4th Annual Developing the Role of the

Nurse Practitioner, 18 March 2014

The Victorian NPC Mentoring

Pilot & VNPP Review

Dan Schiftan

Policy Advisor (Nurse Practitioner)

Nursing & Midwifery Workforce | Health Workforce Branch

Department of Health, Victoria

Nursing & Midwifery Workforce priorities

A sustainable health workforce that meets the healthcare needs

of all Australians in the context of:

• An aging population

• Patient acuity, complex medical conditions

• Changing demands for services

• Workforce supply vs demand gaps

• Changing roles

• Cost of health care

• Pressures to decrease LOS

Contemporary Nursing and Midwifery

Practice Program

Rural and Isolated Practice Endorsed Registered

Nurse (RIPERN)

Nurse Cystoscopy

Nurse Endoscopy

Nurse – Led limited X-ray service (SRHS)

Endorsed Midwives

Nurse Practitioners

The Victorian Nurse Practitioner Program (VNPP)

Scholarships

$3-$6K

Publication

Grants

$4K

Victorian NP

Mentoring

Pilot

NPC

Support

Packages

$8 -$10K

NP

Collaboratives

$15K

NP Model

Development

$37K

NP

ROLES

Nurse Practitioners In Victoria

Endorsement ACT NSW NT QLD SA TAS VIC WA No PPP Total

Dec 12 30 189 11 188 69 20 99 129 2 737

March 13 30 211 12 229 70 20 124 145 2 843

October 13 36 240 15 259 79 22 153 158 4 966

December 13 37 242 13 274 82 23 168 161 4 1,004

Note: No PPP will include practitioners with an overseas address

Figures taken from NMBA Registration Data - December 2013

Many of Melbourne’s Metropolitan Health Services now have >6-8 NP’s & >5 NPC’s

Increasing numbers have > 1 NPC in same area

NURSE PRACTITIONERS IN VICTORIA

0

5

10

15

20

25

30

35

NP NPC

National Employment Settings

Source: ACNP Survey 2012

8

Collaboratives / Communities of Practice

Stroke Care NPC Collaborative Austin Health

Oncology Monash Health

The Vic CDM NP Collaborative (Previously Renal)

Bendigo Health

Palliative care NP Collaborative St Vincent’s Health

Victorian Emergency NP Collaborative Alfred Health

Mental Health and Alcohol and Drugs

Austin and NE Health Wangaratta

Older Persons NP Collaborative

NE Health Wangaratta and Northern Health

VNPP Funding

NMW NP Publication Grants

Up to $4,000 to encourage and support health services to produce papers for publication in peer reviewed industry and professional journals or for presentation at professional or industry conferences that:

•Explore the effectiveness of the NP role, using NP specific outcome measures to support this contention.

and/or

•The methods used to ensure the sustainability and expansion of these roles, into new domains.

The Future of VNPP Funding

Phase 4: Supporting cohorts of NPs in selected areas (Intended to

promote the sustainability of the role)

For this strategy to be effective, health services developing these roles

must:

• Provide sufficient resources

• Policies and guidelines that support the role and inform the multidisciplinary team (Role

clarification)

• Utilise the full potential of the role through the candidacy period with an informed vision

beyond NP endorsement

• Model design that incorporate a model of care inclusive of all collaborating disciplines

• Effective governance structures - both clinical and professional

The Victorian Nurse Practitioner Mentoring Pilot – Developing nurse leaders in Victoria

Nursing leadership is an important topic in the nursing and

management literature (Sheridan and Vredenburgh 1978), with a

focus on the concept of transformational leadership as the

foundation for nursing leadership (Martin et al. 2011).

NPCs are required to show evidence of defined clinical leadership

competencies when they apply for endorsement with AHPRA

Nurse Practitioner National Competency Standards , 2006 (ANMC)

Standard 3 Clinical leadership that influences and progresses clinical care, policy

and collaboration through all levels of health care

Competency Performance Indicators

3.1 Engages in and leads clinical

collaboration that optimise

outcomes for patients/

clients/communities

a) Actively participates as a senior member and/or leader of relevant multidisciplinary

teams

b) Establishes effective communication strategies that promote positive

multidisciplinary clinical partnerships

c) Articulates and promotes the nurse practitioner role in clinical, political and

professional contexts

d) Monitors their own practice as well as participating in intra- and inter-disciplinary

peer supervision and review.

Competency Performance Indicators

3.2 Engages in and leads

informed critique and influence

at the systems level of health

care

a) Critiques the implication of emerging health policy on the nurse practitioner role and

the client population

b) Evaluates the impact of social factors (such as literacy, poverty, domestic violence

and racial attitudes) on the health of individuals and communities and acts to moderate

the influence of these factors on the specific population/individual

c) Maintains current knowledge of financing of the health care system as it affects

delivery of care

d) Influences health care policy and practice through leadership and active

participation in workplace ad professional organizations and at state and national

government levels

e) Actively contributes to and advocates for the development of specialist, local and

national, health-service policy that enhances nurse practitioner practice and the health of

the community.

Nurse Practitioner Standards for Practice (Effective from 1 January 2014)

Standard 4 Evaluates outcomes and improves practice

Statement 4.1 Cues:

Evaluates the outcomes of

own practice

Monitors, evaluates and documents treatments/interventions in accordance with person-

determined goals and health care system outcomes

Considers a plan for appropriately ceasing and/or modifying treatment in consultation with the

person receiving care and other members of the health care team

Applies the best available evidence to identify and select appropriate outcomes measures of

practice

Uses indicators to monitor and measure the effectiveness of strategies, services and interventions

to promote safe practice

Participates in clinical supervision and review

Implements research-based innovations for improving care

Contributes to research that addresses identified gaps in the provision of care and/or services.

Statement 4.2 Cues:

Advocates for, participates in,

or leads systems that support

safe care, partnership and

professional growth

Advocates and provides evidence for expansion to nurse practitioner service where it is believed

that such an expansion will improve access to quality and cost-effective health care for specific

populations

Demonstrates clinical leadership in the design and evaluation of services for health promotion,

health protection or the prevention of injury and/or illness

Articulates and promotes the nurse practitioner role in clinical, political and professional contexts

Acts as an educator and/or mentor to nursing colleagues and others in the healthcare team

Critiques health care policies for their implications on the nurse practitioner role and the

populations for whom they care

Influences health, disability and aged-care policy and practice through leadership and active

participation in workplace and professional organisations.

The Victorian Nurse Practitioner Mentoring Pilot – Developing nurse leaders in Victoria

•Aiming to assist funded NPCs and the Mentors to develop or enhance

their leadership skills

•20 NPCs commenced an 18 month mentoring program that matched

them with senior nurse leaders.

•Mentoring seemed a reasonable approach given the existing evidence

(McCloughen et al. 2006).

•There is also evidence of a positive relationship between mentoring

and leadership in nursing (Daniels 2004), and

•Recognition of the need to support advanced practice nurses, such as

NP candidates, through mentoring (Reay et al. 2003, van Soeren et al.

2007).

The Victorian Nurse Practitioner Mentoring Pilot – Developing nurse leaders in Victoria

•Expressions of Interest were directed to Executive Directors of

Nursing.

•Several self selected, some nominated DONs and 4 selected

endorsed NPs.

•The pilot adopted Vance and Olsen’s definition of mentoring as “a

developmental, empowering, and nurturing relationship extending

over time in which mutual sharing, learning, and growth occur in an

atmosphere of respect, collegiality, and affirmation”(Vance and

Olsen 1998).

Pairs

•There is no conclusive evidence on how best to choose mentor

pairs (McCloughen et al. 2006).

•Mentors did not have clinical disciplines that matched the NPCs so pairs

were matched on reported learning styles (Dunn 1984)

•Effort was made to ensure Mentors and NPCs were from different

organisations (No line management responsibilities).

•Pairs were divided into three groups supported by a skilled facilitator

The Pilot

The Pilot comprised:

• three face to face workshops encompassing mentoring training,

educational sessions on clinical leadership, and opportunities for

reflection and feedback

• monthly face-to-face or telephone mentoring meetings organized by

the mentor pairs, using an action learning model

• monthly email contact with the program facilitators

• program facilitators attending at least one meeting of each mentor

pair; and

• participation in evaluation of the program via pre and post

questionnaire.

Evaluation

The Leadership Practices Inventory (LPI) (Posner and Kouzes 1988, Posner and

Kouzes 1993) was used as a measure of nursing leadership ability (Martin et al.

2010, Tourangeau and McGilton 2004), as the Inventory is able to distinguish

between transformational and transactional leadership (Fields and Herold 1997).

Transformational Leadership

The LPI is based on five leadership practices comprising:

• Challenging the Process

• Inspiring a Shared Vision

• Enabling Others to Act

• Modelling the Way and

• Encouraging the Heart.

The first four practices are related to transformational leadership,

while aspects of the last three practices, with most of the aspects of

Enabling Others to Act, are more closely related to transactional

leadership.

Evaluation

•Participants completed a Pre and Post questionnaire

•Formally evaluated as a pre-post longitudinal intervention study, it is

hoped that the resulting report will guide the development of an

ongoing Victorian NPC mentorship program.

•Two of the mentors experienced changes in their job roles during

the program and were not able to continue as mentors

> Both were replaced.

•The mentors and the NPCs qualitatively evaluated the program as

successful and quantitative data illustrated significant improvement

in self-reported leadership practices among the NPCs.

Reported Improvements in Leadership Skills

In the open-ended questions NPCs and mentors identified aspects of clinical

leadership they felt they had developed during the program.

Figure 1 Reported improvement in leadership skills

NPCs reported significant improvement from the beginning to the end of

the program in eight items of the Leadership Practices Inventory:

Items Leadership Practices

Inventory

T Df Sig

Talk about future trends that will influence how our work gets done. 2.1 28.1 .041

Describe a compelling image of what our future could be like. 3.1 28.9 .005

Actively listen to diverse points of view. 2.1 27.5 .048

Make it a point to let people know about my confidence in their

abilities.

2.4 25.8 .025

Appeal to others to share an exciting dream of the future. 2.1 28.7 .041

Show others how their long term interests can be realised by

enlisting in a common vision.

3.1 25.2 .005

Publicly recognise people who exemplify commitment to shared

values.

2.1 27.3 .044

Build consensus around a common set of values for running our

area.

2.4 24.6 .025

Changes Reported by NPCs Post Program

Table 2: Leadership practices inventory significant differences pre- and post-program for participating NPCs

Changes Reported by NPCs Post Program

•NPCs reported greater competence in the Inspiring a Shared

Vision aspects of transformational leadership, which relates very

closely to the NPC clinical leadership standard.

•Unlike the initial survey with 18 items where the NPCs were

significantly less confident in their leadership abilities than the

mentors, at the conclusion of the program there were no Leadership

Practice Inventory components with significant differences between

the mentors and NPCs.

Discussion

The measures were all self-reports so did not gauge organisational impact

The focus: preparation for endorsement so organizational and health

system impacts were secondary, however the by-line was Developing

Nurse Leaders in Victoria.

Nursing and Midwifery Workforce (NMW) are also looking to the qualitative

data to address these shortcomings:

• Mentors stated they had learnt a great deal about the NP role,

• their capacity to develop these roles in their own organisations and

• the governance structures required to support NP model development

activities

NMW have therefore gained a cohort of highly engaged nurse leaders and

key stakeholders in the formal review of the VNPP

The Report

26

References Australian Nursing and Midwifery Council (2006) National Competency Standards for the Nurse

Practitioner.

Daniels, M. (2004) Mentoring: Link to the future. Reflections on Nursing Leadership, 30(3), 24-25.

Dunn, R. (1984) Learning style: state of the science. Theory into Practice, 23(1), 10-19.

Fields, D.L. & Herold, D.M. (1997) Using the Leadership Practices Inventory to measure

transformational and transactional leadership. Educational and Psychological Measurement, 57,

569-79.

Martin, J.S., Frei, J.A., Suter-Hofmann, F., Fierz, K., Schubert, M. & Spirig, R. (2010) Evaluation of

nursing and leadership competencies - a baseline for practice development. Pflege, 23(3), 191-

203.

Martin, J.S., McCormack, B., Fitzsimons, D. & Spirig, R. (2011) Evaluation of a clinical leadership

programme for nurse leaders. Journal of Nursing Management, 20(1), 72-80.

McCloughen, A., O'Brien, L. & Jackson, D. (2006) Positioning mentorship within Australian nursing

contexts - a literature review. Contemporary Nurse, 23(1), 120-134.

Posner, B.Z. & Kouzes, J.M. (1988) Development and validation of the Leadership Practices Inventory.

Educational and Psychological Measurement, 48(2), 483-96.

References

Posner, B.Z. & Kouzes, J.M. (1993) Psychometric properties of the Leadership Practices

Inventory - Updated. Educational and Psychological Measurement, 53, 191-9.

Reay, T., Golden-Biddle, K. & Germann, K. (2003) Challenges and leadership strategies for

managers of nurse practitioners. Journal of Nursing Management, 11(6), 396-403.

Sheridan, J.E. & Vredenburgh, D.J. (1978) Predicting leadership behavior in a hospital

organization. Academy of Management Journal, 21, 679-689.

Tourangeau, A. & McGilton, K. (2004) Measuring leadership practices of nurses using the

leadership pracfices inventory. Nursing Research, 53(3), 182-9.

van Soeren, M., Fraser, B. & Sanders, J. (2007) NP Roles in Ontario: Looking to the Future. .

Nurse Practitioners' Association of Ontario, Toronto.

Vance, C. & Olsen, R.K. (1998) The mentor connection in nursing, Springer Publishing

Company, NewYork.

QUESTIONS / COMMENTS