A Policy on the Development of Graduate to Advanced Nursing and Midwifery Practice

www.health.gov.ie

www.health.gov.ie

A Policy on the Development of Graduate to Advanced Nursing and Midwifery Practice

Table of Contents

Table of Figures 4

Table of Tables 4

Foreword by The Minister for Health 5

Foreword by The Chief Nursing Officer 6

Values of Nursing And Midwifery 7

Executive Summary 8

1. Introduction 9

1.1. Overview of the Proposed Model 101.2.SupportingIntegratedCare 111.3.TheEducationPathway 121.4.PolicyGoalsandActionsforGraduatetoAdvancedPractice 131.5.Conclusion 16

2. Chapter 2 - Professional Context 17

2.1.StructureoftheNursingandMidwiferyResourceinIreland 182.2.TheClinicalCareerPathway–Graduate,SpecialistandAdvancedPractice 212.3.GraduateNursePractice 252.4.ClinicalSpecialistPractice 262.5.TheCurrentModelofAdvancedPracticeInIreland 28

2.5.1. CurrentAdvancedNursingAndMidwiferyPractice(Anp/Amp)Resources 282.6.EnablersandChallengestotheDevelopmentofAdvancedPractice 33

2.6.1. EnablerstotheDevelopmentofAdvancedPracticeInIrishContext 342.6.1.1.Graduate Profession 342.6.1.2.Existing Roles 342.6.1.3.Regulation 342.6.1.4.Evidence of Achievement 342.6.2. ChallengestotheDevelopmentofAdvancedPracticeIntheIrishContext 342.6.2.1.Geographical Spread and Service Need 352.6.2.2.Lack of Uniformity to Role Development 352.6.2.3.Current Prolonged Pathway to Advanced Practice 352.6.2.4.Current Age Profile and Work Patterns 352.6.2.5.Current Work Patterns 362.6.2.6. Value of Advanced Practice 36

2.7.Summary 373. Chapter 3 - Service Delivery Context 39

3.1.Introduction 403.2.Population,HealthTrendsandDemographicChallenges 403.3.AdvancedPracticeResponsestoServiceChallenges 42

3.3.1. IntegratedCare 423.3.2. WaitingListsAndAccesstoServices 443.3.3. PatientFlow 453.3.4. UnscheduledCareAccessandDelivery 46

3.4.OtherExamplesofTheAdvancedNurse/MidwifeResponsetoServiceChallenges 463.4.1. HospitalAdmissionAvoidance 463.4.2. InterdisciplinaryCollaborationandNurse-Led/Midwifery-LedServices 47

3.5.Summary 484. Chapter 4 - Future Model of Graduate to Advanced Practice 49

4.1.Introduction 50

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Table of Contents (continued)

4.2. Overview of The Proposed Model 504.3.RationaleforProposingaCompetencetoCapabilityModel 524.4.TheEducationalPathwayWithintheModel 534.5.InterprofessionalEducation 534.6.RegulationtoSupporttheModel–ASystemofCredentialing 574.7.Governance 604.8.Measurement 62

4.8.1. MeasuringtheEconomicImpactofAdvancedPractitioners 624.9.Summary 65

5. Chapter 5 - Testing The Model of Graduate to Advanced Practice 67

5.1.Introduction 685.2.SettingTheDirection 68

5.2.1. EstablishingtheSteeringCommittee 685.3.MobilisingCommitment 70

5.3.1. BroadRangingConsultationProcess 705.3.2. ProcuringEducation 715.3.3. ChangingtheRegulatoryFramework 735.3.4. DevelopaMeasurementSystem 74

5.4.DeliveringOrganisationalCapacity 755.4.1. SelectionofSites 755.4.2. CreatingCriticalMass2017 765.4.3. Planningthe2018Programme 775.4.4. CreatingCriticalMass2018 77

5.5.ProvideVisibleEvidence 785.5.1. Evaluation 785.5.2. ProcurementofPEPPAPlusFramework 805.5.3. EarlyResults 80

5.6.Summary 816. Recommendations 83

7. Conclusion 87

References 91

Glossary 103

Appendix 1 Number of Cns/Cms by Speciality 105

Appendix 2 Anp/Amp by Division of Register 106

Appendix 3 The Roles Provided by the Cns and the Anp in Dermatology 107

Appendix 4 Educational Programmes for Advanced Practice 108

Appendix 5 Membership of The Steering Group 110

Appendix 6 Project Initiation Document 111

Appendix 7 Terms of Reference for the Steering Group 117

Appendix 8 Consultation Feedback 118

Appendix 9 Criteria for Demonstrator Site Selection 121

Appendix 10 Creating a Critical Mass of Ranp/Ramps 122

Appendix 11 Logic Model Evaluation 123

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Figure 1 Core Values of Nursing and Midwifery 7

Figure 2 Model to Advanced Practice 11

Figure 3 Education Pathway to support integrated care and within a service delivery focus for graduate to advanced practice 12

Figure 4 Overview of NCNM ANP Registration Process - 2010 21

Figure 5 Number of ANPs per Hospital Group (2016) 32

Figure 6 Model to Advanced Practice 51

Figure 7 Education Pathway 53

Figure 8 Key Principles of Clinical Governance 61

Figure 9 Strategy to Test Model 68

Figure 10 Structure of Steering Committee and Working Groups 69

Figure 11 ANP Distribution by Speciality - 2017 76

Figure 12 PEPPA Evaluation Model, From Bryant- Lukosius and Dicenso (2004) 79

Table 1 Division of Register of NMBI 18

Table 2 Distribution of Nurses by Register 2016 19

Table 3 Specialist and Advanced Practice Roles 20

Table 4 Levels of Education and Competency per Role 22

Table 5 Practical example illustrating the role of graduate, specialist and advanced practice 23

Table 6 Examples of the expanded scope of practice in Ireland 25

Table 7 CNS Distribution - 2016 27

Table 8 International Comparisons 31

Table 9 Challenges and Enablers to the Development of Advanced Practice 33

Table 10 Example of Waiting Lists and RANPs in post - 2018 44

Table 11 Core Learning Areas 56

Table 12 Minimum Dataset 64

Table 13 Feedback from Consultations 70

Table 14 Projected Number of ANPs Registered per year 75

Table of Figures

Table of Tables

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ItisjustovertwoyearsagosinceIlaunchedtheconsultationphaseforthispolicyandIamdelightedthatwearenowpublishingourpolicyonthe“Development of Graduate to Advanced Nursing and Midwifery Practice”.

TheIrishhealthservicetodayfacesmanycomplexchallenges.However,wenowhaveanagreedvisioninSláintecare–our10-yearplantoreformthehealthservice.Drivenbylong-termconsensusreform,weallhaveachancetobeco-authorsofthisnextchapterinIreland’shealthservice.NursesandmidwivesarecriticaltothisjourneyandthatiswhyIamsopleasedthatweareprogressingandsupportingthisareaofreform.Thisinitiativewillprovidepatientswithmoreappropriate,safeandaccessiblecareacrossarangeofservices.

Currently,AdvancedNurseandMidwifePractitionersinIrelandplayanimportantroleincaredeliveryacrossmanyareasincluding;ouremergencydepartments,localInjuryUnits,respiratorycareandrheumatologycare.ThevalueoftheserolesisacknowledgedandaddstothequalityofhealthcareinIreland.Thereare,however,areasofadvancedpracticethatarecurrentlyunderdevelopedwithinourhealthservicesandthispolicy,Ibelieve,outlinesamodeltosupportthedevelopmentofnursesandmidwivestoadvancedpractice.Thiswillensurefullutilisationandappropriateapplicationofthenursingandmidwiferyresourceandoptimisebothoutcomesandimpactforpatientsandservices.

Themodeloutlineschangestothewaynursesandmidwiveswillbeeducatedtoadvancedpracticelevel.Havingdevelopedthemodel,theChiefNursesOfficeoversawtestingitinanumberofdemonstratorsiteprojects.Theresultsareshowingpositiveimpactsonpatientoutcomes,waitinglists,accesstoservicesandreductionsinhospitaladmissions.

Iwouldtothankallthoseinvolvedinthedevelopmentofthepolicy,themembersoftheNationalSteeringCommittee,theLocalImplementationGroupsandtheNursingandMidwiferyBoardofIreland.IwouldliketopayparticulartributetoDrAnnemarieRyan,MsMaryFrancesO’ReillyandMsBerneenLaycockwithoutwhosecommitmentandvisionthispolicywouldnothavebeenpossible.ThedevelopmentofthisPolicythroughconsultation,testingandevidence,isastrongexampleofsuccessfulpolicydevelopment.

IlookforwardtofullrolloutonanationwidebasisandtofurtherintegratingournursesandmidwivesintoourSláintecarejourney.

Simon Harris T.D. MinisterforHealth

Foreword by the Minister for Health

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Foreword by the Chief Nursing Officer

IamdelightedtopresentthispolicyfortheDevelopmentofGraduatetoAdvanced Nursing and Midwifery Practice.Thispolicyaimstomaximisethenursingandmidwiferyresponsetocurrentandemerginghealthserviceschallenges.Itprovidesamodeltosupportthedevelopmentofgraduatetoadvancedpracticethatwillassistinbuildingacriticalmassofnursesandmidwivesworkingatadvancedpracticelevel.Bycreatingacriticalmassofnursesandmidwives,weknow,cancontributeeffectivelyandefficientlytoaddressingpopulationhealthneeds.Theevidencehasshownthattheprovisionofcarebyadvancedpractitionerscanincreasehospitalavoidance,earlydischarge,improveaccesstoservices,integratedcareandpatientflowthroughthehealthservices.

Ourwell-educated,highlyskilledandexperiencednursesandmidwivesareavaluableresourceandthemodeloutlinesabroad-basedapproachtotheeducationprogrammerequiredforadvancedpractice.Placingthepatientatthecentrethemodeloutlinesasystemofcredentialingtobuildthecapabilityofthenursingandmidwiferyworkforcethroughoutthesystem.Thiswillenablenursesandmidwivestopracticeatthetopoftheirlicence,withinaminimumtimeframeandimportantlystayatthepointofcaredelivery.HavingadvancedpractitionersatthepointofcaredeliverywillnotonlysupportthedeliveryofintegratedcareacrossourhealthservicesitwillbeakeyenablerforthedeliveryofSláintecare.

Itisimportanttomethatpolicy,oncedevelopedachievestheoutcomesitintends.Tothisendthetestingofthispolicyinseveraldemonstratorsites

illustratedanumberofpositiveoutcomesforpatientsandservicessuchas,over60%ofpatientsseenbyanadvancedpractitionerintheunscheduledcaresettingreceivedtheirfullepisodeofcareandweredischarged.Thispolicynowsetsthedirectionforthedevelopmentofgraduatetoadvancedpracticethroughanevidencedbasedmodel.

Nopolicyreachesthisstageofdevelopmentwithoutinputfrommanypeople.Iwouldparticularlyliketothankthesteeringcommitteeandlocalworkinggroupswhosegenerositywithtime,contributionandcommitmentdrovethedevelopmentofthispolicy.AspecialwordofthankstoallofthoseontheAdvancedPracticepathway,theirinvaluableexperienceweavesthevaluesofcompassion,careandcommitmentthroughoutthepolicydocumentandintocaredelivery.Thisistrulywhere“policy reaches the patient”.Finally,Iwouldalsoliketoacknowledgethecollaborativeandextensiveworkofmyoffice,Dr.AnnemarieRyanandtheONMSD.

ThisisthesecondpolicyfromtheChiefNursesofficewhichnotonlycreatesadefinedcareerpathwayfornursesandmidwivesanddirectlyimprovespatientcareandoutcomes.ThispolicywillhavesignificantimpactonhealthcareprovisionandtheprofessionsofnursingandmidwiferyforyearstocomeandIlookforwardtoworkingwithallourpartnersandstakeholdersonthisjourney.

Dr. Siobhan O’Halloran ChiefNursingOfficer

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Values of Nursing and Midwifery

TheOfficeoftheChiefNurse(CNO’sOffice)wasestablishedintheDepartmentofHealthin2015toensurethatanursingandmidwiferyperspectiveisbroughttobearonthedevelopmentofpolicywithintheDepartmentandtoensurethataclearvoiceofnursingandmidwiferyispresentindesigningthefutureofIrishhealthcaresystems.TheCNO’sOfficeidentifieskeyhealthsystemproblemswhichnursinghasthepotentialtoimpactpositively.Itthendevelopsapolicyresponse,buildinginaprocessformeasuringtheoutcomeandimpactofthatresponse.Indevelopingpolicy,themethodologiesusedbytheCNO’sOfficeinclude(i)evidencereview,(ii)international,comparativeanalysiswithotherjurisdictionswhichhavetackledthesameproblems,(iii)stakeholderinvolvement,and(iv)nationalconsultation.Policiesaredesigned,tested,modified,andscaled-upcarefully;turningwhathasbeenlearnedintopractical,evidence-basedrecommendations.

ThemissionoftheOfficeistooptimisethecontributionofnursingandmidwiferytohealthserviceprioritiesintheinterestsofserviceusers,theirfamiliesandthewidercommunity.TheOfficeworksinpartnershipwithotherhealthandsocialcareprofessionals,inparticular,ourcolleaguesintheOfficeoftheNursingandMidwiferyServicesDirectorate(ONMSD).

Takingthisapproach,theOfficeoftheChiefNurseturneditsattentiontotheareaofAdvancedPractice(AP).

ValuesValuesareingrainedprinciplesthatguidetheactionsofnursesandmidwives.ThispolicyacknowledgesthecorevaluesunderpinningandguidingthepracticeofnursesandmidwivesinIreland

Thethreecorevaluesidentifiedbytheprofessionsarecare,compassionandcommitment.

Thesevaluesandtheirassociatedbehavioursaretheessenceofnursingandmidwiferypracticeandformthebasisforprofessionaldecisionmakingandactions.Takentogether,thesevaluesrepresenttheuniquecontributionofnursingandmidwiferytosafepatientcare.TheDepartmentofHealth(DoH),HealthServiceExecutive(HSE)andNursingandMidwiferyBoardofIreland(NMBI)arecommittedtosupportingnursesandmidwivespracticethesevalues.

Figure 1. Core Values of Nursing and Midwifery

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Executive SummaryA policy direction for Graduate to Advanced Practice

Policy objective:Topresentamodelforgraduatetoadvancedpracticecapableofdevelopingacriticalmassofnursesandmidwivestoi)addressemergingandfutureserviceneedsandii)driveintegrationbetweenservices.Theoverarchingprincipleunderpinningthepolicyistodevelopthenursingandmidwiferyresourceinresponsetopatientandserviceneed.

Why we need a policy:Sincethecreationoftheroleofadvancednurse/midwifepractitionerin2001,336advancedpractitionershaveregistered,withafurther92candidatesexpectedtojointheregister.Internationalbench-markingindicatethatthisremainsacomparativelylownumber.Challengesstillexiststomeetthecriticalmassrequired.Evidencesuggeststhatcreatingacriticalmassofnursesandmidwivesasspecialistandadvancedpractitionershasbenefitsforserviceprovision,suchasimprovedtimelyaccesstoservices,hospitalavoidance,reducedwaitinglistsandintegrationofservices.Themovetodegreelevelnursingeducationin2002andsubsequentinvestmentinnurseeducationhasprovidedopportunitiesfornursesandmidwivestodemonstratetheaddedbenefitofextendedpractices,e.g.prescribingofmedicinalproductsandx-ray,toserviceprovisionandpatientcare.

Background to developing this policy: Thispolicyisunderpinnedbyanevidencereview.Itwasalsoinformedbyconsultationwithkeystakeholdersincludingnationalandinternationalexperts,educationalists,

regulators,managers,policymakersandchiefnurses.Dataweredrawnfromnationalsources,andtheproposedpolicywasalsopresentedtotheDepartmentofHealthPolicyCommittee.

This policy supports the development of graduate to advanced practice by:

• creating,pilotingandevaluatingthemodelforgraduatetoadvancedpractitionersbasedonserviceneedwithinintegratedcareandservicepathways;

• developingacriticalmassofadvancedpractitionersinaflexible,timelyfashionthatcanprovideafullepisodeofcare;

• introducingacredentialingpathwaythatsupportsnursesandmidwivestodevelopthecapabilitytodeliversafeandresponsivecareinavarietyofservicesettings;

• focusingonabroad-basedapproachwithahealthpopulationfocustomeetcurrent,emergingandfutureserviceneedswithadvancedpractice;

• facilitatinginterprofessionaleducationtopromoteintegrateddeliveryofcare,andthemostefficientdeliveryofeducationandpracticedevelopment;and

• providingrecommendationsforcontinuedandsustainedchange

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Chapter1Introduction

Chapter 1Introduction

1.1. Overview of the proposed model

Themodelhighlightstheinterconnectednatureofmeetingserviceneedswithadevelopmentalpathwaythatpreparesthenursingandmidwiferyworkforce.Itisalsoaregulatorypathwaythatembracescredentialingandcompetence,ensuringacapablenurse/midwifeprovidedandmanagedservice.Centraltothemodelispatient-centredcareandchoice.Themodeloutlinesthepreparationfromgraduatethroughtoadvancedpracticeanddemonstrateshowanurseormidwifecandeveloptheircareerusingabroad-basededucationalapproachanddevelopspecificcompetenciesthatcanbemeasuredforserviceprovision.Thedevelopmentandexpansionofnursing/midwiferypracticewithinthemodelisindirectresponsetoserviceneed.Thecapabilityofthenurse/midwifeisdevelopedfromapositionofrelianceonprotocolandproceduretooneofindependentpracticeanddecisionmaking.Thissupportsthepatienthealth/illnessjourneywherebythenurse/midwifecanmanagetheuncomplicatedtothecomplicatedhealthconditions.

Themodeloutlinesaprocessfordirectorsofserviceandpolicy-makerstosupportthedevelopmentofflexiblemulti-taskedprofessionalsthatsupportthehealthsystemandservicerequirements(Figure2).Themodelsupportsthedevelopmentofaflexibleandresponsiveprofessionaltomeetpatientandserviceneed,embracingqualityandsafetyrequirementsandexpeditethedevelopmentofappropriatelyskilledstaff.

Apatientcentredfocusisinherenttothismodel.Themodelproposesatwo-yeartimeframefromgraduatelevelthroughtoadvancedpractice,whichisreflectiveofcurrentinternationaltrendsinthisarea.ThemodelincludesaprocessofaprogressivecredentialingthatallowstheNursingandMidwiferyBoardofIreland(NMBI)toannotateanurseormidwife’sregistrationtorecognisecontinuingachievements.Thiswouldthenpermitthenurseormidwifetocommenceanadvancedpracticerolewhileundertakingtheformaleducationrequirements.

The benefits of advanced nursing and midwifery practice are extensively evidenced in both national and international literature. The nursing workforce in Ireland is both educated and highly skilled, which is a key enabler for increasing numbers of advanced practitioners.

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Figure 2. Model to Advanced Practice

1.2. Supporting integrated care:

Integratedcareasaconceptforcaredeliverywasintroducedtoaddresschallengesinthehealthandsocialcaresystems.Theaimofintegratedcareistoimproveoutcomesandexperiencesforthegreatestnumberofpatientsbyputtingpatientoutcomesatthecentreofactivity.Integratedcareisdescribedaspreventative,enabling,anticipatory,planned,well-coordinatedandevaluated.Itlooksatprocessesandoutcomesofcareratherthanatstructuralandorganisationissues(HSE2016).Withintheintegratedmodelsofcaredeliveryhealthcareprofessionalsworkinpartnershipacrossdisciplinaryboundariestoproducenewand

moreeffectivemodelsofcare.InIrelandcurrently,therearefiveIntegratedCareProgrammesintheareasofPatientFlow,OlderPersons,PreventionandManagementofChronicDisease,Children,andMaternity.

Thispolicyistosupportanddevelopthecontributionofthenursesandmidwivesfromgraduatetoadvancedlevel,maximisingtheknowledgeandskillsofnursesandmidwivesatalllevelsofpractice.Thispolicyaimstosupportcareprovisionbeingmetbytheappropriateprofessionalacrossprimary,socialandacutecareandmentalhealthservices.

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INTEGRATION AND SERVICE FOCUS

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careChronicdiseases

Older PersonsPaediatricsMidwifery

Acute, primary care, social care and mental health services

ROLE DEVELOPMENT

SPECIALY CERTIFICATIONPG Dip level

CORE COURSESNurse prescribing/x-ray

Advanced Health/physical assessmentPathophysiology

Pharmacology

INTERPOFESSIONAL EDUCATION

BROAD BASED MASTER LEVEL EDUCATION

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EXPERIENCE IN PRACTICE

1-2 YEARS

EXPANDINGPROFESSIONAL COMPETENCE

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RNID

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ENHANCED NURSE

CPD

Figure 3. Education Pathway to support integrated care and within a service delivery focus for graduate to advanced practice

1.3. The Education Pathway

Theeducationpathwayforanurseormidwifesupportsthefivenationalintegratedpathways(HSE2016)ofcare.Theinitialregistrationofanurseunderpinstheintegrationfocusandisbasedon

adevelopmentalmodelthatembracescredentialededucationthatcanbeannotatedbytheNMBI.ThenewtimelinefordevelopmentofaRANP/RAMPistwo-yearsfrominitialregistration.Inthismodelitisalsopossibleforspecialistpracticetodeveloptomeetserviceneed.

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1.4. Policy Goals and Actions for Graduate to Advanced Practice:

Thegoalsandactionstosupportachievingthegoalsforthispolicyaresetoutunderfiveprincipleheadingsasfollows:

GOAL 1 Create a Critical Mass of RANP/RAMP’s through a developmental pathway for graduate and specialist nurses and midwives

Action Details Responsibility

a Alignthedevelopmentofadvancedpracticepositionsfornursesandmidwivestotheintegratedmodelsofcareacrossservicestoensureconsistentprovisionofserviceacrossgeographicareas

HSE

b Developadvancedpractitionerstomeetserviceneed,basedonHSEdata,toincludeareassuchasreductionofwaitinglists,hospitalavoidance,andsupportingaccesstoservicesinareaswheretheintegrationofservicescanbeachieved.

HSE

c Setatargetof2%ofadvancedpractitionersinthenursing/midwiferyworkforcetocreateaninitialcriticalmass.

HSE

d Undertakeamid-pointreviewofprogresstoensuretheachievementofthetargetforadvancedpracticedevelopmentandtheappropriatenessofthetarget

HSE

e Developanationalcareeradvisoryservice,basedonserviceneedthatincludessuccessionplanningforpopulationhealth,whichsupportsnursesandmidwivesindecidingontheirindividualcareerpathway.

NMBI

f Facilitatethecurrentcohortofcandidateadvancedpractitionerstoachieveregistrationwherebusinesscaseshavebeenagreed,serviceneedhasbeenidentifiedandavacancyexists.

HSE

g Determinetheminimumdatasetrequiredforworkforceplanningandreportingpurposes,includingareasofworkandspecialisations.

DOH

h ExplorethecapacityoftheRegisterofNursesandMidwivestocaptureandmaintainthedatarequiredinaction1gaboveasprovidedintheNursesandMidwivesAct(2011).

NMBI

GOAL 2 Change the way we educate and train graduates, specialists and advanced nurse/midwife practitioners

Action Details Responsibilitya Introduceasystemofcredentialingtomeetserviceneed

basedontheinterconnectedmodelforgraduate,specialistandadvancedpractice.

NMBI

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b ImplementunderSection48(3)oftheNursesandMidwivesAct(2011)aprocesstoannotatethenameofanurseormidwifewhosuccessfullycompletescredentialededucationparticularlyrelatedtoskillsacquisition.

DOHNMBI

c Changetheregistrationfornurse/midwifeprescribingtobecomeacomponentofcredentialededucationinacareerpathwayforgraduatetoadvancedpracticetosupportintegratedandcommunitycare.

NMBI

d Recogniseaccreditededucationobtainedinotherjurisdictionsinaclinicalcareerpathwayforanurse/midwifejoiningtheworkforceinIreland.

NMBI

e Reducetheminimumregulatorytimelineforundertakinganadvancedpracticepathwayto2-years.

NMBI

f Developa1-yeargraduatecertificatetypeprogrammeasashortenededucationalpathwayforexperiencednursesandmidwivestoobtainoutstandingeducationalrequirementsforadvancedpractice.

HSENMBIHEI

g Provideforbroader-basededucationpreparationofadvancedpractitionerstoavoidthedevelopmentofmicro-specialisationwithinaservicespeciality.

NMBIHEI

h Establishinterprofessionaleducationstandardsandrequirementswithothermembersoftheinterdisciplinaryteamthatsupporttheconceptofcapabilityforroleshare/exchangebetweenprofessions.

NMBICORUMCIHEI

i Enhancecollaborativeinterprofessionalmentoringsupportsandsystemsacrosstrainingprogrammeswithintheinterdisciplinaryclinicalteams.

HSEHEI

j DevelopapathwaythatallowsforadvancedpractitionerstocontinuetheircareerjourneyinresearchandteachingtoDoctorallevel.

HEIHSE

k Developgovernanceandmanagerialstructuresthatsupportcollaborativeinterdisciplinaryteamworkingthatenabletheskillsofnursesandmidwivesatgraduate,specialistandadvancedpracticebemaximisedforpatient-centredcare.

HSE

GOAL 3 Change how we utilise and deploy the nursing and midwifery resource

Action Details Responsibility

a Creategovernanceandaccountabilitystructuresthatenabletheadvancedpractitionerstoprovideafullepisodeofcareandservicesupportingothermembersofthecareteam.

HSE

b Provideadvancedpractitionerswithaccesstodiagnostics,referralpathwaysandappropriatetreatmentsthatarerequiredtofacilitatetheprovisionoffullepisodesofcarebothinacuteandinthecommunitysectors.

HSE

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c Supportgraduatenurses/midwivestomeetpatient-centredserviceneedandtheexpansionofthescopeofpracticewithinthecredentialingmodel.

HSE

d Reviewpatient/clientpresentationtimestoensuretheserviceprovidedbygraduate,specialistandadvancedpractitionersmatchesthedemandwithinthenormal24/7patternsofnurse/midwifeprovisionofcare.

HSE

GOAL 4 Measure the impact and effectiveness of the new model

Action Details Responsibilitya DevelopasetofKPI’sthatcapturestheoutputactivity

ofadvancedpractitionerstoincludenumbersofpatientsseen;numbersofpatientsaccommodatedfromthewaitinglist;anddatarelatingtoclinicalcareoutcomes,includingcost-effectivenesstoachieveanon-goingeconomicevaluationofadvancedpracticeroles.

HSE

b Explorethefeasibilityofdevelopinganevidence-basedevaluationmodelforadvancedandspecialistrolesunderpinnedbyresearch,similartothePEPPAmodel.

HRB

GOAL 5 Implementation

Action Details Responsibility

PhaseIpre-planning

Establishaplanninggroupthatwilloverseetheplanninganddevelopmentofdemonstratorprojectstotestthemodel.

DoH

Identifythedemonstratorsitesforthedevelopmentofadvancedpractitionerstomeetserviceneedintheareasofhospitalavoidance,reducingwaitinglists,andsupportingaccesstoservicesinareaswheretheintegrationofservicescanbeachievedbasedonHSEdatae.g.frailelderly,rheumatologywaitinglistsanddermatologywaitinglists.

HSE

PhaseIIDemonstratorimplementation

Establishanimplementationgroupofappropriatemembersthatcanoverseethedemonstratorprojects,theimplementationandevaluation.

DoHHSE

Establishlocalimplementationgroups,withtheappropriatemembershipthatcanoperationalisethedemonstratorprojectsforspecifiedservicesutilisingthenursingandmidwiferyresource.

DoHHSE

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1.5. Conclusion:

• Themodelforgraduatetoadvancedpracticesetsoutamechanismtosupportthedevelopmentofacriticalmassofadvancedpractitioners.

• Itoutlinesachangetothewayweeducateandtrainnursesandmidwivesfromgraduatelevelbymovingtoanenablingcredentialingsystemthatfacilitiesnurses/midwivestopracticeatanadvancedleveloncethecapabilitytopracticehasbeenachieved.Nursesandmidwiveswillhaverecognitionoftheachievementofnewcapabilitiesthroughannotationontheregister.

• Theminimumtimeframetoachieveregistrationasanadvancedpractitionerwithinthismodelisreducedto2years.

• Themodelalsosupportsachangetohowweutiliseanddeploythenursingandmidwiferyresourcebymovingtoprovideanursingresponsebasedoncurrentneedsandprioritiese.g.integratedcare,patientflow,hospitalavoidance,waitinglistreductionandaccess.

• Totestthemodelthedemonstratorsiteprojectimplementsthemodelandtargetsthedevelopmentofadvancedpractitionerstomeetserviceneedintheareasofhospitalavoidance(olderpersons);waitinglists(rheumatologyanddermatology);andaccess(unscheduledcareservices).

• Measuringtheimpactandeffectiveness(costandclinical)ofthenewmodelisoutlinedthroughmeasuringtheimpactonpatients,theservice,regulatoryandeducationareas.Aformalevaluationprocessisalsobecarriedout.

• Inconclusionthemeasurementandevaluationofimplementingthemodelhasledtoseveralrecommendationsforfurtherdevelopmentandcontinuedimplementation.

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Chapter2ProfessionalContext

Chapter 2Professional Context

2.1. Structure of the Nursing and Midwifery Resource in Ireland

TheNMBIasaregulatormaintainstheregisterofnursesandmidwivesinIrelandinaccordancewiththeprovisionsoftheNursesandMidwivesAct2011(GovernmentofIreland,2011).TheRegistercontainstendivisionsasoutlinedinTable1.TheNMBI

setsthestandardsandrequirementsfortheeducationregistrationprogrammes.Thestandardsforentryforeachdivisionoftheregisterreflectthescopeofpracticeexpectationsandthecompetenciesofthenurse/midwifeoncompletionoftheprogramme.Since2002theundergraduateprogrammetopreparenursesinIrelandhasbeenafour-yearBachelorofSciencedegree.

Table 1. Division of Register of NMBI

Division Designation Titles Abbreviation Qualification

General RegisteredGeneralNurse

RGN BachelorofScience

Midwives RegisteredMidwife

RM BachelorofScience

ChildrenandGeneral(Integrated)

RegisteredGeneralNurse/RegisteredChildren'sNurse

RGN/RCN BachelorofScience

Psychiatric RegisteredPsychiatricNurse

RPN BachelorofScience

IntellectualDisability RegisteredNurseIntellectualDisability

RNID BachelorofScience

PublicHealth RegisteredPublicHealthNurse

RPHN PostGraduateDiploma

NurseTutor RegisteredNurseTutor

RNT Masters

Nurse Prescribers RegisteredNursePrescriber

RNP PostGraduateDiploma

AdvancedNursePractitioners RegisteredAdvanced Nurse Practitioner

RANP Masters

Advanced Midwife Practitioners

RegisteredAdvanced Midwife Practitioner

RAMP Masters

18

ThedistributionofnursesandmidwivesbyregulatorydivisionisillustratedinTable2.MaintenanceontheRegistercurrentlyrequiresthepaymentofanannualretentionfee,andthiswillultimatelybeaugmentedbyacompetenceregimeinaccordancewiththeNursesandMidwivesAct2011.WhilethedataavailablefromtheNMBIregisterreflectsthenumberofqualificationshelditdoesnotcapturethecurrentareaofpractice,competencies,capabilityorworklocation.ThereissignificantpotentialtousetheNursesandMidwivesRegistertocollectdatacapableofinformingpopulationhealth,serviceandworkforceplanning.Animproveddatasetwouldassistintheseissuesaswellasfacilitatingthedevelopment,accreditationandregulationofadvancedpracticeroles.

Table 2. Distribution of Nurses by Register 2016

Division Active

Advanced Midwife Practitioner

8

Advanced Nurse Practitioner

192

Children's 4,335

General 53,951

IntellectualDisability 4,740

Midwives 10,563

Nurse Prescriber 916

Psychiatric 8,392

PublicHealth 2,423

Tutors' 644

Totals 86,163

TheIrishresearch(asseeninTable3)issupportedbysimilarresearchconductedintheUKwhichdemonstratesthatadvancedandspecialistrolesreducecostsandimproveefficiencybyensuringthebestuseofhospitalconsultanttime,freeingupthetimeofothermembersofstaff,drivinginnovationandofferingvalueformoney(NHS2015,Raffertyetal2015).Specialistandadvancedpractitionersalsoenabletimelyseamlessandintegratedmultidisciplinarycarebymakingtherightcareinterventionandreferralsattherighttimewhilebrokeringcarebetweenhealthcareprofessionalsandotherorganisations(Raffertyetal2015).Begleyetal(2010)intheirstudyoftherespectiveimpactofspecialistandadvancedpracticerolesidentifiedstrongpositivecontributionsacrossarangeofdomains,theimpactofspecialistandadvancedpracticerolesmayseemsimilar,additionalcontributionsareevidentfromadvancedpractitionersparticularlyintheareasofresearchactivities,thedevelopmentofguidelinesfornationaldistributionandthedevelopmentoftheirscopeofpracticeformorecomplexcareprovisionincludingthetotaljourneyofcareuptodischarge.

19

Table 3 - Specialist and Advanced Practice Roles

CNS/CMS and ANP/AMP

• reducedmorbidity

• decreasedwaitingtimes

• earlieraccesstocare

• decreasedre-admissionrates

• increasedevidence-basedpractice

• increaseduseofclinicalguidelinesbythemultidisciplinaryteam

• increasedcontinuityofcare

• increasedpatient/clientsatisfaction

• increasecommunicationwithpatient/clientandfamilies

• promotionofself-managementamongpatients/clients

• workingonexpandinganddevelopingpractice(manyCNS/CMSareworkingtowardsANP/AMP)

• significantmultidisciplinarysupportfortherole

• provisionofclinicalleadership

• aclinicalauditconducted(researchconductedby53%)

• overallnoadditionalcostforCNS/CMSorANPservice

Additional to the RANP/RAMP role

• Developedguidelinesfornationalandlocaluse

• increasedpatient/clientthroughput

• workingonexpandinganddevelopingthescopeofpracticetoincludemorecomplexcareprovision

• demonstratedhighjobsatisfaction

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2.2. The Clinical Career Pathway – Graduate, Specialist and Advanced Practice

TheReportoftheCommissiononNursing:ABlueprintfortheFuture(GovernmentofIreland1998)describedaclinicalcareerpathwayforgraduatenursesandmidwivesthroughtospecialistandadvancedpractice.TheCommissionrecommendedtheestablishmentoftheNationalCouncilfortheProfessionalDevelopmentofNursing

andMidwifery(NCNM)whichsubsequentlypublishedtheoriginalpathwayfornursestoadvancedpractice.Theoriginalpathwayreliedheavilyonextensiveclinicalsupervisionintheareaofspecialityoncequalified.TheNCNMwasdisbandedin2010withsomefunctionsassignedtotheregulatorofnursingandmidwiferyatthattime(AnBordAltranais).

Figure 4 - Overview of NCNM ANP Registration Process - 2010

• Demonstrate competence to perform all aspects of the role

• Verifica�on of documenta�on

• Applica�on form, por�olio

and statement of competencies

• Review of applica�on for relevant informa�on

• Liaison with ANP/AMP candidate

• Establishment of an accredita�on commi�ee

• Verifica�on of documenta�on

• Review against criteria

• Liaison for clarifica�on

• Delibera�on and decision

• Recommenda�on to Na�onal Council

• Na�onal Council delibera�on and decision

• ANP/AMP candidate

• Director of Nursing/Midwifery

• Director of Nursing/Midwifery

• Accredita�on commi�ee

• Na�onal Council execu�ve

• Na�onal Council

Review by Director of Nursing/Midwifery

Applica�on form and por�olio prepara�on

Submission of applica�on to Na�onal Council

Review of applica�on by officers

Review of applica�on by accredita�on commi�ee

Na�onal Council decision

21

ThekeydifferencesinthedomainsofcompetenceandlevelsofeducationassociatedwiththedifferentlevelsofpractitionerareoutlinedinTable4.

Table 4 - Levels of Education and Competency per Role

Graduate Nurse /Midwife Clinical Nurse/Midwife Specialist

Advanced Nurse/Midwife Practitioner

Honours degree level 8 NQAI Graduate diploma Level 9 NQAI

Masters degree Level 9 NQAI

Thegraduatenursedemonstratescompetenciesinthefollowingdomains:• professionalandethicalpractice

• aholisticapproachtocareandintegrationofknowledge

• communicationandinterpersonalskills

• organisationandmanagementofcarePersonalandprofessionaldevelopment

TheCNS/CMSdemonstratescompetenciesinthefollowingdomains:• clinicalfocus• patient/clientadvocacy• educationandtraining• audit,research• consultancy/clinicalleadership

TheANP/AMPdemonstratescompetenciesinthefollowingdomains:• professionalvaluesandconductcompetencies

• clinicaldecision-makingcompetency

• knowledge/cogitativecompetencies

• management/team• clinicalLeadership/professionalscholarship

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Apracticalexampleillustratingtherolesofgraduate,specialistandadvancedpracticeinthecareofpatientsinarheumatologyserviceshowninTable5.

Table 5 - Practical example illustrating the role of graduate, specialist and advanced practice

Staff Nurse CNS Rheumatology RANP Rheumatology

KnowledgeofRheumatology

Developsknowledgeofthepathologyanddiagnosisofrheumatology-relatedillnesses.Abilitytocommunicateinformationtoclientsandtheirfamilyregardingthecurrentstageofillness.

Linksthepathologyofrheumatologyillnesstoappropriatetreatmentoptions.Understandsthepathologicaldifferencesofvariousconditionsandrecognisesappropriatedrugsindifferentillnesses.

Teachesnursingandmedicalstaffaboutnewtheories.Developsawarenessofnewevidence-basedtreatmentswithinnursingandinterdisciplinaryteam.Discusseswiththeclientrelevantinvestigationsandtreatmentoptionsthatareacknowledgedbytheirpeersasexemplary.Provideclinicalleadershipbydemonstratingadvancedtheoreticalknowledgeandclinicalskillsinmanagingdefinedrheumatologyconditions.

GeneralClinical Management

Effectivelymanagesthenursingcareofclients/groups/communitieswithinthehospital.

Articulatesanddemonstratestheconceptofnursingspecialistpracticebybeingresponsibleforowncaseloadandtheprovisionofspecialistknowledgetotheidentifiedclientgroup.Possessesspeciallyfocussedknowledgeandskillsinadefinedareaofnursingatahigherlevelthanthatofastaffnurse–performsanursingassessment,plansandinitiatescareandtreatmentwithinagreedinterdisciplinaryprotocolstoachievepatient/client-centredoutcomesandevaluatestheireffectiveness.

Accountableandresponsibleforadvancedlevelsofdecisionmakingwhichoccurthroughthemanagementofspecificclient/patientcaseload.Demonstrateexpertskillintheassessmentandtreatmentofdefinedaspectsofrheumatologycarewithinacollaborativelyagreedscopeofpracticemodel.InitiatesandmaintainsopencommunicationwiththeMulti-DisciplinaryTeam(MDT).Facilitatesateamapproachtoplannedpatientcare.

CaringforwellRheumatologyPatients

Beabletoidentifythetypeofrheumatologyillness.Offersadviceonmanagementstrategiesandwhentoreferon.Atalltimesforeveryinteractionwithaclient,ensuresclinicalassessmentsaredocumentedandcommunicatedtootherrelevanthealthcareprofessionals.

Identifiestheclinicalneedandprovidesevidence-basedmanagement.Providesacentralpointforcontinuityofcare.Facilitatesaccesstootherservicesasappropriate.Managesnurse-ledclinic.DocumentsallassessmentsandcommunicatestotheMDT.

Usesadvancedclinicalassessmentskillstoperformaholisticassessment.Introducesandevaluatesmanagementprogrammesthataresensitivetotheclient’sneedsinpartnershipwiththem.Atalltimesforeveryinteractionwithaclient,ensuresclinicalassessmentsaredocumentedandcommunicatedtootherrelevanthealthcareprofessionals.

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Thisexampleshowsthediscretecontributionsofeachpractitionerandalsodrawsattentiontotheinterdependentrelationshipofserviceprovision.ArecentstudybyGardneretal(2016)attemptedtodelineatethedifferencesbetweengraduate,specialistandadvancedpractice.Thisstudyshoweddifferencesbetweenthelevelsintheareasofeducation,provisionofcareandautonomy.Insummaryforexamplethegraduatenursewasfoundtobeinvolvedinmoredirectcareactivities.

Thecapacitytomaximisethecontributionofnursingreliesonanumberofpractitionerswiththeappropriateskillsandknowledgeworkingtogethertoaddresstheservicedemands.Kirkham(2014)describesthissystem.Itisnotalinearmodelofcarebutacompositemodelwhereeachmembercontributestheirindividualskillsandknowledgetoprovideaserviceasasystem.

Staff Nurse CNS Rheumatology RANP Rheumatology

CaringfortheDebilitatedClients

Usesclinicalassessmentguidelinestoidentifysymptomsandclinicalneed.Recognisespotentialcomplicationsfrompolypharmacy,drugsideeffects,frequentclinicappointmentandgainsadvicefromtheMDTonmanagementstrategies.

Advisesonself-management,on-goingassessment,andadviseswhencomplicationsarise.Devisesaself-careplanwiththeclient.Assess,plan,implementandevaluatenursinginterventionsalteringtreatmentsasrequiredwithagreedprotocols.

Ensuresthattheserviceisresponsivetochangingneedandensuresgoodcommunicationandquickaccesstoservicewhenrequired.Recognisescomplicationsandmanageschange.

CaringfortheComplexCases

Identifiesaneedforincreasedpatientandfamilysupportandintervention.

Assesses,monitorsandevaluatesdiseaseactivity.Usesexpertise,communicationandcoordinationskillstoensurecontinuityofcarebetweenthehospitalandthecommunitycaresetting.

Receivesreferrals.Worksproactivelywithagenciestopromotegoodqualitymanagementtailoredtotheclient’schoiceandneed.Mediates between services andfacilitatescomplexethicaldecisionmaking.

ResearchandAudit

Understandswhatismeantbyevidence-basedcare.Accessesevidencerelevanttorheumatology.Criticallyappraisesauditresultsandparticipatesintheimplementationoftherecommendationsasappropriate.

Identifies,criticallyanalyses,disseminatesandintegratesnursingandotherevidenceintheareaofspecialistpractice.Carriesoutanauditofkeyaspectsofservice.Interpretstheoutcomesofauditfindingsandrespondswithinitiativestoimproveserviceprovision.

Identifiesresearchprioritiesfortheareaofpractice.Initiatesandcoordinatesnursingresearchwhichensurestheadvancementofnursingpractice,policyandeducationinformingthewiderhealthagenda.Initiates,participatesinandevaluatesauditfindingstoimprove/enhanceserviceprovision.

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2.3. Graduate Nurse Practice

ThecorecompetenciesrequiredbytheNMBIforentrytotheregisteratthegraduatelevelaresetoutintheStandardsandRequirements(NMBI2016).Inaddition,nursesandmidwiveshaveengagedinanexpandedscopeofpracticeinresponsetochangesinserviceneed.Scopeofpracticeisnoteasilydescribedbytasksorproceduresandisinfluencedbythehealthcarecontext.TheNMBIregardexpandingthescopeofpracticeasachangeintheroleofanindividualnurseormidwifetoincludeareasofpracticethathavenotpreviouslybeenwithintheirscope.Thisalsoinvolvesthenurseandmidwifetakingon

newrolesandresponsibilities.Sometimesthescopeofpracticedecisionscanbereactiveandunplannedand,inthesesituations,theindividualnurse/midwifeandthepatientcanbeatrisk.TheNMBIhasthereforedevelopedguidancetoassistregisterednurses/midwivesandtheiremployerstounderstandthescopeofpracticeandtohelpwithmakingdecisionsaboutexpandingthescopeofpracticeindifferenthealthcontexts.Theresearchindicatesthatexpandednursingandmidwiferypracticeresultsinbetterpatientoutcomes,enhancedoutcomesforhealthcarestaffandimprovedservicequality(NMBI2014).

Table 6 - Examples of the expanded scope of practice in Ireland

Sample of Extended Skills /Registered Nurses (ONMSD Oct 2016)

• ECG;

• malecatheterisation;

• suprapubiccatheterinsertion;

• administrationintravenousimmunoglobulins;

• continuouspositiveairwaypressure(CPAP);

• non-invasiveventilation(NIV);

• swallowassessment;

• dopplerAssessment(ABI's);

• foetalUltrasound(EarlyPregnancy);

• suturing(Midwives);

• nurseprescribing(medicinalproducts);

• nurseprescribingionisingradiation;

• percutaneousendoscopicgastrostomy(PEG)re-insertion;

• venesection;

• castingapplication(staffnursewithinEDsetting);

• • castremoval(staffnursewithinanorthopaedicsetting);

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Theintroductionofnurse/midwifemedicationandx-rayprescribingisofrelevanceastheyaretwoillustrativeexamplesofwell-supportedroleexpansion.Onceeducatedandtrainedineitherorbothoftheseskillsthenurses/midwivesbecomeregisteredprescribers.Todaythereare1224nursesandmidwivesasprescribers(RN/MPs).TheRNPsarespreadacross114clinicalareasand183healthserviceproviders(50acutehospitals,126primaryandcommunityservicesand7prisonservices).Thisfigurealsoincludes46RNPsworkingwithprivatehealthserviceprovidersincludingthoseworkingwithG.P.’s.By2016,thedistributionofnurse/midwifeprescribersbygradeareasfollows:

• GraduateNurse=354• CNS/CNM2grade=416• AdvancedPractitioner=146

Theevidencedemonstratesthatmostadvancedpractitionersincorporatenurseprescribing(medicinalproducts)aspartoftheirrole.Inthecontextofthispolicytheevidenceidentifiesanumberofreasonswhynurseandmidwifeprescribing,asanexpandedroleisanimportantconsiderationindevelopinganursingresponsetopatientandhealthservicedemands.Alargestudyofnon-medicalprescribing(NHS,2015)demonstratesnotonlyaverystrongsafetyrecordbutprovidessignificantevidenceofadvantagestopatientsandthesystem.Aspartofthisstudyanauditof1566participantscalculatedthatanaverageaddedvalueofalmost£1,500permonththrough

savingswasdeliveredfromareductioninmedicaltimepreviouslyspentprescribing.Thiscontributedtoaprobabilityvalueofover£32.8mover12months(NHS2015).Increasingthenumberofnon-medicalprescribersleftmoretimeforotherelementsofessentialmedicalcareandthisledtoimprovedpatientoutcomes,effectiveuseofahighlyskilledworkforce,wastereduction,improvementinthequalityofpatientcareandcostefficiencies(NHS2015).ThisisanimportantconsiderationwithintheIrishcontextasexpandingthenumberofnursesandmidwivesthatprescribemedicinalproductscouldequallydemonstrateaddedvalueandefficienciesforservices.Inrecenttimestheexpansionofpracticehasbecomeregularisedthroughtheintroductionofanewgradecalledthe‘EnhancedNurse’.Introducingthisgradeisdesignedtoputinplacearrangementstoallowgraduatenursestoexpandthepracticeinresponsetopatientandserviceneedandtherebyworktothetopoftheirlicence.Thisconstitutesafundamentalchangeintheroleofthegraduatenurseandisregardedasafurtherdevelopmentofthenursingprofession.Thisnowsetsthefuturedirectionforroleexpansioninastructuredway.

2.4. Clinical Specialist Practice In2001specialistpracticeroleswereintroduced.SpecialistpracticerolesaredefinedbytheNCNMasanareaofspecialitynursingormidwiferypracticethat

26

requirestheapplicationofspeciallyfocusedknowledgeandskills,whicharebothindemandandrequiredtoimprovethequalityofpatient/clientcare.Specialistpracticeincludesamajorclinicalfocuscomprisingofassessment,planning,deliveryandevaluationofcaregiventopatients/clientsandtheirfamiliesinhospital,communityandoutpatientsettings.Thespecialistnurseormidwifeworkscloselywithmedicalandpara-medicalcolleaguesandmaymakealterationsinprescribedclinicaloptionsalongwithagreedprotocoldrivenguidelines(NCNM2006).

Thisresourceprovidescomprehensivenurse-ledservicesinanumberofsettingsincludingmentalhealthservices,olderpersonservicesandwomen’shealthservices(NCNM2005).TherolesofClinicalNurse/MidwifeSpecialist(CNS/CMS)inIrelanddevelopedfurthersince2014andreflectedaspecialistfocusonmedicalconditionsandsupportingmedicaldiagnosis,thisiselaboratedinAppendix1.Thenursingandmidwiferyworkforceinthepublichealthservicesconsistsof35,924staff.Thistotalincludes1,332ClinicalNurseSpecialists(CNSs),and44ClinicalMidwifeSpecialists(CMSs)(Caseyetal.,2016).AfullnationalpictureofCNS/CMSpostsisnotentirelyvisibleduetoincompletedataset,forexamplethereareCNS/CMSpostsrecordedasCNM2posts.Table7belowshowsthebreakdownofCNS/CMSpostsperdivisiononthedatabasein2016.

Table 7 - CNS Distribution - 2016

CNS by Division

ClinicalMidwifeSpecialist 44

ClinicalNurseSpecialist(General) 882

ClinicalNurseSpecialist(Children's) 83

ClinicalNurseSpecialist(MentalHealth)

287

ClinicalNurseSpecialist(Community/PrimaryCare)

14

ClinicalNurseSpecialist(IntellectualDisability)

22

TOTAL 1332

Inanattempttorectifythedata,theHSEdevelopedandmaintainedadatabaseofnewCNS/CMS’sappointedsince2014.Thedatabasedetailsbothservicedevelopmentandpostsacrossarangeofspecialitiesincluding:

• acuteserviceswith15specialitiesincludinginfectionpreventionandcontrol,painmanagementandsexualassaultservices;

• mentalhealthserviceswith13specialitiesrangingfromfamilytherapytodeliberativeself-harmtopsychologyoflaterlife;

• midwiferyandwomen’shealthwith6specialitiesfromultrasoundtocolposcopy;

• specificmedicalspecialities;• diabeteswith4subspecialties;

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• cardiacwith5subspecialties;• cancerserviceswith4subspecialties;• palliativecarewith5subspecialties;• respiratorywith5subspecialties,and• gastroenterologywith3subspecialties• communityandintellectualdisability,witheachhavingonlyonenurseappointedinrecenttimestoaspeciality.

NotablythisdataindicatesthatthedevelopmentoftheCNS/CMSroleshasevolvedinawiderangeofspecialisationsandsub-specialisations.However,variationexistsacrossthecountryinrespectofhowtheseroleshavedevelopedandthereisalackofconsistencyinrelationtothescopeofpractice.

TheCNS/CMSisimportanttomeetspecialistpopulationandlocalhealthcareneeds.However,duetothespecialistnatureoftheseroles,theywillnotaddressbroadpopulationhealthcareneedsoraddressthebroaderhealthservicechallenges.A“narrow”specialityfocushasbeenusedasachallengesofCNS/CMSpractice(Caseyetal2015),itremainshoweveranimportantcontextforthedevelopmentofthispolicy.Theemergingcasetoaddressthebroadpopulationhealthcareneedsasthespecialistpracticecontinuestoaddressspecificareasforexampleheartfailure,cancercareorrolesCNSinlymphodemamanagement.Advancedpracticesubsequentlyneedstoevolvetoplayanimportroleinaddressingthebroadpopulationhealthneeds.Asolutiontosupportthiscouldbeforthemajorstakeholders,includingtheHSEand

theNMBI,toutilisethehealthpopulationdataincombinationwiththeadvancedpractice/specialistdatatoinformeffectiveworkforceplanningandcoordinatedservicedevelopmentbasedonpopulationneed.

2.5. The Current Model of Advanced Practice in Ireland

2.5.1. Current Advanced Nursing and Midwifery Practice (ANP/AMP) ResourcesRANP/RAMProleshavebeendevelopedinIrelandinresponsetopatientandserviceneed.TheessentialcriteriaforadvancedpracticerolesassetoutbytheNCNMandNMBI,arethatthepracticeiscarriedoutbyautonomous,experiencedpractitionerswhoarecompetent,accountableandresponsiblefortheirownpractice(NCNM,2008;NMBI,2014).Additionally,thecurrentIrishcriteriarequirethatRANP/RAMP’spromotewellness,offerhealthcareinterventionsandadvocatehealthylifestylesforpatientsandtheirfamiliesinavarietyofsettingsincollaborationwithotherhealthcareprovidersaccordingtoanagreedscopeofpractice.Suchpractitionersmusthaveahighlevelofclinicalcompetencyandtheoreticalknowledgealongwithadvancedcriticalthinkingability(Begleyetal.,2010).Theyfurthermanageapatientcaseload,andakeyfactorinadvancedpracticeisthedegreeofdecisionmakingandaccountabilityratherthanthecomplexityofthetaskscarriedout.Advancedpracticeisthusgroundedinthetheoryandpracticeofnursingandrelatedresearch,managementandleadershiptheories(Hamric,2014).MorerecentlytheNMBIhasdefinedadvanced

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practiceasa‘…careerpathwayforregisterednurses/midwives,committedtocontinuingprofessionaldevelopmentandclinicalsupervision,topracticeatahigherlevelofcapabilityasindependent,autonomous,andexpertpractitioners’(NMBI2016).Ashared,andkey,characteristicofadvancedpracticerolesistheirbroad-basednature.Thepreparationoftheadvancedpracticepractitionerwasoriginallycentredonthesebroadcriteriaandcoreconceptsofprofessionalethics,professionalleadership,accountability,clinicalscholarshipandconsultationandcollaborationskills.Thesecorecharacteristicsreflecttheconceptsutilisedinthedevelopmentofadvancedpracticerolesworldwide.

Atthecommencementofthispolicyin2016therewere192AdvancedPractitioners(Nursing)and8AdvancedPractitioners(Midwifery)workinginacuteandprimarycaresettingsacrossthecountry(Appendix2).InexplainingthedifferencesbetweentherolesoftheCNSandRANP,twoexamplesfromcurrentpracticeareofferedofthebenefitsofroledevelopmentforserviceprovision.

Example 1 is in the Clinical Care Programme for Epilepsy. The Advanced Practitioner in epilepsy works as part of the team in one of 6 (4 adult and 2 paediatric) regional neurology centres supporting G.P.s across the country to manage patients with a stable/chronic disease in the community. They also guide the less well-controlled patients through the health system providing them with the resources to self-manage their illness and if necessary refer for expert care. The Advanced Practitioner provides timely access to expert care and information and support to patients in prevention activities which includes meeting monitoring and prescription needs. The model of care is a shift from hospital-based care to care in the community and reduces length of hospital stay. Currently there are 16.5 WTE Epilepsy APs within adult services nationally at various stages of professional development i.e. candidate APs, Registered APs. Additionally, this is reported to leave the consultant free to manage the 20% of patients that need medical intervention. The value to the health system has been the reduction of 19,000 bed days nationally (NCPE, 2014). Outreach clinics have been developed in the intellectual disability sector (3), the maternity hospitals (2) and general hospitals (4). An evaluation study SENsE (Higgins et al, 2016), found that the epilepsy specialist nurse (CNS) working alongside and complementing the ANP care, provides an improved experience for patients and better management and coordination of epilepsy care at no net cost. This led to the recommendation to move to an Advanced Practitioner supported service.

29

Example 2 is from a nurse led ambulatory low to intermediate risk chest pain service. The Advanced Practitioner evaluates the patient who presents with chest pain to the Emergency Department (ED) and risk-stratifies the patient to identify or exclude Acute Coronary Syndrome (ACS). This enables low risk patients to be safely discharged and followed up in the out-patient setting. The primary goal of this service is admission avoidance. This service is Advanced Practitioner led and provides a consult service to ED/Acute Medical Assessment Unit (AMAU). The Advanced Practitioner has the skill and autonomy to assess, treat and discharge the patient appropriately. Discharged patients are referred for further evaluation in the nurse led chest pain clinic within 72 hours. The benefits and patient impacts from this service are evident and include a reduction in the Patient Experience Time (PET) from 17.5 hours to 7.9 hours overall. There is also evidence of admission avoidance of up to 600 admissions per year, 15% of patients seen were diagnosed and treated for cardiac disease; 75% of patients were discharged to their G.P.; and 9% patients were captured at the primary prevention stage and treated accordingly.

Despitetheevidencesupportingthepositivecontributionthattheserolesmaketopatientsandoverallserviceprovision,thedevelopmentofadvancedpracticeroleshasbeenslow.Thishasresultedinindividualroles/postsdeveloping,sometimesinisolationinlocalareas,ratherthanasthedevelopmentofanANPservice.ThisdataalsoillustratesthatgiventherelativeisolationofRANPsandRAMPswhichimpedestheabilitytorespondtoawholeofserviceneed.Therelativeunderdevelopmentofthesepostsrepresentsamissedopportunityintermsoforientatingtheworkforcetomeetchangingneedsinaneffectiveandcost-efficientmanner.Internationallythenumberofnursesinadvancedpracticerolesstillrepresentsasmallproportionofallnurseseveninthosecountriesthathavethelongestexperienceindevelopingtherole.IntheUnitedStates,NursePractitioners(NPs)represent2.5%ofthetotalnumberofregisterednursesin2008.InCanada,theyaccountedforamuchsmallershare,NPsonlyrepresenting0.6%ofallregisterednursesin2008(DelamaireandLafortune2010).

ThenumbersofANPsincreasedto1.3%ofallRNsin2013inCanada(OECD,2016).Areportcompiledattheendof2015fromtheOECD(Maieretal,2016)comparedtheratiosofadvancedpracticenursestoregisterednursesinsixcountriesasillustratedinTable8below:

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Table 8 - International Comparisons

Country (Name/title of NP/APN)

Year introduced

Total numberof NPs

Activity status

of NPs

NP% of all RNs

UnitedStates(NP)

1965 174,943 ProfessionallyActive

5.6%

Canada (NP)

1967 4,090 Practising/employed

1.4%

UnitedKingdom(England,N.Ireland,Scotland,Wales)(AdvancedNP,NP)

1983 n/a n/a -

Netherlands(Nursespecialist)

1997 2,749 Registered 1.5%

Australia (NP)

2000 1,214 Registered 0.5%

New Zealand (NP)

2001 142 Practising 0.3%

Ireland(AdvancedN/MP)

2001 141 ProfessionallyActive

0.2%

Itseemsreasonablethataworkforceplancouldincorporateatargetforadvancedpracticenursesandmidwives.Basedonthecurrentworkforcesettingatargetfor2%ofthenursing/midwiferyworkforceatRANP/RAMPlevelby2021wouldyieldapproximately700nurses/midwivesprovidingfullepisodesofcareacrossservicesbasedonserviceneedandrequirements.

Bywayofanexample,todemonstratetheimpactofhavingacriticalmassofadvancedpractitioners,adermatologyserviceprovidedbyaRANPcanbefoundinAppendix3.Ofsignificanceistherangeofskillsandinterventionsthatthenursingservicecanaddtothecareteamifprovidedonanationalbasisinacriticalmass.

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Thispicturehoweverisnotreflectiveofthetypeofspecialitiesthatdevelopedtosupportserviceneed(Fig5).Consequently,theHSEcouldalignthedevelopmentofspecialistandadvancedpracticerolesfornursesandmidwiveswiththeclinicalcareprogrammes

andmodelsofcaretoensureconsistentprovisionofserviceacrossgeographicareas.

Figure 5 - Number of ANPs per Hospital Group (2016)

IRELAND EAST HOSPITAL GROUP: 24

SAOLTA HOSPITAL GROUP: 38

UNIVERSITY OF LIMERICK HOSPITAL GROUP: 16

NATIONAL CHILDREN’S HOSPITAL GROUP: 10

DUBLIN MIDLANDS HOSPITAL GROUP: 41

RCSI HOPSITAL GROUP: 22

SOUTH-SOUTH WEST HOSPITAL GROUP: 27

CHO’s: 22

11

IRELAND EAST HOSPITAL GROUP: 24

SAOLTA HOSPITAL GROUP: 38

UNIVERSITY OF LIMERICK HOSPITAL GROUP: 16

NATIONAL CHILDREN’S HOSPITAL GROUP: 10

DUBLIN MIDLANDS HOSPITAL GROUP: 41

RCSI HOPSITAL GROUP: 22

SOUTH-SOUTH WEST HOSPITAL GROUP: 27

CHO’s: 22

11

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2.6. Enablers and Challenges to the development of Advanced Practice

Anexaminationoftheenablersandchallengestothedevelopmentofadvancednursingrolesincludedcredentialing,roleclarityandtitlingclarity,educationandtraining,individualpractitionersandtheirscopeofpractice,workorganisationissuesandcost(Caseyetal.,2016).Thefindingssuggestthatthemainenablersincludehavingamodelofmanagement,educationandregulationthatsupportnursesandmidwivestopracticetothefullextentoftheireducationandtraining.Havingamechanismofregulationthatincludesstandardsofeducation,practiceexpectationsandsupport

formethodsofcredentialingwereessentialissues.Alsoessentialwereroleclarityandunderstandingofjobexpectations.Thechallengeswerereportedasthelackofmanagementsupportwithinorganisationstosupportnurseroledevelopmentandtimeconstraintsthatcurtailednursesintheirabilitytoparticipateinadvancedcarefocussedactivities.Additionally,confusionregardingroles,responsibilitiesandclinicaljurisdictionwerealsoseenaschallenges.Asummaryanalysisoftheliterature(Table9)conductedbyElliottetal(2016)identified13genericchallengesandenablersthatwerecategorisedunderfourstructuraldimensionheadings:

Table 9 - Challenges and Enablers to the Development of Advanced Practice

Structural Dimension Challenges Enablers

Healthcare system-level:

lackofopportunitytoworkatastrategic level

networkingopportunities

Organisational level: largeclinicalcaseload;lackofsupportfromnursingormidwiferymanagementmedicalconsultants,andclinicalstaff;lackofclarity/understandingofroleincludingleadershipandresearchrole;lackofclerical/administrativesupport;lackofauthority/positionwithintheorganisation;insufficientresources(e.g.financial/informationtechnology/library-databasesaccess);lackoftime/supportforresearch,

mentorshipandsupport;clearleadershipsupportandrole;adminsupport;accountability;roleclarity

Team level: lackof‘criticalmass’/loneposition; beingpartofawiderteamofANP’s

Advanced practitioner-level:

lackofleadershipskilldevelopment/education;lackofadvancedpractitioner(AP)leadershipattributes;thelevelofeducation;timewithintherole.

beinginvolvedinresearch;havingnationalstandards

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2.6.1. Enablers to the Development of Advanced Practice in Irish Context

2.6.1.1. Graduate profession Theintroductionofagraduateprofessionsince2001hashadamarkedinfluenceonthedevelopmenttoadvancedpractice.Thepointismadethatthedifferentrolesworkinharmonytoprovideacompositeservicedeliveryratherthantheworkingindependently

2.6.1.2. Existing Roles Thereareadvancedpracticerolesalreadyworkingwithinservices.Thecoreconceptsofprofessionalethics,professionalleadership,accountability,clinicalscholarshipandconsultationandcollaborationskillsdescribedbyFallsbergandHamal(2000)areallembeddedintheseroles.Furtherdevelopmentandimplementationofadvancedpracticeroleshasthereforeaplatformandadirectiontoavoidfurthersub-specialisationandallowtheroletoreflectthebroad-basedholisticapproachrequired

2.6.1.3. RegulationThefunctionsoftheNCNMandNMBIarereferredtointheNursingandMidwiferyAct2011(GovernmentofIreland,2011).ThisActissilentonthespecificsofadvancedpracticebutratherrequirestheBoardtospecifycriteriaforthecreationbyemployersofspecialistnursingandmidwiferyposts.TheBoardhowever,maymakerulesthatestablishproceduresandcriteriaforregistrationandspecificallythesettingofcriteriaforpracticeandexperienceleadingtoregistrationandforannotationofregistration,includingthe

specificationofexamsleadingtoregistration(Appendix4).TheBoardthereforehaspowerstodeterminethestandardsandrequirementsforregistrationofadvancedpracticeandequallytorecogniseadditionalqualificationsforpracticethatmeettheobjectiveoftheBoardistoprotectthepublicinitsdealingwithnursesandmidwivesandtheintegrityofthepracticeofnursingandmidwiferythroughthepromotionofhighstandardsofprofessionaleducation,trainingandpractice.

2.6.1.4. Evidence of achievement Thesignificantexceptiontotheindividualisedandoftensub-specialistapproachforthedevelopmentofadvancedpracticeintheIrishcontextisemergencycare.By2016acriticalmassof78advancedpractitionerpostsinthisareaofcaredelivery.Thepostsaredispersedthroughoutthecountry.Theemergencycareroleprovidescareforsimilarcaseloadsofpatientsandthereforecanaddressservicechallenges.Theevidencefromtheemergencycareareasshowsimprovementssuchas,timelyaccessandtimelytreatmentforpatientswithminorinjuries,ultimatelyleadingtobetterpatientoutcomes.Theadvancedpracticeroleinminorinjurieshasalsoshownpositiveserviceimpactsbycreatingcapacityforotherpatientstobeseensoonerthereforereducingoverallpatientexperiencetimes(PET)inlocalinjuryunits.

2.6.2. Challenges to the Development of Advanced Practice in the Irish Context

Significantchallengesappearundertheheadingofworkorganisation,wheretheimpedimentsassociatedwithcultureand

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managerialissuescometothefore.ArecentstudybyMaierandAiken(2016)reportedchallengesassociatedwithregulatoryrestrictionsandfinancialchallenges.DespitethebenefitstoserviceoftheintroductionofadvancedandspecialistrolesconsiderablechallengesexistintheIrishhealthsystemtotheintroductionofnewroles.

2.6.2.1. Geographical Spread and Service NeedThecurrentnumberofANP/AMPisgeographicallydisparateandthereforecannotbefocusedonbroad-basedpopulationhealthchallenges.Thisimpactsintermsofcollaborativeworkingandservicedeliverymodels.Thisisamulti-dimensionalissueinvolvingbothservicedeliveryandworkforceplanningconsiderations,butitalsodoesnotlinkdevelopmentwithcurrentservicecontext.

2.6.2.2. Lack of Uniformity to Role DevelopmentTodate,postshaveevolvedbasedonindividualroledevelopment,notpopulationorserviceneeds.ThisleadstoinconsistentcareerpathwaysandinterprofessionalcollaborationThereisalsoaconcerninrelationtothecurrentmodelandtheperceivedattainabilityofanadvancedpracticerole,butalsoperceptionsandrealitiesassociatedwithcareerprogression,knowledgeandskillsattainment.Whilethisisanunder-researchedareathereisclearanecdotalevidencethattheattainmentofanadvancedpracticeroleisregardedasundulycumbersomefromapersonalprofessional

perspective.Thisisnotinthesenseofthelevelofskills,knowledge,competencies,orcapabilitiesassociatedwiththerole,butinsteadtheinstitutionalchallengestothedevelopmentofsuchroles,andimpedimentstotheongoingandseamlessrecognitionofattainmentsthroughoutone’scareer.

2.6.2.3. Current Prolonged Pathway to Advanced PracticeTheexistingprolongededucationpathisachallengeasittakesaminimumof7yearstoberegistered.Thelevelofknowledge,skills,competencyandcapabilityattainmentisnotcurrentlyfacilitatedinatimelywaythroughaprogressivecredentialingmodelasrecommended.Thiswillrequireanaccompanyingparadigmshiftintherecognitionandrecordingofknowledge,skills,competencyandcapabilityattainmentwhichfacilitatesatimelyrecognitionofadvancesinpractice.ThiswillbebestachievedthroughaprogressivecredentialingmodelfacilitatedbytheNursingandMidwiferyAct(2011).Theabsenceofongoingandseamlessrecognitionofattainmentsdelayscommencingpracticeatanadvancedleveluntilalleducationalandclinicalrequirementsarecomplete.

2.6.2.4. Current Age profile and Work patternsAnothernotablecharacteristicofthecurrentcohortofadvancedpractitionersisthecurrentageprofile,ofthe192RANPsinpostin2016,32%(n=61)wereovertheageof50yearsandofthe8RAMPsinpost50%(n=4)wereovertheageof50years.Thisraisesanimportantconsiderationforworkforce

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plannerswithregardstosuccessionplanning.TomaintainthecurrentservicesuppliedbyANP/AMPsthetimerequiredtodevelopanANP/AMPmustbetakenintoaccount.Consequently,aspartofanoverallworkforceplanningapproachtheHSEshoulddevelopanintegratedstrategicapproachtodeterminetheserviceandworkforceneedsincludingsuccessionplanningforgraduate,specialistandadvancedpractitionersatanational,regionalandlocallevelthatembracesastandardisedapproachtodeterminingthestaffingacrossthenationalclinicalcareprogrammes.

2.6.2.5. Current Work PatternsThecurrentworkpatternsofadvancedpracticearefocusedaroundtheprovisionofserviceandthatrequiresexplorations.MostRANP/RAMP’sprovideMonday-Fridayserviceseither8am-5pmor8am-8pmoraservice8-10pm.Theadvancedpracticenurses/midwivesinneonatologysupporta24/7service.Afullyresponsivepatient-centredservice-ledmodelwouldrequirethatnursesandmidwivesprovideaservicethatiscommensuratewiththepresentationtimesofpatientsandtheillnesstrajectories.

2.6.2.6. Value of Advanced PracticeTherelativeunder-developmentofadvancedpracticerolesinnumericaltermshasalludedtoapparentunder-valueoftheadvancedpracticeroles.Theseroleshavefallenintosub-specialisation;thereforethefullvaluehasnotbeenrealised.ThedevelopmentoftheRANP/RAMProleshasembracedsubspecialisation,whichhasalsobeenafeature

ofthedevelopmentoftheroleoftheCNS/CMS.Internationally,theUSA,AustraliaandNewZealandhavemovedawayfromsuchsub-specialisationandfromdisease-specificservices,insteadreorientingtheeducationandregulationofadvancedandspecialistpracticetoprovideformoregenericareasofpracticeacrossservices,includingcommunityprimaryhealthcaredeliveredbyproviderswithenhancedcapabilities(Carryer2015).Itisthereforetimelytoreviewhowthesubspecialisationshaveemergedandrevertedtoabroad-basedapproachtotheroleandtitleoftheRANP/RAMPthatreflectscurrentserviceandpopulationneeds.

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2.7. Summary InsummarythischapterhasdescribedthestructureofthecurrentnursingresourceinIreland.Theoriginalpathwayfromgraduatetoadvancedpracticeisdescribed,thisincludesthedifferentrolesofgraduate,specialistandadvancedpractitioners.Particularattentionhasbeenpaidtotheexistingmodelforadvancedpractice.TheenablersandchallengestodevelopingadvancepracticeinIrelandareexploredanddescribed.

ThecaseismadeformovingtowardsarevisedmodelofAPcapableofrespondingtoemergingserviceneedsandreform.Thenextchapterconsiderstheservicedevelopmentandsetsoutthechallengesandhowadvancedpracticecanrespond.

Summary of the Goals and Actions. Goal3setsouttheactionsfordevelopmenttoaddressthechallengesoutlinedinthischapter’sreviewoftheprofessionalcontextofnursinginIreland.

GOAL 3 Change how we utilise and deploy the nursing and midwifery resource

Action Details Responsibilitya Creategovernanceandaccountabilitystructuresthatenable

theadvancedpractitionerstoprovideafullepisodeofcareandservicesupportingothermembersofthecareteam.

HSE

b Provideadvancedpractitionerswithaccesstodiagnostics,referralpathwaysandappropriatetreatmentsthatarerequiredtofacilitatetheprovisionoffullepisodesofcarebothinacuteandinthecommunitysectors.

HSE

c Supportgraduatenurses/midwivestomeetpatient-centredserviceneedandtheexpansionofthescopeofpracticewithinthecredentialingframework.

HSE

d Reviewpatient/clientpresentationtimestoensuretheserviceprovidedbygraduate,specialistandadvancedpractitionersmatchesthedemandwithinthenormal24/7patternsofnurse/midwifeprovisionofcare.

HSE

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Chapter3ServiceDeliveryContext

Chapter 3Service Delivery Context

3.1. Introduction

Thischapterdescribestheservicedeliverychallenges.Developingservicestosupporttheeffectiveandefficientuseofresourcesareexploredalongwithexamplesfrompracticeofcurrentinitiativesthatareprovingworthwhiletothepatientexperienceandtheintegrationofserviceprovision.Anychangeinthedeliveryofservices,andassociatedhumanresourceimplications,shouldbesupportedbyevidencewhichdemonstratesthevaluetopatientsandservices.Theevidencetosupporttheeffectivenessandcostefficiencyofadvancedpracticerolesisevidentinbothnationalandinternationalresearch.Theevidencedescribesadvancedpracticeasbeingsafe,effectiveclinicaldecisionmakerswhomakeadifferencetoservicedeliveryandimprovedpatientoutcomes.FurtherIrishresearchshowsthatspecialistandadvancedpractitionersmakeanimportantcontributiontochronicdiseasemanagementandcommunitycare.Specifically,thisdemonstrates,improvedclinicaloutcomesandimprovementsinareasofpatientsatisfaction,communicationwithpatients,lengthofstayandaccesstocare,andfurtherevidencingareductionincosts,improvedservicedeliverymodelsandwelcomeservicechangeswhichreflecttheneedsofpatients(Begleyetal2013,Begley,2010).

3.2. Population, Health Trends and Demographic Challenges

ThecurrentpopulationinIrelandiscirca4.7millionwithapproximately1.15millioncitizensunder19yearsofageand604,000over65-years(CSO2016).Thedataalsoshowsthatthepopulationofthoseaged65andabovehasincreasedby19%andthoseaged85andaboveby23%since2011.TheCSOandTILDA(2014)havepredictedcontinualannualincreaseswithprojectionsofthoseover65yearsexpectedtoriseby20,000peryear.Asaresult,overthenext10yearsthedemandforhealthcareisexpectedtorisewithaprojected37%increaseindemandforpublichospitalcare,a27%increaseinGPvisits,anda54%increaseindemandforhomecareandresidentialcarehomeplaces(Wrenetal.,2016).TheTILDA(2014)study,anIrishlongitudinalstudyofageingconcurredandidentifiedthesechangingdemographicsandreportedthat21.1%ofparticipantsaged80+yearshadattendedanEDatleastonceinthepreviousyear.Theevidencealsosuggestedalimiteduseofcommunityhealthandsocialcareservicesforpatientswithevidenceoffrailtyandthisisparticularlyrelevantfortheagegroupsidentifiedabove.

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Current Challenges Identified Through Scheduled and Unscheduled Care (DoH)

ED Performance in 2018 compared with 2017: In2018,thenumberofpatientsrecordedaswaitingontrolleysat8amincreasedby2.5%(+2,381)to98,448,comparedto2017.However,theaveragedaily8amtrolleycountnationallywasconsistentlylowerbetweenMayandOctober2018(5.7%loweroverall)comparedtothesamemonthsin2017(DepartmentofHealthData,2019).

In2018,EDattendanceswere1,290,091,up3.5%(+43,484)comparedto2017,whiletherewere156,647EDattendancesbyover75sup5.0%(+7,426).

In2018,EDadmissionswere346,380,anincreaseof9,184(2.7%)comparedto2017.EDadmissionsbythoseover75increasedby4.6%,whencomparedtothesameperiodin2017.

Whileadmissionswerehigheroverallin2018thanin2017,theproportionofattendanceswhichwereadmitted(admission/attendanceconversionrate)fellfrom27.0%to26.8%.TheaboveissupportedbyinternationalevidenceofincreasingutilisationofEDservicesandhospitalsworkingatuptoa100percentcapacity(DoH,2015).

Capacity: Hospitalsareincreasinglyoperatingator

abovecapacity,withyear-rounddemandpressuresthatarefurtherchallengedoverthewintermonths.Thisisimpactingonwaitinglistsandaccesstoservices. Irelandhasamongthehighestacutebedoccupancyratesinthedevelopedworld(currentlyat95%)andfarabovesafeinternationalnormsof85%andlongandgrowingwaitinglistsacrossmostservices.

Thepublichospitalsystemhasseenagrowingdemandforunscheduledcareinrecentyears.Thisgrowthisprimarilyduetoincreasedpresentations,inparticularincreasedpresentationsofhighacuitypatientsintheover75agegroup.TheHSEreportedthatthekeyfactorscontributingtothechallengesassociatedwiththecareofolderpatientsistherequirementforisolationandtheneedformultipleinputstotheirassessmentandcare(HSE,2018).

Attheendof2018,therewereover516,000patientsontheOutpatientWaitingListforafirstappointment.While2018performancesawsomestabilitywithayear-on-yearincreaseof3%,thenumberofpatientswaitingforaccesstoOutpatientservicesremainstoohigh.

In2019,demandforinpatientanddaycaseproceduresisprojectedtoincreasetoover11,500newpatientspermonth,whiledemandforfirstOutpatientappointmentsisprojectedtobealmost68,000new

41

patientspermonth.Thisyear,theHSEisduetodeliver1.155millionelectivehospitalproceduresandoveronemillionnewoutpatientappointments,whiletheNTPFwilldeliver25,000InpatientDayCasetreatments,5,000GastroIntestinalScopesand40,000firstOutpatientappointments.Thistrendisexpectedtocontinue.

Theevidenceillustratesanotherimportantcontextforthispolicy.Itshowsincreasesintheprevalenceofchronicdiseaseinayoungerpopulationwiththoseover50yearsofagelivingwithatleastonechronicdisease(DoH,2016).ThefourmainchronicconditionsinIrelandare;Asthma,ChronicObstructivePulmonaryDisease,DiabetesandHeartFailure(NHQRS2016),andtheseaccountforapproximately1.68billioneuroofacutehospitalsbudget(DoH2016).Asasolutiontheevidencepointstothedevelopmentofprimarycaremodelsthatoffergoodqualitycare.Itisevidentthatimprovingoverallhealthandself-managementcanreducetheneedforanunplannedhospitaladmission.Moreover,earlydetectionandinterventionhavebeenseentopreventcomplicationsormoreseverecomorbiditiesofdisease(DoH,2017).

Thepopulationchangesandassociatedcurrent,emergingandfuturedemandsonthehealthservicesprovideanecessaryimpetusforchangesinthedeliveryofhealthservices.AsoutlinedwithinSláintecareandtheevidencere-orientationofservice

deliverytoimproveaccessandprovidecareclosertohomewillensureahigheravailabilityonpreventativehealthstrategies.Caringforpeopleintheircommunityandavoidingunnecessaryhospitalvisitsisasignificantchallengeforthehealthservicestodayandintothefuture.Thesechallengesprovideanopportunityforthedevelopmentofnursesandmidwivestopracticeatthetopoftheirlicencetomeetpopulationandserviceneeds.ThisalsosupportsthevisionofSláintecarebyfacilitatingdevelopmenttosupportintegratedcareservicesacrosshospitalandthecommunity.Theevidenceshowsintegratedcarecanaddresswaitinglists,earlysupporteddischargeandhospitaladmissionavoidance.Thisapproachisinalignmentwithnationalclinicalcareprogrammesthataredevelopingtosupportandstandardisecareforchronicdiseasemanagementandolderpersonscare.InthecontextofSláintecarethemainchallengestoserviceprovisioninthehealthserviceshavebeenidentifiedas:

• Integratedcare;• Waitinglistsandaccesstoservices;• Patientflow;• Unscheduledcareaccessanddelivery.

3.3. Advanced Practice Responses to Service Challenges

3.3.1. Integrated CareIntegratedcareisbasedontheprinciplesofwell-coordinated,planned,pro-activecareimprovingthepatient’sjourneyacross

42

healthandsocialcare(HamandCurry2011).Thisapproachfocusesontheprocessesofcaredeliveryratherthanthestructuralandorganisationalservicemodels,healthcareprofessionalsworkinginpartnershipacrossserviceboundariestoproducenewwaysofworking(HSE2016).AdvancedPractitionersprovideseniorclinicalleadershipwithinthestructureandcurrentlytherearefiveIntegratedCareProgrammesforpatientflow,olderpersonscare,preventionandmanagementofchronicdisease,children,maternity.

Theintegrationofservicesinvolvesconnectinghealthcaresystemsthroughtheapplicationofinnovativemodelsdeliveringcaretothelocalpopulation(Hendryetal.,2018).Tosupportthis,nursesandmidwivesareideallyplacedtohelpcreatethatenvironmentgiventheirbroad-basedknowledgeandskills.Anexampleofthisisthroughthedevelopmentofendtoendpathwaysofcare,managingcompleteepisodesofcaretosupportpatientsfromdiagnosistolivingwellwithaconditioninthecommunity.Throughthisapproachthepatienthasafocalpointofcontact,thereiscontinuityofcaretosupportcareneedsthroughassessment,engagementandmutuallyagreedtreatmentoptionsinconjunctionwiththewiderhealthcareteam(LongpreandDubois,2017).LongpreandDubois(2017)alsoidentifiedthissupportsthedevelopmentofnurse-ledservicesthatcanspanacrosshospitaltocommunitywitha

strongfocusonprevention,self-managementanddiseasemodification.

TheIntegratedCareProgrammeaimstoaddressfragmentedcare,streamlineservicesandimprovethehealthandwell-beingforindividualsthroughformalisingpathwaysofcarebetweenprimaryandsecondarycareandadoptingacasemanagementapproachtocarewithinamulti-disciplinaryteam(HSE2015,HSE2018).Todate,theevidencefromtheIntegratedCareProgrammeforOlderPersonsisshowingareductioninhospitalbeddayuseandlengthofstay,reductioninhospitalre-admissionsandevidenceofearlysupporteddischarge(HSE2018,Hendryetal.,2018).

ThecurrentchallengestoachievingintegratedcareasdescribedbytheHSE(2016)areinaddressingthefragmentationinhealthsystemsasmorepeoplearelivinglongerandwithcomplexco-morbidities.Integratedhealthservicedeliveryisdesignedtoensurepeoplereceiveacontinuumofhealthpromotion,healthprotectionanddiseasepreventionservicesaswellasdiagnosis,treatment,long-termcare,rehabilitation,andpalliativecareservicesacrossallofhealthcareservicesaccordingtoaperson’sneed.Theimmediatechallengesrelatetotimelyaccesstoservicesasseeninlongwaitinglistsandalsoinhospitalavoidanceparticularlytotheemergencydepartmentsoftheacuteservices.

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3.3.2. Waiting Lists and Access to ServicesTherearesixareasidentifiedinthecurrentwaitinglistwhereANPshavealreadybeendeployed(Table10).ThewaitinglistismatchedbelowwiththecurrentnumbersofRANPsinthesystem.Theimpactofaddressingthewaitinglistsandprovidingnurse-ledservicesasafunctionofintegratingwiththecommunityareoutlinedwiththefollowingspecialities:

Table 10 - Example of Waiting Lists and RANPs in post - 2018

Speciality Total people waiting

Waiting > 18 months

RANP’s in post

CNS in post since 2014

Dermatology 35,028 2549 2 2

Urology 23,958 1838 1 1

Paediatrics 13,745 134 5(ED)+7speciality

areas

1childhealthcommunity

Rheumatology 13,605 1339 2 5

Respiratorymedicine 11,836 657 0 11

Pain relief 7,073 241 4 2

Theevidencehasshownthatdelaysinaccesstoscheduledcarecanleadtofurtherdeteriorationinhealthresultinginhighercareneeds.TheAdvancedPractitionerrolecansupportthisthroughthedevelopmentofnurse-ledservicestofacilitatediagnosis,treatmentplansanddiseasemodificationtoreducescheduledcarewaitinglists.ThenursingresponsetoaddressingwaitingliststhroughthedevelopmentofAdvanced

PractitionersandCNSrolesaredetailedinTable10.ThisinformationinformedthedeploymentofAdvancedPractitionerrolestodemonstratorsitestowardsbuildingacriticalmass.Theserolesareprovidingservicesthatareintegratedwiththecommunitysupportingcontinuity,improvedaccess,improvedflowofpatientinformationandreducedduplicationofcare.

Atanationallevelthereisevidenceofasporadicanddispersedapproachtoadvancedpractitionerservicedevelopment.Theevidencepointsoutthattoaddressissuessuchaswaitinglists,astrategicapproachtoplanninganddeploymentofrolesisrequiredandshouldincludethedemandforscheduledcaretoplandevelopmentofacriticalmassofadvancedpractitioners.Themodeltestedwithinthispolicysupportsthetransition

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fromcompetenttocapabilityworkingasanautonomouspractitionerindeterminingadiagnosis,levelofcareneedsandpotentialfuturehealthcare.Inplanningservicesthataregeographicallyaligned,andpatient-focusedevidencesuggeststhatpeopleprefertoaccesscarelocally(HSE2016).Therefore,thereareopportunitiestodevelopAdvancedPractitionerroleslocallywithincommunitysettingsthatensurethelocalcareneedsareaddressedtoreducepressuresonhospital-basedoutpatientservices. TheevidencereviewbyCasey(2015)examinedstudiesthatcomparedthecareprovidedbyAdvancedPractitionerstothecareprovidedbyjuniordoctors,CNSorG.P.’s.ThefindingsdemonstratethattheAdvancedPractitionerroleisanimportantinclusioninserviceprovisionwiththemainachievementsincost-effectivenessrelatingtoimprovedaccessandimprovementsinqualityofcare.Otherpositiveassociationsoftherolerelatetotheimpactonthelengthofstayandreadmissionstoacutecare.ArecentICNreport(2015)foundthatnomatterwhatsetting,nursepractitionercarehasproventobeahigh-qualityandcost-effectivemeansofdeliveringprimarycare.

3.3.3. Patient Flow Improvingpatientflowisanationalpriorityastheevidenceshowspoorpatientflowleadstounnecessaryhospitaladmissions,longerlengthsofstayandanincreaseincomplexityofcareneeds(HSE2016).Patientflowisdescribedasthemovementof

patients,informationorequipmentbetweendepartments,staffgroupsororganisationsaspartofapatient’spathway(HSE2016).Asanationalstrategicprioritytopatientflowtheneedsandviewsofthepatientareparamountindevelopingjointcareplans.Apatient-centredapproachtocare-planningsupportspatientflowwiththeoptimaluseofresourceswhileaimingtoavoidunnecessarydelaysincare(HSE2016).Thisunderpinsasafeandtimelydischargefromhospitaltohomeandisasanimportantindicatorofqualityandameasureofeffectiveintegratedcare(JointImprovementTeam,2014).Advancedpracticerolesareintegraltopatientflowthroughapproachessuchasthedevelopmentofambulatorycarepathways.Thisimprovespatientflowbyincreasingaccesstooutpatientnurse-ledambulatorycaresettingsfromtheEDandacutemedicaladmissionunits.Patientflowisalsoaddressedthroughinpatientnurse-ledservicesworkingwithinareassuchastheEDand/orchronicdiseasemanagementtodevelopandsupportingtreatmentplansaspartofanin-patientcarepathwayandearlysupporteddischarge.

AdvancedPractitionerroleshavethecapacityandcapabilitytorespondtodelaysinpatientflowthroughoutthesystemandimprovethedeliveryofintegrateddischargesfromhospitaltocommunity.Rolesmustbedevelopedtostrengthenintegrationandreducethenumbersofhealthcareprofessionalsrequiredtoavoidfragmentedcareinthecommunity(HSE2014).

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3.3.4. Unscheduled care access and delivery WithinIrelandannualattendancestotheEDareonaverage1.2millionwithdemandforemergencycareexpectedtoriseoverthenext10years(HSE,2015;Wrenetal.,2017).Tomeettheserviceneeds,advancednurse/midwifepractitionerserviceshaveakeyroletoplayindeliveringcaretosupportEDservicesthatarecost-efficientandeffective.Forexample,inthetreatmentofminorinjuriesandminorailmentstheAdvancedPractitionertriages,assesses,diagnoses,treatsanddischargesfromtheEDorlocalinjuryunit.ThisisdecreasingtheamountoftimepatientsspendintheED.Thisincludesevidenceofimpactonthe6-hourNationalPatientExperienceTimeswith95%ofpatientsseenbyanAdvancedPractitionerrarelyexceedingthe6-hourEDtargettimes(SDU2013).WithintheEDorlocalinjuryunittheAdvancedPractitionerdeterminesimmediatecareneeds,providesinitialtreatmentinterventionsincludingdiagnosticorderingandspecialistreferralinput.Thisensurestimelyserviceaccess,ensuresappropriatereferralontospecialistservicesandimprovespatientflow.Currentlythereare29hospitalsthatprovide24-hourEDand11LocalInjuryUnitsofferingavarietyofserviceswiththemostestablishedAdvancedPractitionerrolesworkinginminorinjuriesandcardiology.Nationallythereare78AdvancedPractitionersworkinginEDwith11CandidateAdvancedPractitionerawaitingregistrationandafurther17candidatesintraining.Basedonpopulationhealthtrends

thereisanopportunitytofurtherdevelopacriticalmassofAdvancedPractitionersintheunscheduledcareareatodeliverolderpersonscareandchronicdiseasesacrossallagegroupstoreceivetimely,accessible,evidence-basedtreatmentandco-ordinatedfollow-up.

TheRANPwithintheEmergencyMedicinesettinghastheabilitytocompleteafullepisodeofcarewhichnotonlybenefitsthepatientbystreamliningtheircarebutalsobydecreasingtheamountoftimetheyspendintheED.WherethereisaRANPdeliveringacompleteepisodeofcare,the6-hourNationalPatientExperienceTimesof95%(UnscheduledCareStrategicPlan,SDU,2013)arerarelyexceeded.ThepotentialforLIU’sandMinorInjuryUnitstobeRANPledanddrivenisonethathasshownbenefitsforboththepatientandtheservice.Thesebenefitsincludeamoreefficientuseofresources,decreasingthefootfalltoED’s,deliveryofexpert,qualitycareandimprovedpatientsatisfaction.However,itshouldbenotedthatwhilethereare78RANP’swithintheemergencymedicineservicetherearegeographicaldisparities.

3.4. Other examples of the Advanced Nurse/Midwife Response to Service Challenges

3.4.1. Hospital Admission AvoidanceTheevidenceshowsthattoreducethedemandonacutehospitalservices,roles

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thataddresshospitaladmissionavoidancesareimportant.Throughtheproactivemanagementofindividualswithafocusonpreventionordelayofchronicillnessandrapidresponsetoachangeinconditionresultsinhospitaladmissionavoidance(Gardner,2014).BasedonreportsfromtheNationalPatientExperienceSurveytherewasevidenceofattendancestohealthcareserviceoveraperiodof3-6monthswithsymptomsupto3timespriortoattendingtheED(HIQA2018).Thereisalsoincreasingdemandforadmissionavoidanceservicestosupportolderpersonsinthecommunitywithreportsshowingthatalmost22percentofallhospitalEDattendeesareaged65-years.Thisaccountsforalargeproportionofacuteemergencymedicaladmissionandtotalhospitalbeddaysusedofupto47percent(HSE,2015).Withinthisupto35percentofolderpersonsaged75yearsandoverareadmittedtohospitalanddemonstratelossoffunctionatthetimeofdischarge(HSE2015).Inmanyinstancestheoriginalmedicalconditionthatrequiredadmissiontohospitalisovershadowedbytheabilitytoself-careondischarge.ThedevelopmentofAdvancedPractitioner-ledservicestohavethecapacityandcapabilitytoaddressthisasacomponentofpreventablehospitalisationsincludingreadmissions,ambulatorycaresensitiveconditions,orothermodifiablefactorstopreventhospitalisation(Coffeyetal2015).Itisalsonotablethatseveralconditionsacrossallagegroupscanoftenbetreatedsuccessfullyinthehome,thus

avoidingunplannedhospitaladmission.OnesuchapproachisreferredtoasHospitalatHome,whereAdvancedPractitioner-ledcarewithsupportfromthemultidisciplinaryteamcanprovideahigherintensityofmonitoringandinterventionswithindefinedperiods(Reillyetal.2015).Similarly,thereisevidenceofAdvancedPractitionerrolesincommunityambulatorycareservicesforrespiratorycareinthecommunityimprovingresponsetimes,reducingunplannedhospitalcareandEDpresentationswithevidenceofimprovedself-management(Bakeretal.,2016).Therefore,thereareopportunitiestostrategicallydevelopadvancedpracticerolesthattargetpopulationsandofferabroad-basedgeneralistapproachtocare.

Asingleeducationalhomevisitbyanurseone-weekpostdischargewasseentohaveanimprovementofqualityoflife,reducedemergencyvisitsandunplannedreadmissions(Aquadoetal.2010).Suchinterventionscanalsobeenhancedwiththeuseoftelehealthandelectronicinterventions.Theevidenceoutlinesthatanyinterventionthatsupportspeopletostayoutofhospital,particularlyinthecaseofolderpeople,withinanintegratedpathwayofcareresultsinbetterpatientandorganisationaloutcomes.

3.4.2. Interdisciplinary Collaboration and Nurse-led / Midwifery-led Services Recognitionandsupportfornurse-led/midwife-ledchangeanddevelopmentisgraduallyincreasing.Nursesandmidwives

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aremakinganincreasinglyvitalcontributiontothehealthofthepopulationandtopopulationhealth.Growingevidence,particularlyfromNewZealanddemonstratesthatpeoplereceivingcareatnurse-ledclinicshaveimprovedhealthoutcomesforarangeofconditions(Pirret2014).However,noonesinglehealthprofessionhasalltheknowledgeneededtoprovidetotalpatient-centredcare(Orchardetal2005).

3.5. Summary Thereisevidenceofanincreaseindemandforscheduledandunscheduledcarewithaneedtodevelopservicesthatfocusonreducedwaitinglists,provideintegratedcare,improvingpatientflowandsupportadmission

avoidance.TheAdvancedPractitionerrolecanrespondtotheseareastoreducetheburdenonacutehospitalservices,bringingcareintoorclosertothehometoimprovethepatientjourney.ToachievethisacriticalmassofAdvancedPractitionersarerequiredtorespondtothepopulationneedsanddeployedstrategicallytoensureappropriateresponseandreducedisparitiesinserviceprovisionnationally.

Summary of the Goals and Actions. Goal1setsouttheactionsfordevelopmenttoaddressthechallengesoutlinedinthischapter’sreviewoftheservicedeliverycontextinIreland.

GOAL 1 Create a Critical Mass of RANP/RAMP’s through a developmental pathway for graduate and specialist nurses and midwives

Action Details Responsibilitya Alignthedevelopmentofadvancedpracticepositionsfornurses

andmidwivestotheintegratedmodelsofcareacrossservicestoensureconsistentprovisionofserviceacrossgeographicareas

HSE

b Developadvancedpractitionerstomeetserviceneed,basedonHSEdata,toincludeareassuchasreductionofwaitinglists,hospitalavoidance,andsupportingaccesstoservicesinareaswheretheintegrationofservicescanbeachieved.

HSE

c Setatargetof2%ofadvancedpractitionersinthenursing/midwiferyworkforcetocreateaninitialcriticalmass.

HSE

d Undertakeamid-pointreviewofprogresstoensuretheachievementofthetargetforadvancedpracticedevelopmentandtheappropriatenessofthetarget

HSE

e Developanationalcareeradvisoryservice,basedonserviceneedthatincludessuccessionplanningforpopulationhealth,whichsupportsnursesandmidwivesindecidingontheirindividualcareerpathway.

NMBI

f Facilitatethecurrentcohortofcandidateadvancedpractitionerstoachieveregistrationwherebusinesscaseshavebeenagreed,serviceneedhasbeenidentifiedandavacancyexists.

HSE

g Determinetheminimumdatasetrequiredforworkforceplanningandreportingpurposes,includingareasofworkandspecialisations.

DOH

h ExplorethecapacityoftheRegisterofNursesandMidwivestocaptureandmaintainthedatarequiredinaction1gaboveasprovidedintheNursesandMidwivesAct(2011).

NMBI

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GOAL 1 Create a Critical Mass of RANP/RAMP’s through a developmental pathway for graduate and specialist nurses and midwives

Action Details Responsibilitya Alignthedevelopmentofadvancedpracticepositionsfornurses

andmidwivestotheintegratedmodelsofcareacrossservicestoensureconsistentprovisionofserviceacrossgeographicareas

HSE

b Developadvancedpractitionerstomeetserviceneed,basedonHSEdata,toincludeareassuchasreductionofwaitinglists,hospitalavoidance,andsupportingaccesstoservicesinareaswheretheintegrationofservicescanbeachieved.

HSE

c Setatargetof2%ofadvancedpractitionersinthenursing/midwiferyworkforcetocreateaninitialcriticalmass.

HSE

d Undertakeamid-pointreviewofprogresstoensuretheachievementofthetargetforadvancedpracticedevelopmentandtheappropriatenessofthetarget

HSE

e Developanationalcareeradvisoryservice,basedonserviceneedthatincludessuccessionplanningforpopulationhealth,whichsupportsnursesandmidwivesindecidingontheirindividualcareerpathway.

NMBI

f Facilitatethecurrentcohortofcandidateadvancedpractitionerstoachieveregistrationwherebusinesscaseshavebeenagreed,serviceneedhasbeenidentifiedandavacancyexists.

HSE

g Determinetheminimumdatasetrequiredforworkforceplanningandreportingpurposes,includingareasofworkandspecialisations.

DOH

h ExplorethecapacityoftheRegisterofNursesandMidwivestocaptureandmaintainthedatarequiredinaction1gaboveasprovidedintheNursesandMidwivesAct(2011).

NMBI

Chapter4FutureModelofGraduatetoAdvancedPractice

Chapter 4Future Model of Graduate to Advanced Practice

4.1. Introduction

Whentheevidence,trendsanddatainrelationtoadvancedpracticeweretakentogether,theypointtoanumberofareaswhichrequirereform.TheIrishdatashowsusthatANProleshavedevelopedinasporadicmanneracrossarangeofspecialisationsandsub-specialisations.Incontrasttheinternationalevidencedemonstratesabroad-basedpopulation-focusedapproachasyieldinggreateroutcomes.Similarly,theIrishdatashowsthatthenumbersremainrelativelylow,whereasevidencecontinuestodemonstratethatwhennursingisre-engineeredasacriticalmasstheworkforcehasthegreatestpotentialtoimpactpatientoutcomesparticularlywhenfocusedonspecificchallengesforexamplechronicdiseasemanagement.Insupportingthedevelopmentofadvancedpractice,theneedforeducationalreformisevidentwherebythepathwayofeducationbuildsonthegraduatetoadvancedpracticetakingcountofabroad-basedpopulationapproach.ThedevelopmentofAPrequiresaregulatorysystemthathastheflexibilitytorecognisecompetenceandskillsacquisitionastheydevelopfromgraduatetoadvancedpractice.AlltheevidenceshowsitispossibletomeasureandquantifythepatientandeconomicvalueofinvestinginAPparticularlywhenthisinvestmentistargetedatservicechallengesanddevelopingacriticalmass.Insummarytheevidencepresentedinthepreviouschaptersmakesacasefor

developinganewmodelofadvancedpracticegroundedinservicedelivery.Thischapterdescribestheproposedmodelofgraduatetoadvancedpracticedevelopment.Theaimofthischapteristodescribeanewmodelforthedevelopmentofgraduatetoadvancedpracticefornursingandmidwifery.ThedevelopmentofthemodelisinformedbyinternationalevidenceandthecurrentchallengesandenablersforadvancedpracticeinIreland.Themodelcomprisesofthekeyfeatures:

• population-basedneedservice,• educationreform,• flexibilityinregulationand• measurementofimpact.

Ofcriticalimportanceisthecentralityofthepatientandensuringnursingservicesdevelopedwithsafetyandqualityatthecore.

4.2. Overview of the Proposed Model

Thepatientiscentraltothemodelandthenurse/midwifesupportsthepatientjourneyinhealthandillness.Themodeldemonstrateshowanurseormidwifecanadvancetheircareerusingabroad-basededucationalapproachanddevelopingspecificcompetencies.Inachievingspecificcompetencies,thenurse/midwifedevelopsthecapabilitytoextendpracticeinlinewithserviceneedanddevelopments.Indevelopingcapability,thejourneyofthepractitionermovesfromprovidingcarethatisdependent

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onstructure,protocolandproceduretobeinapositiontoutilisetheircapabilityindecision-makingtowardindependentpracticeanddecisionmaking.Thisresultsintheabilitytomanageuncomplicatedtocomplicatedhealthconditions.Thisisenvelopedinaregulatorymodelthatbuildsoncompetencethroughcredentialing.

Themodelforgraduatetoadvancedpracticeincorporatestheimportanceofinterconnectingserviceneedswithadevelopmentalpathwayforpreparingthenursingandmidwiferyworkforce.It

acknowledgesinterprofessionalcollaboration.Theintroductionofcredentialededucationfacilitatesandrecognisescompetenceasitisacquired.Thisinturnfacilitatesatimelyapproachtobecomeanadvancedpractitioner.Italsobenefitsservicesasnursesareenabledtocommenceelementsofadvancedpracticeastheyarecredentialled.Thisintroducesanelementofflexibilitywhichinturncanhelptoaddressservicechallenges.Thissupportscollaborativeteamworkingfromprotocoldriven,stablemanagementofdiseasethroughtocomplexdiseasemanagement.

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Figure 6 - Model to Advanced Practice

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Thekeyfeaturesofthismodelare;

• broad-basededucation;• regulationchangesbuildoncredentialing;• measurement;and• increasingcapability.

Themodelcommenceswiththegraduatenursedeliveringbroad-basedpracticeacrosscommon,stablechronicconditionstoadvancedpractitionersdeliveringcompleteepisodesofcareforcomplex,acuteandrareconditions.Thepathwaymovesfromaprotocol-drivenapproachtowardsautonomousnurse-ledpracticedeliveringafullepisodeofcare.Roledevelopmentoccursalongapathwaythatmovesfromcompetencethroughtocapability.Knowledgeandskillstosupportthecontinuedexpansionofpracticearedevelopedalongtheway.

4.3. Rationale for Proposing a Competence to Capability model

Theconceptsofcompetenceandcapabilityhavebeenexploredintheliteratureandarebothrelevantforadvancedpractice.Gardneretal(2007)usedacapabilityframeworkinanefforttodeterminethelevelandscopeofpracticeofthenursepractitionersinAustraliaandNewZealand.Thisstudyfoundthatcompetenciesdescribedmanyofthecharacteristicsofthenursepractitionerbutnotthecompletescope.Theconceptofcapabilityhoweverassistedthisbydescribingfurtherattributesofthenursepractitioner

thusenablingaclearerunderstandingofallelementsforadvancedpractice.Asecondaryanalysisofdatafrominterviewswith15nursepractitionersworkinginAustraliaandNewZealanddescribedtheirroleasinvolving:

• usingtheircompetences;• beingcreativeandinnovative;• knowinghowtolearn;• havingahighlevelofself-efficacy;and• workingwellinteams.

O’Connell,GardnerandCoyer(2014)describecompetenciesasbeingappropriateforadvancedpracticewherestableenvironmentsexistandidentifycapabilityasthecombinationofskills,knowledge,valuesandself-esteemwhichenablesindividualstomanagechangeandmovebeyondcompetency.Theevidenceexploring‘capability’asaframeworkforadvancedpracticestandardspointsoutachallengefor‘capability’inhealthcareinthattraditionaleducationandtrainingconcentratesmainlyondevelopingcompetence.Embracing‘capability’asaframeworkforadvancedpracticeandeducationisrecommendedtofocusonmaximizinganindividual’sfullpotential,developingtheabilitytoadaptandapplyknowledgeandskills,learningfromexperience,envisagingthefutureandhelpingtomakeithappen.Thissetofskillsgenerallyarisesfromtheachievementofaspecialistpracticequalification,experienceorthroughtransitionaleducation(NHSScotland2008).NHSScotland’sNursingPractice

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CompetenceandCapabilityToolkitwasupdatedin2013withtheaimofembracingcapabilityatanadvancedpracticelevel.Toachievethis,itrecommendssupportingdevelopmentthroughaportfoliooflearningandcompetencyassessment.Theportfolioreflectsthekeyelementsofadvancedpracticeandthebreadthofclinicalsettingswithinwhichtheycanbedemonstrated(NHSScotland2013).

NotallAdvancedNursePractitioners,forexampleinScotland,theUnitedKingdomandAustraliawillhaveundertakenaMasterslevelcourse.ForindividualscurrentlyworkinginadvancedpracticepostsandnothavingaformalMasterslevelqualification,compilingaportfoliooflearningandcompetencyassessmentcanhelptodemonstratecompetenceandcapability.Educationprogrammessupportthedevelopmentandrecognitionofadvancedpractice‘capability’andpreparespractitionerstofulfiltherequirementsandexpectationsofanadvancedpracticerole,butdonotgrantthepractitioneradvancedpractitioner’s‘status’.Practitionersareexpectedtoachieveanddemonstratecompetence,confidenceandexpertiseinpracticeandtherequiredlevelofknowledge(NHSScotland2013).

AnexampleofwherethishasbeenrecentlyintroducedisinnursesobtainingtheskillforendoscopyandcolonoscopyinAustraliainadvanceofobtainingcertificationforadvancedpractice(NursingandMidwifery

OfficeQueensland2014).ThisisausefulmodelforadoptinginIrelandwherebyaskillisobtained,credentialedandthenurseispermittedtopracticetheskillpriortofinalcertificationasanadvancedpractitioner.

4.4. The Educational Pathway within the Model

TheNursesandMidwivesAct(2011)makesprovisionfortheNMBItoapproveprogrammesforpost-registrationeducation.Post-registrationeducationleadstoregistrationorannotationinspecialistnursingandmidwiferyeducationandtraining.HigherEducationInstitutes(HEIs)inIrelandprovideeducationforregistrationprogrammesandtailoredprogrammesindefinedpracticeareassuchasemergencynursing,neonatologyandcriticalcarenursing.Educationalpreparationforbothspecialistandadvancedpracticeincludesasubstantialclinicalmodularcomponent(s)pertainingtotherelevantareaofpractice.ThecurrentprogrammesapprovedspecificallyforadvancedpracticebytheNMBIarelistedinAppendix4.Thisapproachsupportsprofessionaldevelopmentthroughapathwaythatoutlinestheexpectationsofpractice,supportsitthrougheducationalpathwaysthatregulateexperientialandreflectivelearning.Credentialingwillallowanurseandmidwifedevelopfromagraduatetoanadvancedroleusingaprogressiveeducationalapproach,throughtheModel.

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Theliteratureillustratesthateducation,expertiseandexperienceofAdvancedPractitionerscanresultindifferingpatientoutcomesandcostswherestandardisededucationalprogrammesdonotexist(Christiansenetal.2013;SchoberandAffara2006).Itisalsoclearfromtheevidencethatthereisaclearbiastowardsdevelopingeducationalprogrammestosupportspecificareasofnursingsuchasmedical,surgicalandemergencynursingandinsomedisease-specificprogrammes(Cronenwettetal.2011).Asaresult,therearemanyopportunitiesforeducationprogrammestodevelopandtheevidenceindicatesthateducationshouldhaveamuchbroaderapproach(Perraudetal.2006).

TwelveeducationalprogrammesforadvancedpracticedevelopedbyuniversitiesacrosstheworldwerereviewedbyCarney(2014).Theevidencesuggeststhatcurriculaforadvancedpracticewouldbenefitfrombroadeningthecontenttoinclude:

• comprehensivephysicalassessment;• currenthealthissuesandsolutions;• communityoutreachinitiatives;• coaching;• diagnostictestsrelevanttotheprogramme;

• diseasemanagementsolutions;• developinginterventionstoimprovepatient/clientoutcomes;

• healthcaredevelopments,logisticalmodelsforpracticedelivery;

• inter-professionalapproaches;• incorporationofmedicinalprescribingandionisingradiation(x-rays);

• mentorshipmodels;• nursingspecificprogrammesbasedonabio-psycho-social-spiritualmodel;

• publicpolicy;• technologyadvancesandoutcomemeasurements.

Thishigh-levelcontentreflectsthebroad-basedknowledgeidentifiedasrequiredforAdvancedPractitionerpreparationtoembracethecapabilitymodelandfurtherdevelopadvancedpracticeroles(O’Connell,GardnerandCoyer,2014).Animportantconsiderationforexample,inthecontextofSláintecareistoincludecurrentpopulationhealthtoenablenursesandmidwivestorespondtotheemerginghealthcareneedsacrossmanyareas.

Theeducationpathwaynowproposedforanurseormidwifesupportsthefivenationalintegratedpathwaysofcare(HSE2016).ThenewtimelineproposedforthedevelopmentofAdvancedPracticeistwo-yearsfrominitialregistration.Thisisalsoapplicabletospecialistpractitionerswhocantodevelopadvancedpracticeoveraone-yearperiod.AnoutlineispresentedinFigure7below.

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4.5. Interprofessional Education

TheWorldHealthOrganisation(WHO,2010)exploredthecontributionofinterprofessionalcollaborationtoachievingbetterhealthandidentifiedinterprofessionaleducationasimportant.Theygiveexamples

ofoverlappingcompetenciesbetweenprimarycarephysiciansandadvancednursepractitionersidentifyingthemascollaborativecompetencies,suchasdiagnosis,treatment,surveillance,healthcommunications,managementandsanitationengineering.Itisfurthersuggestedthat

INTEGRATION AND SERVICE FOCUS

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careChronicdiseases

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Advanced Health/physical assessmentPathophysiology

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}

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Figure 7 - Education Pathway

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collaborativecompetenciesdevelopedthroughinterprofessionaleducationprovideacollaborativepractice-readygraduate(AACN2011).Thereisplentyofevidencetosupportinterprofessionaleducationaspartofanadvancedpracticeprogramme.Centraltothedevelopmentofadvancedrolesanddeliveringtheappropriatecareistoenablehealthcaredeliverybythehealthcareprofessionalmostcapableofdeliveringthecare.Thecorecriteriaforexpansiontoadvancedrolesareidentifiedinarecentreport(HSCP2014)andincludeautonomy,expertclinicalpractice,clinicalleadershipandresearch.TheMacCraithReport(2014),astrategicreviewofmedicaltrainingandcareerstructurerecommendsthefurtherdevelopmentand

expansionofeducation,inlinewith,emergingmodelsofcare,servicerequirements,specialistandadvancednursing/midwiferyandotherclinicalroles.Thisapproachwillnotonlyenableanappropriateskillmixdevelopmentbutalsoprovideopportunitiesforclinicianstopracticetotheoptimumoftheireducationalpreparation.ItalsoprovidesanopportunityforinterprofessionaleducationinanIrishcontext.InternationallythereisevidencethatthisapproachtoeducationisacceptedandtheUniversityofCanterburyforexampledeliversanMScAdvancedPractice(Nursing,MidwiferyandOccupationalTherapy).

Table11belowoutlinesthecoreareas

Table 11 - Core Learning Areas

Concept Examples of possible curriculum topic areas and subjects. The level is determined by the learning needs identified by the practitioner (specialist or advanced) in consultation with peers and related to role function and evaluation.

Person-centred care

Coreconceptsrelatedtonursingandmidwiferysuchasnursingandmidwiferyknowledge,philosophyandpracticeincludingtopicssuchasindividualisedcare,practicemodels,holisticcare.

Autonomy and empowerment

Codeofethicsandprofessionalpractice,thescopeofprofessionalpractice,clinicalgovernance,legislationpowerandempowerment

Professional ethics,

Frameworksforethicaldevelopment,frameworksforthemanagementofethicaldilemmas,ethicaldecision-making

Consultation and collaboration

Frameworksforpartnership,teambuildinganddevelopment,presentationskillsandpublicspeaking

Professional leadership,

Leadershiptheories,managingchangeattheindividualandorganisationallevel,mentorship,interleveldynamics,performancemanagementandmotivationskills

Clinical scholarship

Researchmethodsappliedtopractice,critiquingpublishedresearch,developingimplementationplansforresearchutilisationinpractice,developingpracticeguidelines,developingeducationalprogrammesforothernurses/midwives,developingpatienteducationprogrammes,writingresearchproposalsinconsultationwithanacademicpartnerpublishingresearchoutcomes.

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oflearningforthemodelofspecialistandadvancedpracticetodeterminetheeducationalpreparation(Caseyetal2015).Basedontheevidencethereareopportunitiestoexplorethecontentofthesecoremoduleswithotherhealthprofessionalsthatwouldleadtocollaborativeinterprofessionaleducation.

4.6. Regulation to support the Model – A System of Credentialing

Theevidencedefinestheword‘credential’asproofofaperson’squalificationsandisdistinguishedfromanacademicawardthatdenotesastatuslevelofachievement,namelytheMasterofScience(MSc)inNursing(AdvancedPractice).Casey(2015)consideredthreecredentialingoptionsbasedonAdvancedPractitionercredentialingframeworksfromtheUnitedStates,AustraliaandNewZealand.TherewereelementscommontoallframeworksreviewedsuchasthatalladvancedpractitionersmusthaveaBachelorofScienceinNursingpriortocompletingtheirMScinNursing(AdvancedPractice)degree.TheAustraliannationalnursecredentialingframework(2011)identifiedthattheoptionofcredentialingshouldbevoluntaryandisdistinctfromrecognisingaspecialityareaofpractice(CoNNO2011).Casey(2015)illustratestheAustralianframeworkisbasedon13principlesgroupedundertheelementsof:

• Governanceandreview,

• Operationalmanagement,• Informationmanagement,• Managementofre-credentialingandcredentialingacrossspecialities/areasofpractice.

TheUSframeworkincludesmore‘knowledgeareas’outlinedbelow.ThiscredentialingprocessisbasedonthepremisethatAdvancedPractitionerswillpracticetothefullextentoftheireducationandtraining(InstituteofMedicine,2010)andnotrestrictedtoaspecificareaofpractice.

Credentialing knowledge area criteria include:a. healthpromotionanddiseaseprevention;

b. anatomy,physiologyandpathophysiology;

c. interviewingconceptsandtechniques;d. healthhistory;e. signsandsymptoms;f. physicalexamination;g. laboratory/diagnostictests;h. clinicaldecision-making;i. differentialdiagnosis;j. pharmacologicaltherapies;k. non-pharmacological/complementary/alternativetherapies;

l. diagnosticandtherapeuticprocedures;m.bio-psychosocialtheories;n. patientandfamilyeducationandcounselling;and

o. communityresources.

(AANP,2015)

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IntheUSthisisoverseenbyanindependentcredentialingorganisationandunliketheAustralianapproachtheminimumrequirementisthatregisterednursesmustbeinpracticeforfouryears.Allthreeoptionsreviewedsupportbetween4-6yearsinpracticebeforefullregistrationasanadvancedpractitioner.However,asCasey(2015)pointsoutthereisnoevidencetosupportanydelayinpermittingnursestopracticeattheadvancedlevelwhentheyhaveacquiredtherelevanteducationandtraining.TheUSprocesstosupportthisisanassessmentofbasicknowledgeandcompetenciesmustbeheldtoahighstandardtoprotecttheindividualandthepublicandthereforeincludesanexamination.Thereisalsoarequirementforclinicalexperiencetoreach750hoursofsupervisedpracticeatanadvanced level. InAustralia,AdvancedPractitionersareeligibletoapplyforcredentialingaftersuccessfulcompletionoftheMScinNursing(AdvancedPractice)andsubmissionofaportfoliothatdemonstratesmeetingthecredentialingknowledgeareacriteriathroughongoingeducationandclinicalpractice.Theregulatory/accreditationbodymustapprovetheportfolioinorderforcredentialingtobe granted.

TheapproachinNewZealandthenoffersaslightlydifferentapproachwhereadvancedpractitionersmustsuccessfullycomplete

theMScinNursing(AdvancedPractice).TheAdvancedPractitioneristhensupervisedforthefirstyearofpractice.Thismentoringprocesssupportsthetransitionfromtheroleofthenursetotheroleoftheadvancedpractitionerandissupportedbyfourdomainsofpracticethatdescribetheknowledge,skillsandattitudesofadvancednursingpracticethatthecandidatemustdemonstrate.Thefourdomainsare: • Advancespracticeandimprovedhealthcareoutcomes;

• Assessesusingdiagnosticcapacity;• Planscareandengagesothers;and• Prescribes,implementsandevaluatedtherapeuticinterventions.

Needleman(2014)foundthatnursesandorganisationsperceivecredentialingasaneffectivemechanismtoadvancesafety,improvequality,improveprocessesofcare,clarifyanddefinetherolesofnursesandotherteammembers.Italsoprovidesprofessionalsupportandhasbeenshowntoimprovejobsatisfaction.TherearemanyconsiderationsformtheevidencefordevelopmentintheIrishcontext.

Romano(2014)developedasimpleconceptualmodelofacredentialingpathway.Thepathwaymovesalongatrajectoryinvolvingtheindividualnurseperformance,theorganisationofnursingwork/tasksandtheorganisationleadershipandculture.It

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incorporatesmanyoftheelementsofotherapproachesidentifiedintheliteratureandotherimportantconceptssupportingahigh-levelnursingresponsetoachievebetterpatientoutcomes.

ImportantlyfortheIrishcontext,regulationthroughNMBIalreadyfacilitatescredentialingforspecificskill/knowledgedevelopmentthatmaybeobtainedoutsidethejurisdiction.NMBIisthereforeinagoodpositiontocommencerecognitionofaclinicalcareerpathway,facilitatingannotationagainstthenameofaregistrantasprovidedforintheNursesandMidwivesAct2011.Thecurrentmodelofrecognitionofsupplemental,specialpurpose,minorandmajorawards(QQIframework)providesthebasisofreconsideringrecognitionofachievementbynursesandmidwivesthroughanannotationprocesstoanameontheregister.

Creatingapathwayforskilldevelopmentfromgraduationinameaningful,purposivemannerensuresthecapabilityofthenurse/midwifetorespondandmeetserviceneed.IncontrasttotheRANP/RAMP,theCNS/CMSisnotadivisionoftheNMBIandthereforenotregulated.Therearehowever,minimumeducationalrequirementsspecifiedattheserviceleveltobeemployedasaCNS/CMS.Thecurrentminimumeducationalrequirementstobemetaresetatpost-graduatediplomalevelinthespecialistarea.Theproposedcredentialingmodeltakes

accountoftheseminimumeducationalrequirementsinadditiontospecificskillacquisitionqualifyingforannotationagainstaregistration.RecognitionasaCNS/CMStomeetserviceneeds,therefore,requirescompletionofapost-graduatequalificationtogetherwithaminimumof1yearexperienceworkinginthespecialistarea.ThisisinadditiontomeetingtherequirementssetbytheHSEtoensurethedeliveryofsafe,effectivepracticetomeetservicedemands.TheflexibilitythatisofferedinthisapproachtothedevelopmentandrecognitionoftheCNS/CMSoffersemployersandpractitionersanenablingmethodtoaddressthechangingneedofpopulationdemand.TightregulationoftheroleofCNS/CMShadthepotentialtoinhibitinnovationanddevelopment.TheroleofCNS/CMSofferspractitionersacareerpathwayincorporatingprofessionaldevelopmentwithinaninterprofessionalteamstructure.Thefollowingpathwayisthereforeproposedforthedevelopmentofgraduate,specialistandadvancedpracticenursesandmidwives.

Thepathwayoutlinesatwo-yeartimeframefromgraduatethroughtoadvancedpracticethatisreflectiveofcurrentinternationaltrendsofmeetingeducationalrequirements.ThispathwayadditionallyincludesacredentialingframeworkthattheNMBIshouldconsidersupportingskillacquisitionandcompetencywithinacapabilitycontinuum.Followingrecognitionby

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annotationofaregistrationwiththeNMBI,anurseormidwifecansafelycommencethispracticewhilstundertakingfurthereducationtoachieveastatusofspecialistoradvancedpractitioner.Thiswillensurethatthenurse/midwifekeepstheirskillfreshwhilealsoprovidingvaluableservicetopatientswhorequiretheservice.Theeducationalpathwaysrequireaminimumoftwoyearsinthespecialityareaofpracticetogaintherequiredtwoyearsofexperience.Thismayoccurinconjunctionwithamaster’seducationprogramme.TheminimumtimeframetoachieveregistrationasaRANP/RAMPwithinthisframeworkisnow2years.Thispathwayassistsnurses/midwivestoidentifythegapsforserviceneedandpopulationhealthneeds.Theeducationdecision-makingforcareerdevelopmentbynurses/midwivescanthensupportsuccessionplanningforserviceneed.Inembracingacapabilitycontinuumthroughacredentialededucationpathwaythenurse/midwifecanthenapplytotheNMBItohavetheirregistrationannotatedontheregistertoreflecttheadditionalachievementoftheskill/credentialandtheycanthenpracticethatskill/competencysafely.

4.7. Governance

Thedevelopmentofnursingandmidwiferyrolesalongthepathwayfromgraduatetoadvancedpracticeplacesnewresponsibilitiesuponthepractitioner.Therefore,thereisa

needfororganisationstoensurethatrobustgovernancearrangementsareinplacetoencourage,enableandsupportthesafeandconsistentdevelopmentoftheserolesforpatientbenefit.Organisationsneedtoassurethatrobustgovernancearrangements,surroundingalltypesandlevelsofpractice,areinplacepriortotheirestablishment.Thisisnecessarytoallowadvancedpractitionerrolestofunctionfully.Newprofessionalsupportarrangements,whichrecognisethenatureoftheroleandtheresponsibilitiesinvolved,willberequiredandexistingprofessionalsupportmechanismsmaynotbeenough.Goodgovernanceregardingroledevelopmentandimplementationmust,therefore,bebaseduponconsistentexpectationsofthelevelofpracticerequiredtodeliverahigh-qualityandsafeservice.

Thisisbestachievedthroughthebenchmarkingofsuchpostsagainstnationallyagreedstandardsandprocessesasoutlinedabove.Concernaboutnewrolesisbothprudentandunderstandableandithasbeenarguedthatriskstosafetyarisewhenprofessionalstakeonrolesandresponsibilitiesforwhichtheylackcompetenceorwheretheypracticewithoutadequatesafeguards.However,workbytheCommissionforHealthcareRegulatoryExcellence(CHRE,2009)hasemphasisedthattheactivitiesthatprofessionalsundertakeatadvancedlevelpracticedonotliebeyondthescopeofexistingregulationunlessthe

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natureoftheirpracticechangestosuchasignificantextentthattheirscopeofpracticeisfundamentallydifferentfromthatatinitialregistration.

Thebenefitsofadvancedandspecialistrolesarewellestablished.Therefore,puttinginplacealocalgovernancestructureassuresgoodclinicalandcorporateoversightofallchangesinpracticeandoutcomes.InarecentpaperpublishedbyHudson(2016),onintegratedaccountabilityforintegratedcare,theissuesofdeterminingpriorities,allocatingresources,monitoringprogress,ensuringdeliveryandlearninglessonsarekeyoutputsfromanaccountabilityframework.Corporate,financialandclinicalgovernanceareinterconnected.ClinicalGovernancesystemswhichHSEserviceprovidersareaccountableforincludecreatingenvironmentswherecontinuousimprovementsinthequalityofclinicalpracticeandhighstandardsofcareflourishalongwithinaccountabilityandgovernancestructures.Theadvancednursepractitionerhasamajorroleindeliveringthesehighstandardsofcare.

Notwithstandingthatthekeyprinciplesoutlinedinthispaperaretargetedatthenationallevel,theprinciplesarenolesstransferabletothelocalcontext.Theprinciplesshowninthediagrambelowinclude;

Thesekeyprinciplesofgoodgovernance(Fig8)demonstratetheinterconnectedfactorsuponwhichanyoversightstructurerests.Establishingcomprehensiveandjoined-upoversightofthesysteminwhichanAdvancedPractitionerispractisingistheessentialfirstcomponent.TheoversightofthegovernancestructuremustbebroadenoughtocaptureallareasaffectedbytheAdvancedPractitioner’spracticewhilealsodeepenoughtowitnesstheoutcomes.Achallengeliesinthegovernanceitselfmustbeeconomicaltobothtimeandfinances.Alaboriousandcostlygovernancestructureisself-defeatingandsoonbecomesnon-

Comprehensive and Joined up,

Spanning Quality and Finance

Stable Over Time and

Consistently Applied

Economic of Time and

Money

Clear and Transparent

Robust to Real World Challenges

Rigorous where it Ma�ers but Encourages Innova on

Figure 8 - Key Principles of Clinical Governance

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functioning.Thegovernancestructuremustmaintaintransparencyinallitsdealinginordertoremainaccountable,fairandhonest;thisincludesopenacknowledgementofshortcomingsidentifiedandthedisclosureofinformationwhenappropriate.Throughtransparencyandopenness,arigorousapproachismandated,butthisalsoallowsforreasonableflexibilitytoencourageinnovationtoproblem-solvingandsolutionbuilding.Thesefactorsareinterconnectedtocreateagovernancestructurethatremainssustainableovertime,consistentlyappliedandrobustagainstshort-termchanges.

Aspreviouslyhighlightedthroughoutthispolicy,theserolesshouldnotfunctioninisolation,butratherwithinaserviceofothergraduate/specialist/advancedrolesandwithinthemultidisciplinaryteamtodelivercompositecare.Theyaredependentupontheavailabilityofotherfunctionsandroleswithintheorganisationsasawhole,tomaximisetheirimpact,andgainareturnontheirinvestment.Inordertoenable,supportanddeveloptheseroles,robustgovernanceoftheseroleswithinorganisationsisnecessary.ItisnotablethattheFrameworkforAdvancedNursing,MidwiferyandAlliedHealthPracticepublishedbyNHSWales(2010)andtheScotlandCareerFrameworkGuidance(2008)reflectedmanyoftheprinciplesoutlinedabovebyHudson(2016)report,albeitspecifictotheserolesthatinclude;

• Clarityregardingtheservicetheyworkwithin/deliver;

• Clearobjectivestobeachieved;• Strongorganisationalvalueontheseroles;• Wellthoughtoutprocess/structuresforthedevelopment,implementationandevaluationoftheserolesatlocallevel;

• (AdaptedfromNHSWales,FrameworkforAdvancedNursing,MidwiferyandAlliedHealthProfessionalPractice2010).

4.8. Measurement

Measuringthevalueofnursingandmidwifery’scontributiontohealthservicesisoftendifficulttoquantifyineconomictermsbecauseoftheteam-based,holisticnatureofthework.Thischapterwilloutlinetheliteraturerelatedtoevaluation,explorepotentialperformanceindicatorsanddescribethedatacollectionforAdvancedPractitioners.

4.8.1. Measuring the economic impact of Advanced PractitionersEffortshavebeenmadebytheResearchServicesUnitoftheDoHtoquantifytheimpactineconomictermsofthecontributionoftheeffectiveutilisationofnursesandmidwivesindeliveringhealthcareservices.Aframeworkforthemeasurementoftheeffectivenessofthenursingcontributioninitswidersensetohealthcareprovision,wasexaminedthatpresentedseveralmetrics.Themetricsprovideguidingprinciplesthat

62

shapedanevaluativeframeworktoassesstheeffectivenessofspecialistandAdvancedPractitionersseekingtomeettheneedsofachangingpopulation.

Performancemeasurementisimportantasawayofensuringthatthedeliveryofcareisachievingwhatitissetouttodo.AnevidencereviewcommissionedbytheDepartmentofHealthin2015foundthatKeyPerformanceIndicators(KPIs)arebeingcollectedonasignificantscalethroughoutarangeoforganisationaltypesandlocationsthroughoutIreland.TheKPI’scollectedspanstructural,processandoutcomestypes.ThemainKPIsutilisedthatembracestructural,processandoutcomesmetricsarearoundnursingandmidwiferyworkforcewhichincludetheCNS/CMSandAdvancedPractitioner;qualityofnursing/midwiferycare;clientexperience;casemanagementincludingcoordination;diagnosisandintervention;organisationactivitiestoincludeleadership,educationandresearch.

ThereareanumberofKPIstobedevelopedtomeasuretheimpactofthismodel.TheyrelatetoPatientoutcomesandqualityofcare,professionaleducation,regulationandcost.Performancemeasurementisimperative,toensurethatdeliveryofcareismeetingthetargetedhealthcareneeds.KPIscontributetotheprovisionofhighquality,safeandeffectiveservice,thatmeetstheneedsofserviceusers(HIQA,2012).Significantly

therearenonationaldatacollectionsystemsthatreportonAdvancedPractitionernursingactivitiesoroutcomes.

ThedevelopmentandrolloutofachangedmodelinrelationtoadvancingpracticemustbeaccompaniedbytheHSEsdevelopmentofasetofKPI’sthatcanbeusedtocapturetheoutputactivityoftheAdvancedPractitionersincludingnumbersofpatientsseen;numbersofpatientsaccommodatedfromthewaitinglist;researchactivitiesoftheAdvancedPractitioneranddatarelatingtoclinicalcareoutcomes,includingcost-effectivenesstoachieveanon-goingeconomicevaluationoftheAdvancedPracticeroles.

Futureadditionalmetricsthatshouldbeincludedare:

• Healthstatus;• Qualityoflife;• Qualityofcare;• Patientsatisfaction;• Lengthofhospitalstay;and• Costs.

Inaddition,theopportunitytoobtaindatarelevanttothenursingarenashouldbeexploredwiththeHigherEducationInstitutesandtheRegulatorybody.

ExamplesoftheKPI’satregulatory level include:

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• Evaluatingthetime,ittakestoberegisteredasanAdvancedPractitioner;

• Theeducationcurrentlyavailablethatcanbecredentialedinaportfolio;and

• ThenumberofnursesandmidwiveswhoobtainregistrationasanAdvancedPractitioner.

ExamplesoftheKPIsataneducation level include:

• Provisionofinter-professionaleducationoffered;

• Varietyofprogrammesavailabletosupportserviceneed;

• Provisionofbroad-basededucationoptions;and

• Thenumberofcollaborativementorship/preceptorshipsoffered.

Additionalmetricsthatshouldbeconsidered

formetricswithinastructure,processandoutcomeframeworkincludehealthstatus,qualityoflife,qualityofcare,patientsatisfaction,lengthofstayandcosts.Assuch,thegoalofKPIsistocontributetotheprovisionofhighquality,safeandeffectiveservicethatmeetstheneedsoftheserviceuser(Table12).ThedevelopmentandrolloutofachangedmodelinrelationtoadvancingpracticemustbeaccompaniedbytheHSEsdevelopmentofasetofKPI’sthatcanbeusedtocapturetheoutputactivityoftheCNS/CMSsandRANP/RAMPsincludingnumbersofpatientsseen;numbersofHealthcareAssociatedInfections(HCAI’s)reduced;numbersofpatientsaccommodatedfromthewaitinglist;researchactivitiesoftheRANP/RAMPanddatarelatingtoclinicalcareoutcomes,includingcost-effectivenesstoachieveanon-goingeconomicevaluationoftheCNS/CMSandtheRANP/RAMProles.

Table 12 - Minimum Dataset

Impact Data being collected What this demonstratesWaiting Lists Thenumberofpatientsreviewedfor

thefirsttimebytheANPinscheduledcare clinics.TheNumberofpatientsreviewedbytheANPincomparisontothenumberofpatientsintheclinic

Reductioninvolumeofwaitinglistnumbers.ImpactofANPintheservice

Hospital Avoidance LocationofthepatientwithintheclinicalsettingwhenreviewedbytheANPInterventionscompletedbyANPandoutcomeofpatientegReferredtoANPclinicinsteadofacuteservice

ReductioninEDpresentationsIncreaseinpatientsseenbyANPinthecommunityorprimarycareIncreasenoofpatientsseeninAMAU

Access and Choice NumberofpatientsreviewedbyANPthroughoutthehealthcaresetting.IndirectcontactswithpatientsAveragelengthoftimeforapatienttobereviewedbyanANPfollowingreferral

ImpactofANPsthroughoutthehealthcaresetting.EfficiencyofANPsthroughoutthehealthcaresetting

Patient Flow NumberofpatientshadanepisodeofcaredeliveredbytheANPLocationofthepatientinthehealthcaresettingwhenreviewedbytheANP

ImpactofANPsinunscheduledcareEfficiencyofANPswithinservice

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4.9. Summary

Thenewmodelsetsoutacomprehensiveintegratedapproachtoadvancedpracticedevelopmentbuiltaroundapathwaywhichtakesanurseonajourneyofcompetencetocapabilityfromprotocol-drivencaretoautonomouspracticemanagingtotalepisodesofcareforcomplexillness.Themodelissupportedbyarevisededucationalapproach,aregulatorysystembasedaroundcredentialing.Themodeldrawsattentiontotheimportanceofdevelopingasystemofmeasuringtheimpactonpatientoutcomesandservicedeliveryimprovements.The

modelalsoacknowledgestheneedtosupportmajorreformwiththerobustsystemofclinicalgovernance.Thenextstageindevelopinganewapproachtoadvancepracticewillinvolvetestingofthemodel.Tothisendthenextchaptersetsoutthestrategyemployedtotestthemodelinpracticewithaviewtodeterminingitscapacitytodeliverontheintendedoutcomes.

Summary of the Goals and Actions. Goal2setsouttheactionsfordevelopmenttoaddressthechallengesoutlinedinthischapter’sreviewoftheeducationalcontextofnursinginIreland.

GOAL 2 Change the way we educate and train graduates, specialists and advanced nurse/midwife practitioners

Action Details Responsibilitya Introduceasystemofcredentialingtomeetserviceneedbasedonthe

interconnectedmodelforgraduate,specialistandadvancedpractice.NMBI

b ImplementunderSection48(3)oftheNursesandMidwivesAct(2011)aprocesstoannotatethenameofanurseormidwifewhosuccessfullycompletescredentialededucationparticularlyrelatedtoskillsacquisition.

DOHNMBI

c Changetheregistrationfornurse/midwifeprescribingtobecomeacomponentofcredentialededucationinacareerpathwayforgraduatetoadvancedpracticetosupportintegratedandcommunitycare.

NMBI

d Recogniseaccreditededucationobtainedinotherjurisdictionsinaclinicalcareerpathwayforanurse/midwifejoiningtheworkforceinIreland.

NMBI

e Reducetheminimumregulatorytimelineforundertakinganadvancedpracticepathwayto2-years.

NMBI

f Developa1-yeargraduatecertificatetypeprogrammeasashortenededucationalpathwayforexperiencednursesandmidwivestoobtainoutstandingeducationalrequirementsforadvancedpractice.

HSENMBIHEI

g Provideforbroader-basededucationpreparationofadvancedpractitionerstoavoidthedevelopmentofmicro-specialisationwithinaservicespeciality.

NMBIHEI

h Establishinterprofessionaleducationstandardsandrequirementswithothermembersoftheinterdisciplinaryteamthatsupporttheconceptofcapabilityforroleshare/exchangebetweenprofessions.

NMBICORUMCIHEI

i Enhancecollaborativeinterprofessionalmentoringsupportsandsystemsacrosstrainingprogrammeswithintheinterdisciplinaryclinicalteams.

HSEHEI

j DevelopapathwaythatallowsforadvancedpractitionerstocontinuetheircareerjourneyinresearchandteachingtoDoctorallevel.

HEIHSE

k Developgovernanceandmanagerialstructuresthatsupportcollaborativeinterdisciplinaryteamworkingthatenabletheskillsofnursesandmidwivesatgraduate,specialistandadvancedpracticebemaximisedforpatient-centredcare.

HSE

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Goal4setsouttheactionsfordevelopmenttoaddressthechallengesoutlinedinthischapter’sreviewofmeasurementsrequiredtoassurethesuccessofthemodelofgraduatetoadvancedpractice.

GOAL 4 Measure the impact and effectiveness of the new model

Action Details Responsibilitya DevelopasetofKPI’sthatcapturestheoutputactivityof

advancedpractitionerstoincludenumbersofpatientsseen;numbersofpatientsaccommodatedfromthewaitinglist;anddatarelatingtoclinicalcareoutcomes,includingcost-effectivenesstoachieveanon-goingeconomicevaluationofadvancedpracticeroles.

HSE

b Explorethefeasibilityofdevelopinganevidence-basedevaluationmodelforadvancedandspecialistrolesunderpinnedbyresearch,similartothePEPPAmodel.

HRB

66

67

GOAL 4 Measure the impact and effectiveness of the new model

Action Details Responsibilitya DevelopasetofKPI’sthatcapturestheoutputactivityof

advancedpractitionerstoincludenumbersofpatientsseen;numbersofpatientsaccommodatedfromthewaitinglist;anddatarelatingtoclinicalcareoutcomes,includingcost-effectivenesstoachieveanon-goingeconomicevaluationofadvancedpracticeroles.

HSE

b Explorethefeasibilityofdevelopinganevidence-basedevaluationmodelforadvancedandspecialistrolesunderpinnedbyresearch,similartothePEPPAmodel.

HRB

Chapter5TestingtheModelofgraduatetoadvancedpractice

Chapter 5Testing the Model of graduate to advanced practice

5.1. Introduction

Thischapteroutlinesthestrategicapproachtakentotestandimplementthemodelofgraduatetoadvancedpracticeinaction.Thestrategyinvolves4phaseswhichinclude:settingdirection,mobilisingcommitment,deliveringorganisationcapacityanddemonstratingimpact.Thischaptercontinuestodescribehoweachofthesephasesprogressedandculminatesinasetofrecommendationembeddingtheinitiativeinthesysteminasustainablemanner.

5.2. Setting the direction Settingthedirectioninvolvedseveralstepsincluding:

5.2.1. Establishing the Steering CommitteeIntestingthispolicy,atwo-yeardemonstratorprojectwasmanagedbyaNationalSteeringCommittee(Appendix5).TheSteeringCommitteemanagedtheworkloadassociatedwiththetermsofreferencethroughworkinggroupsparticularlyinrelationto:

• governance;• regulation;• serviceimplementation;• education;and• evaluation.

Thesteeringgroupoperationalstructureisillustratedbelow.Localimplementationgroupswereestablishedtodriveimplementationanddealwithemergingchallenges.

MobiliseCommitment

Set theDirec�on

• Consulta�on• Procure Educa�on• Change Regula�on• Determine Service Area• Develop Measurement System

Establish Steering Group

DeliverOrganisa�onal

Capacity

ProvideVisible

Evidence

• Site Selec�on• Candidate Selec�on

• Evalua�on• Early Results• Recommenda�ons

Figure 9 - Strategy to Test Model

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OneoftheactionslistedintheDraftPolicyforGraduate,SpecialistandAdvancedNursingandMidwiferyPractice,approvedbytheManagementBoardinFebruary2017andmembershiprequestedbytheMinisterforHealth,wastheestablishmentofanationalsteeringcommitteetooverseethetwo-yearimplementationperiodofthepolicy.TheSteeringCommitteewaschargedwithoverseeingtheimplementationofthekeyissuesofgovernance,regulation,service,evaluationandeducation,supportedbyaworkinggroupstructure.TheSteeringCommitteecomprisedabroadrangeofinterestsandexpertise,fromtheDepartmentofHealthandHSEacuteservicesandCHOareas,Primary

CareandSocialCare,DirectorsofNursing,representativeassociations,membersofthepublicandhighereducationinstitutionstoarepresentativeofthecandidateANPs.ThelettersrequestingnominationsfortheCommitteewereissued.ThefirstmeetingoftheSteeringCommitteetookplaceinMay2017andcontinuedmonthly.TheagreedTermsofReferenceoftheSteeringCommitteecanbefoundinAppendix7.

Method of working AProjectInitiationDocumentwasdraftedtooutlinethepurposeandobjectivesoftheproject(Appendix6).Anumberofworkinggroupswereestablished,withsupportfrommembersofthe National

Working with the DOH and

HRB

STEERING COMMITTEE

LOCAL IMPLEMENTATION

GROUPS

Report on local progress and

governance issues including the

collec�on of data

GOVERNANCE REGLUATION

Working with the NMBI

SERVICE

Working withthe HSE

EVALUATION EDUCATION

Workin withthe HSE’s

Oversee implementa�on on key issues for governance, regula�on, service, evalua�on and educa�on

WORKING GROUPSAdvise on specific issues related to the project - membership will include some steering

commi�ee members and other stakeholders as agreed

Figure 10 - Structure of Steering Committee and Working Groups

69

SteeringCommittee.Thepurposeoftheworkinggroupswastopilotandtesttherecommendationsinthedraftpolicy,withaviewtoaddressingissuesthatmayaffecttheimplementationofdemonstratorsitesandtheassociatededucationprogramme.TheChairoftheNationalSteeringCommitteeconvenedmeetingswiththeChairsoftheworkinggroupstoensurethattheoutputswereintegratedintotheworkplanoftheSteeringCommitteeandreportedonmonthlytothecommittee.

Working GroupsAnumberofdocumentsweredevelopedinthecourseofthe2017campaignthroughtheworkinggroupstructure.Theseinclude:

• requirementsandStandardsforAdvancedNursePractitioners(NMB);

• criteriaforRegistrationasanAdvancedNursePractitioner(NMBI);

• adraftguidetomeasuringtheimpactoftheANPinitiative(DoH);

• localImplementationGroupTermsofReferencedocument(HSE);

• clinicalSupervisiondocumentforthecANPs(HSE);

• cANPjobdescription(HSE);• templateforMemorandumofUnderstanding(HSE);

• templateforSiteRotationServiceLevelAgreement(HSE);

• commencementofLegislation(DoH);• NursesRules(NMBIandDoH);and• Regulations&GuidelinesgoverningAdvancedPractice(NMBI).

5.3. Mobilising Commitment

5.3.1. Broad Ranging Consultation ProcessThispolicywasinformedbyextensiveconsultationwithawiderangeofstakeholdersincludingnationalandinternationalexperts,educationalists,regulators,managers,policymakersandchiefnurses.Afive-weeknationalconsultationprocessacrossthecountryandaweb-basedsurveywereconductedthroughoutApril2017(seeTable13).ConsultationonanalignmentwiththeHSEmodelofintegratedcaredeliverywasalsoundertakenwiththeclinicalleadsoftheclinicalcareprogrammesandseniormanagementoftheHSE.Theparticipationandcontributionsfromallstakeholderswerewelcome,withthefeedbackcollectedatthetenregionalconsultations,throughanonlinesurvey,byemailandthroughTwitter.Thee-zineoftheNMBI,whichhasadistributionofapprox.40,000nursesandmidwives,wasusedtonotifyandencourageparticipationbynursesandmidwivesintheconsultationprocess.Feedbackfromthenationalconsultations2017wasreceivedbythefollowingmeans:

Table 13 - Feedback from Consultations

Source Submissions received AnonymousSurvey Monkey 69 Yes

e-mail 16 No

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Thedatacollectedfromtheregionalconsultations,thenationalconsultationprocessandthesubmissionswereindependentlyanalysedbyaqualitativeresearchexpertwhohadnoconflictofinterestintheprocessorthefindings.TheconsultationfindingswereprovidedtotheNationalSteeringCommitteeandtheseinformedtheirworkinthefurtherdevelopmentoftheproject.

Summary of the Consultation Findings Feedbackfromtheconsultationprocesswaspredominantlypositive;forexample:

• TherethattherewasbroadagreementthatanincreaseinthenumberofAPswasrequired;

• WorkingexampleswhereAPwasalreadyinplacewereendorsedsuchas,anasthmamanagementserviceinaprimarycaresetting;

• Thepositiveimpactofhavingtherightskillmixforcaredeliverywashighlighted;

• Therewassignificantsupportforacredentialingmodel;and

• Therewasalsobroadagreementthatadvancedpracticehadbecometoospecialistandneededtochangetoprovideabroad-basedapproachtocaredeliveryinlinewithservicechallenges.

Thefeedbackprovidedanopportunitytoreviewthecurrentmodelsofpracticethatthevariousworkinggroupsthenrefinedin-line

withtheproposedmodel.Thefeedbackalsoidentifiedanumberofchallenges,forexampleroledefinitionintheprimarycaresettingiscomplexandwillneedfurtherworktoprovideclarity.ThefullsummaryoffeedbackisavailableinAppendix8

5.3.2. Procuring education Thepolicysetoutpracticalchangeswithinaneducationframeworkforgraduate,specialistandadvancedpractitionersthatarelinkedtoserviceneedsandintegratedcarepathwaysby:

• DevelopingacriticalmassofRANP/RAMPsinaflexible,timelyfashionthatcanprovideafullepisodeofcare;

• Introducingacredentialingpathwayfornursesandmidwivestoequipthemwiththecapabilitytodeliversafeandresponsivecareinavarietyofservicesettings;

• Streamliningtheeducationalpathwayfrom7yearsto2years;

• Facilitatinginter-professionaleducationtopromoteintegrateddeliveryofcare,andthemostefficientdeliveryofeducationandpracticedevelopment;and

• Focusonensuringabroad-basedavailabilityofserviceproviderstomeetcurrent,emergingandfutureserviceneeds.

TheneweducationmodelandthesignificantincreaseinthenumberofAdvancedNurse

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Practitionerssupportstheintroductionofanintegratedmodelofcarebytheprovisionofcarewithinthehome,avoidingunnecessaryhospitaladmission,reducingthewaitinglists,improvingaccesstoserviceandimprovingpatientflowthroughthehealthservices.

Atenderforabroad-basededucationprogramme,totestthemodel,wasdevelopedincollaborationwiththeHSE,whoconductedthecompetitionbetweenMayandJuly2017.TheprogrammeacknowledgesandcreditspriorlearninganddependingonthedevelopmentofthecandidateANP,theeducationprogrammeprovidesbothaone-yearandtwo-yearoption.TheprogrammecommencedinOctober2017.Thetenderincludedtherequirementbytheeducationproviderto:

• Designanddeliveracurriculumfora1-yearGraduateCertificateEducationProgramme(QQILevel9)anda2-yearpart-timeMastersEducationProgramme,

• WorkinpartnershipandcollaborationwiththeHSE/ONMSDandservicesinthedesignanddeliveryoftheprogrammetoenhance/co-ordinatetheANPexperience;

• Ensureflexibility,easeofaccess,andprovidevariedevidence-basedteaching,learningandassessmentmethodologies;

• Promoteandsupportexperientiallearning;and

• Developadvancedassessment,clinicalreasoninganddecision-makingskillsto

managepatientcaseloads,episodesofcareandreferasappropriate.

TheeducationprogrammeisdesignedtoprovidetheANPswiththeeducationalsupporttoachievetheclinicalpracticeexperienceandcompetenciestomanageafullepisodeofcareforapatient.Theprogrammedevelopsabroadrangeofassessmentskillsanddecision-makingskillsfornursesintheareasofchronicdiseasemanagement,unscheduledcareandolderpersoncare.

TheprogrammedesignandcurriculumwererequiredtopreparetheANPtodevelopandutiliseadvancedclinicalnursingknowledgeandcriticalthinkingskillstoindependentlyassess,diagnoseandprovideoptimumpatientcarethroughcaseloadmanagement.Theholisticmanagementofacaseload,throughprovidingcareormakingtheappropriatereferralswithintheinterdisciplinaryteam,wastoincludehealthpromotion,healthmaintenance,assessment,diagnostics,nursingdiagnoses,therapeuticinterventions,preventativecare,rehabilitationandpalliativecare.

ThecoreelementsoftheprogrammetomeettherevisedStandardsandRequirementsandcompetenciesdevelopedbytheNursingandMidwiferyBoardofIrelandinclude:

• Nurseprescribing/x-ray

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• Advancedassessment,diagnosisandreferral

• Diagnosticreasoninganddecision-making• Casemanagementandfirstpointofcontact

• Leadership• Research

ThecontentisinlinewiththeadvancedclinicalactivitiesidentifiedbyMaierandAiken(2016)whentheycomparedadvancedpracticein39countries.Theeducationprogrammebeganonthe23rdofOctober2017.Thestudentswereallocatedplacesfortheacademicyear2017/2018intheconsortiumledbyUniversityCollegeCorkthatincludesNationalUniversityofIrelandGalway,UniversityCollegeDublinandTrinityCollegeDublin.Thecourse,underpinnedbyinternationalevidence,creditspriorlearningandisbeingdeliveredatmaster’sdegree level.

MinisterforHealthSimonHarrisofficiallylaunchedtheneweducationprogrammeforAdvancedNursePractitionersonthe21stofNovember2018inUniversityCollegeDublin.Afurtherintakeof40ANPscommencedontheprogrammeinSeptember2018. 5.3.3. Changing the regulatory frameworkTheregulationofnursing/midwiferypracticeismanagedbytheNMBI.Theeducationmodelproposescredentialingofspecificskill/knowledgedevelopment,obtainedeitherin

Irelandoroutsidethejurisdiction,thatNMBIwouldrecogniseinaclinicalcareerpathwayandannotateagainstthenameofaregistrantasprovidedforintheNursesandMidwivesAct2011.ThecurrentmodelofCategoryIandCategoryIIapprovalwiththeinherentrecognitionofsupplemental,specialpurpose,minorandmajorawards(QQIframework)providesthebasisofreconsideringrecognitionofachievementbynursesandmidwivesthroughanannotationprocesstoanameontheregister.ThecurrentapprovalrecognitionframeworksofeducationandtrainingprovidedbytheNMBIisunderreviewtoembracenewwaysofworking.

Thekeyfeatureofabroad-basededucationsystemisthatitsupportsstandardsbasedonsectoraloccupationalprofileswhileincorporatingrelevanttransversalskills.Additionally,havingaunifiedandcoherentsystemconnectsfurtherwithhighereducationandtraininginrespectofawards.Specifyinglearningoutcomesasmeaningfulwork-basedlearningcomponentsfacilitatesunderstandingandcomparabilityacrossthesystemswhilefacilitatingmobilityinclearprogressionpathways.TheNMBIdevelopedandapprovedrevisedStandardsandRequirementsthatincorporatecompetenciesforAdvancedNursingPracticeprogrammesin2017.TheNMBIalsoreviewedtheregistrationcriteriaandNursesRulestoreflectamoredynamic,flexibleregistrationprocessthatregistersthenursenotthepost.

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Theeducationpathwaynowproposedforanurseormidwifesupportsthefivenationalintegratedpathways(HSE2016)ofcare.TheinitialregistrationofanurseunderpinstheintegrationfocusandisbasedonadevelopmentalmodelthatembracescredentialededucationthatcanbeannotatedbytheNMBI.ThenewtimelineforeducationdevelopmentofaRANP/RAMPistwo-yearsfrominitialregistration.Inthismodelitisalsopossibleforspecialistpracticeeducationpreparationtodeveloptomeetserviceneedinaone-yearperiod.Additionally,theNMBImadefivesetsofRulesthatweresignedbytheMinisterforHealthtofacilitateaneweducational,registrationandrecognitionpathwayforadvancedpracticenurses.

5.3.4. Develop a measurement system TheChiefNursingOfficeworkedwiththeHealthIntelligenceUnit,theBusinessIntelligenceUnitandITdepartmentoftheHSE,PolicyandStrategy,ResearchandDevelopmentandHealthAnalyticsDivisionsoftheDepartmentofHealthtoidentifyopportunitiestocollectandsharedatainrespectofplanningpopulationhealthneedsinIrelandandidentifyingthenursingresponsetomeettheseneeds.FurthercollaborationoccurredwiththeIntegratedCareProgrammesandtheClinicalCareProgrammestoidentifyopportunitiestocollectandsharedatasets.Astherearenonationaldatacollectionsystemsthatreportonnursingactivity,on

advicefromtheICTDepartmentoftheHSE,toolsweredesignedtocollectactivityandinterventiondataofANPsinthefourspecialities,inconsultationwiththeICPandCCR.ThetoolhasthecapacitytoconnectwithHIPEandNQAISdatasystems.

Theminimumdatasetillustratestheimpactoftheprojectonthecurrentservicechallenges.Thedatacollectiontemplatewasdevelopedandtestedwidelywiththecandidatesacrossthespecialitiesandtheclinicalcareprogrammes.

Thisdatacollectiontoolisunderpinnedbythekeyperformanceindicatorsofclinicalcareandintegratedcareprogrammes.Inadditiontothesekeyperformanceindicatorsthenursinginterventionisalsocapturedtodemonstratetheimpactofnursingonthefourprincipleoutcomesofthepolicy.ThecandidateANPswereissuedwithhandhelddevicestocapturethedataonadatabasedevisedspecificallyforthepurpose.Thefollowingreportsareavailablefromthedatacollection:

• ThetotalnumberofpatientsseenbythecANPorRANP

• TheactivityofthecANPiscapturedthroughouttheunscheduledcaresetting,in-patientsettingandoutpatientsetting.ThiswillthenbeputintocontextusingnationalactivitydatasystemssuchasHiPE.

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• ThetotalnumberofpatientsthatweredischargedfromtheANPserviceorreferredtoanotherhealthcaresettingbythecANPorRANP

• ThetotalnumberofpatientsreferredtoanotherhealthcaresettingbythecANPorRANPfromboththeunscheduledandinpatientcareareas

• ThenumberofpatientsthatwerereferredtoanoutpatientclinicfromboththeunscheduledcareandinpatientareasbyancANPorRANP;and

• TheinterventionscarriedbythecANPorRANPincluding:Comprehensivephysicalassessment;MedicationManagement;MedicinalPrescribing;Ionisingradiationprescribing;ReferraltoAlliedHealthProfessional;andReferraltoanothermedical/surgicalspeciality.

5.4. Delivering Organisational Capacity

5.4.1. Selection of Sites TheworkforceintheHSEbasedontheDecember2016personnelcensustotals35,835nursesandmidwives.Thisshowed1332CNS/CMSemployedintheHSEwithanumberofthesewithvaryingeducationqualificationsandthereforepotentialcandidatestodeveloponthecareerpathway.ItwaspredictedthattocreateacriticalmassofANPsby2021i.e.700ANPs,therewasarequirementfor120nursesandmidwivestobesupportedbytheHSEtoundertaketheeducationprogrammein2017withfurtherdevelopmentasillustratedinTable14.Thetimelineispredictedonthesuccessfulevaluationofthedemonstratorsites.Iftheevaluationindicatesthetargetcanbeachieved.Asbelow:

BasedondatarelatedtowaitinglistsfromtheNTPF,EDattendanceandprofileofpatientsattendingEDtheareasforservicedevelopmentwereagreedbytheManagementBoardoftheDepartmentofHealth.InadvanceofaletterinvitingexpressionsofinteresttoparticipateintheprojectthecriteriaforsiteselectionofsitestodevelopservicesforANPwasagreed

Table 14 – Projected Number of ANPs Registered per year

Year 2017 2018 2019 2020 2021Intake 120 130 140 140

Total 174 294 424 564 706

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� IRELAND EAST HOSPITAL GROUP: 33 UnscheduledCare 2 OlderPersonsCare 2 Respiratory 2 Rheumatology 8

� SAOLTA HOSPITAL GROUP: 23 UnscheduledCare 5 OlderPersonsCare 9 Respiratory 6 Rheumatology 3

� UNIVERSITY OF LIMERICK HOSPITAL GROUP: 7 UnscheduledCare 2 OlderPersonsCare 3 Rheumatology 2

� NATIONAL CHILDREN’S HOSPITAL GROUP: 9 UnscheduledCare 7 Rheumatology 2

� CHO 2 MentalHealth 1� CHO 4 MentalHealth 2� CHO 8 MentalHealth 2

� DUBLIN MIDLANDS HOSPITAL GROUP: 20

UnscheduledCare 3 OlderPersonsCare 9 Respiratory 2 Rheumatology 5

� RCSI HOPSITAL GROUP: 30 UnscheduledCare 11 OlderPersonsCare 6 Respiratory 8 Rheumatology 4

� SOUTH-SOUTH WEST HOSPITAL GROUP: 27

UnscheduledCare 11 OlderPersonsCare 11 Respiratory 2 Rheumatology 3

� CHO 1 OlderPersonsCare 5 MentalHealth 2� CHO 3 MentalHealth 1� CHO 5 MentalHealth 2

bytheNationalSteeringCommittee(seeAppendix9).AninvitationtoapplywithanexpressionofinteresttodeveloptheANPserviceswassenttotheHSEacuteservicesandCHOareasviatheGroupDirectorsofNursingandtheHeadsofSocialcare,Primarycare,andtheONMSDoftheHSE.

5.4.2. Creating Critical Mass 2017AlltheHospitalGroupsandsomeCHOareasrespondedtothecallforexpressionsofinterestyieldingatotalofover250potentialsiteswithapotential404nursesavailabletocommencetheANPeducationprogrammein2017.Ashort-listingexercisebasedontheaimsoftheprojectandtheproposedtargetedareasoftheprojectwasconductedbyasub-

committeeoftheSteeringCommittee.Astheprocesswasoversubscribed,communicationwasmadewiththeunsuccessfulapplicants.124CandidateANP’swereidentifiedfromtheapplicationsintheareasofchronicdiseasemanagement(includingCOPD,Rheumatology),olderpersoncare(includingfrailty)andunscheduledcare(includingacutemedicalassessment)forwhichfundingforeducationandbackfill,wasmadeavailabletoenablethedemonstrationofacriticalmass.Thefinalselectionof124placeswereselectedacrossawidegeographicalspreadthatincludedintegrationwherepossible.Theselectionofplacesonahospitalgroupbasisissetoutbelow(Fig11):

Figure 11 - ANP Distribution by Speciality - 2017

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5.4.3. Planning the 2018 ProgrammeInNovember2017anevaluationmeetingdiscussedthe2017programmewiththeaimofplanningfor2018.Itwasagreedthatthe2017projectwasasuccessandthecooperationbetweenallinterestgroupsledtothesuccessfulintroductionofthenewbroad-basededucationprogramme.ItisunderstoodthatoverhalfofthecANPswillcompletetheeducationprogrammein2018.Thefundingwassecuredforthebackfillingorallposts.

TheSteeringCommitteewasprovidedwithfeedbackfromtheprocessesandimplementationofthe2017project.Thefeedbackwasprovidedunderthethemesofwhatworkedwell;whatlessonswerelearned/challenges;andwhatwecouldimproveon.

Allofthefeedbackwasthenreviewedwiththeavailabledatasurroundingservicechallengesandplannedservicedevelopedinordertobuildcriticalcapacityfor2018.TheclinicalcareprogrammesandtheintegratedcareprogrammeswerecontactedfromJanuarythroughtoMarch.Anumberofprogrammessubmitteddetailedbusinesscaseswithaviewtobeingconsideredforthenationalprojectshouldthespecialitiesbeextended.Thepossibilityofextendingthe4areasofpracticetootherspecialitieswasexplored.ItwasalsoagreedthatprovidingalongerexpressionofinteresttimelinewouldfacilitatetheCHO’sparticipationintheapplicationprocess.

5.4.4. Creating Critical Mass 2018Asin2017,anexpressionofinterestletterwasdistributedtoservicesinApril2017.In2018thiswasmanagedbytheONMSDoftheHSE.However,despitemanyeffortsbothintheDepartmentofHealthandtheHSE,theallocationoffundingforthe2018intakewouldonlystretchtothepermanentbackfillingof30ANPs.Applicationswerereceivedfromall7HospitalGroupsand9CHOareasandreviewedduringMay2018bytheReviewGroup.Siteswerechoseninlinewiththeagreedcriteriaassetoutintheapplicationformandweightingsappliedfromtheresponsessupplied.Theoutcomewasasfollows:

• 278applicationsfor468.5postswerereceived;

• 87applicationsfor132postsdidnotmeetthecriteriaforconsideration;

• Oftheremainingapplications,78 applicationsfor139.5postshavefulfilledthecriteriaforconsiderationinthespecialistareasofchronicdiseasemanagement(RespiratoryandRheumatology),olderpersonscareandunscheduledcare;

• 59applicationsand96postswereproposedasdemonstratorsites: ▪ Rheumatologyx4; ▪ UnscheduledCarex27; ▪ Respiratoryx16;and ▪ OlderPersonsx49

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Thefinalselectionthatmetthecriteriaforthe30postsisshowninAppendix10.TheselectionofcandidateswascompletebyJune2018withregistrationwiththecollegesbytheendofJune2018andcommencementofeducationwithbackfillofpostsinSeptember2018.

5.5. Provide Visible Evidence

5.5.1. EvaluationInrecentyears,therehasbeenincreasinginterestinquantify¬ingnursingandmidwifery’scontributionorvalueineconomictermsandwhiletherearestrongreasonsforidentifyinganddemonstratingsuchvalue,thetruevalueofsuchservicesisdifficulttoquantifyindefinitiveeconomictermsgiventheoftenteam-basednatureoftheworkandtheholisticnatureofserviceprovision.

Whiledifficultiesdoemergeinquantifyingimpactineconomicterms,effortshavebeenmade,includingthoseoftheResearchServicesUnitoftheDepartmentofHealth,who,whenconsideringthecontributionoftheeffectiveutilisationofnursesandmidwivesindeliveringhealthcareservices,consideredaframeworkforthemeasurementoftheeffectivenessofthenursingcontributioninitswidersensetohealthcareprovision,andprofferedanumberofmetrics.Thesemetricsareassociatedwithpatientsandfamilies,providersandteams,healthserviceorganisations,andtheoverallhealthsystem.Thesemetricsprovideguiding

principleswhichshouldshapeanevaluativeframeworktoassesstheeffectivenessinachangedmodelrepresentativeofagreaternumberofspecialistandadvancedpractitionersseekingtomeettheneedsofchangingpopulation.

TheseprinciplesarecapableofcomprehensionwithinthePEPPA Plus Frameworkwhichistheevaluativemodeltoassesstheeffectivenessandongoingcostefficiencyoftherevisedmodel.ThismodeliscurrentlyinuseinSwitzerlandandCanada.Thisframework(Fig12)emanatesfromtheworkofBryant-Lukosiusetal(2016)whodevelopedaframeworkfortheevaluationoftheimpactofadvancedpracticenursingroles.ThisframeworktacksthemetricsproposedbytheDepartmentofHealthandseekstoidentifyAPN-sensitiveoutcomesfromsystematicreviewsandrequiresthatitmustbebroadandflexibleenoughtoaccommodatetheevolvingnatureofAdvancedPracticerolesfromdevelopmentandimplementationtolong-termsustainability.

PEPPAoutlinesstepsforintroducingandevaluatingAdvancedPracticerolesandembracesrolespecificissuesinaDonabedianstructure,processandoutcomeframe.Therole,goalsandoutcomesastheyaffectpatientsandfamilies,providersandteams,theorganisationandthehealthcaresystemarealsomeasuredforimpact.Thestepsforplanningandimplementationaredesigned

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tocreateenvironmentstosupportAdvancedPracticeroledevelopmentandlong-termintegrationwithinhealthcaresystems.Thegoal-directedandoutcome-basedprocessalsoprovidesthebasisforprospectiveongoingevaluationandimprovementofboththeroleanddeliveryofhealthcareservices(Bryant-LukosiusandDicenso2004).AnexampleofanevaluationincancercarewasfoundbyDonaldetal(2014)wherepatients

experiencedimprovementsincare,lowerratesofdepression,urinaryincontinence,pressureulcers,restraintuseandaggressivebehaviourwithanincreaseinpatientandfamilysatisfactionwithservices.Thiscanbeachievedwithaclearandstructuredcareerpathwaywithamoregenericapproachtotheeducationofadvancedpractitioners.ReferencepointsintheformofbenchmarksandKPI’swere

Figure 12 - PEPPA Evaluation Model, From Bryant-Lukosius and Dicenso (2004)

ROLE GOALS AND OUTCOMES

EVALUATIONAIMS

EVALUATIONMETHODS

STRUCTURES

PROCESSES

OUTCOM

E

PATIENTS AND FAMILIES

PROVIDERS AND TEAMS

ORGANIS

ATIONS

HEALTHCARE S

YSTEMS

INTRODUCTION

IMPLEMENTATION LONG-TERM SUSTAINABILITY

TYPE OF APN ROLE

(e.g. Clinical Nurse Specialist, Nurse Prac��oner)

CompetenciesClinical Prac�ce, Ethical Decision-Making,

Guidance and Coaching,Consulta�on, Evidence-Based Prac�ce

Leadership, Collabora�on, Research

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suggestedasusefuladditionstosuchacareerpathwaytoenablenursesandmidwivestoviewtheirprogressanddevelopanindividualcareerpathwaytotakeclientandpatientneedsintoaccount.

5.5.2. Procurement of PEPPA Plus FrameworkEvaluationoftheANPmodelwasputtoanopennationaltendercompetition.ThesuccessfulresearchteamfromajointUCC/TCDbidproposedthePEPPAPlusframeworkasanintrinsicpartoftheiroverallevaluationofthemodel.PEPPAistheonlyvalidatedframeworkavailableandwasacoreevaluationmethodfortheoverallevaluation.Theresearchteamalsoincluded

• Activity-baseddataoftheANPs;• Measuringimpactagainsttheobjectivesrequired.ALogicFrameworkApproachwasutilised.SeeAppendix11;

• Usingvalidatedtoolsforrecruitmentandretention;andperceptionofinterdisciplinaryteams;economicevaluation;and

• Surveys/CaseStudies.

Thisapproachoutlinesthecomprehensiveevaluationofthemodelanditsearlystageimpact.

5.5.3. Early Results Examples of early impact from AP case studies in demonstrator site:

Example 1An Advanced Practitioner was re-deployed from an inpatient to the hospital’s emergency department with the aiming of assessing, treating and managing patient within the Advanced Practitioner’s speciality. A patient who presents with an acute exacerbation of a long-term condition such as asthma, can be fully assessed, which would include taking an appropriate history and among other things conducting an examination of the chest. The findings were interpreted, a decision is made about the severity of the exacerbation, and then, depending on severity, and risk assessment, the appropriate medication is prescribed (e.g. a bronchodilator and oral steroids). The patient may then be maintained at home, depending on the response, with regular re-evaluation, or referred on. Importantly, the ANP will also spend time working with the patient to understand what has happened, why and how it might be prevented in the future. This demonstrates positive patient outcomes i.e. quicker access to a senior decision maker; it also shows positive service impact as patients with a chronic condition have quicker access to specialist service and may avoid hospital admission.

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Example 2:Another example from South Tipperary General Hospital shows that one new ANP in April 2018 saw all patients that attended the ED with respiratory problems. The patients historically (prior to April 2018) would be admitted. The ANP service supported the discharge home of the patients on the appropriate treatment and follow-up telephone consultation avoiding admittance. As per June 2018, STGH has estimated that this service has the potential to reduce the number of bed days consumed by patients attending the ED with chronic respiratory distress by approx. 1700 per annum.

Additional Early ResultsTheInterim Report(Feb2019)acknowledgesadditionalearlyindicatorsoftheModel’ssuccess,forexample:

• Clinicactivity–Advancedpractitionersareseeinganincreasingnumberofbothnewandreturnpatientinoutpatientclinics;

• Thelargestcohortofadvancedpractitionersareworkinginareasofolderperson,respiratory,acutemedicalassessmentunits,rheumatology,andemergencycare,thisconfirmsthatthecriticalmassisdevelopingintheareasthathadidentifiedservicechallenges;

• Alladvancedpractitionersareundertakingnurseprescribinginionisingradiationand

medicalproducts;• 25.7%ofadvancedpractitionerstraveltoseepatientoutsidetheircurrentlocation;includingcommunityclinicsandnursinghomes,patienthomesandotherhospitals;

• Approx.42%ofadvancedpractitionersplantoextendtheirpracticeintocommunitysettings;

• 67.4%ofpatientsseenbyanadvancedpractitionerinanunscheduledcaresettingrequirednofurthercareandweredischargedfromtheservicefollowingafullepisodeofcare;and

• Thecoordinationofcareisanimportantpartoftheadvancedpracticerolein60%ofpatientsseen.

5.6. Summary Theevaluation,followingtheimplementationofthemodelfromgraduatetoadvancedpractice,providesevidencethatthemodeliscapableofdevelopingacriticalmassofadvancedpractitionerstoaddressemergingandfutureserviceneeds.Theevidencedemonstratesthatthisisonlypossiblewhenusinganintegratedapproachwithservicedevelopment,supportedbycredentialingandabroad-basededucationprogramme.Themodelhasalreadydemonstratedsomeearlyresultsinimprovedpatientoutcomes.

Goal5setsouttheactionsfordevelopmenttoaddressthechallengesoutlinedinthischapter’sreviewimplementationofthemodelofgraduatetoadvancedpractice.

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GOAL 5 Implementation

Action Details ResponsibilityPhaseIpre-planning

Establishaplanninggroupthatwilloverseetheplanninganddevelopmentofdemonstratorprojectstotestthemodel.

HSE

Identifythedemonstratorsitesforthedevelopmentofadvancedpractitionerstomeetserviceneedintheareasofhospitalavoidance,reducingwaitinglists,andsupportingaccesstoservicesinareaswheretheintegrationofservicescanbeachievedbasedonHSEdatae.g.frailelderly,rheumatologywaitinglistsanddermatologywaitinglists.

HSE

PhaseIIDemonstratorimplementation

Establishanimplementationgroupofappropriatemembersthatcanoverseethedemonstratorprojects,theimplementationandevaluation.

HSE

Establishlocalimplementationgroups,withtheappropriatemembershipthatcanoperationalisethedemonstratorprojectsforspecifiedservicesutilisingthenursingandmidwiferyresource.

HSE

Ensurethatthedemonstratorprojectsaresupportedbysufficientresourcesandevaluatedwithrobustmeasurements.

HSE

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GOAL 5 Implementation

Action Details ResponsibilityPhaseIpre-planning

Establishaplanninggroupthatwilloverseetheplanninganddevelopmentofdemonstratorprojectstotestthemodel.

HSE

Identifythedemonstratorsitesforthedevelopmentofadvancedpractitionerstomeetserviceneedintheareasofhospitalavoidance,reducingwaitinglists,andsupportingaccesstoservicesinareaswheretheintegrationofservicescanbeachievedbasedonHSEdatae.g.frailelderly,rheumatologywaitinglistsanddermatologywaitinglists.

HSE

PhaseIIDemonstratorimplementation

Establishanimplementationgroupofappropriatemembersthatcanoverseethedemonstratorprojects,theimplementationandevaluation.

HSE

Establishlocalimplementationgroups,withtheappropriatemembershipthatcanoperationalisethedemonstratorprojectsforspecifiedservicesutilisingthenursingandmidwiferyresource.

HSE

Ensurethatthedemonstratorprojectsaresupportedbysufficientresourcesandevaluatedwithrobustmeasurements.

HSE

Chapter6Recommendations

Theimplementationandevaluationofthenewmodelleadtothedevelopmentofthefollowingrecommendationswhichwillsupportongoingapplicationandsustainedchange.TheGoalsthathavenotyetbeencompletedalsoinformtheserecommendations.

Chapter 6 Recommendations

Recommendation 1 Develop a critical mass of Advanced Practitioners utilising the capability model

Action A

Maintainthetargetof2%AdvancedPractitionersinthenursing/midwiferyworkforcetoasaninitialcriticalmass.

Action B

ProvideAdvancedPractitionerswithprescriptiveauthorityfordiagnostics,referralpathwaysandappropriatetreatmentsrequiredtofacilitatetheprovisionoffullepisodesofcare.

Action C

EnsurearobustgovernanceandaccountabilitystructuresareinplacetooverseethedevelopmentandimplementationofAdvancedPractice.

Recommendation 2 Deploy nursing and midwifery resources to impact healthcare service needs

Action A

AlignAdvancedPractitionersroleswithareasofservicechallengestoaddresscurrentandemergingserviceneeds.

Action B

MonitorpatientoutcomestoensureAdvancedPracticemeetsdemand.

Action C

AdvancedPractitionersdeliverservicetomeetdemands,forexample7/7serviceorgeographicallocation.

HSE HSE

HSE

HSE

HSE

HSE

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Recommendation 3 Streamline the education pathway for graduates to advanced nurse/midwife practitioners

Action A

Introduceasystemofcredentialingtomeetserviceneedbasedontheinterconnectedframeworkforgraduate,specialistandadvancedpractice.

Action B

ImplementunderSection48(3)oftheNMA,2011aprocesstoannotatethenameofanurseormidwifewhosuccessfullycompletescredentialededucationparticularlyrelatedtoskillsacquisition.

Action C

Recogniseaccreditededucationobtainedinotherjurisdictions,inaclinicalcareerpathwayforanurse/midwifejoiningtheworkforceinIreland.

Action D

Registrationfornurse/midwifeprescribingisacomponentofcredentialededucationinacareerpathwayforgraduate,enhanced,CNS/CMSandAdvancedPractitionerstosupportintegratedandcommunitycare.

Action E

Provideabroader-basededucationforpreparationofAdvancedPractitionerstoavoidthedevelopmentofmicro-specialisationwithinaservicespecialty.

Action F

Establishinter-professionaleducationstandardsthatsupporttheconceptofroleshare/exchangewithinthemulti-disciplinaryteam.

Recommendation 4 Evaluate Service impact

Action A

MaintainasetofKPIsthatcapturetheoutput,outcomesandimpactactivityoftheAdvancedPractitioners.

Action B - 1

DevelopasetofKPI’sateducationleveltoinclude:• Provisionofinter-professionaleducationoffered.

• Varietyofprogrammesavailabletosupportserviceneed.

• Provisionofbroad-basededucationoptions.

• Thenumberofcollaborativementorship/preceptorshipsoffered.

Action B - 2

DevelopatsetofKPI’satregulatoryleveltoinclude:• Evaluatingthetime,ittakesto

be registered as an Advanced Practitioner.

• Theeducationcurrentlyavailablethatcanbecredentialedinaportfolio.

• ThenumberofnursesandmidwiveswhoobtainregistrationasanAdvancedPractitioner.

Action C

Servicedecision-makerstoutilisedata,toreviewandstrategicallyplanforfuturerequirementsofAdvancedPractitionersdevelopment,whichwillmatchserviceneeds.

NMBI HSE

HSEHEI

NMBI

DoHHSE

DoHNMBI

NMBI

HSEHEI

HEI

NMBI, CORU, MCI, HEI

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Chapter7Conclusion

Bothnationallyandinternationallyhealthcaretrendsshowanincreaseinanageingpopulationwithmultipleco-morbiditiesandgreatercomplexityofcareneeds.Toaddressthis,theIrishhealthcaresystemisundergoingmajorreformunderthedirectionoftheSláintecarestrategy,withadecisiveshiftincaretothecommunity.Eachhealthcareprofessionalhasauniqueandvaluablecontributiontomaketosupportashiftincaretoimprovethepatientjourneyacrossthelife-cycleofcare.Thiswillincludethesustainablechangetoensuretimelyaccesstohealthandsocialcarebasedentirelyonclinicalneed.Integratedapproachestoservicedeliverywillunderpinthiswithhealthcareprofessionalsworkingacrossserviceboundariestoprovidewell-coordinated,plannedcarethatisevaluatedinconjunctionwiththepatient.Todevelopanintegratedapproachtheprocessesofcaredeliveryratherthanstructuralororganisationalservicemodelsarerequired.Throughintegration,nursesandmidwiveshaveanopportunitytodeveloprolesandservicestodelivercareacrosshospitalandcommunitysettingsandaddresscurrentchallengesinthehealthcaresystem.Thisincludesareassuchaspatientflow,waitinglists,earlysupporteddischargeandhospitaladmissionavoidance.Alignmenttonationalclinicalcareprogrammesiskeytoensurethattheclinicalneedsofpatientsaremetwithinlocallyagreedpathwaysofcareandwillsupportnursesandmidwivestopracticeatthetopoftheirlicencewithinevidence-basedpracticemodels.

Withinthiscontext,thebenefitsofadvancedpracticerolesinnursingandmidwiferysupportachangeinthedeliveryofserviceswithevidenceofreducedmorbidityrates,decreasedwaitingtimes,earlieraccesstocare,increasedcontinuityofcareandimprovementsinself-managementandqualityoflifeforpatients.Thisrequiresinterdisciplinarycollaborationinplanning,organisingandprovidingcarethroughenhancedskillsandknowledgethroughrobustclinicalgovernancestructures.Throughthiseffectivecommunicationandcoordinationofprofessionalrolesoccursresultinginstrengthenedpatientoutcomes.Integraltothisisthedevelopmentofnurseandmidwife-ledservicesworkingwithhealthcareprofessionalsinprimaryandacutecaresettingsprovidingtargetedspecificinterventions.Thiswillempowerpatientstotakecontroloftheirownhealthandwell-being.

Torespondtopopulationneedsthedevelopmentofacriticalmassofadvancedpracticenursingandmidwiferyrolesrequiresappropriatecredentialingpathways,educationandtrainingandculturalchangewithmanagerialsupport.Inresponsetothis,throughthispolicythemodelwasdevelopedtoassistnurses/midwivestoprogressfromgraduatetoadvancedpracticelevelwithinatime-frameoftwoyears.Themodelincorporatedevidenced-basedpracticeundercoreconceptsofcaretofacilitateprogressionfromcompetent

Chapter 7Conclusion

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tocapabilityensuringahighlevelofself-efficacythroughgenericknowledgeandskills.Thisisachievedthroughexperience,advancededucation,collaborationandconsultationanddevelopmentofmetricsthatmeasureimpactandarepatientcentred.Atwo-yeardemonstratorprojectunderthedirectionoftheCNO’sofficesupportedbyanationalsteeringcommitteewassuccessfulindevelopingacriticalmassofAdvancedPractitionerstargetingfourareasofpracticebasedonpopulationneedincludingchronicdiseasemanagement(respiratory),waitinglists(rheumatology),olderpersonscare(frailty)andunscheduledcare,forexampleacutemedicaladmissionunits).Integraltothiswasaneducationalprogramme,fundingandrecruitmentprocessesandrevisionofregulatorystructureswithintheNMBI.Thebroad-basededucationprogrammedeliveredbyfourhighereducationinstitutescoveredcoreareasofadvancedassessment,clinicalreasoninganddecision-makingskillstomanagepatientpopulations.Keyperformanceindicatorsatlocalservicelevelmeasuredresponseincludingthetimetoaccessservice,patientexperienceandinterventionswithdatacollectionenabledthroughtechnologysystems.Thepreliminaryresultsgeneratedfromthedemonstratorsitesidentifiedreductionsinwaitingtimes,hospitaladmissionsandimprovedpatientaccessandsatisfaction.Therefore,therecommendationsfromthemodeltestedwithinthispolicyprovidesabroad-basedapproachtosupport

nursesandmidwivestohavethecapacitytomeettheneedsofachangingpopulationacrossthelife-cycleofcare.

 

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Glossaryandappendices

AACN AmericanAssociationofCollegesofNursingAMAU AcuteMedicalAssessmentUnitAPN AdvancedPracticeNurseCMS ClinicalMidwifeSpecialistCNS ClinicalNurseSpecialistCOPD ChronicObstructivePulmonaryDiseaseCPAP ContinuousPositiveAirwayPressureCSO CentralStatisticsOfficeDoH DepartmentofHealthECG ElectrocardiographyED EmergencyDepartmentGP GeneralPractitionerHCAI HealthCare-AssociatedInfectionsHEI HigherEducationInstitutesHSCP HealthandSocialCareProfessionalsHSE HealthServiceExecutiveKPI KeyPerformanceIndicatorNCCP NationalClinicalCareProgrammeNCNM NationalCouncilfortheProfessionalDevelopmentofNursingandMidwiferyNHQRS NationalHealthQualityReportingSystemNHS NationalHealthServiceNIV Non-InvasiveVentilationNMA Nurse and Midwives ActNMBI NursingandMidwiferyBoardofIrelandNP NursePractitionerOECD OrganisationforEconomicCo-operationandDevelopmentONMSD OfficeofNursingandMidwiferyServiceDevelopmentOPD OutPatientDepartmentPEG PercutaneousEndoscopicGastrostomyPET PatientExperienceTimeQQI QualityandQualificationsIrelandRAMP RegisteredAdvancedMidwifePractitionerRANP RegisteredAdvancedNursePractitionerRCOG RoyalCollegeofObstetriciansandGynaecologistsRNP RegisteredNursePrescriberRSU ResearchServicesUnitSDU SpecialDeliveryUnit

Glossary

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APPENDIX 1 Number of CNS/CMS by SpecialityCNS and CMS in the HSE

HSE South

Category CNS/CMS Post Title CHO1 CHO2 CHO3 CHO4 CHO5 CHO6 CHO7 CHO8 CHO9

West / North West Hospital Group

UL Hospitals (Mid West)

South / South West Hospital Group

Dublin Midlands Hospital Group

National Childrens & Paed Group

Ireland East Hospital Group

RCSI Hospital Group (NE)

Infection Control 2 1 1 2

Occ Health 1

HIV 1Neurology 1

Pain Mgt 1 1

Vascular 1

Rheumatolgy/Joint Replacement 1 1 1 1 1

Dermatology 1 1

Infectious Diseases Immunology 1

Urodynamics 1

Health Promotion 1

Tissue Viability 0.5

Sexual Assault 3 1 1

Haemvigilance 1 1 1

Anti Coagulation 2

Family Therapy 1Addications 2 2

Child & Ad MH 1 1 2 1 1CBT 1Home Based Treatment Acute Adult 1

Community MH 8 5 1 1

Deliberate Self Harm 1Resistive Schizophrenia 1Demenita Care 1Positive Beh Support MH 1Speiclist First Episode 1Counselling & Psycho Ther 1

Psy of Later Life 1

Ultrasound (CMS) 3.6 2 4 2

Midwife Lactation Consultant (CMS) 1Midwifery Diabetes (CMS) 2Haematology Obstetrics (CMS) 1Colposcopy (CMS) 1

Bereavement & Loss (CMS) 1

Colposcopy (CNS) 2

Community: Child Health Specilist PHN 1

ID Positive Beh 1

Diabetes 1 4 2 1 1 4

Diabetes Integrated Care 1 1

Paediatric Diabetes 1

Childrens Diabetes 1

Stroke/Neuro Rehab 1 1 2Heart Failure 2 3.85 1 1Cardiac Rehab 1 1Chest Pain 1Cardiology 2

Breast Care 2.5 1

Haematology (Cancer) 1

Oncology 1 1 1.5

Psycho-Oncology 1

Palliative Care 4.5 1.9 2 4.3 2 5.77Childrens Palliative Care 1

Palliative Care - Tissue Viability 1Palliative Care - Diabetes 1

Palliative Care - Infection Control 1

CF 1

Respiratory 2 3 1 1

COPD Outreach 1

Pumonary Outreach /Rehab 0.85

Advacned Airway Mgt 1

Upper GI 1

Lower GI (Colorectal) 4

Stoma 1.5

6 15.5 7.9 2 2 2 3 11.3 2 0 37.1 17.85 6 20.5 7 22.62 11

Gastroentology:

Cancer Services:

CNS/CMS CNS/CMS

HSE West HSE DML HSE DNEHSE SouthHSE West HSE DML HSE DNE

Hospital Groups

Acute:

Cardiac:

CHO Areas

Diabetes

Mental Health:

Respiratory

Palliative Care

Midwifery & Womens Health

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Division of Register No. Area of practice Children’s 12 AmbulatoryCare=1

Diabetes=1ED=5Epilepsy=2Haematology=1Haem/onc=1Neonatology=1

Psychiatric 16 LiaisonMentalHealth=3Dementia=1Recovery&Rehab=1CBT=3Eatingdisorders=1Psychotherapy=4Child&AdolescentMH=1ForensicMH=1PerinatalMH=1

Public Health 2 CommunityOlderAdults=1ChildHealth&Parenting=1

Intellectual Disability 2 Gastroenterology=1Positivebehavioursupport=1

Midwifery 8 Neonatology=1Women’shealth=1Women’spreventativeHealth=2Diabetes=2Emergency=1Midwiferycare=1

General 160 ED=78EDCardiology=4Cardiology=5Heartfailure=3Diabetes=8Ophthalmology=1Strokecare=2Oncology=5Sexualhealth=1Cardiothoracic=5Painmanagement=4Haematology=2Neonatology=7Neurology=2Vascular=1Olderpersonwithdementia=1Colorectal=1Rheumatology=3Womenshealth=2ENT=1Woundcare=1Primarycare=2Epilepsy=3Oncology(radiation)=4Dermatology=2Urology=1Endocrinology=1Gastroenterology=7Criticalcareoutreach=1Lungtransplantation=1Occupationalhealth=1Breastcare=1Rehaboftheolderperson=1Careofolderadultscommunity=1

APPENDIX 2 ANP/AMP by Division of Register

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CNS Dermatology Role RANP Dermatology RoleReceiving Referrals DermatologyConsultantandNCHDs

referralrequestfordermatologytreatments(phototherapy,photodynamictherapy,andwoundcare),investigation(patchtesting)anddiseaseeducation.

WrittenreferralwillbemadebyGP’s,TissueViabilityNurseandConsultantDermatologists,DermatologyNCHD'sandnurses.

Caseload Supportforpatientsandtheirfamilieswithchronicandacuteskindiseaserequiringnursingintervention.Patientsarereviewedinoutpatient,day-careandinpatientsettings.

DefinedpatientcaseloadincludingpatientswithAE,Ps,V.E.,B.P.andlife-threateningdermatoses.Patientsarereviewedinoutpatient,day-careandinpatientsettings.Inaddition,adefinedcaseloadwillbeseeninadomicilesettingasperagreedMOU.

Clinical History ClinicalHistorytakingbyCNSanddiscussedwithConsultant.

CompetentinobtainingacomprehensivehealthhistoryfrompatientswithAE,Ps,V.E.,B.P.andlife-threateningdermatosesandtheirfamily.

Skin Examination SkinexaminationisundertakenbyCNSandfindingsdiscussedwithDermatologyConsultant

Competentinadvanceddermatologyexamination:• DiseasePatternRecognition• DiseaseSeverity• AssessmentofLesionRecognition• ItchSeverityAssessment

Making a Diagnosis TheCNSseesdiagnosedpatientsfortreatment,investigationoreducationoftheirskindiseasefollowingdiagnosisbytheDermatologyConsultantorNCHD.

TheRANPwill:• Completeacomprehensivehealthhistory• Carryoutanadvancedphysicalassessment• Interprettheresultsofinvestigations• Makeadiagnosis• Developandimplementamanagementplan• Thepatientwillbefollowedupastheirdiseaseseverityortreatmentmanagementplanrequires.

• IfnotimprovingreviewandinvestigatefurtherorrefertoDermatologyConsultant.

Requesting/ Interpreting Phlebotomy Tests

PhlebotomyinvestigationsarerequestedandinterpretedbytheDermatologyConsultantsorNCHDs

TheRANPdermatologywillrequestphlebotomytestsbasedontheirpatientassessment.CommontestsincludeFBC,U&Es,LFTs,PIIINP,TPMT.

Requesting/ Interpreting Patch Tests

PatchtestinvestigationsarerequestedandinterpretedbyDermatologyConsultantsorNCHDs

RANPwilldetermineandorderpatchtestseriesfollowingadvancedassessmentandhistorytakingregardinglikelyallergensources.TheRANPwillreviewpatientfollowingpatchtesttodeterminetheclinicalrelevanceofresults.

Management Plan for Dermatology Conditions

Decisionsregardingtreatmentplansaremadebythedermatologyconsultant.TheCNSsupportsthepatientinadheringtothemanagementplan

TheRANPDermatologywillimplementtheappropriateevidence-basedactionplanandhaveadvancedknowledgeofdermatologymedicationsandpossiblesideeffectsforpatientswithAE,Ps,V.E.,B.P.attendingthedermatologyservice.

Documentation TheCNSadherestohospitalpolicyregardingdocumentation

RANPwillgenerateaGPletterfollowingaclinicvisitoutliningconsultation,anyinvestigationsplannedandfollow-uprequired.

Referral onwards TheCNSdiscussedthereferralwiththeDermatologyConsultant

TheRANPdermatologyrefersontomembersoftheMultidisciplinaryTeam(MDT)forfurtherinvestigationsandreviewasperagreedreferralarrangements

Nursing Audit and Research

TheCNSDermatologycarriesoutregularauditsofnursingserviceprovidedasbelow:• Patientwaitingtimes• Effectivenessofminimalerythemadose

• testing• Patientclearanceratesfollowingphototherapy

TheRANPDermatologywillcontinueactiveinvolvementwithnursingauditwithinthedepartmentandanalyseresults,whichmaychangepractice.TheRANPDermatologywillinstigatenursingresearchinrelationPatientoutcomesinBullousPemphigoidRANPclinicseffectivenessoftargetednurseeducationoneczemamanagement.

APPENDIX 3 The roles provided by the CNS and the ANP in Dermatology

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APPENDIX 4 Educational Programmes for Advanced Practice

TheNMBIcurrentlyoperateapost-registrationeducationapprovalsystemofCategoryI,CategoryIIandregistrationeducationprogrammes.TheNMBIdescribecontinuingeducationasalifelonglearningprocesswhichtakesplaceafterthecompletionofthebasicnursing/midwiferyeducationprogramme.Itconsistsofplannedlearningexperienceswhicharedesignedtoaugmenttheknowledge,skills,andattitudesofregisterednursesandmidwivesfortheenhancementofnursingpractice,education,administrationandresearch.CategoryIcoursestypicallyareshortandonlinecoursesfortheIrishnursingandmidwiferyprofessionsthatreflectupto35-hoursofteaching/learning.Completionofacoursecanearnanurse/midwifeContinuingEducationUnitsoftenreferredtoas(CEUs).Withinthelast2-yearstherearealmost2,000approvedCategoryIcourses(NMBIendofJuly2016)with883coursesapprovedbetweenJanandtheendofJuly2016.TheNMA2011(Part11)alsoprovidesforthemaintenanceofcompetenceonanon-goingbasisbyallnursesandmidwives.ThissectionoftheNMA2011hasyettobecommenced.

ThecurrentcoursesapprovedforadvancedpracticebytheNMBIinclude:

• MScNursing(AdvancedPractice)fromUCD

• PostGraduateCertificateNursing(AdvancedPractice)fromUCD

• GraduateCertificateNursing(AdvancedPractice)fromUCD

• Nursing(AdvancedPracticeGastroenterology)GraduateCertificatefromUCD

• MScNursing(AdvancedPracticePrescribingPathway)fromUCD

• MScAdvancedPracticewithPrescribingfromNUIG

• Nursing(AdvancedNursingPracticeinEmergencyNursingincludingNursePrescribingCertificate)MSc,PGDfromTCD

• Nursing:AdvancedNursePractitionerinEmergencyNursingMSc,PGDfromTCD

• AdvancedPainManagementMScfromUCD

• AdvancedPainManagementwithPrescriptiveAuthorityMScfromUCD

• GlobalPerspectivesonClinicalSpecialistandAdvancedPractitionerRolesinNursingorMidwifery–Minor,Special,SupplementalAwardfromUCC

• IndependentStudyinAdvancedNursingorMidwiferyPractice–Minor,Special,SupplementalAwardfromUCC

(Source NMBI August 2016)

AnumberofthesecoursespreparenursesandmidwivesforAdvancedNursePractitioner,AdvancedMidwifePractitioner,ClinicalNurseSpecialistandClinicalMidwifeSpecialistposts.Specificallysince2012-2016163nursesandmidwiveshavebeenfundedtoundertakecoursesleadingtoregistrationasaRANP/RAMP.

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TheproposedCNS/CMSRoleandpreparationis:ClinicalcareisasignificantpartoftheCNS/CMSroleinIreland.TheCNS/CMScaseloadinvolvesworkingwiththeMDTtoprovidespecialisedassessment,planning,deliveryandevaluationofcareusingprotocoldrivenguidelines.TheCNS/CMSrolemaximisestheteamimpactonpatientoutcomes.

Caredeliveryandcaseloadmanagementisdeliveredinlinewithcoreconceptsofclinical focus, patient/client advocacy, education and training, audit and research, consultancy, organisation and management of care, holistic approaches to care and interpersonal relationships.

Qualifications/RequirementsfortheRole:

• BeregisteredwiththeNMBI• Provideevidencethroughaportfolioofcontinuousprofessionaldevelopmentassociatedwiththerole

• Provideevidencethroughaportfolioofexperienceintheareaofpracticeequivalenttoaminimumofoneyear

• Provideevidenceofachievedcapabilitiesfortherolethroughpeerandself-evaluation

• Provideevidencethroughaportfolioofcredentialededucationrequiredfortherole

• Provideevidenceofformalpost-registration/credentialededucationintheareaofpracticethatisequivalenttoalevel9(QQI)majoraward.

TheproposedANP/AMPRoleandpreparationis:TheANP/AMPcaseloadinvolvesholisticassessment,diagnosis,autonomousdecisionmakingregardingtreatment,provisionofinterventionsanddischargefromafullepisodeofcare.CaredeliveryandcaseloadmanagementisprovidedbyANP/AMPsinlinewiththecoreconceptsofperson-centred care, autonomy and empowerment within accountability in clinical practice, professional ethics, consultation and collaboration, professional leadership, clinical scholarship.

Qualifications/RequirementsfortheRole:

• BeregisteredwiththeNMBI• Provideevidencethroughaportfolioofcontinuousprofessionaldevelopmentassociatedwiththerole

• Provideevidencethroughaportfolioofexperienceintheareaofpracticeequivalenttoaminimumoftwo-years

• Provideevidenceofexperientiallearningnecessaryfortheroletoanequivalentof500hours

• Provideevidencethroughaportfolioofachievementofthecoreconcepts/competencies/capabilitiesfortherolethroughpeerandself-evaluation

• Provideevidencethroughaportfolioofcredentialededucationrequiredfortherole

• Provideevidenceofformalpost-registration/credentialededucationintheareaofpracticethatisequivalenttoalevel9(QQI)majoraward.

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APPENDIX 5 Membership of the Steering GroupProposed Membership of the Steering Group for Graduate, Specialist and Advanced Practice• Chairperson:DrAnne-MarieRyan• AcuteHospitalsDivision,DepartmentofHealthandHSE• NationalHumanResources,DepartmentofHealthandHSE• PrimaryCareDivision,DepartmentofHealth• OfficeoftheNursingandMidwiferyServices,HealthServiceExecutive(HSE)• GroupDirectorsofNursing• GroupCEO• CHOManager• Patientrepresentative• ClinicalNurse(StudentrepresentativeoftheANPcohort)• AcuteMedicineProgramme,HSE• ClinicalStrategyandProgrammes,• ClinicalRepresentativeofthedemonstratorsites• PrimaryCare,HSE• SocialCareDivision,HSE• IrishAssociationofDirectorsofNursing(IADNAM)toincludeAcuteHospitalsandDPHNrepresentation

• SIPTU/INMO• NMBI• NursingAcademicwithExpertiseinSpecialist,AdvancedPracticeandPracticeExpansion• InternationalExpertise–credentialing,advancedpractice

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APPENDIX 6 Project Initiation DocumentProject Initiation Document / Scope Document for Demonstrator Projects

Project Title DevelopingGraduatetoAdvancedNursingandMidwiferyPractice

Project Number N/A

Project Sponsor / Senior Responsible Officer (SRO)

SiobhanO’Halloran

Division CNOOffice

Unit

Project Lead Anne-MarieRyan

Version Number 1.1

Business Plan Reference and Priority

Notapplicablefor2016

Purpose of the ProjectThepurposeofthisprojectistopilot,indemonstratorareas,themodelforgraduate,specialistandadvancedpracticeandexploreifthemodeliscapableofcreatingacriticalmassofnursesandmidwivestodriveintegrationbetweenservicesinresponsetopatientandserviceneed.

Thepilotswilltakeplaceinserviceareasthatrequirepatientstoreceivetimelyaccesstocare,avoidhospitaladmission,andsupportthepatienttostayasclosetohomeaspossible.Thepilotswillconcentrateonserviceareasthataddresschronicdiseasemanagementandolderpersoncarethroughafacilitativeeducationandregulatorypathway.

ObjectivesTheobjectivesoftheprojectrelatetomeetingserviceneed,creatingflexible

educationpathwaysandaresponsiveregulatorymodelto:

1. DevelopapathwayforgraduateandspecialistnursesandmidwivesintwoHEI’sthatsupportseachofthepilotareassothatXnumberofRANP/RAMP’scanbe created;

2. DeterminetheareasfortheinitialdevelopmentofCNS/CMSandRANP/RAMProles;

3. Putinplacenewregulatorysupportsforgraduate,specialistandadvancedpractitionersthatrecogniseeducationalandcompetencyachievements;

4. IntroduceaprocesstodevelopasystemofcredentialingintheNMBIinSeptember2017tomeetserviceneedbasedontheinterconnectedmodelforgraduate,specialistandadvancedpractice.ImplementunderSection

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48(3)oftheNMA2011aprocesstoannotatethenameofanurseormidwifewhosuccessfullycompletescredentialededucationparticularlyrelatedtoskillsacquisitionoverthetwo–yearimplementationprocess;

5. Commissionanddevelopa1-yeargraduatecertificatetypeprogrammethatcanbegininSeptember2017intwoHEI’s,withXnumberofplaces,subjecttoavailablefinances,asashortenededucationalpathwayforexperiencednursesandmidwivestoobtainoutstandingeducationalrequirementsforRANP/RAMPintheselectedpilotareas;

6. Commissionarevisedtwo-yearmasterslevelbroad-basededucationprogrammeforRANP/RAMP’sthatmeetstheregulatorystandardsoftheNMBI;

7. EstablishwiththeNMBIandotherregulatorsinterprofessionaleducationstandardsandrequirementswithothermembersoftheinterdisciplinaryteamthatsupporttheconceptofcapabilityforroleshare/exchangebetweenprofessions;

8. Identifyandrecruitacriticalmassofnursescapableofimpactingonserviceissues(timelyaccesstocare,avoidinghospitaladmission,andsupportingthepatienttostayasclosetohomeaspossible)andarewillingtoengageinadevelopmentalpathway;

9. ExplorewiththeHSECNS/CMSandRANP/RAMP’saccesstodiagnostics,referralpathwaysandappropriate

treatmentsthatarerequiredtofacilitatetheprovisionoffullepisodesofcarebothintheacuteandinthecommunitysectorsby2018;

10.DevelopwiththeHSEandtheNMBItheappropriategovernanceinfrastructureforthepracticeofnursesandmidwivestoprovideintegratedcare;

11.IdentifyanI.T.solutionthatbuildsonexistingICTsolutionsandareintegratedwiththeICTarchitectureoftheHSEtomanagedatageneratedfromthepilotprojects;

12.DevelopwiththeHSE,bytheendof2018,asetofKPI’sthatcapturetheoutputactivityoftheCNS/CMSandtheRANP/RAMPtoincludenumbersofpatientsseen;numbersofpatientsaccommodatedfromthewaitinglist;anddatarelatingtoclinicalcareoutcomes,includingeffectivemedicinesmanagementandcost-effectivenesstoachieveanon-goingeconomicevaluationoftheCNS/CMSandtheRANP/RAMProles;

13.Developanevidence-basedevaluationmodelforadvancedandspecialistrolesunderpinnedbyresearch,potentiallysimilartothePEPPAmodel.

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High-Level RequirementsThehigh-levelrequirementsfortheprojectareasfollows

• Withineachofthetenareas; ▪ EstablishLocalImplementationGroups ▪ Identifythelocalproject/s ▪ Agreetasksforimplementation ▪ Agreethelocalgovernancearrangements

▪ Identifytheeducationalrequirementsandsupports

▪ Putinplacethenecessaryeducationalsupports

▪ Identifyandrecruitnursestoundertaketheeducationpathway

▪ Agreethedatatobecollected ▪ Agreetheevaluationmodel ▪ IdentifytheICTsolutiontocapture

data ▪ Agreereporting

Assumptions and ConstraintsThefollowingassumptionsarebeingmade;

• Dataforeachpilotareaisavailableeg:Rheumatologywaitinglistdata.

• TheICTsolutioniscurrentlyinplaceandcanbebuiltupon.

• HR-ExistingresourcesinthesystemwillfilltherolesandthereiscapacityintheHSEtobackfillanyvacanciescreated;

• Supportfromthemainstakeholdersincludingtheregulatorandstaffassociations;

Thefollowingconstraintsareknown;

▪ CurrentCultureofCareprovision ▪ CurrentAuthorityandAccountabilityforDecision-making

▪ Integrationofservicesandworkingacrosssettings

▪ Resistancetochange–nursesandotherhealthprofessionals

▪ Governance–changedgovernancetoaserviceledmodel

▪ Regulatory-changestothestandardsandrequirementsforregistration-Newcredentialingconceptwithannotation

Anticipated Costs BreakdownWorkisongoingwithregardtoidentifyingtheindividualestimatedcostsofthedemonstratorprojects.ThiswillbecompletedinJanuary2017andwillbeinfluencedbythenumbersneededateachsitetocreateacriticalmasscapableofdeliveringtherequiredoutput.

Aninitialconsiderationofthetotalpolicyimplementationcostsarebrokendownasfollows:

Implementation Costs (over 4 years)

Project Operational Costs

ANP Information

ANPposts€35mBackfillingofANPposts€18mEducationx1year€1.5Educationx2year€4m Total €58.5m

Estimatesareindevelopmentbutinitialcostingswouldindicateapproximately€600kperproject

CurrentANPsemployed153Currentpostsvacant(fundingissues)47AMPstrainedbutnotinpost141

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InordertocreatetheadditionalANP’stomeetthe2%targetby2021anadditional500ANPstothecurrent200arerequired.Thisrequirementwillgeneratea€35,000,000paybillforthisadditionalresourcetothesystem(calculated500x€70,000salary).Thiswillariseoverafouryearperiodorapproximately€9mperannum.Inthefirstinstanceitisproposedtopilottheseproposalsthroughanumberofdemonstratorprojects.

Theresourcewillrequireeducationalsupportbuttherearemanynursesinthesystemthathavesomeelementoftheeducationrequiredsousinganaveragecalculationof€10,000pernurseandtheneedtoeducateapprox.150nursesthiswillaccrueaneducationbillofapprox.€1,500,000fortheone-yearcourseoverthe4years.Approximately200nurses/midwiveswillrequiretoundertakethetwo-yearmasterseducationprogrammeatapprox.€20,000atthecostof€4,000,000plusbackfillingofthepostfor1year(€70,000)is€14,000,000totallingapprox.€18,000,000.Thiswouldbethesubjectofaprocurementprocesswhichmayproducesavings.InadditionthesecostingsdonottakeaccountofanyexistingfundingintheHSE.

Theadditionalcostsinvolvebackfillingofsomeofthepostsatanaverageof€70,000perbackfill.Itisproposedthat100ANP’saredevelopedeachyear.Thisatmaximum(notanticipated)willaccrueabillofapprox.€7,000,000.

Therearecurrently47ANPpostsnotfilledintheHSEmainlyduetofundingissuesrelatedtoappointingpeopletoapprovedposts.Fillingthesepostswillcost€3,290,000(calculated47x€70,000).

Therearecurrentlyafurther141nurseswhohavebeensupportedtoundertaketheANPeducationpathwayssorequirenoeducationfunding.

High-Level RisksThefollowingareknownhigh-levelrisks:

1.Fundingwillbesecured2.Resourceswillbeavailable3.Therewillbelocalcooperationfromthenecessaryprofessionalbodies

4.Therewillbeanimpactonexistingservices

5.Courseswillbedeveloped6.Acriticalmasscanbeestablished7.Regulatorystructureswillbeputinplace8.Governancearrangementscanbeputinplace

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Summary Milestone Schedule

2017 2018

Pilot Model for Graduate Specialist AP Nurses and Midwives

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Identifythetenareastopilotin X

Establishasteeringcommittee X

Implementationplanforpilotinginonearea-Ex:Rheumatology X

IdentifyLocalImplementationGroups X

Agreetasksforimplementation X

Datacollection X

Agreeevaluationcriteriaandkeyperformanceindicators X

EvaluationModel X

GoLive X

IdentifyResourcetocollectdata X

Education X

Develop1YrHigherDiploma X

Develop2YrMastersProgrammetoincludeelementsofChronicDiseaseMgt,OlderPersonsCare,Children'sServices,Acute Care

X

Identifynurses X

Regulation X

GetnewcourseapprovedbyNMBI X

PutinplaceaStatutoryInstrument(S.I.)forannotationonregistration X

ITSolutiongoeslive X

InterimReportProduced X

FinalReportProduced X

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Summary BudgetThebudgetrequiredisindevelopment.

ResourcingThefollowingresourcesarerequiredforthisproject.

• Anne-MarieRyan–ProjectManager• ProjectSupport–projectassistant;researchersupport;adminsupport

Stakeholder ListThefollowingstakeholdersaredirectlyinvolvedintheprojectassponsors.

Organisation Sponsor Name

HSE: Dr.AineCarroll

JohnHennessy

MaryWynne

BrianMurphy

RosariiMannion

NMBI: MaryGriffin

Essene Cassidy

Championsfortheprojecthavebeenidentifiedandinclude:

• ProfessorGaryCourtney• ProfessorEilisMcGovern• DrDavidO’Hanlon

OtherStakeholdersidentifiedtodateare: ▪ AcuteHospitalsDivision,DepartmentofHealthandHSE

▪ NationalHumanResources,DepartmentofHealthandHSE

▪ PrimaryCareDivision,DepartmentofHealth

▪ OfficeoftheNursingandMidwiferyServices,HealthServiceExecutive(HSE)

▪ GroupDirectorsofNursing ▪ GroupCEO ▪ CHOManager ▪ Patientrepresentative ▪ ClinicalNurses/Midwives ▪ AcuteMedicineProgramme,HSE ▪ ClinicalStrategyandProgrammes, ▪ ClinicalRepresentativeofthedemonstratorprogrammes

▪ PrimaryCare,HSE ▪ SocialCareDivision,HSE ▪ IrishAssociationofDirectorsofNursing(IADNAM)toincludeAcuteHospitalsandDPHNrepresentation

▪ SIPTU/INMO ▪ NMBI ▪ NurseEducationalists ▪ HigherEducationProvidersofNursing/MidwiferyeducationandInterprofessionaleducation

Legal ConsiderationsTherearenospecificlegalconsiderations.TherearelegislativeissuesrelatedtodevelopingandenactingofRulesbywayofanS.I.toannotateanurse’snameontheRegisterofNurses(NMA201148(3)).

Assigned Project ManagerDr.Anne-MarieRyan

Name and authority of the SponsorDr.SiobhanO’HalloranChiefNursingOfficer

 

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APPENDIX 7 Terms of Reference for the Steering GroupProposed Terms of Reference for the Steering Group for Graduate to Advanced Practice Demonstrator ProjectsThissteeringgroupwill:

• Adviseonandoverseethedevelopmentoftheservicesupports,educationalprovisionandregulatoryrequirementstoenablethepreparationofanursingservicecapableofmeetingserviceneedto ▪ reducewaitinglistsinforexampleadultandchildren’srheumatologyservices;

▪ addresschronicdiseasemanagementcaseloadfromabroad-basedapproachbydevelopingClinicalNurseSpecialist(CNS)andRegisteredAdvancedNursePractitioner(RANP)inforexampleAMAUsandintegratedcareforthecommunity

▪ preventpeopleattendinghospitalforexampleolderpersonswhencarecanbeprovidedinthecommunity

▪ developaresponsivecareserviceforexample-urgentcarechildren’sservice

• Adviseandoverseetheselectionofthesitesforthedemonstratorprojectsandtheestablishmentandoperationofthelocalimplementationgroups.

• Setoutclearlytheevaluationcriteriauponwhichtheimpactofserviceprovisionisdetermined

• Overseethedevelopmentoftheevaluationprocessofboththeeducationprogrammeandintegrationofnurseservicesinthedemonstratorsites.Afeatureoftheevaluationforboththeeducationprogrammeandtheimplementationofthedemonstratorprojectsisachievingintegratedcareinthecommunity.

• Theobjectivesofthedemonstratorprojectsareto: ▪ contributetoserviceneedsandreducewaitinglists,keeppatientsathomeorasclosetohomeaspossibleandcreatepathwaysofintegratedcare

▪ testthecapabilityofthemodeltodeliverbetteroutcomes(Patient/StaffandEconomic

▪ createacriticalmassofRANP/RAMP’sthroughadevelopmentalpathwayforgraduateandspecialistnursesandmidwives

• Supportthelocalimplementationgroupstodelivertheprogrammesofeducation,andserviceutilisationinthedemonstratorprojectstoincludetherelatedpolicies,accessandreferralproceduresandgovernancearrangementsandmonitorprogress.

• Oversee,andreviewthereportsofthelocalimplementationgroups.

• Makerecommendationsaroundimplementationandmonitoringofthemodelincludingthenecessaryeducation,training,governanceandguidancerequiredtoachieveinterprofessionalcollaboration. 

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APPENDIX 8 Consultation Feedback

Consultation Workshops (n=4 with 19 participants)Figureof2%forANPsandtherationaleforthisfigure.

Thetopicofnursesasmanagersratherthanmanagersmanagingnurseswasdiscussedanditwasagreedthiswasthewayforward.

Thedetailsofeligibilityfortheseservices,whoiseligibleandhowtheserviceswouldbeaccessed(veryrelevanttohomecarepackages);Privateversuspubliccarepricemodelsforexamplethetherapiesareasandindependentchargesfornursingservices.Thesignificanceofpricingandeligiblyshouldnotbeunderestimated(incIT/billing/costassociated)howtocostsuch?

ItwasadvisedthatsomeofthestructuresinthePrimarycareteamsarenotinplaceandstillatatheoreticalstage.Needtobeawareoftheimpactofthisonthepolicy.

TherewasadiscussionregardingtheproposedreportingrelationshipsinrelationtotheCHOstructureandwhohadresponsibilityforthebudgetsandthegoverningstructuresinthecommunity.

RiskifallPrimaryCareTeamsnotfunctioningwellbeforeimplementation.RiskinrelationtoGPsandenquiresifanyissueshadbeenraisedbytheINMO/Consultant/GPunionsoranyIRproblems.Draftpoliceshavenotbeencirculatedtothatareaasofyet.

AnexamplewasdiscussedrelatingtoAsthmawhichledtoareductionofGPreturnvisits.OtherexamplesintheUKwherediscussedincludingthetypesofroutineworkseebyGPswhichcouldbeseenbynurses.

DoHneedstoconsideralliedprofessionals(upskillingandroles)notmerelyfocusondevelopmentofnursing

Questionwhetherweneedreconfigurationorredefinitionofcommunitynursingrole

Therewasadiscussionregardingthepapersandhowtheycanpositivelyimpacttheservicesandtheeffecttheycouldhaveonwaitinglists.

Discussionsaroundpolicieswouldneedaculturalchangeforprofessionalsandpatients.Questionsinrelationtopatienteducationtoknowwheretoreceivingneedtobeavoided.

TherewasadiscussionaroundtheOECDreportwhichreferredtousingtherightskillmixtotreatthepatient.ThisdiscussionledontoconversationsregardingexamplesofNurseprescribersbeenemployedinanED’sandhowthispositivelyimpactedwaitingtimes/dischargetimes.

Envisagedthatnurseswillbothworkacrossthecommunityandacutesystemssoasnottobecomede-skilled.HowinpracticewillnursesworkinboththeAcuteandCommunitysystems?

NeedtohaveacleardefinitionoftheroleoftheGPandtheroleofanurseforcurrentnegotiationswithGPsregardingthemanagementofchronicdiseases.Cautionwasadvisedforhavingtwoseparateavenuesforpatientsmayleadtoproblems.

Green Signifiesfeedbackalreadyincorporatedintothepolicies

Amber Signifiesfeedbackisbeingaddressedinlightoftheplanninganddevelopmentofdemonstratorprojects

Blue Signifiesfeedbackthatisnotwithinthescopeofthecurrentpolicies

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Written Submissions to the Consultation (n=4)

Budgetimpactandeconomicevaluation Reviewofservicesfrompracticenurses

Interdisciplinarylearningandevidencebasedpractice

AnticipatedcostsofthedemonstratorprojectsAbudgetimpactassessmentwitheconomicevaluationwilladdrigourtotheproposal

Fundingandresourceimplications–diagnosticequipment,ICTandadmin

IstheG.P.partoftheprimarycareteam?

Fundingforchangeinstaffmix IsthetriagenursepalatabletotheG.P.?

ABFintheOPDandcommunityataveryearly stage

NeedtodemonstrateintheprojectsEDavoidanceandareductioninthewaitinglists

Researchservicesandcommunitycostingprogramme

ArelegislativechangesrequiredtorefertotheED?

Inconsistenteligibilitytoservicesacrossthecountry

Needtosupportachangeinculture

Regulationsregardingreferrals–(follow-uprequestedoftheunit)

Governanceofthesharedrecord

Promotionofmultidisciplinaryteam-basedlearningisrecommended

EstablishmentofEducationStandards(coresyllabus,competenciesandassessment)inevidence-basedpractice/clinicaleffectiveness.

Specificeducationandtraininginclinicaleffectiveness,evidencebasedpractice,implementationscienceandhumanfactorsisrecommended

HSE Feedback

Developtheroleofthepracticenurseinthepapersandcareerpathways

Needtobackfillpostsforthistobesuccessful-10ANP’s=€700k

Developprescribingandcompliancewithmedicinesincludingde-prescribingasindicatorsinthedemonstratorprojects

Needtomonitorx-rayprescribingbynursesthroughoutthesystem

PharmacistneedstobepartofthePHCTforintegrated care

DevelopbroadlyeducatednursestoANPleveltoprovidecareacrossservicesandchronicdiseasemanagementinordertogettocriticalmass

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Possible Demonstrator Project and assistance

ElderlyandRespiratoryusefuldemonstratorprojectsEndoscopyCancerSurvivorshipMentalhealth(CAMHS)

TelemedicineANPAcuteservicesANPfortheAMAU’sandED’sRheumatologywaitinglistsI.D.Liaison

NCECwillforwardinfooneducationandtrainingforclinicaleffectivenessandimprovementscience

HSEmaybeofassistanceinpracticallyandprojectswithgoodpracticeexampleswhichmayresultinquickwins.

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APPENDIX 9 Criteria for Demonstrator Site Selection

Criteria for Selecting the Sites

PurposeThepurposeofthisdocumentistooutlinetheapproachtoselectthepilotsitesforparticipationinthedemonstratorprojects.

Thedemonstratorprojectsarerequiredtomeetserviceneedobjectivesof:Accesstoservice;hospitalavoidance;earlydischarge;patientflow;waitinglists.

OpportunityforthedevelopmentofClinicalNurseSpecialist(CNS)andRegisteredAdvancedNursePractitioner(RANP),inparticularrolesinchronicillnessmanagement,communityintegratedcareforolderpersonsandambulatorycareneedstobeexploredindetail.

ThecurrentissuesareevidencedthroughdatafrompresentationstoED;WaitinglistsandDelayedDischargesfromtheacuteservices.

No. Criteria Rationale Ranking 1 Impact on

meeting Service need

Acoreprincipleofthepolicyistocontributetoserviceneedsandreducewaitinglists,keeppatientsathomeorasclosetohomeaspossibleandcreatepathwaysofintegratedcare.

1-lowuse5-moderateuse10-highuse

2 ICT Infrastructure

Acoreoutputfromthepilotistotestthecapabilityofthemodeltodeliverbetteroutcomes(Patient/StaffandEconomic).ThereforeICTcapacityatlocalleveltomeasuretheseviaaccessto:iPIMS/PAS/NIMIS/other,FinancialSystemsandHRSystemsalongwithICTsupportatlocallevel(giventhepilottimeline)areakeyfactor.

1–lowlevelofcapacityandsupport2–moderatelevelofcapacityandsupport3–highlevelofcapacityandsupport

3 Governance Hospital/HospitalGroupinfrastructuretofacilitateprovisionofservicefromhospitaltocommunityandcommunitytohospitalgovernanceisakeyoutputfromthepolicies.Similarlylocalgovernancetofacilitatethedemonstratorprojectiskey.ThereforethestageofdevelopmentoftheHospital/HospitalgroupstructureandlinkwiththeCHOisakeyenablerintheproject.Thiswillbemeasuredunderthefollowing; 1 Group Director of Nursing agreement 1-No2-Yes 2 Director of Nursing agreement 1-No2-Yes 3 Group HR lead agreement 1-No2-Yes 4 Service identified and Plan submitted 1-No2-Yes

4 Within a group with Model 4, 3, & 2

ThepolicyneedstobetestedacrossaHEIandarangeofservices.Thereforetheidealisthatthedemonstratorprojectsareideallyatamaximumwithintwogeographicalhospitalgroups,thatincludetwoHEI’sgiventhetimeframefortheproject.

1–No2–Yes

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APPENDIX 10 Creating a Critical Mass of RANP/RAMPs

ThepurposeofthispaperistooutlinetheproposedareasfordevelopmentofRANP/RAMP’sasdemonstratorprojects.Theareashavebeenidentifiedthroughexaminationofthewaitinglistsandpatientpresentationtotheemergencydepartments,theinternalconsultationprocesswithUnitsintheDepartmentfollowingreviewbytheManagementBoardonthe14November,andalsothroughengagementwiththeHSEmanagementleads,andthenursingleadsintheNCCPoftheHSEandtheONMSD.Theexamplesbelowareindicativeatthisstageandsubjecttofurtherreviewandamendment. Objectivesofthedemonstratorprojectsareto:

1. CreateacriticalmassofRANP/RAMP’s

throughadevelopmentalpathwayforgraduateandspecialistnursesandmidwives;

2. Changethewayweeducateandtrainnursesandmidwivesfromgraduatelevel;

3. Changehowweutiliseanddeploythenursingandmidwiferyresource.

4. Measuretheimpactandeffectivenessofthenewmodel

5. Implement1-4abovethroughdemonstratorprojectsoverthenext2years.

Table1belowoutlinestheproposedImpact/OutcomeofDemonstratorprojectstoserviceneedinareasofchronicdiseasemanagement(COPD,Rheumatology),Olderpersoncare(FrailElderly),acutecare(ED,AMAU),Children’sservices(Childrenurgentcare)Endoscopy.

Services Objective Areas for Demonstration

COPD

Rheu

mat

olog

y

Frai

l Eld

erly

ED AM

AU’s

Canc

er S

urvi

vors

hip

Child

ren

urge

nt c

are

Endo

scop

y

I.D. L

iais

on

Men

tal H

ealth

Access X X X X X X X X X X

Hospital avoidance X X X X X X X

Early discharge X X X X X

Patient flow X X X X X X X X X

Waiting lists X X X

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APPENDIX 11 Logic Model Evaluation

Logic ModelEvaluating the impact of a critical mass of ANPs on the Irish healthcare system using a Logic Framework Approach (LFA)

Definition of a Logic Model“A logic model is a graphic display or ‘map’ of the relationship between a programme’s resources, activities, and intended results, which also identifies the programme’s underlying theory and assumptions” (KaplanandGarrett,2005).

Logicmodelscanillustratetherelationshipsandassumptionsofwhataprogrammeaimstoachieveandtheexpecteddeliverablechanges.

Thisprocessmayidentifygapsandbarriersduringtheimplementationphaseofaprojectandhelptocrystallisetheunderlyingassumptionsandanticipatedoutcomes.

ALogicModelsupportstheresearchprocessforevaluationasitcompelstheparticipants(policymakers,clinicians,healthcaremanagers)tofullyarticulateandclearlydefinetheaimsandvisionoftheANPpolicyfromindividualorsectoralhealthcareperspectives.WhiletheLogicModelprocessmakesexplicitwhatisoftenimplicit(Jordan2010).Itenablesandfacilitatescommunicationrequiredbetweenthevariousstakeholderstoexaminetheunderlyingassumptionsof

thisANPprogramme.HavingaclearvisualmodeloftheANPprogrammesupportscommunicationandcollaborationatlocalorganisationallevelstherebyfacilitatingbothformativeandsummativeevaluation.TheflexibilityoftheLogicModeladaptstohigh-levelorganisationalevaluationneedsthatcanbeintegratedwithindifferentlocalcontexts(Helitzer,2010).TheLogicModelcanidentifybestpracticesolutionsgroupsincertainpracticeswhilehighlightingbothunintentionalandintendedoutcomes.ItisintendedthattheLogicModelforeachservicearea,chronicdiseasemanagement(rheumatologyandrespiratorymedicine),olderpersonscare,andunscheduledcarewillfosterstakeholdercollaborationsonsharingperspectivesandgoals.SignificantlytheLogicModelprocessshouldbringindividualteammemberstogetherwhomayhaveworkedindividuallyratherthaninateamsettingpreviously.

TheevaluationteaminconjunctionwiththecandidateAPs(APs)basedinthefourspecialityareasof(rheumatology,respiratory,olderpersonsandunscheduledcare),developedaseriesofparticipatoryprogrammelogicmodels.Theseidentifytherelationshipsbetweeninputs(resourcesallocatedtothisinitiative),outputs(directinterventionsbyANPs),outcomes(benefitsforpatients)andimpactonpatient’slives(i.e.qualityofLife).Thesemodelsweredevelopedthroughaqualitativeapproach,withANPs

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ineachoftheclinicalareasaswellasbeinginformedbydatacollectedintheIntroductionphaseofthePEPPAPlusFramework.TheapproachusedinthedevelopmentofthelogicmodelswasbasedonthatadvocatedbytheCentreforDiseaseControl(CDC2006)andenabledtheidentificationofinputs,activities,outputs,outcomesandimpactsthatrelatetotheroleofANPs.Usingactivity-baseddatacollectedbytheAPsandtheexistingdataavailableinthehealthservices,incooperationwiththeNationalClinicalandIntegratedCareProgrammesoftheHSE,theevaluationteamdesignedastudymethodologytoidentifytheimpactofacriticalmassofcandidateANPsbeingrecruitedtotheIrishhealthcaresystem.ThistoolprovidesinformationonthetypeofclinicalcareprovidedbytheANP.ThedevelopmentoftheProgrammeLogicModeland,theclinicalcontextinwhichtheANPissituated,enabledthefollowingactivity-baseddatatobecollectedfromANPs:

• Totalnumberofpatientsseen• Assessments• Follow-upvisits• Diagnosticinvestigations• Intervention/managementplans• Medicationprescribing• Multidisciplinarymeetings• Consultationsbyphone• ConsultationwithGPs• Consultationwithprimary/secondaryhealthcareproviders

Thesample,atthisphaseoftheresearch,includedANPs.Datawerecollectedfromprimaryandsecondarysources.

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