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Integrating Advanced Practice Nurses (APNs) Dr. Alba DiCenso, McMaster University Linda Sawchenko, Interior Health Dr. Sophie Nadeau, McGill University Grace Neustaedter, Calgary Pelvic Floor Clinici Wednesday, March 17 th, 2010 12:00 1:30pm EDT 2
Objectives To distinguish the 3 types of APNs in Canada To outline the facilitators t and challenges to their full integration into the Canadian healthcare system To present examples of successful integration i of these roles 3
Advanced Practice Nurse Registered nurse Graduate nursing degree Expert clinician with advanced clinical decision-making skills and a high level of autonomy Expanded scope of practice Formal credentialing process 4
APN Competencies Clinical Education Research Leadership Consultation & Collaboration 5
Types of Advanced Practice Nurses in Canada Primary Health Care Nurse Practitioners (PHCNPs) (also known as family or all-ages ages NPs) Acute Care Nurse Practitioners (ACNPs) (l (also known as specialty ilt NPs, adult, dlt pediatric diti or neonatal NPs) Clinical Nurse Specialists (CNSs) 6
Nurse Practitioners involved in health promotion, disease prevention & acute and chronic illness management diagnose order and interpret diagnostic tests prescribe pharmaceuticals perform specific procedures within their legislated scope of practice 7
Clinical Nurse Specialists contribute t to development of nursing knowledge and evidence-based practice and facilitate system change address complex health care issues for patients, families, other disciplines, administrators, and policy makers specialize in specific area of practice that may be defined in terms of a population, a setting, a disease or medical subspecialty, type of care, or type of problem 8
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Advanced Practice Nursing Workforce by Province in 2008 NA NA 52 <10 99 2 5 88 3 210 98 46 29 663 303 872 63 115 80 555 415 49 2 5 Canadian NP Total = 1,626 Canadian CNS Total = 2,222 Source: Regulated Nursing Database, Canadian Institute for Health Information * 4 8
Decision Support Synthesis To conduct a review of the literature and stakeholder interviews to: Identify and describe distinguishing characteristics of CNS and NP role definitions and competencies Identify key barriers and facilitators for effective development and utilization of CNS and NP roles 11
Decision Support Synthesis Scoping Review of Literature 468 papers (all Canadian papers of any type or date and international review papers 2003-2008) Key Stakeholder Interviews (81) APNs, government policymakers, nurse administrators, regulators, educators, physicians, other health care team members 12
Effectiveness of APNs Numerous randomized controlled trials (RCTs) and systematic reviews have shown that APNs are effective, safe practitioners who can positively influence patient, provider and health system outcomes: ACNPs: 18 RCTs (11 since 2000) PHCNPs: 28 RCTs (18 since 2000) CNSs: 32 RCTs (20 since 2000) 13
General Key Facilitators Systematic patient-focused planning to guide role development including early stakeholder involvement Clearly defined APN roles Public and health provider awareness 14
PHCNPs Facilitators and Challenges Facilitators: Government legislation and regulation Government funding for NP positions Emphasis on interprofessional collaboration facilitated by a shift away from FFS physician reimbursement model Challenges: Working out relationship between two autonomous clinicians (NPs and GPs) with substantial overlap in scope of practice Inconsistencies in educational preparation across Canada 15
ACNPs Facilitators and Challenges Facilitators: Support from medical & nursing administrators within hospitals Support from physician colleagues who appreciate help with heavy ypatient care demands Challenges: Difficulty implementing non-clinical i l dimensions i of the role Limitations to scope of practice due to hospital restrictions on NPs autonomous ordering and prescribing Inconsistent t team acceptance Funding of role 16
CNSs Facilitators and Challenges Facilitators: Support of health administrators Increased emphasis on promoting evidence-based practice Challenges: Lack of a common vision and understanding of the CNS role Limited access to CNS-specific graduate education programs Lack of title protection or credentialing 17
Nurse Practitioner/General Practitioner (NP/GP) Primary Health Care Model Linda Sawchenko, RN, MSHA Regional Practice Leader, Interior Health 18
Interior Health/BC Context Legislation enacted in 2005 allowing for the introduction of NPs in British Columbia Provincial co-ordination ordination including CNOs, VPs Medicine, Ministry & College of Registered Nurses BC Common title, wage scale & scope of practice document Broad NP scope of practice including diagnosis, i prescribing, referral Dedicated funding to health authorities; however, majority of primary care provided in fee-for-service (FFS) GP offices 19
Interior Health, British Columbia 17 NPs in Rural and Urban Settings 20
5 Years Later - NP Progress in IH 17 family NPs employed in Interior Health 1 acute care NP in thoracic surgery 4 NPs in FFS GP PHC Model 100% retention rate since 2005 Key factor: Community of Practice support 21
Early Success of NP/GP Collaboration Ministry of Health Best Practices Innovation Award Enderby PHC 22
NP/GP FFS PHC Model Early success achieved in funded PHC sites Need identified to build partnerships with FFS physicians and a call for proposals was sent out to community physicians Model has health authority funded NPs situated in FFS GP office practices NPs provide health care services from a holistic nursing perspective, diagnose and treat acute and chronic illnesses, including prescribing medications 23
NP/GP FFS PHC Model Qualitative Evaluation Findings 2008 Patient and Physician Satisfaction Having an NP has increased my access to health care. (patient) The GP and NP seem to be in tune with one another they consult one another to make decisions and they listen to each other and communicate well. (patient) This model makes primary health care easier and more sustainable. (physician) 24
Reduced ED Visits/Acute Care Admissions The NP is instrumental in keeping patients out of the hospital and Emergency. I know that because I am no longer driving up to the hospital everyday to see patients I can go for three weeks without a patient in acute care. (physician) 25
The NP and physician work together e with me, I feel I have more personal control over my care plan and feel like I am part of the decision making process. (patient) Patient-Focused Care 26
Improved Achievement of Chronic Disease Management Targets The collaborative approach to health care has improved results related to the management of chronic diseases, such as diabetes, and their related complications. (physician) 27
Priorities/Next Steps Celebrate and publish the success of this model Ongoing knowledge exchange activities Conduct quantitative research on outcomes related to the NP/GP FFS PHC model Expand the model to other communities Continue to support the NP Community of Practice 28
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Quebec Neonatal Nurse Practitioners: History and Challenges Sophie Nadeau, MD, FRCPC Medical Director, McGill University Health Centre NNP Program Medical Coordinator, NNP Graduate Program 30
Montreal Children s Hospital Early 1990 s: Shortage of residents 94-96: Home-made training program 97-98: Pilot project accepted by the Collège des Médecins du Québec 99-00: MSc Nurs @ Stony Brook U 31
Quebec Government Bill 90: Nurse practitioners as a distinct profession (2002): allowed them to Prescribe diagnostic tests Perform diagnostic tests that are invasive or place the patient at risk Prescribe medications and other substances Prescribe medical treatments Perform medical treatments that are invasive or place the patient at risk 32
Ordre des Infirmiers et Infirmières du Québec- Collège des Médecins du Québec OIIQ Exams and certification Continuous education CMQ «Règles de soins»: practice boundaries Labs Meds Techniques 33
McGill University MSc Nursing at McGill (NNP stream) Developed in 2002-20032003 First students in 2004 Full accreditation ti in 2008 34
Unique Contributions of NNPs Provision of holistic care to infants and families Co-ordination of care for infants requiring multiple services Facilitation of family communication and support Provision of interdisciplinary educational opportunities Education of nurses, nursing students and NNP students Education and support of pediatric residents 35
70% clinical i l time: MUHC NNP Role Antenatal consultations Attendance at high-risk deliveries Admission and stabilization of critically ill infants Completion of history and physical exams Formulation of clinical impressions Development, implementation, and evaluation of treatment plans Discharge planning Transport calls 36
MUHC NNP Role 30% non-clinical time: Research Teaching/education Administration Quality improvement/quality assurance 37
Évaluation de l implantation du programme d intéressement au titre d infirmière praticienne spécialisée Ministère de la Santé et de Services sociaux du Québec Mars 2007 38
Challenges Integration of the NNP role in the clinical setting (multidisciplinary) It Interpretation tti of the role: in between bt nursing and medicine Competition for type of patients, procedures, etc. (RTs, residents) Administrative estructure ucueof the role: oe nursing us gdirector eco +/- medical director: lines of communication 39
Challenges Recruitment of new students/candidates Minimal requirements: bachelor degree and 2 years of experience Heavy Master s degree training program Bursaries during training: not enough to survive Level of responsibilities: too elevated Salary: too low No jobs available post-training (no money for recruitment) 40
Retention of NNPs Challenges Heavy workload/not enough colleagues Non-clinical time: almost impossible! Salary: too low for the level of responsibilities Unionized position: why? 41
Challenges Perpetuation of the NNP role Lack of students (1-2/year) Lack of training resources: teachers (both NNPs and MDs), clinical teaching sites McGill (anglophone institution) 42
Facilitators: What Can We Improve? (Retention) Increased role satisfaction Role diversity, feelings of accomplishment, working in a challenging environment, cohesive atmosphere Role expansion Research, teaching, education, presentation at conferences, publications Successful transition of NNP students Sufficient compensation ($$$$) 43
Quebec = 7 «Active» NNPs McGill University (MUHC + JGH) MUHC: 4 (+1) NNPs JGH: 0 NNP Université de Montréal (HSJ + HMR) HSJ: 3 (+1) NNPs HMR: 0 NNP Université de Sherbrooke (CHUS): 0 NNP Ui UniversitéLaval (CHUL): 0 NNP 44
Clinical Nurse Specialist Grace Neustaedter, RN, MN, NCA CNS, Pelvic Floor Clinic Calgary, Alberta 45
Objectives Identify key practice components of a CNS role Review background of the CNS role in Canada Clarify differences between CNS and NP roles Review role of CNS in acute care settings Review role of CNS in the Pelvic Floor Clinic in Calgary 46
CNS Role Practice Components (CNA) 1. Direct nursing care in specialty area 2. Clinical consultant to nurses and other healthcare professionals 3. Educator to healthcare professionals, students, clients, families, communities 4. Researcher developer of research projects, evaluator of care and program delivery, user of research in program development 5. Leader develops standards, policies, programs of care to meet needs of specialty population 47
Background of CNS Role in Canada CNS emerged in 1970 s as client care grew more complex Fiscal cutbacks in 80 s and 90 s eliminated many of these positions Regaining gprominence as concerns build over quality and safety of patient care 48
Differences Between CNS and NP Roles Both roles work with multidisciplinary teams NP focus - direct patient t care emphasizing i health promotion and the treatment and management of health conditions; focus is on individual client level CNS focus - expert nursing care for specialized client populations; emphasis on development of clinical guidelines and protocols; focus on facilitating system change 49
CNS in Practice Specialty area in any acute care setting Program development to address needs of their population (e.g., education for children with newly diagnosed chronic conditions to stabilize, treat, support families, avoid admission to acute care) Development of guidelines and policies (e.g., wound care, suctioning, discharge planning evidence-based guidelines that affect system of care rather than individuals only) Working with staff nurses by providing education and support Research regularly reviewing current literature and applying to the setting or population; involved in research activities in own setting Consultant to other organizations or bodies 50
Pelvic Floor Clinic 7 nurses, plus CNS 3 urogynecologists, 2 fellows Family doctor 3 physiotherapists Support staff 51
Development of CNS Role in Clinic 1998 2 nurses working with 2 physicians (one providing physician support (Grace); one doing urodynamic testing for patients) 2000 Grace began fitting and following patients requiring pessaries throughout Calgary region (nurse-led clinic) Completed Nurse Continence Advisor course (McMaster University) and MN (U of Calgary) 52
CNS Role in Pelvic Floor Clinic Formal clinic began in 2002 with funding Patient Education Workshop introduced by Grace in 2002 Initial assessment clinics by RNs began (in addition to pessary clinics) Expansion of staff in clinic (more nurses, physiotherapists and family doctors); created training and learning modules used to train new staff More outside requests for workshops, inservices, presentations to nursing groups (eg (e.g., UNC), community groups (physician groups), seniors groups (LTC homes), pharmacists, public settings, medical resident groups Development of clinic processes, protocols and educational resources (teaching handouts, brochures, public education) 53
Clinic Progression More awareness in Calgary, southern Alberta, BC and Saskatchewan Longer waiting lists (6+ months) 2008 in attempt t to shorten wait lists and benefit all patients t equally, began teaching 2 workshops per week to most new patients as a required first appointment Positive feedback, reduction of wait times, creation of increased availability of appropriate appointments, reduction of unnecessary appointments 54
CNS Role in Pelvic Floor Clinic 1. Direct nursing care 2 days per week of patient clinics, providing clinical support for other team members as required 2. Teaching clinic patients through workshops within Southern Alberta and now internationally (using telehealth), teaching other RNs to teach classes 3. (Education and) consultation to family doctors, Ob/Gyn residents, university nursing students, enterostomal therapy students, NCA students, public health nurses, the public, pharmacists, physiotherapists (locally, nationally, internationally) 55
CNS Role in Pelvic Floor Clinic 4. Nursing Research publication of research project on readiness for urodynamic testing forthcoming; currently 3 other nursing research studies being developed; regularly reviewing and implementing current research in clinic 5. Leadership developing nursing standards for care; reviewing and revising clinic processes; improving programs within the clinic and outside by providing consultation 56
Summary CNS role both formal education and experience Using scientific research, methods, and knowledge to develop standards and policies Expert in clinical practice, passes on expertise to other clinicians and to patients Role expands and develops to meet the needs within the specialty area Personal challenge to get it all done!! 57
Representatives: CHSRF Roundtable April 2009 Policy makers, nursing and medical professional leaders, regulators, administrators, practitioners, educators Mandate: To develop recommendations for policy, practice & research 58
Recommendations Create a vision statement that clearly articulates the value-added role of APNs across settings. Establish a pan-canadian multidisciplinary task force involving key stakeholder groups to facilitate the implementation of APN roles. 59
Recommendations Consider advanced practice nursing as part of health human resources planning based strategically on population healthcare needs. Standardize APN regulatory and educational standards, requirements and processes across the country. 60
Recommendations Include components that address inter-professionalism in undergraduate and post-graduate health professional training programs. Develop a communications strategy to disseminate to a wide readership the positive contributions of advanced d practice nursing. 61
Recommendations Protect funding support for APN positions and education to ensure stability and sustainability. Conduct further research on: the value-added of APN roles their impact on healthcare costs the CNS role 62
Next Steps Dissemination of APN Decision Support Synthesis and recommendations Implementation of recommendations 63
Dissemination Special report on CHSRF website Special issue of Canadian Journal of Nursing Leadership, Spring 2010 (10 papers) CHSRF Mythbuster Organization for Economic Co-operation and Development (OECD) ICN INP/APNN Conference in Australia Sept 2010 June issue of Canadian Journal of Nursing Research on APNs 64
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