices it promoted. The discourses reveal different patterns of sense making among participants involved in the same event. Uneven participation is comprehended from the multiple patterns as a consequence of the participants' discursive practices. Articulating differences in discursive design will assist to create conditions useful for an authentic communication among participants engaged in change programs.

No description available.

No description available.

The 2019-2020 Academic Affairs Committee was charged with identifying promising practices in academic-practice partnerships and professional pharmacy organization initiatives that are accelerating the transformation of a workforce prepared to assume responsibility for society’s medication use needs in 2030 and determining the role AACP can plan in supporting these partnerships and initiatives. The committee identified a set of ideal principles, characteristics, and design elements of a high-quality, large-scale workforce development program. The committee also categorized current mechanisms for professional workforce development, in addition to identifying their strengths and weaknesses, with the realization that novel approaches are needed to accomplish the goal of large-scale workforce trans-formation. This report also highlights two existing initiatives aligned with accelerating the transformation of the workforce (ie, the Community Pharmacy Enhanced Services Network (CPESN) ACT (Academia-CPESN Transformation) Pharmacy Collaborative and the American Pharmacists Association ADVANCE platform) and is proposing a policy statement affirming AACP’s support. Further-more, the committee is proposing another policy statement supporting colleges and schools of pharmacy taking an active role in implementing innovative and novel approaches for the development of the current workforce. In order to truly understand the many factors influencing large-scale workforce transformation, the committee is also proposing a stakeholder conference with a wide range of participants and a targeted set of questions focused on current and future needs.

While holistic care is fundamental to occupational therapy (OT) practice, organizational and systemic factors often push for compartmentalized and specialist practice. Because services in many practice areas are compartmentalized, occupational therapy practitioners’ (OTPs) continuing professional development (CPD) efforts typically focus on one clinical specialty, and many often do not learn skills across different clinical areas. It is imperative that OTPs continue to learn and integrate knowledge across specialty areas so as to provide comprehensive and holistic care to all individuals who seek OT services. In addition to this, there is a known knowledge-to-practice gap that limits the implementation of research into practice. Numerous research studies (Summers et al. 2015; Stewart et al. 2020; Jones et al. 2015; Thomas et al. 2020) support the need for active engagement in CPD, implementing the most recent research into practice, and maintaining a holistic and integrated approach to healthcare. However, many clinicians experience barriers to the implementation of that knowledge, such as time, cost, staffing, and organizational influence. Healthcare organizations, on the other hand, must function in a competitive healthcare industry, by optimizing client outcomes while maintaining qualified and engaged staff. Occupational Therapists Fostering Unified Expertise and Learning (OT F.U.E.L.) was designed with these barriers in mind, and addresses them by creating a cost-effective, timely, and engaging platform for knowledge exchange across the profession of occupational therapy. OT F.U.E.L. is designed as an online community of practice, focusing on intra-professional social learning and knowledge implementation for OTPs working in the various siloed specialties of OT, including pediatrics, orthopedics/hand therapy, inpatient/outpatient rehabilitation, and mental health. The objective is to reconnect with the common roots and approaches of occupational therapy, and enhance practice skills and expertise — integrating clinical knowledge and skills from various clinical specialties across the profession. Overall group size will be limited to 16 participants, with subspecialty groups of approximately four members to ensure diversity of experience. The groups will be moderated by a “knowledge broker” who can facilitate interconnections between the specialty areas. There will be three phases to the piloting of this program. In the initial pilot (Phase 1), participants will be OTPs who are also fieldwork educators (FWEs), recruited using established affiliations with an entry-level Master of Occupational Therapy program. For the pilot, FWEs will be recruited through their employer in order to get organizational buy-in for their engagement in the program, as well as encouragement from management to participate. A secondary objective for this approach is to demonstrate the value of organizational support of professional development during established work hours. Phase 2 of piloting will involve running the program through other Universities in a variety of regions within the United States. Phase 3 will be potential dissemination through the American Occupational Therapy Association (AOTA). Ultimately, OT F.U.E.L is expected to result in several intermediate and long-term outcomes, including OTPs increased the confidence and competence with integrating skills and concepts across specialty areas in their practice. By reducing the barriers and facilitating the implementation of new knowledge, the clients will benefit, and likely demonstrate improved outcomes.

Background: Accrual of continuing medical education credits is part of licensure in family medicine but opinions are mixed as to whether the training has an impact on clinical practice. Literature does suggest that practice change is most likely when training involves multiple interactive exposures, and when the benefit to patients is apparent. Aim: To determine whether an interactive peer-lead educational intervention for General Practitioners in British Columbia, the Practice Support Program Mental Health Module, resulted in measureable change in clinical practice of the Vancouver Island participants. Method: Administrative information from British Columbia Ministry of Health databases was obtained for analysis regarding physician billing and prescribing, and hospitalizations on Vancouver Island. Paired t-tests were used to compare physician-patient interactions among module participants before and after the training regarding a) initiation of antidepressants and anti-anxiety medication, and b) use of the mental health plan billing code, used to support patients who struggle with activities of daily living. In addition, mental health hospitalizations among participants' patients before and after training were used to measure its impact on patient outcomes. Results: One-hundred and ninety-seven General Practitioners on Vancouver Island completed the mental health module between 2008 and 2011. While no significant difference was found in the numbers of mental health patients seen during the pre- and post- periods (M=142.06, SD=97.45) and (M=144.44, SD=103.00); t(196)=-0.679, p=0.498, α=.05, the change in the proportion of new prescriptions between pre-period mean (M=0.0796, SD=.06527) and post-period means (M=.0530, SD=.03877); t(195)=6.668, p<0.001 was found to be significant and indicative of a relative decrease between 31.2 and 33.4%. The change in the proportion of mental health plans was also found to be significant between pre-period (M=0.1142, SD=.018598) and post-period means (M=.1674, SD=.23973); t(180)=-3.586, p<0.001. This indicated a relative increase between 42.0 and 46.6%. No significant change in patient hospitalizations was found between the pre- and post-period means: (M=0.039, SD=.0612) and (M=.0392, SD=.0978); t(192)=-0.055, p=0.956. Conclusion: This educational intervention appears to have resulted in significant changes in the practice patterns of the physician participants. Future research using better indicators may reveal more about the impact of physician training on patient outcomes. / Graduate

For over half a century, it has been widely known that lithium is the most efficacious treatment for bipolar disorder. Yet, despite this, its prescription has consistently declined over this same period of time. A number of reasons for this apparent disparity between evidence and clinical practice have been proposed, including a lack of confidence amongst clinicians possibly because of an absence of training and lack of familiarity with the molecule. Simultaneously, competition has grown within the pharmacological armamentarium for bipolar disorder with newer treatments promoting an image of being safer and easier to prescribe primarily because of not necessitating plasma monitoring, which understandably is appealing to patients who then exercise their preferences accordingly. However, these somewhat incipient agents are yet to reach the standard lithium has attained in terms of its efficacy in providing prophylaxis against the seemingly inevitable recrudescence of acute episodes that punctuates the course of bipolar disorder. In addition, none of these mimics have the additional benefits of preventing suicide and perhaps providing neuroprotection. Thus, a change in strategy is urgently required, wherein myths regarding the supposed difficulties in prescribing lithium and the gravity of its side-effects are resolutely dispelled. It is this cause to which we have pledged our allegiance and it is to this end that we have penned this article.

Cette thèse s’intéresse à l’amélioration des soins et des services de santé et touche aux relations entre 3 grands thèmes de l’analyse des organisations de santé : la gouvernance, le changement et les pratiques professionnelles. En nous appuyant sur l’analyse organisationnelle contemporaine, nous visons à mieux comprendre l’interface entre l’organisation et les pratiques cliniques. D’une part, nous souhaitons mieux comprendre comment l’organisation structure et potentialise les pratiques des acteurs. D’autre part, dans une perspective d’acteurs stratégiques, nous souhaitons mieux comprendre le rôle des pratiques des professionnels dans l’actualisation de leur profession et dans la transformation et l’évolution des organisations. Notre étude se fonde sur l’hypothèse qu’une synergie accrue entre l’organisation et les pratiques des professionnels favorisent l’amélioration de la qualité des soins et des services de santé. En 2004, le gouvernement ontarien entreprend une importante réforme des soins et services dans le domaine du cancer et revoit les rôles et mandats du Cancer Care Ontario, l’organisation responsable du développement des orientations stratégiques et du financement des services en cancer dans la province. Cette réforme appelle de nombreux changements organisationnels et cliniques et vise à améliorer la qualité des soins et des services dans le domaine de l’oncologie. C’est dans le cadre de cette réforme que nous avons analysé l’implantation d’un système de soins et de services pour améliorer la performance et la qualité et analysé le rôle des pratiques professionnelles, spécifiquement les pratiques infirmières, dans la transformation de ce système. La stratégie de recherche utilisée correspond à l’étude approfondie d’un cas correspondant à l’agence de soins et de services en oncologie en Ontario, le Cancer Care Ontario, et des pratiques professionnelles infirmières évoluant dans ce modèle. Le choix délibéré de ce cas repose sur les modalités organisationnelles spécifiques à l’Ontario en termes de soins en oncologie. La collecte de données repose sur 3 sources principales : les entrevues semi-structurées (n=25), l’analyse d’une abondante documentation et les observations non participatives. La thèse s’articule autour de trois articles. Le premier article vise à définir le concept de gouvernance clinique. Nous présentons l’origine du concept et définissons ses principales composantes. Concept aux frontières floues, la gouvernance clinique est axée sur le développement d’initiatives cliniques et organisationnelles visant à améliorer la qualité des soins de santé et la sécurité des patients. L’analyse de la littérature scientifique démontre la prédominance d’une vision statique de la gouvernance clinique et d’un contrôle accentué des pratiques professionnelles dans l’atteinte de l’efficience et de l’excellence dans les soins et les services. Notre article offre une conception plus dynamique de la gouvernance clinique qui tient compte de la synergie entre le contexte organisationnel et les pratiques des professionnels et soulève les enjeux reliés à son implantation. Le second article s’intéresse à l’ensemble des leviers mobilisés pour institutionnaliser les principes d’amélioration continue de la qualité dans les systèmes de santé. Nous avons analysé le rôle et la portée des leviers dans l’évolution du système de soins en oncologie en Ontario et dans la transformation des pratiques cliniques. Nos données empiriques révèlent 3 phases et de nombreuses étapes dans la transformation du système. Les acteurs en position d’autorité ont mobilisé un ensemble de leviers pour introduire des changements. Notre étude révèle que la transformation du Cancer Care Ontario est le reflet d’un changement radical de type évolutif où chacune des phases est une période charnière dans la transformation du système et l’implantation d’initiatives de qualité. Le troisième article pose un regard sur un levier spécifique de transformation, celui de la communauté de pratique, afin de mieux comprendre le rôle joué par les pratiques professionnelles dans la transformation de l’organisation des soins et ultimement dans le positionnement stratégique de la profession infirmière. Nous avons analysé les pratiques infirmières au sein de la communauté de pratique (CDP) des infirmières en pratique avancée en oncologie. En nous appuyant sur la théorie de la stratégie en tant que pratique sociale, nos résultats indiquent que l’investissement de la profession dans des domaines stratégiques augmente les capacités des infirmières à transformer leurs pratiques et à transformer l’organisation. Nos résultats soulignent le rôle déterminant du contexte dans le développement de capacités stratégiques chez les professionnels. Enfin, nos résultats révèlent 3 stratégies émergentes des pratiques des infirmières : une stratégie de développement de la pratique infirmière en oncologie, une stratégie d’institutionnalisation des politiques de la CDP dans le système en oncologie et une stratégie de positionnement de la profession infirmière. Les résultats de notre étude démontrent que l’amélioration de la qualité des soins et des services de santé est située. L’implantation de transformations dans l’ensemble d’un système, tel que celui du cancer en Ontario, est tributaire d’une part, des capacités d’action des acteurs en position d’autorité qui mobilisent un ensemble de leviers pour introduire des changements et d’autre part, de la capacité des acteurs à la base de l’organisation à s’approprier les leviers pour développer un projet professionnel, améliorer leurs pratiques professionnelles et transformer le système de soins. / This thesis looks at the improvement of health and social services and touches upon the three major themes in the analysis of healthcare organizations: governance, change and professional practice. Based on contemporary organizational analysis, our aim is to better understand the interface between the organization and clinical practices. On the one hand, we wish to better understand how an organization structures and potentiates actors’ practices. On the other hand, from the perspective of strategic actors, we wish to better understand how professional practices contribute to the actualization of their professions and to the transformation and evolution of organizations. Our study is based on the hypothesis that a heightened synergy between the organization and professional practices stimulates improvement in the quality of healthcare and services. In 2004, the Ontario government undertook a major healthcare system reform in the cancer field and reviewed the roles and mandates of Cancer Care Ontario, the organization responsible for developing strategic orientations and for the funding of cancer services in the province. This reform called for many organizational changes and transformations in clinical practices, with the aim of improving the quality of cancer care and services. It was in the context of this reform that we analyzed the implementation of a system of care and services to improve performance and quality, as well as the role of professional practices, specifically nursing practices, in transforming this system. The research strategy we used was an in-depth case study, the case being the Ontario system of cancer care and services and the nursing professional practices that developed within this model. We deliberately selected this case based on organizational modalities that are specific to Ontario with regard to oncology. For data collection we used three main sources: semi-structured interviews (N = 25), analysis of an abundance of documentation, and non-participative observations. The thesis is organized around three articles. The first article aims to define the concept of clinical governance. We present the origin of the concept and define its principal components. A concept whose delineation is somewhat vague, clinical governance focuses on the development of clinical and organizational initiatives aimed at improving the quality of healthcare services and patient safety. Analysis of the scientific literature revealed the predominance of a static view of clinical governance and an emphasis on controlling professional practices to achieve clinical performance and organizational excellence. This article offers a more dynamic conception of clinical governance that takes into account the synergy between organizational context and professional practices and raises a number of issues related to its implementation. The second article examines the various levers mobilized to institutionalize the principles of continuous quality improvement in healthcare systems. We analyzed the role and the scope of levers in the evolution of Ontario’s cancer care system and in the transformation of clinical practices. Our empirical data showed three phases and many steps in the system’s transformation in which actors in positions of authority mobilized levers to introduce changes. Our study revealed that the transformation of Cancer Care Ontario reflected a radical evolutionary change, each phase of which was a pivotal period in the evolution and implementation of a system to improve the quality of oncology care and services and enabled levers to be mobilized at all levels of the system. The third article examines one specific lever for transformation, that of the community of practice, to better understand the role of professional practices in transforming the organization of care and ultimately in the strategic positioning of the nursing profession. We analyzed nursing practices in the practice community of oncology advanced practice nurses (APNs). Basing ourselves on the conceptual framework of strategy as social practice, our results indicated that the profession’s investment in strategic areas increased nurses’ capacities to transform both their practices and the organization. Our results also underscored the determinant role of context in the development of strategic capacities among professionals. Finally, our results revealed three emergent strategies in nurses’ practice: a development strategy for oncology nursing practice, a strategy for institutionalizing APN policies within the oncology system, and a strategy for positioning the nursing profession. The results of our study showed that healthcare quality improvement is situated. Transforming an entire system, such as Ontario’s cancer care system, depends, on one hand, on the capacity for action of actors in positions of authority who mobilize a variety of levers to introduce change; and on the other hand, on the actors at the organization’s base adopting levers in their own clinical practices to develop a professional plan and, at the same time, transform the system in which they are evolving.

Cette thèse s’intéresse à l’amélioration des soins et des services de santé et touche aux relations entre 3 grands thèmes de l’analyse des organisations de santé : la gouvernance, le changement et les pratiques professionnelles. En nous appuyant sur l’analyse organisationnelle contemporaine, nous visons à mieux comprendre l’interface entre l’organisation et les pratiques cliniques. D’une part, nous souhaitons mieux comprendre comment l’organisation structure et potentialise les pratiques des acteurs. D’autre part, dans une perspective d’acteurs stratégiques, nous souhaitons mieux comprendre le rôle des pratiques des professionnels dans l’actualisation de leur profession et dans la transformation et l’évolution des organisations. Notre étude se fonde sur l’hypothèse qu’une synergie accrue entre l’organisation et les pratiques des professionnels favorisent l’amélioration de la qualité des soins et des services de santé. En 2004, le gouvernement ontarien entreprend une importante réforme des soins et services dans le domaine du cancer et revoit les rôles et mandats du Cancer Care Ontario, l’organisation responsable du développement des orientations stratégiques et du financement des services en cancer dans la province. Cette réforme appelle de nombreux changements organisationnels et cliniques et vise à améliorer la qualité des soins et des services dans le domaine de l’oncologie. C’est dans le cadre de cette réforme que nous avons analysé l’implantation d’un système de soins et de services pour améliorer la performance et la qualité et analysé le rôle des pratiques professionnelles, spécifiquement les pratiques infirmières, dans la transformation de ce système. La stratégie de recherche utilisée correspond à l’étude approfondie d’un cas correspondant à l’agence de soins et de services en oncologie en Ontario, le Cancer Care Ontario, et des pratiques professionnelles infirmières évoluant dans ce modèle. Le choix délibéré de ce cas repose sur les modalités organisationnelles spécifiques à l’Ontario en termes de soins en oncologie. La collecte de données repose sur 3 sources principales : les entrevues semi-structurées (n=25), l’analyse d’une abondante documentation et les observations non participatives. La thèse s’articule autour de trois articles. Le premier article vise à définir le concept de gouvernance clinique. Nous présentons l’origine du concept et définissons ses principales composantes. Concept aux frontières floues, la gouvernance clinique est axée sur le développement d’initiatives cliniques et organisationnelles visant à améliorer la qualité des soins de santé et la sécurité des patients. L’analyse de la littérature scientifique démontre la prédominance d’une vision statique de la gouvernance clinique et d’un contrôle accentué des pratiques professionnelles dans l’atteinte de l’efficience et de l’excellence dans les soins et les services. Notre article offre une conception plus dynamique de la gouvernance clinique qui tient compte de la synergie entre le contexte organisationnel et les pratiques des professionnels et soulève les enjeux reliés à son implantation. Le second article s’intéresse à l’ensemble des leviers mobilisés pour institutionnaliser les principes d’amélioration continue de la qualité dans les systèmes de santé. Nous avons analysé le rôle et la portée des leviers dans l’évolution du système de soins en oncologie en Ontario et dans la transformation des pratiques cliniques. Nos données empiriques révèlent 3 phases et de nombreuses étapes dans la transformation du système. Les acteurs en position d’autorité ont mobilisé un ensemble de leviers pour introduire des changements. Notre étude révèle que la transformation du Cancer Care Ontario est le reflet d’un changement radical de type évolutif où chacune des phases est une période charnière dans la transformation du système et l’implantation d’initiatives de qualité. Le troisième article pose un regard sur un levier spécifique de transformation, celui de la communauté de pratique, afin de mieux comprendre le rôle joué par les pratiques professionnelles dans la transformation de l’organisation des soins et ultimement dans le positionnement stratégique de la profession infirmière. Nous avons analysé les pratiques infirmières au sein de la communauté de pratique (CDP) des infirmières en pratique avancée en oncologie. En nous appuyant sur la théorie de la stratégie en tant que pratique sociale, nos résultats indiquent que l’investissement de la profession dans des domaines stratégiques augmente les capacités des infirmières à transformer leurs pratiques et à transformer l’organisation. Nos résultats soulignent le rôle déterminant du contexte dans le développement de capacités stratégiques chez les professionnels. Enfin, nos résultats révèlent 3 stratégies émergentes des pratiques des infirmières : une stratégie de développement de la pratique infirmière en oncologie, une stratégie d’institutionnalisation des politiques de la CDP dans le système en oncologie et une stratégie de positionnement de la profession infirmière. Les résultats de notre étude démontrent que l’amélioration de la qualité des soins et des services de santé est située. L’implantation de transformations dans l’ensemble d’un système, tel que celui du cancer en Ontario, est tributaire d’une part, des capacités d’action des acteurs en position d’autorité qui mobilisent un ensemble de leviers pour introduire des changements et d’autre part, de la capacité des acteurs à la base de l’organisation à s’approprier les leviers pour développer un projet professionnel, améliorer leurs pratiques professionnelles et transformer le système de soins. / This thesis looks at the improvement of health and social services and touches upon the three major themes in the analysis of healthcare organizations: governance, change and professional practice. Based on contemporary organizational analysis, our aim is to better understand the interface between the organization and clinical practices. On the one hand, we wish to better understand how an organization structures and potentiates actors’ practices. On the other hand, from the perspective of strategic actors, we wish to better understand how professional practices contribute to the actualization of their professions and to the transformation and evolution of organizations. Our study is based on the hypothesis that a heightened synergy between the organization and professional practices stimulates improvement in the quality of healthcare and services. In 2004, the Ontario government undertook a major healthcare system reform in the cancer field and reviewed the roles and mandates of Cancer Care Ontario, the organization responsible for developing strategic orientations and for the funding of cancer services in the province. This reform called for many organizational changes and transformations in clinical practices, with the aim of improving the quality of cancer care and services. It was in the context of this reform that we analyzed the implementation of a system of care and services to improve performance and quality, as well as the role of professional practices, specifically nursing practices, in transforming this system. The research strategy we used was an in-depth case study, the case being the Ontario system of cancer care and services and the nursing professional practices that developed within this model. We deliberately selected this case based on organizational modalities that are specific to Ontario with regard to oncology. For data collection we used three main sources: semi-structured interviews (N = 25), analysis of an abundance of documentation, and non-participative observations. The thesis is organized around three articles. The first article aims to define the concept of clinical governance. We present the origin of the concept and define its principal components. A concept whose delineation is somewhat vague, clinical governance focuses on the development of clinical and organizational initiatives aimed at improving the quality of healthcare services and patient safety. Analysis of the scientific literature revealed the predominance of a static view of clinical governance and an emphasis on controlling professional practices to achieve clinical performance and organizational excellence. This article offers a more dynamic conception of clinical governance that takes into account the synergy between organizational context and professional practices and raises a number of issues related to its implementation. The second article examines the various levers mobilized to institutionalize the principles of continuous quality improvement in healthcare systems. We analyzed the role and the scope of levers in the evolution of Ontario’s cancer care system and in the transformation of clinical practices. Our empirical data showed three phases and many steps in the system’s transformation in which actors in positions of authority mobilized levers to introduce changes. Our study revealed that the transformation of Cancer Care Ontario reflected a radical evolutionary change, each phase of which was a pivotal period in the evolution and implementation of a system to improve the quality of oncology care and services and enabled levers to be mobilized at all levels of the system. The third article examines one specific lever for transformation, that of the community of practice, to better understand the role of professional practices in transforming the organization of care and ultimately in the strategic positioning of the nursing profession. We analyzed nursing practices in the practice community of oncology advanced practice nurses (APNs). Basing ourselves on the conceptual framework of strategy as social practice, our results indicated that the profession’s investment in strategic areas increased nurses’ capacities to transform both their practices and the organization. Our results also underscored the determinant role of context in the development of strategic capacities among professionals. Finally, our results revealed three emergent strategies in nurses’ practice: a development strategy for oncology nursing practice, a strategy for institutionalizing APN policies within the oncology system, and a strategy for positioning the nursing profession. The results of our study showed that healthcare quality improvement is situated. Transforming an entire system, such as Ontario’s cancer care system, depends, on one hand, on the capacity for action of actors in positions of authority who mobilize a variety of levers to introduce change; and on the other hand, on the actors at the organization’s base adopting levers in their own clinical practices to develop a professional plan and, at the same time, transform the system in which they are evolving.