Providing Treatment, Restoring Hope

Redesigning Nurses WorkThomasine D. Guberski, PhD, CRNP

Associate ProfessorUniversity of Maryland School of Nursing

Track 1 MeetingSeptember 24, 2007

Slide 2

Scope of the Problem

Increasing number of patients Number of medical officers

Range is 4.1 (Tanzania) to 26.9 (Nigeria) MO per 100 000

Number of nurses Range is 11.3 (Zambia) to 108 (Kenya) per

100 000

World Bank, 2004

Slide 3

Current Care Paradigm

General Care Patients in Stable Condition

Providers Nurses and CO’s

General Care Patients in Unstable Condition

Providers Nurses and CO’s

Patients on ART in Unstable Condition

Providers MO’s and CO’s

Patients on ART in Stable Condition

Providers MO’s and CO’s

Slide 4

Breaking the paradigm

How do we effectively shift to new care paradigm, without losing quality of care? Break the paradigm that ART care must be given

only by MO and CO Implementation of the team model for HIV care Formally increase patient care responsibilities for

nurses The redesign of nursing roles and

responsibilities to more effectively care for patients with HIV/AIDS requires a different level of authority, responsibility and accountability

Slide 5

Current Initiatives

Strengthen community nursing care for all HIV+ patients

Nurses assume primary responsibility for patient triage in all settings

Follow stable patients on ARV therapy in a variety of settings

Train community health workers to assess symptoms

Facilitate transition from episodic to continuity care

Develop, implement and evaluate the nursing roles and responsibilities in the treatment plan for their institution.

Design, implement and evaluate clinic structure and flow for continuity care.

Slide 6

Slide 7

Current Initiatives

Establish nurse-run clinics in which the nurses will provide care to patients across the spectrum of HIV:

diagnose and manage common opportunistic infections assess and manage common signs and symptoms in HIV

infected patients provide community nursing for enrolled patients refer patients for and provide palliative care follow patients on ARV therapy recognize appropriate referral parameters refer patients to the MO/CO as appropriate

Slide 8

Successes and Challenges

Breaking the paradigm that only MO/CO can enroll patients

Improvements in patient flow Nurse run refill clinics Triage in home-based care Nurse run clinics in Rwanda Nurse run clinics in Mombasa Nurse practice acts Sustainability

Slide 9

Slide 10

Viral Suppression Rates on Therapy

92%

8%

Suppressed

Not Suppressed

Two nurse run clinics Rwanda

Slide 11

Percentage of Patients with a Documented OIs at ART Start

46%

24%

30%

None

One

Two or More

(Uganda & Kenya) Total 545 Patients with Documented OI

Number of OI/patient

None

one

2 or more

Slide 12

Shifting the paradigm

How do we effectively shift to new care paradigm, without losing quality of care?

Slide 13

How to Make Paradigm Shift a Reality

Include nurses in all phases of planning and implementation

Shift responsibility for stable ART patient care to nurses Increase MO responsibility for unstable general care

patients Implement nurse triage in all settings Improve recognition of potential OI’s by all nurses Community nurse referral required for all unscheduled,

non-emergency visits Increase education and responsibility of community

health workers Implement paradigm shifting protocols across all settings

Slide 14

Breaking the Provider Paradigm

General Care Patients in Stable Condition

Providers Nurses and CO’s

General Care Patients in Unstable Condition

Providers MO’s and CO’s

Patients on ART in Unstable Condition

Providers MO’s and CO’s

Patients on ART in Stable Condition

Providers Nurses and CO’s

Slide 15

Slide 16

Senior level nurse educators

Thomasine D. Guberski, PhD, CRNPAssociate Professor, UM School of Nursing

Yvelline Auguste, MS, FNP HaitiAmy Bositis, MS, CRM Zambia

Cara Endyke-Doran, MSN, MPH, ZambiaYvonne Henley, AS, RN TanzaniaAlphonse Kajiranga, RN RwandaNike Kehinde, RN, RM, Nigeria

Beatrice Kiama, RN KenyaMarik Moen, MSN, MPH, RwandaBarbara Smith, PhD, RN, FAAN

Professor and Associate Dean for Research UM School Of Nursing