Pathway to Becoming a Nurse Practitioner Training and preparation

1. Pathway to Becoming a Nurse PractitionerTraining and preparation Helen Bowen (Nurse Practitioner) Dr John Shepherd (Geriatrician) Older Adults & Home Health WDHB

2. Understanding NP scope • Growing NPs: NP Candidate • Identifying potential NP roles within services • Our experience • Role of medical mentor and supervision

3. Where are NPs currently working? • 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 • Specialized areas • Diabetes • Cardiac care • Neo-natal care • Urology • Ophthalmology • Palliative care • providing direct clinical care and consultative services to more complex patients

4. Developing NP roles Based on service gaps • Identify a NP position (based on a service gap); grow an NP into it over several years… • Have a nurse suitable who is well on the way to NP and develop a training programme around her/him …

5. 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

6. Adrianne MurrayNP Primary Health Care/Whanau Ora Northlands DHBA 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.

7. 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

8. Dr Michal BoydNP Services for Older Adults - Waitemata DHB Identified Need: • 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 • 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 • Residential Aged Care Integration Project. provides DHB Gerontology Nurse Specialist/Practitioner outreach to residential aged care. 

9. NP Trainee Programme Core Components • Clinically-based (situated/experiential/apprenticeship/internship style) training programme • Around 2-years or part-time equivalent. • 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

10. 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.

11. Important programme components (contd) Supervision • 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 • 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.

12. 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

13. Graded responsibilities over the training period

14. 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?

15. 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 clinicsSecondary care Community settings Residential aged care

16. The Work of the GNP Case Finding Case Management 80,000 – 100,000 65+ living with 4+ chronic conditions Asymptomatic Population screened to identify unmet need or existing disability Targeting high risk individuals 2-5% Practice Nurse/GP assessment/ ECC/ Secondary care 2-5% Communication Collaboration Communication Collaboration GNP/GNS & MDT Team Follow Up GNP & MDT team Brief assessment / screening with further comprehensive assessment and management for those at risk

17. 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

18. SMO SMO SMO Registrar Registrar SMO SMO SMO House Officer House Officer House Officer Registrar House Officer NP Intern HO Junior Doctor Shortage 2008 Full Medical Staffing Model Shortage Staffing Model 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 • SMO, Registrar and NP intern carried 15 patients • “10 beds would have been closed for 6-9 months” (CNM)

19. 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 • Differential diagnoses • Order interventions • Monitor / evaluation / plan patient care • Plan / facilitate discharges, family meetings etc • Work with the MDT team

20. 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

21. 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

22. 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

23. Challenges Uncertainties inherent in developing a new role • 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” • 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”

24. 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

25. 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

26. 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

27. 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”

28. 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.”

29. 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”

30. GOAL When thinking about NPs within your service • Identifying gaps • Improving patient outcomes • Collaboration as key • Never about competition between / among health professionals

31. The final word “The role was an indication from the health board that they were investing, … making a real investment in older people”