Advanced Practice in Diabetes'

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Advanced Practice in Diabetes.

• Helen Burke
• Advanced Nurse Practitioner (Diabetes)
• University College Hospital Galway.

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Definition of Advanced Nurse/Midwife Practitioner
(Ireland)

• Grounded in the theory and practice of
  nursing/midwifery
• Incorporates other related research, management
  and leadership theories and skills
• To encourage a collegiate, multidisciplinary
  approach to quality patient/client care
• ANP/AMP roles developed in response to
  patient/client need and healthcare service
  requirements at local, national and international
  level
• ANPs/AMPs must have a vision of areas of practice
  that can be developed beyond the current scope of
  practice and a commitment to the development of
  these areas

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Criteria for Approval as ANP

• Have a minimum of 7 years post-registration
  experience, which will include 5 years experience
  in the chosen area of specialist practice
• Have substantive hours at supervised advanced
  practice level.
• Have the competence to exercise higher levels of
  judgement, discretion and decision making in the
  clinical area above that expected of the
  nurse/midwife working at primary practice level
  or the clinical nurse/midwife specialist
• Demonstrate competencies relevant to context of
  practice and
• Provide evidence of continuing professional
  development.

• Be a registered nurse or midwife on An Bord
  Altranais live register
• Be registered in the division of An Bord
  Altranais register for which application is being
  made (in exceptional circumstances which must be
  individually appraised, this criterion may not
  apply)
• Be educated to masters degree level (or higher).
  The post-graduate programme must be in
  nursing/midwifery or an area which is highly
  relevant to the specialist field of practice
  (educational preparation must include a
  substantial clinical modular component(s)
  pertaining to the relevant area of specialist
  practice)

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Diabetes Mellitus

• It is estimated that 194 million people worldwide
  have diabetes with this figure expected to
  double by 2025.
• IDF (2003) described diabetes alongside global
  warming ,emerging diseases and environmental
  pollution as one of the worlds biggest
  environmental disasters.
• The effect of Aids in the last 20 years will be
  repeated by diabetes in this century

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• The alarming increase in diabetes is as a result
  of ageing populations, dietary changes, reduced
  physical activity and other unhealthy and
  behavioural patterns.
• A new trend of increasing cases of type 2
  diabetes in children and adolescents is emerging.
  These patients are likely to have kidney and
  cardiovascular disease much earlier in life,
  adding to the health economic burden (IDF 2003)
• The financial and social burden of diabetes will
  be intolerable if measures are not taken to
  address this disease.

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Diabetes Day Centre University College Hospital
Galway.

• Services provided focus on diagnosis, treatment
  and patient education.
• The centre facilitates many sub-specialist
  clinics/services to enhance care for patients
  with diabetes.
• Specialist clinics. Young Adults clinic/Combined
  nephrology and diabetes service/Combined
  obstetric and diabetes service and pre-pregnancy
  service / Obesity clinic/Annual review/foot
  clinic.
• Services provided include. Podiatry, Dietetics
  ,Psychology, Phlebotomy ,DAFNE, ,Telephone
  support service, Group education and Retinal
  screening.
• Paediatric/Adolescent Diabetes services are
  provided from the Paediatric unit/outpatients
  department.
• Transitional service.

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Getting Started
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Rationale for ANP in Diabetes.

• Develop clinical career pathway for an
  experienced nurse in Diabetes Care.
• Provide clinical leadership
• Enhance the quality of service delivered by the
  multi-disciplinary team to patients with diabetes
• Provide more timely, but safe, service leading to
  improved patient satisfaction
• Release physician time to deal with increasing
  acute workload

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Process.

• Service applies to have the post approved as an
  ANP/AMP post ( Job Description/Site Preparation)
• The nurse/midwife applies to be accredited as an
  ANP/AMP to the approved post( individual
  accreditation)

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My Journey.

• 2001-Establishment of the Diabetes Day Centre.
• 2001-Appointment of Professor of Medicine/
  Endocrinology
• 2002- The development of the ANP/Diabetes was
  discussed formally with nursing/medical
  management. The intention to develop the post was
  discussed with relevant stakeholders.
  (Consultants ,laboratory, nursing colleagues,
  dietetics, general practitioners).
• 2003- Commenced the Masters in Health
  Science/Advanced Practice at NUI Galway.
• 2004- Approval for post for ANP/Diabetes included
  in service plan.

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• 2005- preliminary job description submitted to
  NPDU.
• 2005- Completed Masters in Health Science/
  Completed supervised clinical hours.
• Multidisciplinary Working group established for
  candidate ANPs in UCHG/Mayo general/Portiuncla
  to discuss
• role development for the 3 sites/UCHG/Mayo
  General/Portiuncla Hospital
• Commenced work on site preparation.
• 2006- June/Site visit from National council.
  August- submitted Job portfolio. September
  received accreditation from the National Council.

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Site Preparation

• Review of National policy documents relevant to
  diabetes services.
• Review of research data pertaining to diabetes.(
  DCCT/UKPDS/ Diabetes Care Securing the Future).
• Review of service Adult and Paediatric need. (
  7,000 patient visits 2005).
• Audit current activity of service
• Service need established
• Client group caseload identified
• Identify outcome measurement
• Stakeholder BUY IN
• Demographics of region.( Fastest growing city in
  Europe, Student population, Tourism, 50 of
  boards population under 30 years, Higher
  percentage of people over 65 years 14 national
  average 11, Large rural population.
• Predictions for Future diabetes services based on
  demographics and epidemiology studies. (DFI 2003)

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Developing the Role while doing the masters.

• Supervised Clinical Hours.
• Meetings with Relevant Stakeholders.
• Meetings with Nursing Management to discuss site
  preparation.
• No Structured time to commence site
  preparation.

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Job description

• Detailed job description containing details of
  the role and responsibilities of the post,
  reporting relationships, reflecting the required
  experience and education as specified by the
  National council.
• Incorporate definition of ANP role, together with
  core competencies for the role.
• Autonomy in Clinical Practice.
• Expert Practitioner.
• Pioneering Professional and Clinical Leadership.
  
• Research.

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Clinical Supervision

• Major commitment required by clinical
  mentor/supervisors.
• Clinical Supervision by Professor of
  Endocrinology/Paediatrics.
• Planned supervision and Clinical skills
  assessment.

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Selling The Role.

• To ensure successful integration of the role
  employers and the ANP must give consideration to
  how best integrate the role in the context of
  the multidisciplinary team and the effect of the
  role on the work of other health care
  professionals.
• We spoke about the role and met with other health
  care professionals and departments that we would
  be referring patients to. Article in Newsletter.

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Service needs addressed by post.

• Education-Patients with Diabetes have many
  education needs. Therefore the health education
  component of the ANP role is central to the
  empowerment of patients/families.
• Specialised clinics. The benefits for specialist
  clinics for complicated groups have been well
  established and demonstrated( NICE 2004) The ANP
  has been central to the development of these
  clinics.
• We optimise care at clinics by attending to
  the special needs of these group of patients.
  Young Adults/Annual Review.

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• Paediatric/Adolescent Clinics. The diabetes
  service at UCHG provides a structured
  multidisciplinary service to this cohort of
  patients and their families.
• The ANP is actively involved in providing and
  optimising patient and family care
• Implemented transitional care for adolescents
  transferring to adult services.
• Service for schools
• Involved in the implementation of a support
  clinic
• BRUCIE Programme
• One home visit post discharge
• Implementation of NICE guidelines for the care of
  children/adolescents with diabetes
• Parent support workshops.

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• Linking Primary to secondary care.
• Involved in the development of a shared care
  scheme in the Galway area.
• Involved in the Development of Diabetes
  guidelines for the HSE West.
• Provide education programmes/workshops for
  GPS/Practice nurses/public health nurses.
• Involved in the development of the DESMOND
  Programme( hospital/community)
• Deliver the diabetes component of the Diabetes
  module for practice nurses NUI GALWAY/

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Advanced Nurse Practitioner

• Referral
• OPD
• IN-PATIENT Service. Adult/Paediatric.
• Maternity Services.
• Dietetics
• Social Work Department
• Primary care
• Podiatry.
• Health Promotion.

• Caseload
• Patients with Type 1 and Type 2 Diabetes. New
  onset Diagnosis. Existing patients.
• New Type 2 clinic/GP referral.
• Children 0-13 years.
• Adolescents 13-18 years.
• Support clinic/BRUCIE Programme
• Young Adults 18-26 years.
• Annual Review clinic.
• MDI Programmes.
• Group education programmes.

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Advanced Nurse Practitioner Scope of
Practice/Diabetes.

• Independent practice
• Assess patients with diabetes.
• Diagnose. Physical examination/Patient history/
  Laboratory investigations.
• Treat. Insulin Therapy/oral hypoglycaemic
  Therapy/antihypertensive agents/statins
• Discharge to GP or to other specialist clinics
• Referral pathway to appropriate service.
  Dietetics/ ophthalmology /nephrology/ vascular/
  podiatry/ health promotion.
• Education Patient/ other health care
  professionals involved in diabetes care.
• Consultancy

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Guidelines for Practice

• Collaboratively agreed (Nursing
  management/Consultants/ Paediatrician/Nurse
  Practitioner)
• Evidence based.
• Standard approach to managing clinical
  presentations for the diabetes department.
• Regularly reviewed by Consultants/ANP.

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Education Activity

• Clinical teaching clinical supervision.
• In-service education medical nursing staff.
• Lecture on various post-graduate programmes in
  3rd level institutions.

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Consultancy

• Provide nursing consultancy service to
  multi-disciplinary team members.
• Provide consultancy to primary care services.
• Provide Nursing consultancy on DSAG (Diabetes
  services advisory group)
• Authority/clinical nursing expertise for diabetes
  care
• Provide support to specialist areas outside
  diabetes engaged in ANP role development

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Research Audit

• Identify Research Projects.
• MIND Study , Evaluation of MDI Programmes Audit
  of paediatric services.
• Audit of group education programmes.
• Clinical focus to research.
• Evidence for care
• Audit of service need ( case mix/Patient activity
  levels.

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Case Scenario.

• Jane -21ys.
• Type 1 diabetes 10 years.
• Poor glycaemic control during adolescence, HBA1C
  10-12.
• June 2006- Hba1c 12.4.
• Complications- right background diabetic
  retinopathy, left pre-proliferative retinopathy.
• Microalbuminuria (Ramipril 10mg/nocte).
• Symptomatic of hyperglycaemia, tired, thirsty,
  weight loss ,irritable and fed up.
• Attending young adults clinic.

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ANP INPUT

• Empowered Jane to become involved in her care
  and decide on her treatment choices/ decisions.
• Changed insulin Therapy ( 4 injections/daily
  /novorapid/lantus)
• Twice monthly visits to ANP.
• 3monthly visits to young adults clinic.
• Telephone support weekly
• Referred to dietician
• Psychologist.
• Referral to ophthalmology. Will be followed up
  yearly. No laser treatment required.
• Hba1c September 9.1. December 7.8 February 7.8
  
• Jane feels much better, not symptomatic of
  hyperglycaemia and happier that she is assuming
  control and self managing her diabetes.
• Referred back to young adult service will be seen
  2 monthly.
• Continue telephone support/weekly.

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Case Study.

• Jack-Age 68 yrs.
• Diagnosis type 2 diabetes 1986.
• Attending G.P. Services.
• Treatment- Glucophage 850mgs/tds.
• Diamicron 80mgs/bd.
• Complications- Coronary Artery disease. MI 2003.
  Coronary Artery by-pass 2003.
• Diabetic Neuropathy.
• Diabetic Retinopathy
• Referred to Diabetes Service 2005.
• Attending annual review clinic.
• HBA1c 9.4.

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ANP Input.

• Commenced on Lantus once daily. Remains on
  Glucophage 850mgs /tds.
• Referred to dietician.
• Referral to ophthalmology.
• Referral to chiropody( Community chiropodist)
• Telephone support twice weekly x 2 weeks, then
  weekly x 2 weeks for advice on insulin dose
  adjustment.
• Group education.
• Continue telephone support weekly or Jack
  e-mails blood glucose readings.
• HBA1c March 8.0
• Referred back to annual review clinic.

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Putting things into perspective.

• The aim of diabetes care must be to ensure the
  best outcomes for patients, bearing in mind the
  risks associated with poor glycaemic control.
• Risk of complications associated with a 1 rise
  in HBA1c levels.
• Event
  Increase in risk of event.
• Diabetes related death.------------------------21
  .
• Myocardial infarction.--------------------------14
  .
• Peripheral vascular disease.------------------
  43.
• Microvascular disease.--------------------------37
  .
• Cataract extraction.-----------------------------1
  9.

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Reality of Advanced Practice

• Autonomy.
• Confidence.
• Job satisfaction.
• Opportunity to develop new ANP Services.
• Increased Workload.
• Appointment of CNS to cover workload.
• Lack of Secretarial Support.
• Space/Equipment.
• Site Preparation Co-ordinator.
• Inclusion of module on Guideline and Policy
  development and Site Preparation in Masters
  Programme.
• Difficult to have dedicated time for
  research/audit.
• Nurse Prescribing.

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Career Pathway

• Structured
• Focused.
• Rewards talent expertise in practice

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Job Satisfaction.

• The main reason I love my job is that I am
  dealing with and have time to spend with
  patients. I particularly like the fact that I
  have time to spend with children , adolescents
  and young adults who may be experiencing
  difficulties with their diabetes and this input
  may make a difference to their overall
  management. Patient empowerment is essential and
  I value and encourage patient input regarding
  their treatments choices. The fact that I can
  make decisions with patients about their care,
  assess, treat and discharge them satisfied and
  happy means a lot to me in terms of how I do my
  work

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ANY QUESTIONS ? THANK YOU