Post-conference Sharing

1. Post-conference Sharing 2nd ICN International Nurse Practitioner Advanced Practice Nursing Network Conference �Making the Future : Practice, Policy and Partnerships� In Adelaide, Australia Wong Lai King, Grace Wong, Judy Tin, Elaine Mau, Fiona Ng, Sharon Lee

2. Introduction Modern health care development ? expand and enhance nursing roles - maintain continuity of holistic care - promote health - prevent diseases ? advanced practice nursing emerges Favourable factors of nurses First contact & greatest proportion of care Excel in e.g. health education and counselling, disease prevention, psychosocial care Existence of experienced nursing workforce with advanced clinical and leadership competencies

3. Introduction Nurse Clinics Steering Committee, QEH Facilitate best utilization of advanced clinical nurses� potential Build up the existing competencies Take new initiatives ? to develop quality care across boundaries

4. 2nd ICN International NP/APN Network Conference Aims Enhance role development Facilitate networking and sharing ideas Theme Making the future : Practice, Policy and Partnerships Sub-themes Practice Research Education Clinical governance

5. Areas Explored Explore issues on NP / APN Clinical governance Wong Lai King & Grace Wong Clinical practice & professional issues Judy Tin Nurse-led clinics, hospital & community health services interface Elaine Mau & Fiona Ng Competencies & educational preparation Sharon Lee

6. Our Aims of Visit : ICN Conference Advanced practice nursing Increase awareness of global development Share innovative ideas and explore related issues Create networking Expand horizons to facilitate future planning and actualization at work

7. Visit Itinerary 30 Oct 02 � Educational visit Joanna Briggs Institute Department of Clinical Nursing, Adelaide University Royal Adelaide Hospital 31 Oct to 2 Nov 02 � ICN Conference End of the day meetings (nocte) � sharing and consolidation learning experiences among members

9. NP/APN in Global Perspectives Part 1 - definition, role development A. International Council of Nurses ICN B. American Academy of Nurse Practitioner C. Royal College of Nursing D. Royal College of Nursing, Australia E. Nursing Council of New Zealand

10. NP/APN in Global Perspectives Part 2 - summary a. NP/APN Successful factors b. Role development & implementation c. Advantages of APN / NP d. Outcome measures & evaluation of NP/APN Part 3 - in Practice a. nurse -led clinic b. Nurse-Run Centre VS Doctor-Run Health Centre - London c. NP in acute care setting

11. A. International Council of Nurses ICN World-wide - NP & APN roles Def : A nurse practitioner/ APN is a RN who has acquired the expert knowledge base, complex decision making skills and clinical competencies for expanded practice, the characteristics of which she is credentialed to practice. A master level is recommended for entry level.

12. A. ICN define NP/APN Characteristics 1. Educational - advanced level - formal recognized program for NP - formal licensure, registration, certification 2.Practice - prof autonomy, independent practice, caseload, adv health assessment, decision making skills, diagnostic reasoning skill, advanced clinical competency, provide consultation, recognized first point of contact

13. A. ICN - NP/APN regulatory mechanism - varies in country 1. Right to diagnose 2. Authority to prescribe medications 3. Authority to prescribe treatment 4. Authority to admit patient 5. Legislation to confer & protect the title NP/APN 6. Officially recognized title

14. B. American Academy of Nurse Practitioner APN - expert clinician in practice APN includes - Nurse practitioner NP - Certified nurse-midwives CNM - nurse anesthetist CRNA - clinical nurse specialist CNS

15. B. AANP - NP roles NP - family, adult, pediatric, geriatric, women health, occupational health, emergency, neonatal and acute care Practice - health promotion & maintenance, disease prevention, diagnosis and manage acute & chronic disease ( health & medical care)

16. B. AANP - NP practice Serves as - primary care provider - specialty care provider - as consultant for individual, family, community in outpatient & inpatient settings - Practice autonomously - under Nurse Practice Act of the state

17. B. AANP - NP education - entry master degree - clinical & educational course - self-directed continue learning - professional development * maintain clinical competency * core competency defined by NONPF

18. B. AANP - NP Prescribing - advocate unlimited prescriptive authority - have adv education on pathophysiology, pharmacology - to diagnose, prescribe, treatment within own specialty area - 7 states plenary authority, others collaborative - 2 states prescribe under Drs� signature

19. B. AANP - Climate for NP - 30+ year of practice & research - NP - cost-effective - high quality care - serve -low income urban - rural communities - cost containment environment- NP effective, profitable way meet primary care

20. B. AANP - Standard of Practice 1. Assess health state, order Inx 2. Diagnosis -critical thinking 3. Treatment plan -EBP, test, medication, intervention, education, referral 4. Implement plan 5. F-UP & evaluate pat 6. Care priority- pat education, self-care, health, continue care, promote safe environment 7. Patient advocate 8. Quality assurance 9. NP roles- provider, mentor, educator, researcher, manager, consultant ###

21. C. Royal College of Nursing Background - 1992 RCN NP program primary care NP - walk-in centres, A&E, minor injury units, acute/ chronic care 3000 NP in UK Recognition UKCC not define NP NMC intend to identify NP RCN � RN with NP program is competent as NP

22. C. RCN - NP define Define NP - RN - specific course at least first degree Make prof autonomous decision accountable Education content of NP program ~ the core competency by NONPFaculties

23. C. RCN � NP Practice L evel Primary Care NP caseload shared with colleagues Patient can consult NP / GP or both Work care plan with patient Wide Kn & skill + a specialist Not Dr substitute Complementary source of care Secondary Care NP A&E, minor injuries unit, outpatient & inpatient High autonomy First point of contact Have continuity of care Holistic approach

24. C. RCN � Autonomy in NP RN accountable for actions NP accountable for actions Need to have authority to make decision Authority & autonomy derived from sound Kn base apply to practice = high quality care right to self-govern, make decision ~being accountable Not independent practice Collective work Vulnerability = extent of NP able to acknowledge limitations Overcome by meticulous pr, good recording, adeq education, self-assess, critical appraisal

25. C. RCN � Practice Issues lack agreed definition in professional & legal levels Insufficient comparison of diversity of roles Difficult to compare level of competency only judged by the standard for the post not for the person in the post ? Educational preparation important to avoid negligence No explicit description limit development of NP roles Public not know NP do

26. C. RCN � climate for NP government aim more nurse-led primary care NHS- all patients able to see a primary care professional within 24 hr and a GP within 48 hr by 2004 nurse increasing leading & providing service in walk-in centers, minor injury unit, general practice Need more education & training Need legislation, need lobby, define NP roles to public

27. D. Royal College of Nursing Australia (RCNA) Definition - APN - a level of nursing practice using extended and expanded skills, experience and knowledge in assessment, planning, implementation, diagnosis & evaluation of care - post-graduate - work as specialist/ generalist capacity - work autonomously, accurate decision making - basis for NP

28. E. Nursing Council of  New Zealand In 2001 finalized policy for certifying NP. Regulation for nurses prescribing in progress Process for implementing NP needs partnership with profession, government, regulatory body

29. NP/APN Successful factors Finding the right pitch developing appropriate education collaborate & consult with multidisciplinary team organizational climate to support nurses aspiring to become NP

30. Role development & implementation In UK see to client population and check for greatest need set up scope of practice Tuition by doctors develop structured program select small & well chosen group of nurses

31. Role development & implementation Australia -project manager Set up task force advisory committee community & practitioner consultation - indicate the need for NP Nurses Act 2002

32. Advantages of APN / NP Increase flexibility in mode of health care delivery Offer greater diversity in service better manage and coordinate service option for clients Early/ improved access to service more cost-effective improve continuity reduced readmission early health problem identification & intervention improve career ladder improve outcome increase staff satisfaction

33. Outcome measures & evaluation of NP / APN Patient satisfaction comparative data with medical colleagues perception of patient with NP/GP level of empowerment & participation of patients Reduce waiting time shorten LOS improve healing rate improve quality of life indicators cost-saving - decrease visits high patient & carer satisfaction

34. A general impression about the overseas experience in the implementation of Nurse-led Clinic / Services Country / Place Different places in the world had had different stages of development and implementation of nurse-led (NP and APN ) clinic / service. Background The reasons to introduce or develop nurse-led clinic / services were related to service need, medical shortage and need of professional advancement as well. Scope of practice Advancement of nursing practice was evident in these nurse-led clinics/ service, including : n assessment, investigations - blood taking, ECG recording n diagnosis, treatment +/- prescription

35. Mode of practice n Mostly collaborative relationship with doctors and other health professionals n Level of independence varied. Source of clients walk-in (mostly), referral Service set-up : � Recruitment n Nurses with certain clinical experience � Training n Received special training / education, mostly master level � Develop guidelines n Protocols & Standards of practice were usually available for guidance and monitoring as well.

36. Service evaluation n Patient satisfaction increased - speed and convenience of access improved n Staff satisfaction improved -- increased autonomy, increased sense of control over work, strong sense of teamwork and job satisfaction. Future challenges / opportunity Different countries were facing different challenges, including : n Continue to identify potential areas for development of NP/ APN services n Develop succession plan for the existing nurse-led clinic / service n Striving for recognition in statutory body n Searching for legislation in various issues, such as licensure issue , nurse prescribing issues n Anticipating financial issue n Improving skills in e.g. physical assessment (adult & child), mental health n Gaining and sustaining trust and acceptance both from the public and other health professionals.

37. Nurse-Run NHS Walk-In Centre VS A Doctor-Run Health Centre - London Teenagers and young adolescent preferred nurse-led centre, children and elderly attended the physician-led centre. Most of youth seek for emergency contraception methods More acutely ill patients in GP than those of nurse practitioners. nurse-led centre promoted nurses autonomy, job satisfaction, role enhancement, client satisfaction, and high quality of health care.

38. However, nurses were working at absolute limited skill and knowledge. Nurse practitioners stressful - to assess patients within 15 min limited feedback and skill mix from nursing leaders Actually, patients showed little selectivity in choosing nurse-led or doctor-led services in South London. Recommendation > nurses need to (i) strengthen the physical assessment and diagnostic skills (ii) study the advanced education program (iii) improve referral pathways (iv) access clinical advice (v) continuous education.

39. Nurse Practitioner in Acute Care Setting Background pat from ICU has complex care needs nurse & junior Dr not competent enough long ICU stay & high readmission created a post to bridge the gap

40. Nurse Practitioner in Acute Care Setting Case management accept referrals staff education adm & discharge order tests, therapeutic Rx - approved clinical guidelines Comprehensive assessment consultation to medical grief counselling develop database for record of practice

41. Nurse Practitioner in Acute Care Setting Outcome measures decrease LOS in ICU reduced ICU readmission early identify patient problem improve support/ education to staff Overcome Barriers collaboration & regular meetings protocol driven guidelines legitimate support by key executive

42. Competencies Describe generic practice of nurses in advanced practice Form a reference for Development of guidelines & standards of practice Curriculum development Evaluation of practice & educational programs

43. Competencies Manage health / illness Nurse-client relationship Teaching function Professional role Influence health care delivery systems Ensure quality of health care practice Cultural competence (NONPF 2001) Articulate and advance nursing practice Collaborative practice Leadership and consultancy Influence health / socioeconomic policies Research inquiry into nursing practice Prescribe interventions within scope of practice (Nursing Council, New Zealand 2001)

44. Education Historical perspective No national strategy for training and implementation NPs seem to take �technical� or �medically� related tasks No �officially� recognized education programs Education preparation varies � few days in-service training to diploma program

45. Education Desirable NP/APN profile Graduate preparation Higher clinical and cognitive skills Independent practice and autonomy Effective collaborative practice Role eclecticism

46. Education Characteristics of APN�s education Educational preparation at advanced level Formal recognition of educational programs Formal system of licensure, registration, certification and credentialing (ICN 2002)

47. Education Current status Demands of APN increases Regulation on �professional agenda� Disparity in educational preparation Degree / master Focus Clinical specialty Life course Disease Generic Continuing education : workshops, seminars, conferences

48. Education Examples of content outlines Therapeutic nursing care Comprehensive physical assessment Health & disease History taking & clinical decision-making skills Applied pharmacology & evidence-based prescribing Care management Research Organizational, interpersonal & communication skills Accountability � including legal & ethical issues

49. Education Challenges of teaching advanced clinical skills What are the appropriate skills ? How to develop safe and competent APN ? What are the valid & reliable assessment strategies ? How to enhance APN�s confidence ?

50. Issues Considered Fit for purpose (respond to service needs & competencies) Maintain primacy of clinical practice Equal emphasis on �process� & �outcome� Equip not only for the �here and now�, but also for the future Resources What level - Diploma / degree / master ? X Diploma Degree � initial preparation ? Master � Higher level of clinical complexity, enhanced leadership and role development

51. Policy/Regulation/Licensure/Legislation(1) Australia as an example Regulatory authority - The Nursing Board Achieved through the Nurses Act: 1991, 1993� Supported by: the Health Department

52. Policy/Regulation/Licensure/Legislation (2) Role of the Health Department Develop Task Force, implement guidelines, framework and process for the recognition and development of NP Annual re-licensure -Proof of relevant practice within previous 5 years

53. Leadership(1) Commonalities: good interpersonal relationship, motivation, guidance, change agent, conflict management Collaborative care and practice Critical thinking � integration of theoretical and practical knowledge

54. Leadership(2) Expert clinical decision-making skills e.g. Drug prescription - quality, safe efficacy, timely access Participative management - policies and legislation

55. Leadership (3) Personal quality and attributes Team building: collaborative care Social ability 6C

56. Leadership (4) 6C: Conviction : passion, accept criticism Character : integrity, honest Care Course : willing to stand up for beliefs Composure : appropriate response Competence: Culture competence for international perspectives

57. Policy/Regulation/Licensure/Legislation (2) Role of the Health Department Develop Task Force, implement guidelines, framework and process for the recognition and development of NP Annual re-licensure -Proof of relevant practice within previous 5 years

58. Policy/Regulation/Licensure/Legislation (3) Approach/Regulation for the development of NP system & policy: Protect the title for the job: amendment / endorsement of the Nurses Act Set up Steering Committee Consult stakeholders

59. Policy/Regulation/Licensure/Legislation (4) Get doctors involved Share ideas Develop conjoint protocols Seek funding support : Government, Hospital Develop training programs Work on Mentor/Pilot study Set and implement evaluation strategies

60. Policy/Regulation/Licensure/Legislation (5) Variances in education/legislation/ scope of practice A National working group for the standardization is under studied Major concerns : referral, prescription right

61. Observation/Conclusion(1) Diversified system/boundaries within one country/one country to another Competencies / Continuing competencies/ Standards / Scope of Practice as major focus for protection of the community & the staff Regulation: Prescribing is a major concern

62. Observation/Conclusion (2) Funding/Resources supports are essential throughout the processing e.g. for research elements Need to Protect the Title for �Safe� Financing/Insurance System of the country as one essential direction for NP development e.g. Reimbursement need, self-help group

63. Observation/Conclusion (3) Outcome measures/Evaluation indicators are essential Not all potential staffs/whilst taking relevant roles are suitable as APN/NP e.g.personal traits-the staff should know his / her limit, have lateral thinking, and be ambitious... Collaborative practice in addition to independent practice