The Development The Development of an of an

Advanced Nurse Advanced Nurse PractitionerPractitioner

RoleRole

Valerie Small. Valerie Small. RGN. RNT. MSc. PG Dip CHSE.A&E Cert.RGN. RNT. MSc. PG Dip CHSE.A&E Cert.

Advanced Nurse Practitioner (Emergency)Advanced Nurse Practitioner (Emergency)

St James’s HospitalSt James’s Hospital

DublinDublin

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ResumeResume• Registered General NurseRegistered General Nurse• Registered Nurse TutorRegistered Nurse Tutor• SpecialisedSpecialised in A&E Nursing: 20+ years in A&E Nursing: 20+ years• Post registration qualification in A&E NursingPost registration qualification in A&E Nursing• Masters in Nursing, Trinity College DublinMasters in Nursing, Trinity College Dublin• Post-graduate diploma in Clinical Health Post-graduate diploma in Clinical Health

Sciences Education, Trinity College DublinSciences Education, Trinity College Dublin• Member of National Council for Professional Member of National Council for Professional

Development of Nursing & MidwiferyDevelopment of Nursing & Midwifery• Developed first accredited ANP site in IrelandDeveloped first accredited ANP site in Ireland• First accredited Advanced Nurse PractitionerFirst accredited Advanced Nurse Practitioner• Lecturer/course coordinator advanced nurse Lecturer/course coordinator advanced nurse

practitioner programme practitioner programme

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IntroductionIntroduction• International Development of Advanced International Development of Advanced

Practitioner RolesPractitioner Roles

• Framework for establishment/development Framework for establishment/development of Advanced Practitioner Roles in Irelandof Advanced Practitioner Roles in Ireland

• Experiences of Developing ANP Sites in Experiences of Developing ANP Sites in Emergency Nursing in IrelandEmergency Nursing in Ireland

• Educational ProgrammesEducational Programmes

• Emerging ANP Roles in IrelandEmerging ANP Roles in Ireland

• Role Development-Getting StartedRole Development-Getting Started

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International DevelopmentsInternational Developments

• New South WalesNew South Wales

• Western AustraliaWestern Australia

• New ZealandNew Zealand

• CanadaCanada

• UKUK

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• Statutory body established 1999 to oversee Statutory body established 1999 to oversee continuing professional development of nursing & continuing professional development of nursing & midwiferymidwifery

• Establish definitions of Clinical Nurse/Midwife Establish definitions of Clinical Nurse/Midwife Specialist/Advanced Nurse/Midwife PractitionerSpecialist/Advanced Nurse/Midwife Practitioner

• Monitor development of specialist roles in Monitor development of specialist roles in association with NPDU’sassociation with NPDU’s

• Fund continuing education programmes for nurses Fund continuing education programmes for nurses and midwivesand midwives

National Council National Council for the for the Professional Development ofProfessional Development ofNursing and MidwiferyNursing and Midwifery (NCNM) (NCNM)

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National Council National Council for thefor theProfessional Development Professional Development ofofNursing and MidwiferyNursing and Midwifery

• Framework for establishment of ANP Framework for establishment of ANP Nursing/Midwifery roles (2001)Nursing/Midwifery roles (2001)– Site Preparation and Approval of PostSite Preparation and Approval of Post– Accreditation of Advanced PractitionerAccreditation of Advanced Practitioner

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Site Preparation Site Preparation

• Service Need Identified Service Need Identified • Collaboration of Key StakeholdersCollaboration of Key Stakeholders• Funding of post identified within Funding of post identified within

service planservice plan• Principle of Vicarious Liability Principle of Vicarious Liability

AcceptedAccepted• Understanding of legislation, rules, Understanding of legislation, rules,

guidelines relating to nursing (guidelines relating to nursing (non-non-nursing stakeholdersnursing stakeholders) )

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Site Preparation Site Preparation • Job Description/ Scope of Practice AgreedJob Description/ Scope of Practice Agreed

• Reporting Relationships established.Reporting Relationships established.

• Audit Procedures OutlinedAudit Procedures Outlined

• Location of Service/Clinical Space/Access Location of Service/Clinical Space/Access to ITto IT

• Integration of role within Integration of role within nursing/midwifery servicenursing/midwifery service

• Integration of role within Integration of role within multidisciplinary teammultidisciplinary team

• Other Resource Implications (training, Other Resource Implications (training, study leave, clerical supportstudy leave, clerical support))

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Personal CriteriaPersonal Criteria• RGN/RMRGN/RM• Masters Degree (or Higher)Masters Degree (or Higher)• 7 years post-registration experience (5 7 years post-registration experience (5

specialist area)specialist area)• Substantive hours at supervised Substantive hours at supervised

advanced practiceadvanced practice• Have competence to exercise higher Have competence to exercise higher

levels of judgment and decision making levels of judgment and decision making in the clinical area in the clinical area

• Demonstrates Competence in specialist Demonstrates Competence in specialist areaarea

• Evidence of Continuing Professional Evidence of Continuing Professional DevelopmentDevelopment

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Development of ANP Roles in Development of ANP Roles in Emergency NursingEmergency Nursing

• St James’s Hospital – 1996 (pilot St James’s Hospital – 1996 (pilot project)project)

• Mater Mater Hospital - 2000Hospital - 2000

• James Connolly Memorial Hospital - James Connolly Memorial Hospital - 20002000

• AMNCH - 2001AMNCH - 2001

• Our Lady of Lourdes - 2002Our Lady of Lourdes - 2002

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St James’s Hospital 1996 St James’s Hospital 1996 Pilot Project: Pilot Project: • AIM AIM

– To train a suitably qualified, experienced To train a suitably qualified, experienced emergency nurse to independently emergency nurse to independently assess, diagnose, treat, discharge / refer assess, diagnose, treat, discharge / refer patients with a range of common patients with a range of common injuries which present to the emergency injuries which present to the emergency department.department.

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RationaleRationale•To develop a clinical career To develop a clinical career

pathway for experienced pathway for experienced emergency nursesemergency nurses

•To enhance the quality of service To enhance the quality of service delivered by the multi-delivered by the multi-disciplinary team (MDT) to disciplinary team (MDT) to patients with minor injury and patients with minor injury and illnessillness

•To provide a timely, but safe, To provide a timely, but safe, service for patients leading to service for patients leading to improved patient satisfactionimproved patient satisfaction

•To release physician time to deal To release physician time to deal with increasingly acute workload with increasingly acute workload

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ED ActivityED Activity

• Located inner city Dublin,IrelandLocated inner city Dublin,Ireland

• Catchment area:Catchment area: ¼ ¼ million million patientspatients

• 50,000 New Patients annually50,000 New Patients annually

• Primary health care facility for Primary health care facility for many patientsmany patients

• Initiative on nurse practitioner Initiative on nurse practitioner service proposed & piloted 1996service proposed & piloted 1996

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Scope of PracticeScope of Practice

• AssessAssess

• DiagnoseDiagnose

• TreatTreat

• DischargeDischarge

• Refer to other appropriate serviceRefer to other appropriate service

• AuditAudit

• ResearchResearch

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Scope of PracticeScope of PracticeTypes of InjuryTypes of Injury• Minor Head Minor Head & &

Facial Facial Injury Injury • Laceration face, Laceration face,

trunk & limbtrunk & limb• Skeletal & Soft Skeletal & Soft

tissue tissue injuryinjury• Initial management Initial management

of fracturesof fractures• Hand & fingertip Hand & fingertip

InjuryInjury• Minor burns < 2% Minor burns < 2%

TBSATBSA• Soft tissue infectionSoft tissue infection• Incision & drainage Incision & drainage

abscessabscess

Referral ArrangementReferral Arrangement• RadiologyRadiology• OOPDPD• PhysiotherapyPhysiotherapy• Occupational therapyOccupational therapy• Social Work Social Work

DepartmentDepartment• Primary care providerPrimary care provider• Outside Agencies Outside Agencies

Homeless, Drug Homeless, Drug treatment services, treatment services, woman's aid woman's aid

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Audit Audit • Daily activity documented since Daily activity documented since

1996 and collated monthly 1996 and collated monthly • Annual activity published Annual activity published • Continuous Audit on clinical Continuous Audit on clinical

aspects of care & patient aspects of care & patient outcome outcome

• Quantitative & Qualitative Quantitative & Qualitative research on range of aspects research on range of aspects related to servicerelated to service

• 29,000 Patients treated 1996-29,000 Patients treated 1996-20032003

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Audit of Patient FlowAudit of Patient Flow

Attendance Time %Patients

00:00-04:00 11.88%

04:00-08:00 6.39%

08:00-12:00 21.60%

12:00-16:00 25.86%

16:00-20:00 18.84%

20:00-00:00 15.43%

TOTAL 100.00%

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Audit of Activity 98-03Audit of Activity 98-03

ANP Activity 1998-2003

0200400600800

Month

Num

ber o

f Pa

tient

s

1998

1999

2000

2001

2002

2003

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Current ActivityCurrent Activity• 4 Advanced Nurse Practitioner 4 Advanced Nurse Practitioner

Sites and Posts approved by Sites and Posts approved by NCNM NCNM

• 4 Accredited 4 Accredited ANP’sANP’s (Emergency) (Emergency)• 2 Further applications to NCNM- 2 Further applications to NCNM-

Site Approval /AccreditationSite Approval /Accreditation• Expansion in range of Expansion in range of

activities/scope of practice activities/scope of practice • Research clinical Research clinical

issues/professional developmentissues/professional development

2020

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Education Programmes Education Programmes (Advanced Practice Strand)(Advanced Practice Strand)

• The University of Dublin, Trinity The University of Dublin, Trinity College College

• University College, DublinUniversity College, Dublin

• University College, GalwayUniversity College, Galway

• University College, Cork (In progress)University College, Cork (In progress)

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Advanced Practice StrandsAdvanced Practice Strands

• Clinical Diagnostic Skills for Clinical Diagnostic Skills for Advanced Nurse Practitioner Advanced Nurse Practitioner (Emergency) in Association with TCD(Emergency) in Association with TCD

• Generic MSc programme with Generic MSc programme with advanced practice strand-UCD, UCG, advanced practice strand-UCD, UCG, UCCUCC

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Clinical Diagnostic Skills for Clinical Diagnostic Skills for Advanced Nurse Practitioner Advanced Nurse Practitioner (Emergency)(Emergency)• Module on MSc in Nursing, Trinity Module on MSc in Nursing, Trinity

College DublinCollege Dublin• Stand alone option: criteria applied for Stand alone option: criteria applied for

entryentry• 10 weeks theory/applied anatomy10 weeks theory/applied anatomy• 10 weeks observation of expert 10 weeks observation of expert

practicepractice• Clinical Competency Assessment Clinical Competency Assessment • Theoretical AssessmentTheoretical Assessment• 500 Hours clinically supervised practice 500 Hours clinically supervised practice

in students ED prior to formal signing in students ED prior to formal signing offoff

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Developing Sites Developing Sites (Emergency)(Emergency)

• 5- St James’s Hospital (+1)5- St James’s Hospital (+1)

• 4- Mater Hospital4- Mater Hospital

• 2- James Connolly Memorial Hospital2- James Connolly Memorial Hospital

• 1- AMNCH1- AMNCH

• 1- Our Lady of Lourdes Hospital1- Our Lady of Lourdes Hospital

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Emerging ANP RolesEmerging ANP Roles• GeneralGeneral Breast CareBreast Care

Pain ManagementPain ManagementEmergencyEmergencyCardiac SurgeryCardiac SurgeryDiabetesDiabetesChest pain assessmentChest pain assessmentIntensive Care(Outreach Service)Intensive Care(Outreach Service)

• PsychiatryPsychiatry AddictionAddictionFamily InterventionFamily InterventionChild & Adolescent ServicesChild & Adolescent ServicesLiaison (Emergency)Liaison (Emergency)BereavementBereavementBehavioral TherapyBehavioral Therapy

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Emerging ANP RolesEmerging ANP Roles• Care of the ElderlyCare of the Elderly Stroke CareStroke Care

RehabilitationRehabilitation

• MidwiferyMidwifery Midwifery led care Midwifery led care hospital/communityhospital/community

• NeonatalNeonatal Neonatal Intensive CareNeonatal Intensive Care

• PaediatricPaediatric EmergencyEmergencyCystic FibrosisCystic FibrosisHaematology/OncologyHaematology/Oncology

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Accredited ANP’sAccredited ANP’s

• 4- Emergency4- Emergency

• 1-Sexual Health1-Sexual Health

• 1-Rheumatology1-Rheumatology

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Role Development :Role Development :Getting StartedGetting Started

•NO QUICK FIXNO QUICK FIX

•NOT A CHEAP OPTIONNOT A CHEAP OPTION

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Role DevelopmentRole Development• Identify Service Need- AuditIdentify Service Need- Audit

– Service drivenService driven– Client group identifiedClient group identified– Stakeholder ‘BY IN’Stakeholder ‘BY IN’

• Identify Resources- (personnel & Identify Resources- (personnel & Finance)Finance)– Change Agent (not always MSc prepared)Change Agent (not always MSc prepared)– MotivationMotivation– ExperienceExperience– Ability to succeedAbility to succeed

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Role DevelopmentRole Development• Establish ‘working group’ (MDT)Establish ‘working group’ (MDT)

– Set GoalsSet Goals– Specify action stepsSpecify action steps– Establish timelinesEstablish timelines– Identify indicators of successIdentify indicators of success

• Network with established ANP sites Network with established ANP sites

• Contact NCNM for advice and Contact NCNM for advice and assistanceassistance

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Useful ContactsUseful ContactsNational Council ExecutiveNational Council Executive• Kathleen Mac Lellan: Head Professional Kathleen Mac Lellan: Head Professional

DevelopmentDevelopment• Mary Farrelly :Professional Development Officer Mary Farrelly :Professional Development Officer

(psychiatry)(psychiatry)• Jenny Hogan : Professional Development Officer Jenny Hogan : Professional Development Officer

(general)(general)• Christine Hughes: Professional Development Christine Hughes: Professional Development

Officer (Mental Handicap)Officer (Mental Handicap)• Georgina Farren : Professional Development Georgina Farren : Professional Development

Officer (Midwifery)Officer (Midwifery)• www.ncnm.i.e.www.ncnm.i.e.• Email: Email: admin@ncnm.ieadmin@ncnm.ie

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Relevant SitesRelevant Sites• American Academy of Nurse Practitioners- American Academy of Nurse Practitioners-

www.aanp.orgwww.aanp.org • Australian Nurse Practitioner’s Association Australian Nurse Practitioner’s Association

www.nursing.aust.edu.auwww.nursing.aust.edu.au• Department of Health (WA)- Department of Health (WA)-

www.nursing.health.wa.gov.auwww.nursing.health.wa.gov.au• The Nurse Practitioner Association of Ontario- The Nurse Practitioner Association of Ontario-

www.npao.orgwww.npao.org • New South Wales Health-Nurse Practitioner New South Wales Health-Nurse Practitioner

www.health.nsw.gov.au/nursing,noract.htmlwww.health.nsw.gov.au/nursing,noract.html • New Zealand Nursing Council-Nurse Practitioner New Zealand Nursing Council-Nurse Practitioner

www.nursingcouncil.org.nz/nursepractioner.htmlwww.nursingcouncil.org.nz/nursepractioner.html• Nurses Board of South Australia Nurses Board of South Australia

www.nursesboard.sa.gov.au/www.nursesboard.sa.gov.au/ • NHS.National Institute of Clinical Excellence. NHS.National Institute of Clinical Excellence.

www.nice.org.uk/www.nice.org.uk/