Developing a sustainable and strategic policy framework for NP Services

Transcription

1 Developing a sustainable and strategic policy framework for NP Services Katy Fielding A/Chief Nursing Advisor June 2011 Acknowledgements In health care, invention is hard, but dissemination is even harder. Don Berwick 2003 Policy is easy, implementation is hard. John Menadue 2008 Because almost every government inspired initiative is treated as a threat, policy making for health care becomes an exercise in conflict management. S Sax, 1984 (final words of a Strife of Interests) 1

2 Victoria - What s so different? 32,500 FTE nurses/midwives in public sector ¼ ENs 2/3 in metro area Governance: >80 public health services Nursing and midwifery FTE range Each governed by a board of directors/board of management, accountable to the Minister for Health Devolved governance local, responsive, flexible Output based funding Nurses and midwives employed by the health services. NPs where are we now? The end of the first decade First 5 years preparing the ground, next 5 sowing the seeds, now nationally, over 110 are emergency >65 in Victoria and 100% employment, portability of prescribing authority, partnership between NPC & employer, processes that are compatible with governance structures. 2

3 NPs: Where? 70:30 metro-rural (non metro) split NPs and NPCs working in diverse settings, from: -Walwa BNC (NP & CEO!) to -Alfred Trauma Centre (6 NP/NPC managing 10-15% of total ED presentations) Local service setting and gaps determines the practice models How many now? Currently supporting more than 50 NPCs in public services (through models implementation and/or NPC Support Packages) Palliative Care 16 NPCs Mental health, drug & alcohol services 15 NPC Oncology 5 NPCs Renal 5 NPCs Rest chronic disease management, aged care etc More not DH funded + those studying but not candidates Most larger services have 3 or more NPCs Increasing numbers have >1 NPC in same area 3

4 So, we don t. Don t approve NP or NPC positions Don t directly fund NP salaries or positions Don t set specific credentialing requirements for NPs Don t set the specific employment arrangements for NPs We do: Identify departments priority areas (A good idea, at the right time!) Provide funds for model implementation (Nike, no more pilots) Data, gap analysis Consultation, communication and collaboration Clinical & corporate governance Candidacy arrangements Scholarships for tertiary studies (Three is not a crowd) NPC Support Packages NP Collaboratives (It s the glue) Publication grants (its no good if you don t tell others about it) 4

5 We drive: Form must follow function, address service need/gap, improves one or more dimension of quality in health care Access, Appropriateness, Efficiency. Acceptability, Safety, Effectiveness Strategic priorities/directions Organisational readiness Critical mass Expectation of responsive models, evolve as de novo services NP Service Planning Questions Where and what is the demand for services? What gap(s) need to be addressed? Will a nurse endorsed as NP, bridge that gap? Could a CNC do it? How will a NP service improve outcomes (rather than duplicate)? How will a nurse change outcomes (rather than other discipline)? 5

6 Organisational readiness Strategic framework for supporting advanced nursing roles A process for assessing & supporting NP proposals Ability to resource the reform/change appropriately Executive sponsor, change champions, CME, Sound process for appointment of NPCs, and Processes and structures to ensure they realise the return on investment. Implementing NP roles, is about redesigning care at the team level not the individual level re-negotiating who does what, where and when improving, enhancing services not duplication strategic, long term investment for health services identifying those roles that clearly requires the extended practices to meet a service need roles that are grounded within a nursing framework but clearly articulated to the roles of other health professionals and are integrated in the current model of care, and making a clear business case Sustainability. 6

7 Sustainable models Attention on defining and developing sustainable services is needed (Considine, J. Fielding, K) Sustainability is now the key driver for innovation Argue that rather than trying to resolve the dichotomy between ethical/emotional and economic rationalist, decision makers in healthcare should use the targets of efficiency, effectiveness and sustainability. (Salviano, M., Bassano, C & Clabrese, M. 2010) Balancing the EES Triple Target of Management in Healthcare Service Systems Prevent the risks of instability in the system We may treat the need to be sustainable as corporate, social responsibility, divorced from business objectives Sustainability is the point of balance between front (client) effectiveness and back stage (organisation) efficiency. 7

8 Challenges: Cross service/cross provider models Find or create coalitions of the willing eg: Palliative Care Consortia s, Integrated Cancer Services, MOUs, NP as facilitator of successful boundary transitions transboundary role Gerontic NPs crossed multiple boundaries, including two-way crossing of intra and inter organisational boundaries and established long term relationships with patients (K Bail et al, 2009) Challenges: Size matters Smaller/rural services often have the advantage in making things happen, but with NPs.. NPs require high levels of resources to establish the service model and deliver an appropriate candidacy Not a short term investment Usually single practitioner models that are vulnerable Generalist skill set needed May need to be second wave adopters 8

9 Challenges: Succession planning Largely absent 1 practitioner is a niche role not a service and even working full time is less than a full time service Talent pool? NPCs whose next? The link between organisational strategic objective and succession planning for advanced practice is a critical one organisational survival/continuity Move from contingency to continuity (K Currie, 2010) Challenges: Mentoring capacity Contrary to many sources, supervisors are not scare. Not clinical skills acquisition issue per se, but Emergent nature, means frequently the supervisor is medical, reinforcing the bio-medical model Not all nurses/npc are working in organisations with senior nurses (GMs, community health, drug services etc) a process in which the mentor is able to support and help the mentees to develop their knowledge, skills, thinking and behaviours and thus problem solving and performance in a current role as well as longer term career development planning. Mason 2005 High quality mentoring by expert nurse mentors is CRITICAL Pilot program for Victorian NP mentors and mentees

10 Challenges: Its always about who pays Simple answer is: We fund health services to provide services, they are health dollars not Dr dollars and Nurses dollars Complex answer is: Most intra organisational funding is historically based, about the squeaky wheel or last man standing Not many public organisations zero base to program level Nurse managers who want NPs need to get financially literate and strategic. The higher the ratio of physician executives in strategic decision making process the greater the decision quality, commitment and understanding of the rationale of the decisions. (Parayitam and Phelps, 2007) MBS & PBS reforms - how do we stimulate community based/primary care models Challenges: Its not what you do, it s the way that you do it! Implementing Collaborative practice for NPs can be minefield, at best it is: Integration of individual approaches - SYNERGISM 1+1 = 3 Collection of individual approaches - ADDITION 1+1=2 7 elements essential for optimum collaboration (Way, Jones & Busing, 2000) The alternative can be restrictive, unyielding and a lose: lose. Expertise at negotiating the practice change is essential but not always accessible, agreements to get it across the line (without review points etc) need to be part of the implementation repertoire. 10

11 Challenges: Implementing advanced practice Systematic review and meta-synthesis Focus on role development in specialist & advanced practice roles in acute hospital settings Identified a range of barriers and facilitators affecting specialist & advanced nursing practice, but most important factors were: relationships with other key personnel, and role definitions and expectations Relationships with other staff groups and role ambiguity are the most important factors which hinder or facilitate the implementation of specialist and advanced nursing roles. These factors seem interlinked, and the associated problems do not appear to resolve spontaneously when staff become familiar with the new roles. Jones, M L (2005) References Considine, J., Fielding, K. Sustainable Workforce Reform: A case study of Victorian NPs. Aust Health Review 2010, 34, Bail et al., Potential scope and impact of a transboundary model on nurse practitioners in aged care. Aust J Primary Health. 2009, 15, Parayitam, S., Phelps, L. Strategic decision making in the healthcare industry: the effects of physician executives on decision outcomes. Management Research News : Currie, K. Succession planning for advanced nursing practice ; contingency or continuity. The Scottish experience. J Healthcare Leadership , Way, D., Jones, L., Busing, N. Implementation strategies: Collaboration in Primary care Family Doctors and Nurse Practitioners delivering Shared Care. Ontario College of Family Physicians. Discussion paper. Jones, M L (2005) Role development and effective practice in specialist and advanced practice roles in acute hospital settings: systematic review and metasynthesis. Journal of Advanced Nursing. 49, 2; p. 191 Salviano, M., Bassano, C & Clabrese, M A VSA-SS Approach to healthcare service systems. The Triple Target of Efficiency, Effectiveness and Sustainability. Services Sciences (1/2)

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