ADVANCED PRACTICE NURSE - APN
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1 Bern, the 2nd of October 2014 ADVANCED PRACTICE NURSE - APN in primary health care Medizentrum Schüpfen AG APN - a task analysis Masters thesis Bern University of Appliec Sciences Health Master of Science in Nursing
2 Background and Problem Description A medical centre for outpatients in the rural environment of a large city in Switzerland had identified a need to implement an ANP-role within a short period of time In Switzerland the concept of Advanced Nursing Practice (ANP) is partially implemented in inpatient and outpatient settings. APN role definition and terminology vary worldwide: e.g.: Advanced Nurse Practice (ANP), Advanced Practice Nurse (APN), Clinical Nurse Specialist (CNS), Nurse Practitioner (NP) (Burgess et al., 2011, Robertson & Baldwin, 2007, Ruel & Motyka 2009, Lindblad et al. 2011). 2
3 APN-Concept by Hamric et al. (2009) seven core competencies by Hamric et al. (2009), own representation 3
4 APN a task analysis Question What are potential areas of activity and activities/tasks of an APN nurse in a primary care setting for outpatients in a rural area of Switzerland? Research design and methodology Descriptive analysis of activities with participant observation Process 1 Process 2 Process 3 Process 4 Data collection: activity grid Data analysis: DACUM model, portfolio Validation process Association in terms of expertise and complexity, as well as classification of the potential ti lapn activities iti with weighting 4
5 Activity grid 1. process step 25 patient situations were observed through participant observation (9 outside the medical centre / 16 within the medical centre) Main actors: doctor/physician, assistant physician, members of a freelance community nursing care, physician i assistants t (MPA) Aim Situation / Mandate Einschätzung Visit at home: outside the medical des Allgemein- centre zustandes nach Spitalaustritt Area of action A patient has been discharged from hospital to home. A member of a freelance home healthcare visits this patient to assess her general health condition... 5
6 APN eine Tätigkeitsanalyse it Masterthesis th DACUM-Modell und Portfolios 2. Prozessschritt DACUM-Modell: 1. Abstraktions- niveau 25 Portfolios 2. Abstraktionsniveau Gewichtung: Stufe 1 Stufe 2 6
7 Validation process 3 rd step Validation committee has validated nine situations ti (sample selection) spectrum of potential APN activities gray zone 7
8 Activities allocation 4th step validated Serving-added opportunities, classified according rather high complexity of the activity rather high... professional competency similar, equal... results collective name 8
9 Results: rather high level of expertise Collective terms for Activities (situation) Activities (situation) activities iti weighting 1 weighting 2 Triage, patient assessment decide autonomously System focused history, Clinical assessment perform Assessment of musculoskeletal abscess Intervention Interpretation blood values Knowledge about perfusion therapy. therapy frequency and respective follow-up (e.g., blood values) and subsequently perform and develop adequate care plan 9
10 Results: rather high complexity of activities Collective terms for activities Activities (situation) weighting 1 Activities (situation) weighting 2 Clinical assessment, system focused and medical history Clinical assessment perform eart-lung inspection Psycho-social support, consulting and coaching of patient? Professional consultations, topical therapy 10
11 Results: rather equal/similar complexity and competency? Medical decision- making Collective terms for Activities (situation) Activities (situation) activities iti weighting 1 weighting 2 Make autonomous decision about the inclusion of patients regarding medication adjustment Intervention Perform INR and adjust blood sugar, control medication Treatment procedure Interpret blood values in consultation with the specialist procedure? 11
12 Comparison with the literature: APN model by Hamric et al. 12
13 Sketch of potential APN activity and potential APN activities/tasks potential APN activity complex nursing practice potential APN activities/tasks Clinical Assessment interdisciplinary collaboration Leadership, management, administration (med.-nursing and operational levels) medical-ethical decision making psychosocial support, counseling and coaching therapy decision dependent care Evidence-based practice/research 13
14 What happened 3 years after the implementation of this pioneering study about potential APN activities and tasks? The APN in the Medizentrum Schüpfen AG 14
15 MediZentrum Schüpfen AG "Doctors/physicians and therapists are located under one roof and offer a comprehensive range of outpatient ti t medical services (MediZentrum). The MediZentrum was developed 20 years ago out of a group practice of two doctors/physicians. Today it is unique in Switzerland and encompasses about 40 fulltime and part-time employees. 15
16 MediZentrum Schüpfen AG The main director of the MediZentrum is the senior physician, Dr. Blunier. He supervises the following structure: Medical services offered by six physicians including one physician assistant Mental health services and other therapeutic services offered by one psychologist, one psychiatrist, one nutritionist, physiotherapists and a diabetic nurse Physician assistants (MPA) and nursing staff with general nursing training (ACP) constitute a total of 11 employees, and one APN Five medical consultants working part-time Independent, professional home care consisting of five professional women (dipl. Nursing women and «Höfa» I Administration: one accountant, two secretarial/administrative assistants and two 16 students in administration
17 Current Implementation of the APN role in the MediZentrum Schüpfen APN practice role - within the centre: perfusion therapy ear wash wound management Clincal Assessment care of rheumatic patients measuring INR with subsequent drug regulation/adaptation APN practice role outside the centre: conduct assessments of patient situations during home visits interventions perfusions, drug adaptation, wound dressings etc. support to patients support as well as coaching the patients and their family members case management 17
18 Practice examples Example/situation 1: A patient t calls in to the centre. she has abdominal pain and wants to be visited by a physician: Response: A visit by the APN Assessment of the history Clinical assessment of the abdomen Consultation with doctor by the phone or in the praxis Perform interventions; bringthe medications, if need, organize professional nurse (Spitex) 18
19 Practice examples Example 2: Care of patients t in a nursing home. Regular INR checks and subsequent adaptation of medication Case Management therapy overview and information/exchange with oncologist, nursing home and the responsible physician: coordination APN is the first contact person Care of patients in another nursing home. Visit together with the physician: perform consultation together 19
20 Practice examples 20
21 Practice examples Example 3: Care of rheumatological patients Remicade perfusions with regular controlling of the blood values Methotrexat therapy with regular controlling of the blood values 21
22 Problems financial compensation not yet solved No clear definitions of APN skills with MPA's and community nursing care In the law, the prescription by APN is not yet included 22
23 Future The APN will play an increasingly important role in primary care clearly defined role of the APN, the MPA's and nurses Refining and deepen the skills for conducting clinical Assessments Billing system 23
24 Bibliography Bundesministerium, d. I. (2010). Handbuch für Organisationsuntersuchungen und Personalbedarfsermittlungen.,from OrganisationsHandbuch/DE/6 MethodenTechniken/65 Bewertungsverfahren/652 Qualitative/qualitative-node.html? nnn=true, konsultiert am Hamric, A. B., Spross, A., & Hanson, C. M. (2009). Advanced Practice Nursing: An Integrative Approach(4 ( th ed.). USA: Saunders Elsevier Kohn, G. (1997). DACUM: ein Instrument zur Entwicklung von beruflichen Tätigkeitsprofilen Bundesinstitut für Berufsbildung, 43, Norton, R. E. (1998). Quality Instruction for the High Performance Workplace: DACUM., 1-5. Retrieved from ERIC: Education Recources Information Center website: SearchValue_0=ED419155&ERICExtSearch_SearchType_0=no&accno=ED419155, konsultiert am Schober, M., & Affara, F. (2008). Advanced Nursing Practice (ANP) (1th ed.): Hans Huber Verlag. Lamnek, S. (2010). Qualitative Sozialforschung (5th ed.). Weinheim, Basel: Beltz Verlag. Flick, U., Von Kardorff, E., & Steinke, I. (2010). Qualitative Forschung - Ein Handbuch (8th ed.). Hamburg: Rowohlts. 24
25 Thank you for your attention! Do you have any questions? 25
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