Advanced Nurse Practitioner Emergency Service

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Advanced Nurse Practitioner (Emergency) Service

• Margaret Mallen
• Advanced Nurse Practitioner
• (Emergency)

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Emergency Services

• Monaghan General hospital is in a unique position
  in the HSE Dublin North East region with regard
  to emergency services as it is the only hospital
  without an emergency department .

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• Various reports commissioned nationally and by
  the then NEHB outlined the necessity for the
  development of a minor injuries unit in Monaghan
  General Hospital and the establishment of an
  Advanced Nurse Practitioner (ANP) service within
  that unit.

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Reports

• National Health Strategy (2001)
• St. Pauls HRRI Report (2001)
• St. Pauls Consultancy (2003)

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Reports

• Bonner Report (2003)
• Comhairle na nOspideal (2002)
• Hanley Report (2003)
• Teamwork (2006)

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• The Quality and Fairness Document (2001) outlined
  the requirement for the management of non-urgent
  cases within minor injuries units under the
  auspices of Advanced Nurse practitioners.

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Establishing the service

• Based on a perceived service need
• Established using the criteria set out by the
  National Council for the Professional Development
  of Nursing and Midwifery (NCNM)

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Establishing the service

• The CNM2 for the then Treatment room and the ADON
  sourced advanced practice programmes nationally
  and opted to go for the UCD MSc in Advanced
  Nursing Practice.
• It was agreed that the successful candidate would
  be seconded to OLOLH Drogheda to gain the
  necessary clinical expertise.

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Education

• UCD MSc in Nursing (advanced practice).
• Generic programme.
• Documentation and history taking.

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Education

• Pathology, physiology, pharmacology, complete
  physical assessment.
• No specific minor injuries component

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Supervised Practice

• ANP spent 18 months in the Emergency department
  of OLOLH
• 1000 hrs supervised practice under care of
  consultant in emergency medicine in Our Lady of
  Lourdes Hospital.
• Weekly teaching sessions with emergency
  department SHOs. Individualised teaching as
  deemed appropriate by consultant.

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Clinical Protocols

• It was agreed collaboratively between the ANPs,
  Directors Of Nursing and the lead consultant in
  emergency medicine regionally that ANPs
  (Emergency) in Monaghan General hospital and Our
  Lady of Lourdes in Drogheda would treat both
  adults and children presenting with minor
  injuries.

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Scope of Practice

• Assess
• Diagnose
• Treat
• Discharge
• Refer to other appropriate services

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Referrals From ANP
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Core Concepts NCNM (2001)
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Liability

• Covered by the Clinical Indemnity Scheme (CIS)

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Types of injuries

• Minor head and facial trauma
• Lacerations to face ,trunk and limbs
• Skeletal and soft tissue injuries
• Initial management of fractures
• Hand and fingertip injuries
• Minor burns
• Eye injuries

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Issues

• Radiology
• Prescribing

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Other protocols/guidelines

• Interhospital transfer protocols for paediatrics,
  orthopaedics and surgical patients
• Regional wound management guidelines
• Infection control guidelines

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MINOR INJURIES TREATMENT UNIT

• Monaghan General hospital has a 6 bedded Minor
  injuries Treatment Unit which is the designated
  area for the assessment and treatment of patients
  presenting with minor injuries and medical
  conditions. The ANP has a dedicated room in this
  department.

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ANP Room
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Today's service

• Based in MITU
• All adults and children presenting with minor
  injuries can be treated by the ANP
• Provide supervision and teaching for nursing
  staff within the unit, including mentoring
  student undertaking post graduate programmes.

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Today's service

• Consultants in charge of the Minor Injuries
  Treatment Unit provide supervision on site as
  required for the ANP
• ANP attends weekly SHO teaching by the Consultant
  in Emergency Medicine in Cavan General Hospital
  Emergency department

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Today's service

• Consultant in Emergency Medicine Cavan/Monaghan
  Based in CGH with weekly sessions here does
  regular chart reviews for the ANP.
• Dedicated research time, used for audit, record
  keeping, research, networking and support

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Today's service

• I network regionally with other emergency ANPs in
  OLOLH.
• Present at regional and national conferences and
  workshops on advanced practice for the NCNM and
  the NMPDU

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Today's service

• Keep up with my basic nursing skills by being
  actively involved as part of the nursing team.
• Looking forward to other ANPs coming on board

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DEVELOPING AN ADVANCED NURSE PRACTITIONER
SERVICE IN EMERGENCY NURSING

• SIOBHAN ROTHWELL
• Advanced Nurse Practitioner (Emergency)

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OUR LADY OF LOURDES HOSPITAL, DROGHEDA
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IDENTIFICATION OF SERVICE NEED

• Analysis of Emergency Department statistics
• Review of range of injuries and conditions
• Adult and paediatric service needs
• Waiting times
• Quality of service
• Career pathways in nursing

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Educational and Training Requirements

• Direction from the National Council for Nursing
  and Midwifery
• Educated to masters level (or higher)
• Substantive clinical component
• Supervised practice to level of competency

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EDUCATION

• MSc Nursing T.C.D.
• Clinical Module St James Hospital
• Clinical Diagnostic Skills for Advanced Nurse
  Practitioners (Emergency Nursing)

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CLINICAL MODULE

• Anatomy
• Theory and Practice of Injury and Wound
  Management
• Documentation and History Taking
• Radiology
• Pharmacology
• Supervised Practice

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SUPERVISED PRACTICE

• St James Hospital (under supervision of ANPs)
• Our Lady of Lourdes Hospital (under supervision
  of Consultant in Emergency Medicine)

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SCOPE OF PRACTICE

• Adult Minor Injuries
• Paediatric Minor Injuries
• - Significant service need
• - Consultant led education and supervised
  practice
• Clinical Protocols developed collaboratively

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ISSUES IN PRACTICE

• Radiology
• Prescribing

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SITE PREPARATION AND JOB DESCRIPTION

• Working group established following a meeting
  with the National Council
• Comprised of DONs both sites (Drogheda and
  Monaghan)
• ED Consultant
• Representative NMPDU
• Practice Development
  Nurse
• Nurse Managers ED
• Nurses pursuing
  Accreditation

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MINOR INJURIES UNIT
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MINOR INJURIES UNIT
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CLINICAL PROTOCOLS

• Scope of practice
• Service need
• Collaboration with Consultant in Emergency
  Medicine
• Evidence based practice
• Nursing perspective
• Adult and Paediatric Protocols

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The Service Today

• 1 accredited ANP
• 2 ANP Candidates
• 7 day service
• Involvement in education and audit
• Resource for colleagues

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The Service Today

• Site for other ANP candidates to receive specific
  training particularly in minor injuries in
  children
• Leadership opportunities within working groups
  and clinical committees
• Management of adults and children presenting with
  a range of minor injuries

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PLANS FOR THE FUTURE

• Increase in number of ANPs in Emergency Nursing
  in the HSE North East Region
• Expansion of Scope of Practice as determined by
  service need
• Cross-site research and audit to add to the body
  of knowledge and enhance the quality of patient
  care
• Potential to become a formal training site for
  ANPs (Emergency)

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Site preparation/job description

• Margaret Mallen
• Advanced Nurse Practitioner
• Emergency

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National Council for Nursing and Midwifery

• Developed a definition for the Advanced Nurse
  Practitioner Role
• Laid down minimum educational and experiential
  requirements

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National Council for Nursing and Midwifery

• Identified 4 core concepts which defines the role
  of the ANP
• Outlined a process of site and personal
  development leading to accreditation

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SITE PREPARATION AND JOB DESCRIPTION

• Working group established following a meeting
  with the National Council
• Comprised of DONs both sites (Drogheda and
• Monaghan)
• ED Consultant
• Representative NMPDU
• Practice Development
  Nurse
• Nurse Managers ED
• Nurses pursuing
  Accreditation

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SITE PREPARATION

• Health needs
• Laws, rules, regulations and guidelines governing
  nursing and midwifery practice
• Vicarious Liability

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SITE PREPARATION

• Guidelines for good practice
• Benefits to patients from the ANP service
• Consistency of service within Organisational
  Philosophy

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SITE PREPARATION cont/d

• How change will meet the service plan
• Location of the service
• Integration of the ANP into the multidisciplinary
  team

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SITE PREPARATION cont/d

• Definition of the role content within the
  framework of nursing
• Resource implications

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JOB DESCRIPTION

• Background to post
• Generic Background
• Specific Background

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JOB DESCRIPTION

• Evolution of the role of the Advanced Nurse
  Practitioner
• Effects of policy changes on Professional
  Practice in the Region

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JOB DESCRIPTION cont/d

• Geographical aspects of the service/demographics
  of the region
• Service Need
• Purpose of the post

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CLINICAL PROTOCOLS

• Scope of practice
• Service need
• Collaboration with Consultant in Emergency
  Medicine
• Evidence based practice
• Nursing perspective
• Adult and Paediatric Protocols

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SCHEDULE OF EVENTS

• Guidance from the National Council
• Bi-monthly meetings of the working group
• Goals identified and set

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• Time frame highlighted
• Objectives achieved

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TIME FRAME

• June 2003 Met with NCNM
• November 2003 1st draft of Site Preparation and
  Job Description document
• January 2004 2nd Draft sent to NMPDU

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TIME FRAME

• March 2004 - Met with NMPDU to review document
  and prepare for final submission
• April 2004 Submission of document
• May 2004 Review by Accreditation Committee
• September 2004 Site Visit
• Submission of Personal Portfolio

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SUBMISSION DOCUMENT

• Developed collaboratively
• Different service needs identified
• National Council Framework Document (2001) used
  as a template

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SUBMISSION DOCUMENT

• NCNM provided support and direction
• Drafts x 2 submitted before completion of final
  document

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SUBMISSION DOCUMENT cont/d

• Site preparation and job description
• Relevant appendices
• Reference list
• Clinical Protocols

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SUBMISSION DOCUMENT cont/d

• Application form
• Letters from DON and NMPDU
• Financial approval form

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CHALLENGES

• Time management combining MSc with Site
  Preparation Process
• Meeting targets regular meetings with the
  working group
• Fostering understanding of the role across the
  MDT
• Paediatrics was a bone of contention for both
  sites

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STRENGTHS

• Team building
• Support
• Ownership of the process
• Sense of achievement
• Job satisfaction

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Considerations when Developing an ANP Service

• Siobhan Rothwell
• ANP (Emergency)

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Scope of Practice

• Scope of Nursing and Midwifery Practice Framework
  (2000)
• Provided nurses and midwives with professional
  guidance and support on matters relating to
  clinical practice
• Uses a decision-making framework to assist
  within scope of clinical practice

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What is Scope of Practice?

• Range of roles, function, responsibilities and
  activities which a registered nurse or midwife is
  educated, competent and has the authority to
  perform
• It is determined by legislation, E.U directives,
  international developments, social policy,
  national and local guidelines, education and
  individual levels of competence
• (An Bord Altranais 2000a)

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Aims of the Framework

• Provides principles which should be used to
  review, outline and expand parameters of practice
• Support and promote best practice
• Seen as an enabling document
• Promotes flexible and innovative practice
• (An Bord Altranis 2000a)

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Considerations in determining Scope of Practice

• Competence
• Accountability
• Autonomy
• Continuing Professional Development

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Competence

• The ability of the nurse or midwife to practice
  safely and effectively fulfilling their
  professional responsibility within their scope of
  practice
• Judgement
• Develop and maintain competence (competence is
  not static)
• Acknowledge limitations

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Accountability

• Being answerable for the decisions made in the
  course of professional practice
• Must be prepared to make explicit the rationale
  for decisions made
• Accountable legally and professionally
• Accountable to the patient, the public,
  regulatory body, employer and any relevant
  supervisory authority
• Applies to actions and omissions

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Autonomy

• Accountability cannot be achieved unless autonomy
  is in place
• The freedom to make discretionary and binding
  decisions in accordance with scope of practice
  and to act on those decisions

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Continuing Professional Development

• Encompasses experiences, activities and process
  which contribute towards the development of the
  professional
• Lifelong process of learning structured and
  informal
• Planned learning experiences designed to augment
  knowledge, skills and attitudes

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Continuing Professional Development

• Essential to practice efficiently and safely in
  an ever-changing healthcare environment
• Required in order to maintain and enhance
  professional standards and provide the highest
  quality healthcare

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Principles for determining Scope of Practice

• Is primary motivation in the best interest of the
  patient?
• Will expansion be within the definition and
  values of nursing and midwifery?
• Is expansion made with due consideration to
  legislation, policies and guidelines?
• Is the nurse/midwife competent?

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Principles for determining Scope of Practice
cont/d

• Will the nurse/midwife take measures to maintain
  competence and acknowledge limitations of
  practice?
• Is expansion based on appropriate assessment,
  planning, communication and evaluation?
• Is the delegating nurse/midwife aware they are
  accountable for the delegated role?
• All nurses and midwives are accountable for their
  practice

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Protocols

• Clinical practice protocols
• Adults and children with specific considerations
  within both
• Medication management protocols for adults and
  children
• Collaboratively developed
• Reviewed every 2 years

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Core Concepts of Advanced Practice

• Provision of expert care
• Accepting the concepts of autonomy and
  accountability
• Education of others in the MDT
• Audit of practice
• Identification of research topics and undertaking
  and collaboration in the process of research
• NCNM 2004

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Expert Care

• Articulates and demonstrates concepts of nursing
  practice within parameters
• Advanced decision-making
• Health promotion priorities
• Implements health
• promotion strategies

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Autonomy and Accountability

• Accountable and responsible for practice
• Performs comprehensive assessments
• Plans and initiates care
• Uses professional
• judgement in referral
• to other healthcare
• agencies

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Professional and Clinical Leadership

• Vision
• Contributes to professional and policy
  development
• Initiates and implements change
• Mentorship
• Leadership in practice
• Contributes to the professional body of nursing
• Identifies needs and leads development of
  clinical standards

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Audit and Research

• Identifies research priorities
• Leads, conduct and disseminates research
• Initiates, participates in and evaluates audit
• Uses outcomes to improve
• service provision
• NCNM 2004

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Collaboration
ANP
Patient
Doctor
Allied Health Professionals
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Barriers to Role Development

• Few barriers to role development
• Nurse prescribing and role autonomy
• Radiology issues
• Complexity of role lack of understanding
• Attending to all 4 competencies

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Drivers to Role Development

• Buy-in from the beginning from all stakeholders
• Goal setting and meeting deadlines
• Bi-monthly review of progress
• Input and support from National Council for
  Nursing and Midwifery
• On-going support from nursing management

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Philosophies of Care

• Adults
• ..acknowledge the individual needs of each
  patient and through a partnership approach,
  provide a responsive, effective service which
  incorporates advanced decision-making and an
  innovative approach to care while retaining the
  philosophical underpinnings of nursing

• Children
• ..to provide holistic, child orientated and
  evidence-based quality care for children and
  their families. Every child and family will be
  treated on an individual basis with respect and
  dignity. We aim to support parents in looking
  after their sick or injured child by providing
  high quality, advanced nursing care and
  appropriate education

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QUESTIONS?