Development of the role of the Advanced Nurse Practitioner in Diabetes

1. Development of the role of theAdvanced Nurse Practitioner in Diabetes Helen Burke Advanced Nurse Practitioner (Diabetes) University College Hospital Galway.

2. Historical Development ANP Roles Internationally • Role of Nurse Practitioner developed in 60’s by Loretto Ford in Colorado (Paediatric) • CNS and NP programmes in the US ran parallel in mid 60’s. • These roles were quickly adapted throughout much of the U.S. and with the development of university based educational programmes delivered at masters degree level, this type of primary care role heralded the development of many similar roles in primary and more recently in acute care settings( Brown& Grimes1995, Walsh 2001,Guido 2004)

3. Defining Advanced Practice. • ICN Defines advanced practice as “The Nurse Practitioner/ Advanced Practice Nurse is a registered nurse who has acquired the expert knowledge base, complex decision making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and country in which he/she is credentialed to practice”. A Masters degree is recommended for entry level(ICN2002)

4. Origins of ANP Roles in Ireland • Commission on Nursing 1998 • Commission on Nursing recognised that promotional opportunities should be made available for nurses wishing to remain in clinical practice and accordingly recommended a clinical career pathway leading from registration to clinical specialisation and to advanced practice. • The development of this career pathway serves to develop clinical nursing and midwifery expertise in the interest of holism and excellence in patient care. • National Council for the Professional Development of Nursing and Midwifery 1999. • Framework for the development of ANP/AMP Posts 2001 (revised 2004)

5. Definition of Advanced Nurse/Midwife Practitioner (Ireland) • Advanced practice - autonomous, experienced, competent, accountable and responsible for own practice • Highly experienced in clinical practice • Educated to masters degree level (or higher) • Promote wellness, offer healthcare interventions and advocate healthy lifestyle choices for patients/clients, their families and carers in a wide variety of settings in collaboration with other healthcare professionals, according to agreed scope of practice guidelines • Utilise sophisticated clinical nursing/midwifery knowledge and critical thinking skills to independently provide optimum patient/client care through caseload management of acute and/or chronic illness

6. Definition of Advanced Nurse/Midwife Practitioner (Ireland) • Grounded in the theory and practice of nursing/midwifery • Incorporates other related research, management and leadership theories and skills • To encourage a collegiate, multidisciplinary approach to quality patient/client care • ANP/AMP roles developed in response to patient/client need and healthcare service requirements at local, national and international level • ANPs/AMPs must have a vision of areas of practice that can be developed beyond the current scope of practice and a commitment to the development of these areas

7. Be a registered nurse or midwife on An Bord Altranais’ live register; Be registered in the division of An Bord Altranais register for which application is being made (in exceptional circumstances which must be individually appraised, this criterion may not apply) Be educated to masters degree level (or higher). The post-graduate programme must be in nursing/midwifery or an area which is highly relevant to the specialist field of practice (educational preparation must include a substantial clinical modular component(s) pertaining to the relevant area of specialist practice) Have a minimum of 7 years post-registration experience, which will include 5 years experience in the chosen area of specialist practice Have substantive hours at supervised advanced practice level. Have the competence to exercise higher levels of judgement, discretion and decision making in the clinical area above that expected of the nurse/midwife working at primary practice level or the clinical nurse/midwife specialist; Demonstrate competencies relevant to context of practice; and Provide evidence of continuing professional development. Criteria for Approval as ANP

8. Breast Care Cardiology Cardiothoracic Child & Adolescent Mental Health & Psychotherapy Diabetes Emergency Emergency Cardiology Gastroenterology Neonatology Oncology Palliative Care Primary Care Rheumatology Sexual Health Stroke Care Approved ANP Posts

9. DiabetesMellitus It is estimated that 194 million people worldwide have diabetes with this figure expected to double by 2025. IDF (2003) described diabetes alongside global warming ,emerging diseases and environmental pollution as one of the worlds biggest environmental disasters. “The effect of Aids in the last 20 years will be repeated by diabetes in this century”

10. The alarming increase in diabetes is as a result of ageing populations, dietary changes, reduced physical activity and other unhealthy and behavioural patterns. • A new trend of increasing cases of type 2 diabetes in children and adolescents is emerging. These patients are likely to have kidney and cardiovascular disease much earlier in life, adding to the health economic burden (IDF 2003) • The financial and social burden of diabetes will be intolerable if measures are not taken to address this disease.

11. Irish Situation • It is estimated that 200,000 people in Ireland have diabetes with a further 200,000 undiagnosed with the condition. The majority of these people will be diagnosed through an acute medical event due to the complications of long term untreated hyperglycaemia. • A further 250,000 have impaired glucose tolerance or pre-diabetes of which 50% will develop diabetes in the next 5 years if lifestyle changes are not made.( Diabetes Care: Securing the Future 2002) • In Ireland diabetes care accounts for 10% of the total health budget ( 350 million euro). More than half of this(59%) is spent on treating complications.

12. Diabetes Day Centre University College Hospital Galway. • Established in 2001. • Services provided focus on diagnosis, treatment and patient education. • The centre facilitates many sub-specialist clinics/services to enhance care for patients with diabetes. • Specialist clinics. Young Adults clinic/Combined nephrology and diabetes service/Combined obstetric and diabetes service and pre-pregnancy service / Obesity clinic/Annual review/foot clinic. • Services provided include. Podiatry, Dietetics ,Psychology, Phlebotomy ,DAFNE, ,Telephone support service, Group education and Retinal screening. • Paediatric/Adolescent Diabetes services are provided from the Paediatric unit/outpatients department. • Transitional service will be provided from June 2007.

13. Getting Started

14. AIM To train a suitably qualified, experienced nurse to independently assess, diagnose, treat, discharge / refer patients with diabetes attending diabetes services at University College Hospital Galway.

15. Rationale • Develop clinical career pathway for experienced nurses • Provide clinical leadership in critical area • Enhance the quality of service delivered by the multi-disciplinary team to patients with diabetes • Provide more timely, but safe, service leading to improved patient satisfaction • Release physician time to deal with increasing acute workload

16. Process. • The process for the establishment of an ANP service comprises two important parts. • Service applies to have the post approved as an ANP/AMP post ( Job Description/Site Preparation) • The nurse/midwife applies to be accredited as an ANP/AMP to the approved post( individual accreditation)

18. My Journey. • 2001-Establishment of the Diabetes Day Centre. • 2001-Appointment of Professor of Medicine/ Endocrinology • 2002- The development of the ANP/Diabetes was discussed formally with nursing/medical management. The intention to develop the post was discussed with relevant stakeholders. (Consultants ,laboratory, nursing colleagues, dietitics, general practitioners). • 2003- Commenced the Masters in Health Science/Advanced Practice at NUI Galway. Professor of medicine agreed to act as medical mentor ( supervised clinical practice hours) • 2004- Approval for post for ANP/Diabetes included in service plan.

19. 2005- preliminary job description submitted to NPDU. • 2005- Completed Masters in Health Science/ Completed supervised clinical hours. • Multidisciplinary Working group established for candidate ANP’s in UCHG/Mayo general/Portiuncla • Set Goals • Specify action steps • Establish timelines • Identify indicators of success • role development for the 3 sites/UCHG/Mayo General/Portiuncla Hospital • Commenced work on site preparation. • 2006- June/Site visit from National council. August- submitted Job portfolio. September received accreditation from the National Council.

20. Site Preparation • Review of National policy documents relevant to diabetes services. • Review of research data pertaining to diabetes.( DCCT/UKPDS/ Diabetes Care: Securing the Future). • Review of service Adult and Paediatric need. ( 7,000 patient visits 2005). • Audit current activity of service • Service need established • Client group & caseload identified • Identify outcome measurement • Stakeholder ‘BUY IN’ • Demographics of region.( Fastest growing city in Europe, Student population, Tourism, 50% of boards population under 30 years, Higher percentage of people over 65 years =14% national average 11%, Large rural population. • Predictions for Future diabetes services based on demographics and epidemiology studies. (DfI 2002) • Review of current roles and their effectiveness through audit. (Review similar roles and the effectiveness of these roles).

21. Job description • Detailed job description containing details of the role and responsibilities of the post, reporting relationships, reflecting the required experience and education as specified by the National council. • Incorporate core concepts and definition of ANP role, together with core competencies for the role • Developed in line with service plan and NMPDU

22. Clinical Supervision • Major commitment required by clinical mentor/supervisors ( 1,400 supervised hours) • Generates an environment conducive to learning for all

23. Selling The Role. • The integration of the ANP role into the practice setting has implications for patients, nurses and midwifes, medical colleagues, and other health care professionals. • To ensure successful integration of the role employers and the ANP must give consideration to how best integrate the role in the context of the multidisciplinary team and the effect of the role on the work of other health care professionals. • Talk to other health care professionals about the role. Liaise with departments that you will be referring patients to. Organise Meetings/ articles re Advanced practice in hospital newsletter.

24. Service needs addressed by post. • Education- Need. Patients with diabetes and many primary and secondary health education needs. The health education component of the ANP role is central to the provision of this need. Response- ANP supports the empowerment of patients/families. Individualised care plans are developed for each patient incorporating holistic management. • 2)Specialised Clinics-Need. The benefits of specialised clinics for complicated and specialised groups have been well established and demonstrated( NICE 2004) The ANP is central to the continued development and management of these clinics Response- Optimise care for patients attending young adults/annual review clinics attending to the special needs of these group of patients.

25. Paediatric/Adolescent Clinics. Need- The diabetes service at UCHG provides a structured multidisciplinary service to this cohort of patients and their families. Recommendations for paediatric diabetes care continue to be updated and implemented( NICE 2004/ISPAD 2004) Response- The ANP is actively involved in providing and optimising patient and family care .a) Involved in setting up transitional care for adolescents transferring to adult services .b) Service for schools. C) One home visit post discharge d) Implementation of NICE guidelines for the care of children/adolescents with diabetes e) Parent support workshops.

26. Linking Primary to secondary care Need- To foster and develop links between both services for people with diabetes. Response- The ANP is involved in the development process for a shared care scheme in the Galway area. Involved in the Development of guidelines for best practice which will be used throughout the HSE West/North West/Mid-West. Provide education programmes/workshops for GPS/Practice nurses/public health nurses. Involved in the development of the DESMOND Programme( hospital/community) Deliver the diabetes component of the Diabetes module for practice nurses NUI GALWAY/

27. Caseload Patients with Type 1 and Type 2 Diabetes. New onset Diagnosis. Existing patients. New Type 2 clinic/GP referral. Children 0-13 years. Adolescents 13-18 years. Young Adults 18-26 years. Paediatric review clinic. Annual Review clinic. MDI Programmes. Group education programmes for Type 2 patients, Referral OPD IN-PATIENT Service. Adult/Paediatric. Maternity Services. dietetics Social Work Department Primary care Podiatry. Health Promotion. Advanced Nurse Practitioner

28. Advanced Nurse Practitioner Scope of Practice/Diabetes. • Independent practice • Assess patients with diabetes. • Diagnose. Physical examination/Patient history/ Laboratory investigations. • Treat. Insulin Therapy/oral hypoglycaemic Therapy/antihypertensive agents/statins • Discharge to GP or to other specialist clinics • Referral pathway to appropriate service. Dietetics/ ophthalmology /nephrology/ vascular/ podiatry/ health promotion. • Education –Patient/ other health care professionals involved in diabetes care. • Consultancy

29. Guidelines for Practice • Collaboratively agreed (Nursing management/Consultants/ Paediatrician/Nurse Practitioner) • Evidence based. • Standard approach to managing clinical presentations for the diabetes department. • Regularly reviewed by Consultants/ANP. • Allow for safe innovation in practice Laboratory, Medication Management. • Describes what the ANP does.

30. Education Activity • Clinical teaching & clinical supervision • Nurses ( hospital nursing staff, practice nurses/public health nurses/nursing students) • Doctors (SHO’s, Training SPRs, Med students-General Practitioners) • Allied professionals (dietetics, podiatry, psychology, social work) • In-service education medical & nursing staff. • Lecture on various post-graduate programmes in 3rd level institutions.

31. Consultancy • Provide consultancy service to multi-disciplinary team members. • Provide consultancy to primary care services (PHN, Practice Nurses, GP’s). • Provide Nursing consultancy on DSAG (Diabetes services advisory group, HSE WEST/North west/Mid-West) • Authority/clinical nursing expertise for diabetes care • Provide support to specialist area’s outside diabetes engaged in ANP role development

32. Research & Audit • Identified research priorities for role. A) MIND Study B) Evaluation of MDI Programmes C) Evaluation of paediatric education programmes. D) Type 2 Group education programmes. • Clinical / Patient focus to research. • Evidence for care • Audit of service need ( case mix/Patient activity levels adult/paeds) • Audit of quality.

33. Case Scenario. • Jane -21ys. • Type 1 diabetes 10 years. • Poor glycaemic control during adolescence, HBA1C 10-12%. • June 2006- Hba1c 12.4%. • Complications- right background diabetic retinopathy, left pre-proliferative retinopathy. • Microalbuminuria (Ramipril 10mg/nocte). • Symptomatic of hyperglycaemia, tired, thirsty, weight loss ,irritable and fed up. • Attending young adults clinic.

34. ANP INPUT • Empowered Jane to become involved in her care and decide on her treatment choices/ decisions. • Changed insulin Therapy ( 4 injections/daily /novorapid/lantus) • Twice monthly visits to ANP. • 3monthly visits to young adults clinic. • Telephone support weekly • Referred to dietitian • Psychologist. • Referral to opthalmology. Will be followed up yearly. No laser treatment required. • Hba1c September 9.1%. December 7.8% February 7.8% • Jane feels much better, not symptomatic of hyperglycaemia and happier that she is assuming control and self managing her diabetes. • Referred back to young adult service will be seen 2 monthly. • Continue telephone support/weekly.

35. Case Study. Jack-Age 68 yrs. Diagnosis type 2 diabetes 1986. Attending G.P. Services. Treatment- Glucophage 850mgs/tds. Diamicron 80mgs/bd. Complications- Coronary Artery disease. MI 2003. Coronary Artery by-pass 2003. Diabetic Neuropathy. Diabetic Retinopathy Referred to Diabetes Service 2005. Attending annual review clinic. HBA1c 9.4%.

36. ANP Input. Commenced on Lantus once daily. Remains on Glucophage 850mgs /tds. Referred to dietitian. Referral to opthalmology. Referral to chiropody( Community chiropodist) Telephone support twice weekly x 2 weeks, then weekly x 2 weeks for advice on insulin dose adjustment. Group education. Continue telephone support weekly or Jack e-mails blood glucose readings. HBA1c March 8.0% Referred back to annual review clinic.

37. Putting things into perspective. The aim of diabetes care must be to ensure the best outcomes for patients, bearing in mind the risks associated with poor glycaemic control. Risk of complications associated with a 1% rise in HBA1c levels. Event Increase in risk of event. Diabetes related death.------------------------21%. Myocardial infarction.--------------------------14%. Peripheral vascular disease.------------------ 43%. Microvascular disease.--------------------------37%. Cataract extraction.-----------------------------19%.

38. Benefits of an ANP Service • High Quality • Promotes Safe Care • High Satisfaction • Utilises competence of experienced nurses • Improves recruitment and retention of workforce • Improves risk management

39. Career Pathway • Structured • Focused • Not a cul de sac • Rewards talent & expertise in practice

40. Job Satisfaction. The main reason I love my job is that I am dealing with and have time to spend with patients. I particularly like the fact that I have time to spend with children , adolescents and young adults who may be experiencing difficulties with their diabetes and this input may make a difference to their overall management. Patient empowerment is essential and I value and encourage patient input regarding their treatments choices. The fact that I can make decisions with patients about their care, assess, treat and discharge them satisfied and happy means a lot to me in terms of how I do my work”

41. ANY QUESTIONS ? THANK YOU