NURSE PRACTITIONERS IN NEW ZEALAND Frances Hughes Chief Advisor Nursing

1. NURSE PRACTITIONERS IN NEW ZEALANDFrances Hughes – Chief Advisor Nursing  

2. OUTLINE Key Principles Nurse Practitioner Research Cycle Impact of Nurse Practitioners on Population Health Outcomes Cost-Effectiveness of Nurse Practitioners Collaboration With Other Health Professionals Nurse Practitioner Models of Care Employment of Nurse Practitioners

3. Work towards health gain to address and reduce inequalities and inequities in health Most advanced level of clinical nursing practice Centred on patient and population needs and improving health outcomes Continue to evolve in response to changing societal and health needs. NURSE PRACTITIONERS IN NEW ZEALAND – KEY PRINCIPLES

4. NURSE PRACTITIONERS IN NEW ZEALAND – KEY PRINCIPLES Population health status drives the provision of nurse practitioner services Complements the role of other health professionals Autonomous practitioners certified to practice by the Nursing Council of New Zealand Practice based on collaboration with other health professionals.

5. The New Zealand Health Strategy

6. Primary Health Care Strategy

9. THE NURSE PRACTITIONER ROLE: Prevents unnecessary hospital admissions Targets specific populations or client groups, emphasising health promotion and maintenance and disease prevention Builds on existing personal health services and provides a way of working with consumers preventively

10. Assists DHBs to achieve their objectives Uses different models of nursing care to lead or collaborate in health care Allows for the prescription of interventions and authorised medicines within a defined scope of practice.

11. Nurse Practitioners are competent to: Obtain health histories and perform physical examinations Diagnose and treat acute health problems such as infections and injuries Case manage clients with highly complex conditions, assisting them to access services to keep them in their homes and family environment

12. Diagnose, treat and monitor chronic diseases such as diabetes and hypertension Undertake clinical management and monitoring of treatment regimes Order, perform and interpret diagnostic studies such as laboratory test results and X-rays Prescribe medications and other treatments within their scope of practice

13. Provide family planning and women’s health services Provide wellchild care, including screening and immunisations Provide health maintenance care for adults, including annual physical checks Provide care that is culturally appropriate and specific for Mäori

14. Promote positive health behaviours and self-care skills through education and counselling Collaborate with other health professionals as needed Refer to other health professionals as necessary Accept referrals from other health professionals.

15. Evolution of NP Research Descriptive Who are they and what do they do? Legitimisation Do we need then? Proving worth What can they offer? Comparative How do they compare to MDs? Proving difference What do they do that is different? Economic modelling Are they cheaper? Cost effectiveness Are they cost effective? Clinical outcomes What are the effects of NP practice on health outcomes of consumers?

16. Outcome Measures Used in APN Research Care-related Patient-related Number of blood transfusions NP job satisfaction Prenatal/postpartum visits Clinical competence Low birthweigth rates Performance ratings Rates of caesarean section Collaboration Number of induced labours Procedure complication rates Use of fetal monitoring Revenue generation Analgesia/anaesthesia used Physician recruitment and retention Forceps deliveries Time savings for house staff MDs Amniotomies Effect on MD workload Apgar scores Adherence to best-practice guidelines Infant growth and development Index scores on management of common medical problems

17. Outcome Measures Used in APN Research Care-related Patient-related Cost Patient satisfaction Length of stay Patient access to care In-hospital mortality Patient compliance Morbidity Patient complaints Readmission rates Health maintenance Occurance of drug reactions Return to work Procedure success rate/complications Stress levels Clinic wait time Knowledge Time spent with patients Blood pressure control Number of visits per patient Diet and weight control Blood glucose levels Performance-related Acute care home visits Quality of care Clinic wait time Interpersonal skills Emergency room wait time Technical quality Drug reactions Time spent in role components Alcohol consumption

18. Outcome Measures Used in APN Research Care-related Use/ordering of lab tests Rate of drug prescription Management of common medical problems Number of consultations Infant immunisations Diagnoses made Diagnostic screening tests ordered

19. IMPACT OF NURSE PRACTITIONERS ON POPULATION HEALTH OUTCOMES Lewis and Resnick (1967) – Patient care outcomes from a nurse-led clinic primary health care service for adults with chronic illness Significant reduction in the frequency of complaints Marked reduction in patients seeking out doctors for minor complaints Shift in the preference of patients for nurses to perform certain functions Nurses provided competent and effective care to uncomplicated chronically ill patients comparable to that of physicians in outpatient clinics and that this care was based on patient need rather than physician prerogative.

20. Fall, Waters and Read (1997) – Costs and benefits of nurse-led ear care service in Rotherham and Barnsley in Britain Nurses trained in ear care: Reduce costs Reduce general practitioner workload Reduce the use of systemic antibiotics Increase patient satisfaction with care.

21. Mundinger, Kane, Lenz (2000) – comparison of health outcomes for 1316 patients randomly assigned to nurse practitioners or physicians for primary health care follow-up and ongoing care after emergency department visit Where nurse practitioners had the same: authority responsibilities productivity administrative requirements patient population as primary care physicians patients’ outcomes were comparable.

22. Horrocks, Anderson, Salisbury (2002). Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ 324 11 trials and 23 observational studies met all the inclusion criteria Patients were more than satisfied with care by a nurse practitioner No differences in health status were found Nurse practitioners had longer consultations,and made more investigations than did doctors No differences were found in prescriptions, return consultations or referrals Quality of care was in some ways better for nurse practitioner consultations Concluded that the increasing availability of nurse practitioners in primary health care is likely to lead to high levels of patient satisfaction and high quality care.

23. COST EFFECTIVENESS OF NURSE PRACTITIONERS US Department of Health and Human Services (Fitzgerald et al 1995) The cost of an office visit to see a nurse practitioner ranged from about 10 to 40 percent less than the cost for comparable primary health care services provided by a physician

24. Hummel and Pirzada (1994) When compared with the cost of teams made up solely of doctors of medicines (MDs) the overall costs of using an MD/NP team in a long-term care facility were 42 percent lower for immediate and skilled-care residents and 26 percent lower for long-term residents Significantly lower rates of emergency room transfers, hospital length of stays and specialty visits for patients covered by MD/NP teams

25. Jenkins and Torrisi (1995) A year long study comparing a physicians managed family practice and a nurse practitioner managed practice within the same managed care organisation. NP managed practice had 43 percent of the total emergency room visits and 38 percent of the inpatient days of the physician managed practice NPs total annualised per-member monthly cost approximately half that of the physician managed practice.

26. RESEARCH ON PATIENT SATISFACTIONVenning et al (2000) patient satisfaction is an important component of nearly all studies looking at the role of nurse practitioners patients generally report high levels of satisfaction with nurse practitioner care.

27. Kinnersley et al (2000) Study sought to ascertain differences between care from nurse practitioners and from general practitioners for patients seeking same day consultations Patients consulting NPs were significantly more satisfied with their care Patients managed by NPs reported receiving significantly more information about their illness.

28. COLLABORATION WITH OTHER HEALTH PROFESSIONALS Nurse practitioners offer an approach to care based on the art and science of nursing Nurse practitioner services complement those of other health professionals Responsibility for client care is ongoing and may be shared or sit with one practitioner

29. COLLABORATION WITH OTHER HEALTH PROFESSIONALS The practice of nurse practitioners is based on collaboration and colleagueship which has been defined as ‘interprofessional relationships between the nurse practitioner and other health team members based on: Concern for mutual goals Equality in such dimensions as status, power, prestige, and access to information Diversity in expertise, skills, knowledge and practice.

30. Options for collaborative practice A nurse practitioner and another health professional may share responsibility for all or part of the care of a population group. Nurse practitioners and other health professionals may have formal clinical meetings and together are acknowledged as the team.

31. THE PRESS STORY Nurses' bigger role 'scary' 05 August 2002 By MICHELLE BROOKER Doctors see more conflict with nurses on the horizon as nurses prepare to take on more of the duties traditionally done by GPs.

33. NURSE PRACTITIONER MODELS OF CARE Model 1: Integrated Nursing Teams   A team of nurses and nurse practitioners provide, co-ordinate and manage health promotion and disease prevention across the continuum of care. For example, integrated primary health care nursing teams working out of Primary Health Organisations undertaking risk assessments, first contact care, case management of clients with chronic conditions.

34. Model 2: Nurse Consultancy works independently refers clients to other health professionals where required collaborative practice arrangements and care decisions may also dominate, eg within hospital settings, between primary health care services and secondary services, and between secondary services and tertiary services, or between non-Government organisation providers. Provides leadership to nurses and referral to other disciplines.

35. Model 3: Independent Practice Nurse practitioners are self-employed and establish their own independent practices offering care and services directly to the public. For example, nurse practitioners contract themselves for services to other agencies, hospitals, primary health organisations, non-government organisations, direct to clients.

36. Model 4: Nurse Practitioner Specialty Services / Clinics The nurse practitioner is the recognised lead health professional within the health care team for establishing and managing specialty clinics/services for a particular health specialty and/or population group. For example, pain management, anaesthetists, wound management, rehabilitation, disease management.

37. Employing nurse practitioners Nurse practitioners could be: Direct employees of the DHB Employees of primary health organisations or private providers Professionally independent Employed in locum positions between services in the DHB provider arm or within the private sector.

38. Funding to develop the nurse practitioner role Direct sources of funding: DHBs individually or collectively develop funding proposals and budgets to support the development of the nurse practitioner role in their DHB or region.

39. Funding to develop the nurse practitioner role Indirect sources of funding: Cost savings generated from initiatives to strengthen the current nursing workforce (eg collaboration on recruitment and retention strategies) Improved nursing skill mix within DHBs Improved access to primary health care Savings in medical staff costs in some areas.

40. Nurse Practitioners in New Zealand Copies available from the Ministry of Health’s website: www.moh.govt.nz Wickcliffe: (04) 496 2277 or email: pubs@moh.govt.nz

41. The New Zealand Nurse Practitioner?

42. Nurse Practitioner ? competencies 1. Articulates scope of nursing practice and its advancement. 2. Shows expert practice working collaboratively across setting and within interdisciplinary environments. 3. Shows effective nursing leadership and consultancy.

43. Nurse Practitioner ? competencies - continued 4. Developed and influences health/socio-economic policies and nursing practice at a local and national level. 5. Shows scholarly research inquiry into nursing practice. 6. Prescribes interventions, appliances, treatments and authorised medicines within the scope of practice.

44. Nurse Practitioner? Education Programmes Nursing Council assess and audit Master’s programmes for Nurse Practitioners (including Nurse prescribing). Strong clinical focus required in the programmes. Collaboration between service and education providers essential.

45. Nurse prescribing education programmes These programmes are required to include content specific to the nurse’s scope of practice in the following areas: Assessment process (advanced clinical assessment, differential diagnosis, bioscience) Prescribing process (clinical pharmacology, interventions, medicines choice) Monitoring process (legal issues, critical appraisal of clinical trials)

46. Assessment of Nurse Practitioners Nursing Council considers the Nurse’s portfolio which includes: Scope of practice as defined by the nurse Record of factual information (e.g. education qualifications) Professional practice history (e.g. evidence of practice, research and professional activities) References

47. Nursing Council’s Assessment process Assessment process includes: Selection of a relevant panel Desk review of portfolio Assessment of educational equivalence Referee checks - including nominated referees, clinical managers, peers, students Panel interview. The nurse is required to meet with the panel and present aspects of their practice - a clinical viva may form part of the process.

48. Assessment of Nurse Practitioners Application with portfolio Desk audit Assessment of educational equivalence Preparation for assessment Panel assessment Nursing Council Decision Review of decision

49. Educational Equivalence When assessing educational equivalence, evidence is required of the applicant’s ability to integrate theory, research and practice. The applicant must be able to demonstrate the application of nursing frameworks to her/his practice and the application of critical thinking and evidence as the basis of clinical decision making.

51. Our experience since July 2001 21 applications received 9 endorsed nurse practitioners 1 has completed panel assessment process and is awaiting Council consideration 5 failed educational equivalence. 2 on hold pending further information. 4 have been declined

53. Implementation challenges Educating health providers about the Nurse Practitioner. Changing the Government’s regulatory framework for nurse prescribing and developing Nursing Council systems

54. Exciting opportunities lie ahead Nurses with extensive clinical experience will be retained in nursing practice. Huge potential for nurses to offer innovative solutions to meet health need. Opportunity for nurses to improve the quality and effectiveness of health care in New Zealand.