The Development The Development of an Advanced Nurse of an Advanced Nurse

PractitionerPractitionerRoleRole

The Realities in PracticeThe Realities in PracticeA Joint PresentationA Joint Presentation

April 12April 12thth 2005 2005Valerie Small. Valerie Small. Siobhan RothwellSiobhan Rothwell

St James’s HospitalSt James’s Hospital Our Lady of Lourdes Hospital Our Lady of Lourdes Hospital Dublin Dublin DroghedaDrogheda

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IntroductionIntroduction

• Development of an ANP role in two Development of an ANP role in two Emergency Departments Emergency Departments

• Outline of education programmes Outline of education programmes available in Irelandavailable in Ireland

• Update on post’s and accredited Update on post’s and accredited ANP’sANP’s

• Getting startedGetting started

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St James’s Hospital 1996 St James’s Hospital 1996 Pilot Project: Pilot Project: • AIM AIM

– To train a suitably qualified, experienced To train a suitably qualified, experienced emergency nurse to independently emergency nurse to independently assess, diagnose, treat, discharge / refer assess, diagnose, treat, discharge / refer patients with a range of common patients with a range of common injuries which present to the emergency injuries which present to the emergency department.department.

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RationaleRationale•To develop a clinical career To develop a clinical career

pathway for experienced pathway for experienced emergency nursesemergency nurses

•To enhance the quality of service To enhance the quality of service delivered by the multi-delivered by the multi-disciplinary team (MDT) to disciplinary team (MDT) to patients with minor injury and patients with minor injury and illnessillness

•To provide a timely, but safe, To provide a timely, but safe, service for patients leading to service for patients leading to improved patient satisfactionimproved patient satisfaction

•To release physician time to deal To release physician time to deal with increasingly acute workload with increasingly acute workload

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ED ActivityED Activity

• Located inner city Dublin,IrelandLocated inner city Dublin,Ireland

• Catchment area:Catchment area: ¼ ¼ million million patientspatients

• 50,000 New Patients annually50,000 New Patients annually

• Primary health care facility for Primary health care facility for many patientsmany patients

• Initiative on nurse practitioner Initiative on nurse practitioner service proposed & piloted 1996service proposed & piloted 1996

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Scope of PracticeScope of Practice

• AssessAssess

• DiagnoseDiagnose

• TreatTreat

• DischargeDischarge

• Refer to other appropriate serviceRefer to other appropriate service

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Patient CaseloadPatient CaseloadTypes of InjuryTypes of Injury• Minor Head Minor Head & &

Facial Facial Injury Injury • Laceration face, Laceration face,

trunk & limbtrunk & limb• Skeletal & Soft Skeletal & Soft

tissue tissue injuryinjury• Initial management Initial management

of fracturesof fractures• Hand & fingertip Hand & fingertip

InjuryInjury• Minor burns < 2% Minor burns < 2%

TBSATBSA• Soft tissue infectionSoft tissue infection• Incision & drainage Incision & drainage

abscessabscess

Referral ArrangementReferral Arrangement• RadiologyRadiology• OOPDPD• PhysiotherapyPhysiotherapy• Occupational therapyOccupational therapy• Social Work Social Work

DepartmentDepartment• Primary care providerPrimary care provider• Outside Agencies Outside Agencies

Homeless, Drug Homeless, Drug treatment services, treatment services, woman's aid woman's aid

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Audit Audit • Daily activity documented since Daily activity documented since

1996 and collated monthly 1996 and collated monthly • Annual activity published Annual activity published • Continuous Audit on clinical Continuous Audit on clinical

aspects of care & patient aspects of care & patient outcome outcome

• Quantitative & Qualitative Quantitative & Qualitative research on range of aspects research on range of aspects related to servicerelated to service

• 36,500 Patients treated 1996-36,500 Patients treated 1996-20052005

DEVELOPING AN ADVANCED NURSE DEVELOPING AN ADVANCED NURSE PRACTITIONER SERVICE IN PRACTITIONER SERVICE IN

EMERGENCY NURSINGEMERGENCY NURSING

THE SITE PREPARATION PROCESS THE SITE PREPARATION PROCESS

SIOBHAN ROTHWELLSIOBHAN ROTHWELL

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IDENTIFICATION OF SERVICE IDENTIFICATION OF SERVICE NEEDNEED

– Analysis of Emergency Department Analysis of Emergency Department statisticsstatistics

– Review of range of injuries and conditionsReview of range of injuries and conditions– Adult and paediatric service needsAdult and paediatric service needs– Waiting timesWaiting times– Quality of serviceQuality of service– Career pathways in nursingCareer pathways in nursing

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EDUCATIONEDUCATION

• MSc Nursing – T.C.D.MSc Nursing – T.C.D.

• Clinical Module – St James’ Clinical Module – St James’ HospitalHospital

‘ ‘Clinical Diagnositic Skills for Clinical Diagnositic Skills for Advanced Nurse Advanced Nurse Practitioners (Emergency Practitioners (Emergency Nursing)’Nursing)’

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SCOPE OF PRACTICESCOPE OF PRACTICE• Adult Minor Injuries Adult Minor Injuries

• Paediatric Minor InjuriesPaediatric Minor Injuries - Significant service need- Significant service need - Consultant led education - Consultant led education

and supervised practice and supervised practice • Clinical Protocols Clinical Protocols

developed collaboratively developed collaboratively

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SCOPE OF PRACTICESCOPE OF PRACTICE

• Limb injuries – STI, fractures etcLimb injuries – STI, fractures etc

• WoundsWounds

• Foreign bodiesForeign bodies

• Facial injuries – Fractures, wounds, Facial injuries – Fractures, wounds, dental etcdental etc

• Eye injuriesEye injuries

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ISSUES IN PRACTICEISSUES IN PRACTICE

•Radiology

•Prescribing

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SITE PREPARATION AND JOB SITE PREPARATION AND JOB DESCRIPTIONDESCRIPTION

• Working group established following a meeting with Working group established following a meeting with the National Councilthe National Council

• Comprised of: DONs (Region)Comprised of: DONs (Region) ED ConsultantED Consultant Representative NMPDURepresentative NMPDU Practice Development NursePractice Development Nurse Nurse Managers EDNurse Managers ED Nurses pursuing Accreditation Nurses pursuing Accreditation

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SITE PREPARATIONSITE PREPARATION

• Health needsHealth needs

• Laws, rules, regulations and guidelines governing Laws, rules, regulations and guidelines governing nursing and midwifery practicenursing and midwifery practice

• Vicarious LiabilityVicarious Liability

• Guidelines for good practiceGuidelines for good practice

• Benefits to patients from the ANP serviceBenefits to patients from the ANP service

• Consistency of service within Organisational Consistency of service within Organisational PhilosophyPhilosophy

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SITE PREPARATION cont/dSITE PREPARATION cont/d

• How change will meet the service planHow change will meet the service plan

• Location of the serviceLocation of the service

• Integration of the ANP into the Integration of the ANP into the multidisciplinary teammultidisciplinary team

• Definition of the role content within the Definition of the role content within the framework of nursingframework of nursing

• Resource implicationsResource implications

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JOB DESCRIPTIONJOB DESCRIPTION

• Background to postBackground to post - Generic Background- Generic Background - Specific Background- Specific Background - Evolution of the role of the Advanced - Evolution of the role of the Advanced

Nurse PractitionerNurse Practitioner - Effects of policy changes on Professional - Effects of policy changes on Professional

Practice in the RegionPractice in the Region

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JOB DESCRIPTION cont/dJOB DESCRIPTION cont/d

• Geographical aspects of the Geographical aspects of the service/demographics of the regionservice/demographics of the region

• Service NeedService Need

• Purpose of the postPurpose of the post

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SCHEDULE OF EVENTSSCHEDULE OF EVENTS

• Guidance from the National CouncilGuidance from the National Council

• Bi-monthly meetings of the working groupBi-monthly meetings of the working group

• Goals identified and setGoals identified and set

• Time frames highlightedTime frames highlighted

• Objectives achievedObjectives achieved

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TIME FRAMETIME FRAME

• June 2003 – Met with NCPDNMJune 2003 – Met with NCPDNM

• November 2003 – 1November 2003 – 1stst draft of draft of Site Preparation and Job Site Preparation and Job Description documentDescription document

• January 2004 – 2January 2004 – 2ndnd Draft sent to Draft sent to NMPDUNMPDU

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TIME FRAMETIME FRAME

• March 2004 - Met with NMPDU to review March 2004 - Met with NMPDU to review document and prepare for final submissiondocument and prepare for final submission

• April 2004 – Submission of documentApril 2004 – Submission of document

• May 2004 – Review by Accreditation CommitteeMay 2004 – Review by Accreditation Committee

• September 2004 – Site Visit September 2004 – Site Visit

• Submission of Personal PortfolioSubmission of Personal Portfolio

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SUBMISSION DOCUMENTSUBMISSION DOCUMENT

• Developed collaborativelyDeveloped collaboratively• Different service needs identifiedDifferent service needs identified• National Council Framework Document National Council Framework Document

(2001) used as a template(2001) used as a template• NCNM provided support and directionNCNM provided support and direction• Drafts x 2 submitted before completion of Drafts x 2 submitted before completion of

final documentfinal document

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SUBMISSION DOCUMENT SUBMISSION DOCUMENT cont/dcont/d

• Site preparation and job descriptionSite preparation and job description• Relevant appendicesRelevant appendices• Reference listReference list• Clinical ProtocolsClinical Protocols• Application formApplication form• Letters from DON and NMPDULetters from DON and NMPDU• Financial approval formFinancial approval form

2 COPIES – 1 BOUND AND 1 UNBOUND2 COPIES – 1 BOUND AND 1 UNBOUND

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PERSONAL PORTFOLIOPERSONAL PORTFOLIO

• Template on the NCNM websiteTemplate on the NCNM website

• Personal detailsPersonal details

• Education recordEducation record

• Competencies relevant to the roleCompetencies relevant to the role

• Professional developmentProfessional development

2 COPIES – I BOUND AND 1 UNBOUND2 COPIES – I BOUND AND 1 UNBOUND

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PLANS FOR THE FUTUREPLANS FOR THE FUTURE

• Increase in number of ANPs in Emergency Nursing Increase in number of ANPs in Emergency Nursing in the North Eastern Health Boardin the North Eastern Health Board

• Expansion of Scope of Practice as determined by Expansion of Scope of Practice as determined by service needservice need

• Cross-site research and audit to add to the body of Cross-site research and audit to add to the body of knowledge and enhance the quality of patient careknowledge and enhance the quality of patient care

• Involvement in teaching on pre- and post-Involvement in teaching on pre- and post-registration programmesregistration programmes

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Education Programmes Education Programmes (Advanced Practice Strand)(Advanced Practice Strand)

• The University of Dublin, Trinity The University of Dublin, Trinity College College

• University College, DublinUniversity College, Dublin

• University College, GalwayUniversity College, Galway

• University College, Cork (In progress)University College, Cork (In progress)

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Advanced Practice StrandsAdvanced Practice Strands

• Clinical Diagnostic Skills for Clinical Diagnostic Skills for Advanced Nurse Practitioner Advanced Nurse Practitioner (Emergency) in Association with TCD(Emergency) in Association with TCD

• Generic MSc programme with Generic MSc programme with advanced practice strand-UCD, UCG, advanced practice strand-UCD, UCG, UCCUCC

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Clinical Diagnostic Skills for Clinical Diagnostic Skills for Advanced Nurse Practitioner Advanced Nurse Practitioner (Emergency)(Emergency)• Module on MSc in Nursing, Trinity College Module on MSc in Nursing, Trinity College

DublinDublin• Stand alone option: criteria applied for entryStand alone option: criteria applied for entry• 10 weeks theory/applied anatomy10 weeks theory/applied anatomy• 10 weeks observation of expert practice10 weeks observation of expert practice• Clinical Competency Assessment Clinical Competency Assessment • Theoretical AssessmentTheoretical Assessment• 500 taught hours on course St James’s Hosp500 taught hours on course St James’s Hosp• 500 Hours clinically supervised practice in 500 Hours clinically supervised practice in

candidates ED prior to formal signing offcandidates ED prior to formal signing off

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Development of ANP Roles in Development of ANP Roles in Emergency NursingEmergency Nursing• St James’s Hospital – 1996-2005 (6posts)St James’s Hospital – 1996-2005 (6posts)• Mater Mater Hospital – 2000-2001-2002(4posts)Hospital – 2000-2001-2002(4posts)• James Connolly Memorial Hospital – 2000(3posts)James Connolly Memorial Hospital – 2000(3posts)• AMNCH – 2001(1post)AMNCH – 2001(1post)• Our Lady of Lourdes – 2002-2004 (2posts)Our Lady of Lourdes – 2002-2004 (2posts)• Waterford Regional – 2004 (2posts)Waterford Regional – 2004 (2posts)• Monaghan(1 post)Monaghan(1 post)• Portiuncula(1 post development phase)Portiuncula(1 post development phase)• Letterkenny(1 post development phase)Letterkenny(1 post development phase)• Sligo (1post development phase)Sligo (1post development phase)• Cork (project officer appointed)Cork (project officer appointed)• Limerick (early development)Limerick (early development)

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ANP APPROVED SITE’sANP APPROVED SITE’s

• EmergencyEmergency

• Sexual HealthSexual Health

• RheumatologyRheumatology

• Breast careBreast care

• DiabetesDiabetes

• Chest pain assessmentChest pain assessment

• Primary CarePrimary Care

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Emerging ANP RolesEmerging ANP Roles• Care of the ElderlyCare of the Elderly Stroke CareStroke Care

RehabilitationRehabilitation

• MidwiferyMidwifery Midwifery led care Midwifery led care hospital/communityhospital/community

• NeonatalNeonatal Neonatal Intensive CareNeonatal Intensive Care

• PaediatricPaediatric EmergencyEmergencyCystic FibrosisCystic FibrosisHaematology/OncologyHaematology/Oncology

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Emerging ANP RolesEmerging ANP Roles• GeneralGeneral Pain ManagementPain Management

Cardiac SurgeryCardiac SurgeryIntensive Care (Outreach Service)Intensive Care (Outreach Service)Practice NursingPractice Nursing

• PsychiatryPsychiatry AddictionAddictionFamily InterventionFamily InterventionChild & Adolescent ServicesChild & Adolescent ServicesLiaison (Emergency)Liaison (Emergency)BereavementBereavementBehavioral TherapyBehavioral Therapy

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Role Development :Role Development :Getting StartedGetting Started

•NO QUICK FIXNO QUICK FIX

•NOT A CHEAP OPTIONNOT A CHEAP OPTION

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Role DevelopmentRole Development• Identify Service Need- AuditIdentify Service Need- Audit

– Service drivenService driven– Client group identifiedClient group identified– Stakeholder ‘BY IN’Stakeholder ‘BY IN’

• Identify Resources- (personnel & Identify Resources- (personnel & Finance)Finance)– Change Agent (not always MSc prepared)Change Agent (not always MSc prepared)– MotivationMotivation– ExperienceExperience– Ability to succeedAbility to succeed

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Audit of Patient FlowAudit of Patient Flow

Attendance Time %Patients

00:00-04:00 11.88%

04:00-08:00 6.39%

08:00-12:00 21.60%

12:00-16:00 25.86%

16:00-20:00 18.84%

20:00-00:00 15.43%

TOTAL 100.00%

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Audit of Activity 98-04Audit of Activity 98-04

ANP Activity 1998-2004

0100200300400500600700800

Nu

mb

er

of

Pa

tie

nts

1998199920002001200220032004

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Role DevelopmentRole Development• Establish ‘working group’ (MDT)Establish ‘working group’ (MDT)

– Set GoalsSet Goals– Specify action stepsSpecify action steps– Establish timelinesEstablish timelines– Identify indicators of successIdentify indicators of success

• Network with established ANP sites Network with established ANP sites

• Contact NCNM for advice and Contact NCNM for advice and assistanceassistance

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Useful ContactsUseful ContactsNational Council ExecutiveNational Council Executive• Kathleen Mac Lellan: Head Professional Kathleen Mac Lellan: Head Professional

DevelopmentDevelopment• Mary Farrelly :Professional Development Officer Mary Farrelly :Professional Development Officer

(psychiatry)(psychiatry)• Jenny Hogan : Professional Development Officer Jenny Hogan : Professional Development Officer

(general)(general)• Christine Hughes: Professional Development Christine Hughes: Professional Development

Officer (Mental Handicap)Officer (Mental Handicap)• Georgina Farren : Professional Development Georgina Farren : Professional Development

Officer (Midwifery)Officer (Midwifery)• www.ncnm.i.e.www.ncnm.i.e.• Email: Email: admin@ncnm.ieadmin@ncnm.ie

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Relevant SitesRelevant Sites• American Academy of Nurse Practitioners- American Academy of Nurse Practitioners-

www.aanp.orgwww.aanp.org • Australian Nurse Practitioner’s Association Australian Nurse Practitioner’s Association

www.nursing.aust.edu.auwww.nursing.aust.edu.au• Department of Health (WA)- Department of Health (WA)-

www.nursing.health.wa.gov.auwww.nursing.health.wa.gov.au• The Nurse Practitioner Association of Ontario- The Nurse Practitioner Association of Ontario-

www.npao.orgwww.npao.org • New South Wales Health-Nurse Practitioner New South Wales Health-Nurse Practitioner

www.health.nsw.gov.au/nursing,noract.htmlwww.health.nsw.gov.au/nursing,noract.html • New Zealand Nursing Council-Nurse Practitioner New Zealand Nursing Council-Nurse Practitioner

www.nursingcouncil.org.nz/nursepractioner.htmlwww.nursingcouncil.org.nz/nursepractioner.html• Nurses Board of South Australia Nurses Board of South Australia

www.nursesboard.sa.gov.auwww.nursesboard.sa.gov.au// • NHS.National Institute of Clinical Excellence. NHS.National Institute of Clinical Excellence.

www.nice.org.ukwww.nice.org.uk//