Implementing Advanced Practice in Ireland - Professor Cecily Begley Chair of Nursing and Midwifery
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Implementing Advanced Practice in Ireland
Professor Cecily Begley
Chair of Nursing and Midwifery,
Trinity College Dublin
Ireland
and Visiting Professor, University of Gothenburg, Sweden
Overview
• How the roles of Clinical Nurse and Midwife
Specialist (CS) and Advanced Nurse and
Midwife practitioners (AP) were initiated
• How they were introduced into healthcare in
Ireland (legislation, education)
• How the roles evolved over the past 17 years
• The future plans for these roles
2
Nursing and midwifery in 1990s
• Dark ages
3
Great discontent
4
The Commission on Nursing
• Set up in April 1997 to examine the needs of
the two professions
5
The Commission on Nursing
6
1999 strike
7
The Commission on Nursing
• Four-year honours degree education for all
nurses 2002 onwards
• Four-year honours degree education for all
midwives 2006 onwards
8
The Commission on Nursing
• The Report of the Commission on Nursing (Government
of Ireland 1998) was the catalyst for the introduction of a
clinical career pathway encompassing progression from:
Advanced Nurse or
Midwife Practitioner
(ANP/AMP)
Clinical Nurse or
Midwife Specialist
(CNS/CMS)
Staff nurse or
Staff midwife
9
The NCNM
• The National Council for the Professional
Development of Nursing and Midwifery was
formed in November 1999 under a statutory
instrument (SI No. 376 of 1999), on foot of a
recommendation made by the Commission on
Nursing.
(Government of Ireland 1998, para 6.12).
10Main statutory functions
• to monitor the ongoing development of
nursing and midwifery specialties (taking into
account changes in practice and service need);
and
• to support and assist the health boards in the
creation of specialist and advanced practice
nursing and midwifery posts.
11Frameworks
• The National Council established frameworks for
the clinical career pathway in nursing and
midwifery in 2000, using core concepts devised
by the Commission on Nursing.
• http://www.lenus.ie/hse/displaygastats?handle=
10147/141052&viewall=downloads
• (site includes Key Performance Indicators for the
posts, and evaluations, as well as frameworks)
12“Grandfather rights”
Arrangements were
made for nurses and
midwives already
working in
CNS/CMS posts
13CNS/CMS
Five key aspects:
Clinical focus
The CNS/CMS’s work must have a
strong patient/client focus.
Provides direct care - assessment, planning, delivery and
evaluation of care to patients and their families.
…and indirect care - relates to activities that influence others in
their provision of direct care.
14CNS/CMS
Patient/client advocate
The CNS/CMS role involves:
• communication
• negotiation
• representation of the
patient/client values
and decisions in collaboration with other health care
workers and community resource providers.
Consultant
Inter and intra-disciplinary consultations, across sites and
services 15CNS/CMS
Education and training
The CNS/CMS provides educational
opportunities to facilitate
• staff development and
• patient/client education
Engages in continuing professional
development, to ensure clinical credibility
among nursing/midwifery, medical
and paramedical colleagues.
16CNS/CMS
Audit and research
Audit of current practice and evaluation of
improvements in the quality of patient/client care.
Keep up to date with relevant current research to ensure
evidence-based practice and research utilisation.
Contribute to nursing/midwifery research which is relevant to
his/her area of practice.
Outcomes of audit and/or research should contribute to the next
service plan.
17CNS/CMS requirements
Registered nurse/midwife, registered in the division in which the
application is being made
Minimum of 5 years post-registration experience, including >2
years in the specialist area
Ability to practise safely and effectively, within his/her scope of
practice
Provide evidence of continuing professional development.
Level 8 NQAI post-registration education relevant to area of
specialist practice (Higher/Post-graduate Diploma, usually one
year of study, post degree)
18ANP/AMP Four key aspects: Autonomy in clinical practice Accountable and responsible for advanced levels of decision making in specific patient/client caseload. Demonstrate expert skill in the clinical diagnosis and treatment of acute and/or chronic illness. Nursing or midwifery knowledge and experience should continuously inform the ANP’s/AMP’s decision making, even though some parts of the role may overlap the medical or other healthcare professional role. 19
ANP/AMP
Expert practice
Expert practitioners
demonstrate practical and
theoretical knowledge and
critical thinking skills that are
acknowledged by their peers as
exemplary
20ANP/AMP Professional and clinical leadership ANPs/AMPs …may initiate and implement changes in healthcare service in response to patient/client need and service demand Have a vision of areas of nursing/midwifery practice that can be developed beyond the current scope of nursing/midwifery practice Provide new and additional health services to many communities in collaboration with other healthcare professionals (HCPs) Participate in educating nursing/midwifery staff, and other HCPs through role-modelling, mentoring, sharing and facilitating the exchange of knowledge in the classroom and clinical area 21
ANP/AMP
Research
Required to initiate and coordinate nursing/midwifery audit and
research.
Identify and integrate nursing/midwifery research in areas of the
healthcare environment that can incorporate best evidence-based
practice
Carry out nursing/midwifery research which contributes to quality
patient/client care and which advances nursing/midwifery and
health policy development, implementation and evaluation.
22ANP/AMP requirements
Registered nurse/midwife, relevant to specialist area
Minimum 7 years experience, with >5 years in specialist area
Provide evidence of continuing professional development.
MSc relevant to area of specialist practice, including clinical hours,
with substantive hours at supervised advanced practice level:
1,000 clinical hours, 500 of which is supervised
Competence to exercise higher levels of judgement, discretion and
decision making in the clinical area above that of the CS
Demonstrate competencies relevant to context of practice
23ANP/AMP requirements
Prescribing rights?
Now included in the education
programme
24ANP/AMP requirements
In addition, the sites had to be prepared according to the
Framework guidelines
“Framework for the establishment of advanced nurse practitioner
posts - 3rd ed.” http://www.lenus.ie/hse/handle/10147/45620
Included agreement from the site that the medical practitioners
were supportive, and that funding was in place
25• So, were they any good?
26The SCAPE study:
Specialist Clinical & Advanced Practice Evaluation
School of Nursing and Midwifery,
Trinity College Dublin, University of Dublin
and
School of Nursing and Midwifery,
National University of Ireland, GalwayThe SCAPE study:
Specialist Clinical & Advanced Practice Evaluation
At the time of the study (2008), there were 2053 CS
posts in Ireland and 48 APMethodology and Design
29Discipline/ Sites with post Sites without
profession holders (n=23) post holders
(n=23)
General nursing 9 9
Midwifery 3 3
Intellectual 2 2
Disability N
Mental Health N 5 5
Children’s N 2 2
Public Health N 2 2
30Data Postholding Non Total
collection sites postholding
method
Observation 23 CS/APs 23 clinicians 184 hrs
2 hrs x 2
Interviews 21 20 41
(clinicians x 2)
Interviews 20 21 41
(SUs)
Interviews 8 10 + 5 23
(DON or M)
Survey (SUs) 154 125 279
31Number and speciality of ANPs and CNS/CMSs
included
Discip./profess ANP CNS/CMS
General nursing Emergency Stroke care, pulmonary
3 ANPs Dept., sexual outreach, heart failure, anti-
6 CNSs health, coagulation therapy, pain
endoscopy management, colposcopy
Midwifery 0 AMP Prenatal screening, diabetes
3 CMSs care, infectious diseases
Intellectual 0 ANP Challenging behaviour,
disability 2 CNS early intervention
Mental health Child and Family therapy, cognitive
nursing adolescent behaviour therapy, psych-
1 ANP, 4 CNSs mental health otic disorders, addictions
Children’s Emergency Dept. ENT (1 CNS)
nursing 1 ANP (children’s)
Public health Practice nursing Older person care
Total 6 17
32Interviews with policy-makers
•12 policy-makers interviewed to put the
findings in context
•From DOH, HSE and relevant organisations
that govern or shape health policy
33Interpretation from all datasets
34We merged evidence across all data sets:
One example….
35Focus Delphi Case study: Case Policy- Evid-
group out- interviews, study: maker ence
out- comes field notes question- inter- rating
comes and naires views
documentary
evidence
2
Patient/ Patient/ Good relationships CS/APs Policy- Very
client client (8.2.5.1.), better spent longer makers strong
satis- satisfact- knowledge and with clients believe evidence
faction ion with health (8.2.5.2., (8.2.3.). that there (from 5
informat- 8.2.5.3. Decreased Significantly is an sources)
ion, with litigation (9.3.4.) higher rates impact on
technical of patient/
aspects satisfaction in client
of care post holding satisfact-
(e.g., sites (76% ion, and
patient vs. 66%) decreased
evaluat- (8.2.6.4.). litigation
ion of (11.2.2.)
service 36
delivery)Delphi Case study: interviews, field Case study: question-naires Policy-maker interviews Evidence rating
Focus outcomes notes and docu-mentary
evidence
group
outcomes
2
Patient/ Patient/client
satisfaction
with
Good relationships (8.2.5.1.),
better knowledge and health
(8.2.5.2., 8.2.5.3.)
CS/APs spent longer with
clients (8.2.3.). Significantly
higher rates of satisfaction in
Policy-makers believe that
there is an impact on
patient/client satisfaction,
Very strong evidence
(from 5 sources)
information, post holding sites (76% vs. and made comments on
client with
technical
aspects of
66%) (8.2.6.4.). Decreased
litigation (9.3.4.)
decreased litigation (11.2.2.)
care (e.g.,
satisfaction patient/client
evaluation of
service
delivery)
37Focus group Case study: Case study: question- Policy-maker Evidence rating
outcomes
Delphi outcomes interviews, field
notes and docu-
mentary
naires interviews
evidence
2
Patient/
client satis-
faction
Patient/client Good
relationships
(8.2.5.1.), better
CS/APs spent longer with
clients (8.2.3.). Significantly
higher rates of satisfaction
Policy-makers
believe that
there is an
Very strong evidence
(from 5 sources)
satisfaction with knowledge and
health (8.2.5.2.,
8.2.5.3.)
in post holding sites (76%
vs. 66%) (8.2.6.4.).
Decreased litigation
impact on
patient/client
satisfaction,
(9.3.4.) and made
information, with comments on
decreased
litigation
technical aspects of (11.2.2.)
care (e.g.,
patient/client
evaluation of
service delivery)
38Focus group Delphi outcomes Case study: Policy-maker Evidence rating
outcomes
Case study: question-naires interviews
interviews, field
notes and docu-
mentary evidence
2
Patient/
client satis-faction
Patient/client
satisfaction with
information, with
Good relationships CS/APs spent longer
with clients (8.2.3.).
Significantly higher
Policy-makers
believe that there is
an impact on
Very strong
evidence (from 5
sources)
technical aspects of
care (e.g.,
patient/client
(8.2.5.1.), better rates of satisfaction
in post holding sites
(76% vs. 66%)
patient/client
satisfaction, and
made comments on
evaluation of service (8.2.6.4.). decreased litigation
delivery)
knowledge and Decreased litigation
(9.3.4.)
(11.2.2.)
health (8.2.5.2.,
8.2.5.3.)
Decreased
litigation (9.3.4.)
39Example: good relationships
• She is our first point of contact
for anything. We ring her before
we even ring the GP. We find that
she knows us and what is best for
us to do. …She gives the best advice, as she knows us the
best so we rely completely on her. I don’t know what I
would do if she was gone. I am not sure I could handle it.
(Service user, postholder site, CNS)
40Example: improved health knowledge
• I listened to her advice and it was that that
really saved me... I started going to bed in
the afternoon to rest. I began to take my
medications as now I understood them. I
also use oxygen.. I have less episodes of
being hospitalised… I have radically reduced the amount
of times I take antibiotics and I have less fluid in my lungs.
I feel so much better.
(Service user, postholder site, CNS)
41Example: improved health
• They [CNSs] play a very important role..
and make life very easy for the cardiac
clinician...these patients have the CNS’s
phone numbers and they could literally
phone them at any time during the
weekdays and give them advice over the phone or if
there was any concern they could be seen, even before
their due appointment...it actually prevents these
patients deteriorating...they get medical attention at the
right time.
(Doctor, postholder site, CNS)
42Example: decreased litigation
• [ANP] delivers...a significant enhanced level of care
for that cohort of patients... I think what it’s reflected
in is a hugely reduced litigation...for our department.
We generally don’t tend to see problems relating to
missed injuries...so it has also been a cost-effective
measure within the service.
(Consultant, postholder site, ANP)
43Focus group Delphi Case study: Policy-maker Evidence
outcomes outcomes interviews, field
notes and docu-
mentary evidence
Case study: interviews rating
questionnaires
2
Patient/
client satis-
faction
Patient/client
satisfaction
with
Good relationships
(8.2.5.1.), better
knowledge and
CS/APs spent longer Policy-makers
believe that there is
an impact on
Very strong
evidence (from
5 sources)
information,
with
technical
health (8.2.5.2.,
8.2.5.3.) with clients (33% for 31 patient/client
satisfaction, and
made comments
aspects of on decreased
care (e.g.,
patient/client
evaluation of
minutes or longer vs. litigation (11.2.2.)
service
delivery) 14% in non post holding
sites) (8.2.3.6.).
Significantly higher rates
of satisfaction in post
holding sites (76% vs.
66%) (8.2.6.4.).
44Focus group Delphi Case study: Case study: Evidence rating
outcomes outcomes interviews, field notes
and docu-mentary
evidence
question-naires
Policy-maker
interviews
2
Patient/
client satis-faction
Patient/client
satisfaction with
information, with
Good relationships
(8.2.5.1.), better
knowledge and health
CS/APs spent longer
with clients (8.2.3.).
Significantly higher
Policy-makers Very strong evidence
(from 5 sources)
technical aspects
of care (e.g.,
patient/client
(8.2.5.2., 8.2.5.3.) rates of satisfaction in
post holding sites
(76% vs. 66%)
believe that there
evaluation of (8.2.6.4.). Decreased
service delivery) litigation (9.3.4.)
is an impact on
patient/client
satisfaction, and
made comments
on decreased
litigation (11.2.2.)
45Example: decreased litigation
• ...that’s being seen the
world over, that there’s
been a decrease in the
litigation in relation to
advanced practice. That
they have been very safe practitioners.
That’s for sure.
(Policy-maker 5)
46Focus Delphi Case Case study: Policy-
group outcomes study: question- maker Evidence
out- interviews, naires interviews
comes field notes rating
and docu-
mentary
evidence
2
Patient/ Patient/client Good CS/APs spent Policy-
client satisfaction relationship longer with makers
satis- with s (8.2.5.1.), clients (8.2.3.). believe that Very
faction information, better Significantly there is an
with knowledge higher rates of impact on strong
technical and health satisfaction in patient/client
aspects of (8.2.5.2., post holding satisfaction, evidence
care (e.g., 8.2.5.3.) sites (76% vs. and made
patient/client 66%) comments on (from 5
evaluation of (8.2.6.4.). decreased
service Decreased litigation sources)
delivery) litigation (11.2.2.)
(9.3.4.)
47Findings (1) • 20 individual patient/client outcomes, and of these there was very strong evidence to support 15, strong evidence for 4 – e.g. • promotes self-management skills • reduces exacerbations of condition • earlier diagnosis and intervention • conducts holistic assessment • decreases morbidity
Findings (2) • 11 outcomes specific to other healthcare staff, with very strong evidence for 7, strong evidence for 3 – e.g. • reduces de-skilling of staff • increases knowledge and skill of other care providers • provides role model • motivates staff • empowerment of other staff (more in APs)
Findings (3)
• 21 outcomes specific to the health services, with
very strong evidence for 14, strong for 5 – e.g.
• reduces waiting times (more in APs), reduces
readmission rates, increases throughput
• improves continuity of care
• reduces costs
• implements research,
conducts audit
• conducts research
(more in APs)Findings (4) • A clear difference was shown between CS and AP posts
Comparing APs and CSs • Waiting time for treatment appeared very much lower in AP (12 hours) and CMS (1 hour) sites than in non-postholding sites (239 hours). This may be due to the level of autonomy in the AP and CMS services
Comparing APs and CSs • APs scored more highly than CSs in some aspects of communication, being open and honest, explaining medicines, treating SUs with respect (Table 8.14).
Comparing APs and CSs • CMSs spent more time with SUs than AP or CNS (Tables 8.14, 8.16). • More SUs attending CMS noticed a difference in care given (Table 8.15).
Comparing APs and CSs • CMSs scored more highly than APs and CNSs in explaining why SUs needed specific tests, and explaining the results to them (CMSs 92%, APs 77% and CNSs 51%) (Table 8.14) and in teaching, advising, and being easy to understand (Table 8.16)
Comparing APs and CSs • Research was conducted by all 6 APs (100%) and 9 CSs (53%) (section 9.4.3) • Leadership shown at higher level by APs
Economic analysis
Economic analysis
Economic analysis • Overall, no difference when costs are averaged over different sites. • There is some evidence that the higher salaries payable to CS/APs can be partially or completely offset by an increase in productivity.
Summary (1) • Benefits of CS/APs shown in terms of: Improved patient/client care Increased education and support of staff Improved service delivery, development and quality Conduct of audit and research • Definitions of, and national criteria for, CS/AP posts are more clear than in other countries • Site support and preparation for AP roles was seen as a benefit by the study sites
Summary (2)
• A clear difference was shown between CS and
AP roles:
CSs gave quality care,
APs (and CMSs) gave quality care at a higher
level (e.g national)
• Advanced practice roles demonstrated
more clinical leadership: education, support, role
modelling, research activity
a clear governance and accreditation structureConclusion • There is a strong case for introducing more nurse and midwife CS and APs as clinical and health services benefits have been demonstrated, and they do not result in higher costs.
Recession 2008 - ??? Report published 2010
Changes The Nursing and Midwifery Board of Ireland now registers all CS/APs https://www.nmbi.ie/Registration/Advanced- Practice There are 193 advanced nurse practitioners and 8 advanced midwife practitioners (August 2016)
Future plans
• The Minister for Health has approved the Draft Policy on
Graduate, Specialist and Advanced Nursing and
Midwifery Practice….
……which aims to create a critical mass of ANP/AMPs
(700 by 2021)
(http://health.gov.ie/office-of-the-chief-nursing-officer/our-
policies/developing-graduate-specialist-and-advanced-
nursing-and-midwifery-practice/)
65Future plans
HOWEVER…..preparation time has been reduced
from 7 years to 2 years.
66The future is bright….
67Or is it….?
68Many thanks to all who supported,
and participated in,
the SCAPE study
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