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Nurse Practitioners – ‘Strengthening the point of entry into the Healthcare

system’ Dr. Majid Al-Maqbali, RN, PhD

Director of Nursing & Midwifery Affairs

June 2014

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Outline:

Introduction – Advanced Nursing Practice, What is it?

Driving Forces and Restraining Forces.

Our Approach – Situational Analysis

Why do we need ANP?

Roles and Responsibilities

What are the benefits for Patients and Services?

Recommendations

Conclusion

Purposes of the Presentation

Develop consensus

Highlight the importance of the role

Advise Top Authorities

Implementation Plan

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Purposes of the Presentation

MOH is held accountable for patient safety, nurse’s

achievements, positive patient outcomes, cost

containment, etc.

High standards = high performance

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Advanced Nursing Practice, What Is It?

“A registered nurse with expert knowledge base,

complex decision making skills and clinical

competences for expanded practice, governed by

the context and country in which practice is

credentialed. A master’s degree is recommended for

entry level internationally” (ICN, 2002)

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Advanced Practice ‘What are the Driving Forces?’

Service Driven – Shortfall in doctors both numbers

and specific expertise (Affara, & Schober 2012)

Emerging Health problems due to lifestyle changes

e.g. Diabetes, hypertension – (1996) overall OPD

morbidity 0.6% - 2012 – 1.3% (MOH, 2012)

The global trend of moving care closer and deeper

in the community (De Geest, et al. 2008)

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Advanced Practice ‘What are the Driving Forces?’

People are living longer and are more likely to

develop long term conditions requiring specialist

care. (MOH, 2012)

Clinical career pathway for nurses: the opportunity

to stay at the bedside. (MOH, 2013)

What are the Restraining Forces?

Requires ‘full buy in’ from senior

officials – ANP, project commenced

April 2010 and is still active

Some resistance regarding prescribing

and ordering of tests

Immature regulatory framework to

guide safe and effective practice and

put safeguards in place (Affara &

Schober, 2012)8

Our Approach – Situational Analysis

Build on the work of Schober– Site visits, focus groups, workshop (2006).

Questionnaire data gathered and analysed from PHC settings

(2011).

Nursing stakeholder focus groups discussions, (2011).

A review of International literature on Nurse Practitioners / Advanced

Practice (2010-2014).

Questionnaire - perceptions of health professionals on the ANP role

(2012)

Visit American Universities (2013)9

Why do we need them?

Increased number of Elderly (4.7% in 2005 and

6% in 2012 (MOH, 2012)

Increased number of people with long term

conditions e.g. Diabetes

Limited access to PHC Physicians

Difficult Geographical / demographic locations

60% of PHC Nurses currently practicing

Advanced skills due to Physician shortages (Affara

& Schober 2012)

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The Current Situation:Percentage of nurses practicing Advanced role

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4610

5486

161

4721

91

2356

0

252

401

76

302321

69 75

337

576

448

221

0

100

200

300

400

500

600

700

North Sharqiya

Dhakliya Al Wosta South Sharqiya

Dhofar Buraimi Musandam South Batinah

Muscat North Batinah

Dhahira

Number of nurses practising the role Total Nurses in PHC

The Role in Primary Health care

Work alongside Nurses and Family Physicians

to strengthen the patient point of contact in PHC

Provide care coordination linking patients to

other parts of the healthcare system

Expert support for community health services /

home care emphasising health promotion

Strengthen community based chronic disease

management and self-care e.g. hypertension,

Diabetes

ANP provides shared care with Physicians or

can see patients independently (Affara &

Schober 2012)12

The Role in Hospital Services

Focus on specialization for a specific patient population e.g. Neonates,

Emergency, Endoscopy, etc.

Expansion of practice and role autonomy

Manages own caseload including advanced practice skills (e.g. intubation and

ventilation)

Applying critical thinking and evaluation skills to solve clinical problems using

advanced skills

Knows own limitations and makes referrals to senior colleagues when required

Integration of theory research evidence and practical knowledge to deliver patient

centered care (Bryant – Lukosius, et al 2004)13

General Role

Enhance skills, knowledge, and attitudes of other nurses

Foster collaborative atmosphere

Establish positive systems to improve leadership, teaching, and healthcare

providers’ performance.

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o Advanced Nurse Practitioners (ANP) deliver high quality care the same as

Physicians (OECD, 2010)

o Enable Physicians to focus on complex health problems of an uncertain

nature. (Sibbald, 2008)

o Increase access for patients to PHC and emergency services (Peltonen, 2009)

o Decrease emergency visits to Physicians by 18-25% (Hukkanen & Villimies –

Patomaki, 2005)

o Better results in health promotion and self care than Physicians (EROS, 1999)

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What are the benefits for – Patients – Services?

What are the benefits for – Patients – Services?

Longer Individualized patient consultations by ANP, more information is

given and patient satisfaction is higher (Edwards et al, 2003)

Higher quality chronic disease management by ANP(Russell et al, 2009)

Reduced admissions for unplanned acute relapses e.g. Asthma (Griffin et al,

2004)

Significant improvement in patient blood pressure and diabetes control

(Litaker et al, 2003)

No documented negative impact of ANP transfer of tasks from Physicians

to ANP (OECD, 2010)

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Conclusion

• Currently the driving forces for ANP are stronger than the restraining forces,

therefore it’s introduction would be supported

• Shortage of Physicians and burden of long term and chronic conditions are the

main drivers

• ANP will strengthen community based chronic disease management and self-

care e.g. Diabetes

• ANP will enable Physicians to focus on complex health problems of an uncertain

nature (Sibbald, 2008)

• Implementation requires a strategic approach that involves all key stakeholders

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Establish an Advanced Practice national taskforce to:

• Determine Scope of practice, competences, standards, domains

• Develop and source an education curriculum to meet the above

standards

• Ensure title, registration and licensure requirements are met

• Ensure Job description are agreed by stakeholders

• Ensure ANP is an official category in national health Humans

Resources plan18

Recommendations

Recommendations

• Develop an implementation, monitoring, and evaluation plan

(Taskforce)

• Recruit international expert with proven track record in ANP education

and role development (DNMA)

• Upgrading of Nurses in PHC already working in extended roles through

a locally determined education curriculum to safeguard the public

(DNMA)

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Extended to Advanced Practice Continuum Model

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Affara, F. & Schober, M. (2012) Assignment Report – Sultanate of Oman, April 2012, ICN: Geneva

Bryant – Lukosius, D. DiCenso, A. Browne, G. Pinelli, J. (2004) Advanced practice nursing roles: development, implementation and evaluation, Journal of Advanced Nursing, 48, (5) p 519 - 529

De Geest, S. Moons, P. Callens, B. Gut, C. Lindpaintner, L. Spirig, r. (2008) Introducing advanced practice / nurse practitioners in health systems: A framework for reflection and analysis, Swiss Med. Weekly, (138) p33-34

Edwards J.B., S. Oppewal and C.L. Logan (2003), “Nurse-managed primary care: outcomes of a faculty practice network”, Journal Am Acad Nurse Pract, 15 (12): 563-9.

EROS Project team (1999), “Training nurse practitioners for general practice”, The EROS Project Team, Br J. Gen Pract, 49 (444): 531-5.

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References

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References:

Griffiths C. et al. (2004), “Specialist nurse intervention to reduce unscheduled asthma care in a deprived multiethnic area: the east London randomised controlled trial for high risk asthma (ELECTRA)”, British Medical Journal, 10.1136.37 950, January.

Hukkanen E. and M. Vallimies-Patomaki (2005), “Cooperation and division of tasks in ensuring access to care, a survey of the pilot projects on labour division carried out within the National Health Care Project”, Ministry of Social Affairs and Health, Helsinki, 2005:21, Helsinki, available at http://pre20090115.stm.fi/pr1129788573664/passthru.pdf[in Finnish]

International Council of Nurses, (2002) Definitions and characteristics for nurse practitioner / advanced practice nursing roles. www.icn.ch/networks_ap.htm [Accessed March 20 2014]

Litaker, D. et al. (2003), “Physician-nurse practitioner teams in chronic disease management: The impact on costs, clinical effectiveness, and patients' perception of care”, Journal of Interprofessional Care, 17(3), 223-237.

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References:

Ministry of Health, (2013) Career pathway for nurses & midwives, Muscat, Sultanate of Oman Ministry of Health,

Ministry of Health, (2012) Annual Healthcare Statistics, Department of planning, Muscat, Sultanate of Oman, Ministry of Health

OECD, (2010) Health working papers no 54 – Nurses in advanced roles; A description and evaluation of experiences in 12 developed countries, Paris; OECD[Available from] http://www.oecd.org/els/health/workingpapers [Accessed 20 March 2014]

Peltonen E. (2009), “The Doctor-Nurse Pair Model and the Admissions Team Model in Primary Health Care: a Comparative Study”, E. Social Sciences 168, Doctoral thesis, University of Kuopio (In Finnish, English abstract), [available at] http://www.uku.fi/vaitokset/2009/isbn978-951-27-1227-4.pdf Accessed 20 March 2014]

Sibbald B. (2008), “Head to head - Should primary care be nurse led? Yes”, British Medical Journal, 4th of September, 337: a1157