The Contribution of Advanced Nursing and Midwifery Practitioners to Patient Outcomes

Transcription

1 The Contribution of Advanced Nursing and Midwifery Practitioners to Patient Outcomes Professor Mary Casey Presentation on behalf of Prof. Laserina O Connor, Dr Rita Smith, Dr Denise O Brien, Dr Denise O Leary, Prof. Gerard Fealy, Prof. Martin McNamara, Mr Diarmuid Stokes and Ms Claire Egan. UCD School of Nursing, Midwifery & Health Systems. Acknowledgement of funding from the Department of Health, Dublin

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4 Important Historical Development of ANP in Ireland 1998 The Report of the Commission on Nursing: A Blueprint for the Future (Government of Ireland 1998) led to the establishment of the National Council for the Professional Development of Nursing & Midwifery and to the development of advanced nursing and midwifery persons and posts Development of the definition, core concepts and framework for ANPs and (AMPs) was published by NCNM. This framework had two prerequisites for the implementation of these roles: firstly, the approval of job description and site preparation, and secondly, the accreditation and registration of the individual ANP/AMP Department of Health & Children assigned this function to An Bord Altranais (Nursing and Midwifery Board of Ireland) An evidence review to inform future specialist and advanced nursing and midwifery practice was commissioned by the Department of Health (Casey et al. 2015) made 10 recommendations.

5 } A rapid review of the relevant national and international literature, regulatory and policy documents relating to the establishment and definition of nurses and midwives advanced practice roles was undertaken over an 8 week period (Casey et al., 2015). } A descriptive qualitative aspect was undertaken by the university as part of this review. This explored the views of key stakeholders and participants on specialist and advanced nursing and midwifery practice, on the outcomes and impact of these roles on practice.

6 Location of ANPs/AMPs in Ireland (2017) Total 205 (6 AMP)

7 The clinical impact of these roles has been difficult to measure (Kennedy et al., 2011). Gerrish, McDonnell and Kennedy (2011) identify a number of outcome areas such as impact on patients, work colleagues, clinical speciality, the organisation and the health service. Elliott et al., (2013) identified four leadership outcome categories which can be used to evaluate practice. They are: (i) capacity and capability building of multidisciplinary team; (ii) measures of esteem; (iii) new initiatives for clinical practice and healthcare delivery; and (iv) clinical practice based on evidence. Begley et al., (2014) revealed that ANPs were able to take self-referrals and referrals from other health professionals, showed greater autonomous decision-making powers and were thus able to improve case management processes.

8 } A qualitative study of the perceptions of key stakeholders of the roles of specialist and advanced nursing and midwifery practitioners. } Purposive sampling with key stakeholders (n=15) was employed. Semi structured interviews were undertaken with nurses and midwives working in specialist and advanced practice roles and participants from legislative, regulatory, policy, pharmacy, medicine and education. } Ethical approval was obtained UCD. All participants signed informed consent and had the option of withdrawing from the study at any stage. All data was anonymised. } Data analysis - constant comparative technique (Corbin & Strauss, 2008). Two researchers analysed the same transcript and agreed a coding framework which was then used to code the other interviews.

9 Demographic Data Number of Participants Age Range Gender Male 2 Female 13 Highest Level of Education Post Grad Diploma 3 Masters 10 Doctorate 2 Time in Current Role Less than 1 year years years 3 Over 10 years 2

10 Titles Number Identifier Registered Advanced Nurse Practitioner Registered Advanced Midwifery Practitioner 4 Identified as AP 1-4 Clinical Nurse Specialist Clinical Midwife Specialist Clinical Mental Health Specialist (Community) 3 Identified as CS 1-3 Policy, Registration and Management and Education 5 Identified as PRME1-5 Medicine, Pharmacy and Nursing Representative Body 3 Identified as MPNRB1-3 Total 15

11 Two major themes emerged in relation to the contribution of ANPs/AMPs. 1. Impact of Specialist and Advanced Practice Roles on Patient Outcomes. 2. Specialist and Advanced Practice Roles in an Interdisciplinary Context.

12 Four subthemes contributed to this theme. 1. Contribution of the CNS/CMS/ANP/AMP role in the health service/system. 2. Advanced and specialist nurses and midwives enhance patient care. 3. Measuring impact of specialist and advanced practice roles. 4. Quality, safety and patient access to care.

13 It is a cheaper and better way of delivering the service. There is a cost for people coming into hospitals, there is a cost for the consultant, the doctor, for the nurse, but there is also the general cost of running a hospital which is shared out amongst everybody who uses it including the day care patients. There is the patient convenience, which is an important issue, and there is also the clinical outcomes. (MPNRB1) With the current services at the moment I would say that nearly 70% - 80% of women are seeing a doctor unnecessarily it is wasting time, unnecessary time waiting around and time where somebody more needy should be seeing that particular medic. (AP4) Management recognise that we are achieving a lot. They are very positive towards us really and...but I would say they don't really know what we do. (AP3)

14 if it is a case of hospital work{ing} being transferred to GPs and other work isn't transferred to other sectors, the GPs are just going to be overrun, it is not going to work. (MPNRB1) The other big benefit I suppose to patients is that we give them a lot of individualised care and continuity of care because they will nearly always see the same AMP again. (AP3) In terms of outcome I think... We can see how we can marry the nursing actions with the medical diagnosis and the medical care in a way that the consultant and the registrars mightn't necessarily see. (AP1)

15 A lot of it is auditing your own work what they love about the AMP..your appointment time tends to be your appointment time. Time has become really, really precious today. (AP4) We try to improve patient education part of our function here is smoking cessation... as nurses and midwives we sometimes see the consultants will meet a patient that smokes on their first visit and they will give them an absolute head wrecking lecture on smoking... and never review that issue again (AP3) when there's an ANP on {duty} they are seen much quicker, much more efficiently by somebody actually who knows what they are doing. They are not seen by somebody junior [doctors] who escalates it up.... (AP2) the way the system works they{the patients} are all under a named consultant our patient administration system does not count all [ANPs] cases and I actually think that until we have some {way}where patients are being registered 'as my patient then really it will not be noticed nationally. (AP3)

16 a lot of the advanced practice is being able to communicate and being able to make sure that they {patients} are fully involved in the decision making about their health. They understand what s being done and the reason for it and that they are comfortable about it.... (AP3) They [referring to patients] can pick up the phone... Okay well I have five referral pathways, obstetricians, midwives, clinical governance, the GP, and the woman herself. So in a nutshell, Access is very, very easy. (AP4) ANP services is provided free...there's no charge. Whereas if you go into A&E they have 100 euros. (AP2)

17 Two subthemes contributed to this theme. 1. Working with the medical staff in an interdisciplinary context. 2. Others views of specialist and advanced practitioner nursing and midwifery roles.

18 I think... we would work as a team... patients will often reveal things to a nurse... and sometimes what the patient needs is a caring sympathetic...do you know...it's like a Ying and a Yang type thing. We can approach it as a team not necessarily freeing up time but we get more done working together in that way. (MPNRB2) They [referring to ANPs] are the central piece they are the piece that kind of seals up a multidisciplinary team as a central conduit for all the patient information. Because they are the ones that will know about the results (MPNRB3) it's becoming increasingly obvious over the years...after five o'clock when the consultant goes home...they can go home slightly more relaxed and less worried because they know that their NCHD, that they have left behind...even if they are inexperienced has an ANP there until half eight or nine o'clock at night. (AP1)

19 We can talk ourselves out of our own roles I think we need to have a revamp and a rethink how we market advanced practice and clinical nurse specialist and bring it into being a really cherished part of nursing. But that has to balance with staff nurses and midwives are cherished as well in another way, they do a different job. But I think collectively sometimes it is used as a divisive thing that, oh they are advanced practice or clinical specialist rather than embracing it as a whole. (MPNRB3) I was silently working away there and just never giving anybody any trouble and everything was getting done and there was no complaints coming and you know I suppose I wouldn't be the most vocal person. I'm not there every day telling them how much I do or I'm not telling people that I'm there until seven or eight o'clock at night... Sometimes I think I'm invisible.(ap )

20 Outcome of the Evidence Review The most significant outcome and impact of this evidence review report (Casey et al.,2015) was it provided the evidence base for the development and implementation of a national Government Policy on the future of graduate specialists and advanced nursing and midwifery practitioners in Ireland. This policy initiative involved 1) Revision of Educational Programme. 2) All ANPs/AMPs to become prescribers. 3) Decoupling of the individual practitioner from the site approval process. 4) Introducing a system of accreditation for experienced nurses/midwives 5) Increasing the number of participants on educational programmes nationally to increase the number of ANPs by 120 approximately each year (ongoing) 6) Evaluating the impact of the role of advanced practitioners (in progress).

21 Recent relevant publications which impact on future development of ANP/AMP in Ireland Advanced Practice (Nursing) Standards and Requirements (2017). Advanced Practice (Midwifery) Standards and Requirements (2018).

22 Conclusion: Recent Relevant Publications