Transcript Helen Bowen, John Shepherd - The Goodfellow Symposium 2012

Pathway to Becoming a
Nurse Practitioner
Training and preparation
Helen Bowen (Nurse Practitioner)
Dr John Shepherd (Geriatrician)
Older Adults & Home Health WDHB
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Understanding NP scope
Growing NPs: NP Candidate
Identifying potential NP roles within services
Our experience
Role of medical mentor and supervision
Where are NPs currently working?
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Broad areas of practice
– primary health care/general practice
– acute care
– mental health
– chronic disease management
– older persons health
• providing a broad range of services
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Specialized areas
– Diabetes
– Cardiac care
– Neo-natal care
– Urology
– Ophthalmology
– Palliative care
• providing direct clinical care and consultative services to more complex
patients
Developing NP roles
Based on service gaps
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Identify a NP position (based on a service gap); grow an
NP into it over several years…
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Have a nurse suitable who is well on the way to NP and
develop a training programme around her/him …
How Can NPs Fill the Gaps
The key is understanding what the NP qualification entails
Nurse Practitioner is a legal title for a nurse working in an advanced clinical
role who has:
• completed higher education and training (minimum of a clinical masters) in
a specific area of practice.
• Advanced clinical skills (many which have traditionally been in the domain
of medicine only)
• Includes a wide range of assessment and treatment interventions, including
differential diagnoses, ordering and interpreting diagnostic and laboratory
tests, administering therapies for the management of potential or actual
health needs, admitting and discharging from hospital; carrying out
specific procedures eg colposcopy, cystoscopy
• They practise both independently and in collaboration with other health
care professionals to promote health, prevent disease and manage people’s
health needs.
The NP can take full clinical responsibility for patients
Adrianne Murray
NP Primary Health Care/Whanau Ora Northlands DHB
A Mobile Primary Health Care Service
Identified Need:
• Gaps in service provision for Maori clients in primary care,
particularly those living in remote areas.
• Target populations are ‘at risk’ Maori whanau within Primary Care.
Service Delivered:
• Primary health care to geographical population previously without
primary care services, including a Mobile Outreach Clinic providing care
to a coastal/rural region in the Far North
Outcomes:
• Successful establishment of NP clinics in rural outreach communities
previously without primary care services
• >80% Maori clients enrolled with service
• Quantitative and qualitative data supports effective service outcomes
(number of consultations, number of presentations via age
group/ethnicity, co morbidity of conditions seen etc.)
• Reduced rates of readmissions for chronic care clients and high needs
children accessing GP due to NP service.
Michael Geraghty
NP Adult Emergency Care Nurse Auckland DHB
Identified Need:
• Long waiting times in ED for medical review
• Poor compliance with triage sign-on times
• Poor patient satisfaction & high level of violence.
Service Delivered:
Michael sees patients with uncomplicated injuries and
illnesses - assessed, diagnosed, treated and
discharged.
• The model initially developed was a hybrid of
emergency nurse practitioner roles successfully
established in the USA and UK, but tailored to the
unique needs within New Zealand
Outcomes:
• Increased compliance with triage sign on times
• Decreased waiting times
• Decreased length of stay for NP patient group
• Decreased episodes of violence
• Increased patient satisfaction
Dr Michal Boyd
NP Services for Older Adults - Waitemata DHB
Identified Need:
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Older adults with high and complex issues (approx 5% >65yrs)
require individualized care coordination, proactive advanced
nursing assessment and intervention to prevent illness exacerbation.
Lack of coordinated care for high needs older adults results in:
• Avoidable hospitalisations and Emergency Department presentations
• Fragmentation of care leading to gaps and duplication in services
• Decreased client and family coping ability
Service Delivered
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Clinical responsibility and care coordination for people for older adults with high and
complex needs. Responsibilities include:
– Chronic illness care, medication review and symptom management
– Comprehensive gerontology assessment and care planning
– Coordination with the inter-disciplinary team across health care settings
Development of NP Intern to increase NP positions – now 3 NPs practicing in the
service
New programme development
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Residential Aged Care Integration Project. provides DHB Gerontology Nurse
Specialist/Practitioner outreach to residential aged care.
NP Trainee Programme Core Components
• Clinically-based
(situated/experiential/apprenticeship/internship style)
training programme
• Around 2-years or part-time equivalent.
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Clinical Sciences
Clinical Practice
Nursing Studies
Often the programme will occur in conjunction with the
final academic NP papers (the practicum papers), thereby
allowing the NP trainee to put into practice what s/he is
learning academically
Important programme components
Practice Environment
• Clinical practice alongside an advanced clinician (doctor or NP)
• Access to adequate numbers of patients with relevant health needs/
degree of complexity required to challenge and extend practice on
repeated occasions.
• A range of experiences to gain broad experience with appropriate
supervision processes to ensure extension of practice and patient
safety.
• Additional education programme from within the service delivered
by skilled and experienced staff (clinical meetings, seminars,
tutorials, other professional forums).
• Ensure NP trainee linked with appropriate mentor in preparation for
Nursing Council NZ interview process.
Important programme components (contd)
Supervision
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Supervision and assessment necessary to ensure quality of training,
general progress, suitability to continue training, and readiness to submit
an application to Nursing Council for assessment for registration
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Clinical Supervision must be performed by appropriately qualified experts
in the specialty area - both nursing and medical.
– An NP or medical practitioner within the specialty who has the time to
supervise practice on a daily basis.
– In addition some supervision may be provided by an advanced practice
nurse in the specialty area ‘recognised’ within the specialty as an
advanced practitioner (post-grad education)
– A multidisciplinary team or direct access to relevant practitioners
• They will supervise not only clinical situations but also record-keeping,
audit, teaching and preparation of scientific material, and the skills,
knowledge and attitudes desirable in a NP.
Important programme components (contd)
Learning Environment
Release Time
• The NP trainee will need to have release time for:
– academic papers (academic attendance and additional
study time leave)
– leadership opportunities
– Supervision
– Portfolio development
Graded responsibilities over the training period
Gaps
• To identify potential NP roles within your service
– Analyse any gaps in service provision and your
organisation’s health needs assessment
• Then analyse whether specific gaps could potentially be
met by creating a NP position
– Analyse the gaps against the NP competencies
– Eg Gerontology Nurse pilot with WDHB, WaitemataPHO,
UoA
• Can a NP fill a gap created by a shortage of other health
professionals?
Scope of Practice
• Adults aged 65 years and older with chronic
illness and geriatric conditions. Adults close in
age and interest (Maori, Pacific people and other adults aged
55 years and older with health conditions more usually associated
with the geriatric population).
• Practice across health care settings:
Assessment, Treatment and Rehabilitation
Outpatient clinics
Secondary care
Community settings
Residential aged care
The Work of the GNP
80,000 – 100,000 65+ living
with 4+ chronic conditions
Case Finding
Case Management
Asymptomatic
Population screened to
identify unmet need or
existing disability
Practice
Nurse/GP
assessment/
ECC/
Secondary
care
Targeting high risk
individuals
2-5%
2-5%
Communication
Collaboration
GNP/GNS & MDT
Team Follow Up
Communication
Collaboration
Brief assessment / screening with further
comprehensive assessment and management
for those at risk
GNP &
MDT
team
Background – Drivers for change
AT&R (WDHB) faced a significant and worsening house
officer shortage in 2008.
• Goal
– to potentially create a more robust and flexible staffing
arrangement
– provide an opportunity for experienced nurses to practice
at the highest clinical level
– Intern position - training towards obtaining NP registration
(with prescribing) with the nursing council
Full
Shortage
MedicalStaffing
StaffingModel
Model
Junior Doctor
Shortage 2008
SMO
SMO
SMO
SMO
SMO
SMO
RegistrarRegistrar
Registrar
NP
House Officer HO
House Officer House OfficerIntern
House Officer
43 Patients on west AT&R ward
– Normal Staffing:
3 house officers, 2 registrars, 2 full time SMO, 1 part time SMO
– During Shortage:
1 house office, part time locum HO, 1 registrar, SMO’s and NPi
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SMO, Registrar and NP intern carried 15 patients
– “10 beds would have been closed for 6-9 months” (CNM)
NP Role
In AT&R
• Carry case load within the medical team
• Admissions
– comprehensive geriatric assessment
– physical, functional and psychosocial assessment.
• Order / interpret tests
– laboratory / imaging studies
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Differential diagnoses
Order interventions
Monitor / evaluation / plan patient care
Plan / facilitate discharges, family meetings etc
Work with the MDT team
NP Role
In Outpatient clinic
• Driver - prolonged waiting times
• See new and follow-up patients
• Mainly patients with changes to memory / cognition,
complex medical / nursing issues
• Allows timely triage of pts who are more medically
complex to geriatrician
• Case consultation
Case management of complex AT&R discharges
– Ongoing review until care transitioned to community team
Medical Mentor Role
• Clinical mentor
– Role central to acquisition / development of skills
– Expectations - case studies, clinical case presentations,
teaching (over and over again)
– Managing pt care needs to happen in clinical practice
– Expect practice at level of RMOs
• Understand NP student needs
– Additional / enhanced clinical autonomy
• Professional sanction for NP role
• Challenge traditional ways
• Advocate with medical colleagues
– Non acceptance by other health care professionals
Medical Mentor Role - contd
• Support NP as steps into “medical domains”
– Learn politics, language, processes.
• Role open to criticism
– Impact of challenges on learning, decision making
• Awareness of challenges faced from nursing colleagues
• Recognising change is never easy.
• Be active in preparing the service for change
– Traditional boundaries and managing sensitivities relating
to these
– Change to the structure of teams; change management
– Promoting the NP role in terms of what it can do to
improve population health
Challenges
Uncertainties inherent in developing a new role
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Lack of clarification around role and responsibilities
Implementation during crisis did not allow for appropriate orientation.
Legislation that creates barriers
– Eg opiate prescribing, no access to GMS, Driver Licensing
Ambiguity/uncertainty about boundaries / roles
Challenges with each medical / allied health / nursing rotation
• With time - understood within unit
“we thought it would be a 1:1 substitution but we’ve realized its not”
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Patient expectations around models of care. Not always understood by
families / older people
“ I thought it was good that she was taking the time to talk to
him and give him his medicine. I just thought she was a very
nice doctor”
Challenges
• Managing safety concerns
– Recognition - no different than any other team
member
“it comes down to a judgment decision. Is this person
going to be safe when my back is turned? Yes or no?”
– With prescribing
“we are always concerned about safe prescribing but we would think
(the NP intern) would be a safer prescriber than most of the
doctors.” (pharmacy)
– “keenness to over monitor” by some departments
• Providing ongoing education / training
Benefits
Service Provision
• Kept beds open
• Reduced waiting times
• Freeing of geriatricians for more medically complex
patients
• Improve adherence to care pathways / plans
• Continuity between medical / allied health rotations
• Education and support of staff
• Enhance skill mix across the team
• Improved collaboration with medicine
Benefits
Knowledge / experience
• Specialist gerontology knowledge
• Experience and new knowledge to the ward
• Role model for patient centered care
“Not just focused on the person but the bigger areas, who is going to be
caring for that person, who else is going to be affected”
“…the social impact of the person’s condition”
• Resource for nursing staff
• Complimentary learning between medicine and nursing
“part of this model has been about doctors learning to be nurses and visa
versa”
• Developing unique care model
“crossing bridges” between different professional disciplines
Benefits per pts and families
Communication
• Patients and families commented on improved communication and
understanding
“Complex information in everyday language”
“you knew that the doctors knew what they were doing but you didn’t know
what they were doing but if you asked (the NPI), you knew too” (Family)
• Synthesis of advanced nursing and medical knowledge enhances
patient care
“Mum’s been in hospital a number of times. We’ve sort of been made to feel
well she's had a good life and this is her lot, whereas the NPI always
seemed to be that you might have had a good life but lets see what better
quality we can still get out of it”
To sum up
When getting started
• Responding to a crisis helped get everyone on board.
• Began small with vision from GM, supportive geriatricians.
“People in the service have to have a vision and a desire for
something to be different in that setting and in that service, and
be willing to drop some things and create space … it can be a
bit tense, a bit fraught, even with people who are really open to
this new thing.”
Getting started
“The importance of the right supervision and support
cannot be underestimated. The NPI currently has a
multilayered mixture of formal and informal support
available provided by a mentor, the NP champion,
the service manager, peers, members of the
multidisciplinary team”
GOAL
When thinking about NPs within your service
• Identifying gaps
• Improving patient outcomes
• Collaboration as key
• Never about competition between / among health
professionals
The final word
“The role was an indication from the
health board that they were investing,
… making a real investment in older
people”