The Advanced Practice Role of the Perioperative Nurse

Transcription

1 The Advanced Practice Role of the Perioperative Nurse Andrew Lynn RN. PNSA. With acknowledgement to: Toni Hains MClinSc(PNSA) MNPractSt PhD Candidate - UQ

2 What is Advanced Practice? International Council of Nurses (2008): A Nurse Practitioner/Advanced Practice Nurse is a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. A Master s degree is recommended for entry level.

3 What is Advanced Practice? Nursing and Midwifery Board of Australia 2014 Advanced nursing practice is a continuum along which nurses develop their professional knowledge, clinical leadership and judgement, skills and behaviours to higher levels of capability. Nurses practicing at an advanced level incorporate clinical leadership, education and research into their clinically based practice. Their practice is effective and safe. They work within a generalist or specialist context and they are responsible and accountable in managing people who have complex health care requirements.

4 Stimulus for International Development of Advanced Practice Nursing Roles International shortages in the healthcare workforce Economic forces Political forces - health reform Changes in technology Changes require more than adding resources Changing healthcare demands involve reexamination of traditional roles (Radford 2003)

5 What is happening Internationally? Sheer, B: Wong, F. 2008

6 International Titles for APN Nurse Practitioner title legislated in some countries Advanced Practice Nurse Advanced Nurse Practitioner Clinical Nurse Specialist Nurse Specialist Professional Nurse Expert Nurse Certified Registered Nurse Practitioner Chief Professional Nurse with post-basic training-primary Health Care Nurse Consultant Specialist Nurse Practitioner Primary Healthcare Nurse Perioperative Nurse Surgical Assistant Registered Nurse First Assistant Advanced Perioperative Practitioner Advanced Scrub Practitioner Surgical Care Practitioner Pulcini 2010

7 What do advanced nurses do? Two broad types of activities Substitution Supplementation Example: Nurse Practitioners, Perioperative Nurse Surgical Assistants or Nurse Endoscopists Services formerly provided by doctors Main aims: reduce workload of doctors, improve access to care, and reduce cost Example: Clinical Nurse Specialists (ex-aust.) or Clinical Nurse Consultant New services (e.g. quality improvement) IV Access Nurses, Breast Care Nurses, Pre- Admission Clinic. Main aims: improve services/quality of care, not directly (but indirectly) reduce cost i.e speciality condition nurse Crohn s Disease, Sexual Health, Pain Management

8 Advanced Practice Nurse (APN) and Nurse Practitioner (NP) roles APN Title not yet protected Expanded practice Highly developed autonomous practice profile as an RN within the requirements of the Nurses Act Legislative Structure NP Title protected in several countries & jurisdictions Extended practice Authorization to practice as a nurse practitioner with legal provisions to diagnosis, prescribe medication, order diagnostic tests and refer to other health professionals No formal competencies in place Governing bodies are yet to identify specific APN role on the register Complies with APHRA NP Competencies Endorsement on the APHRA register required

9 Why do we need Advanced Practice Nursing (APN) Roles? The positive effects of APN on patient outcomes have been widely documented (Hughes 2003, Morgan and Ward 2005, Heaton 2007, O Brien 2007, Schroeder 2008, Newhouse et.al. 2011) and include health improvement increased patient satisfaction (Loftus & Weston 2001; Wong & Chung 2006) reduced hospital admissions and shorter lengths of stay (Pearson & Peels 2002, Naylor et al. 2004). Economic savings to the healthcare system are a natural consequence (McCauley et al. 2006).

10 How are Positive Effects Achieved? What is the Impact on Patient Care?

11 What impact on patient care? Quality: APN are able to deliver same quality of care as doctors for a range of services Substitution/supplementation of doctors by nurses (Laurant, Reeves et.al. 2004) Meta-analysis 4253 articles screened 25 articles Focus was primary care Conclusion: working with collaboration appropriately trained nurses can produce a high quality of care and achieve good health outcomes for patients.

12 What impact on patient care? Patient satisfaction: At least equal, if not higher (because of quicker access, possible longer consultations, no increase in complications) Access: Advanced practice nurses can improve access to services and reduce waiting times First contact for people with minor illness in A&E or community based clinic Routine follow-up of patients with chronic conditions such as Hypertension, Heart Failure, Asthma, Cystic Fibrosis or diabetes clinics More focus on patient education Expert knowledge of new technology i.e. intra-operative robotics

13 Example of impact on patient care? St Mary s Trust Hospital London Surgical Care Practitioner nursing or allied health professions 381 excision of skin lesions (including 3 malignant Melanomas) under LA or GA 71% of pts seen within 1 month of referral 59% were seen and treated with 20 mins of their appointment time (initial consultation) Patient Audit 100% patient satisfaction 98% happy to see a SCP instead of a Dr

14 Main barriers and facilitators to implementing advanced practice nursing Professional interests Opposition from some medical professional organisations and individual medical practitioners Facilitation from medical stakeholders such as Royal College of Surgeons England - due to strict rules of working hours for training registrars etc. Schober & Affara, 2006

15 Main barriers and facilitators to implementing advanced practice nursing Education and training opportunities Universities differing educational requirements and degrees, quality of educational programs APHRA not all advanced practice roles or courses are recognised by APHRA Specific APN roles not yet placed into APN definition. Only NP role given extended APN status. Schober & Affara, 2006

16 Main barriers and facilitators to implementing advanced practice nursing Organisation of care and funding providers Governance in Healthcare institutions NP vs Admitting Dr Recognition from Medicare, Health funds, DVA, WorkCover AANSA Inc for PNSA s working on recognition with these groups Schober & Affara, 2006

17 Main barriers and facilitators to implementing advanced practice nursing Legislation and regulation on scope of practice Ambiguity, poor role clarification, proliferation of titles APHRA only NPs are regulated and identifiable Hospital credentialing process ACORN/AANSA endorsing specialist APN roles Eg; PNSA Schober & Affara, 2006

18 Supporters and Advocates of the NP/APN Internationally (34 countries responded) International Survey on Advanced Practice Nursing: Education, Practice and Regulatory Issues: 2008 Pulcini et.al

19 Opposition to the NP/APN Role Internationally (34 countries responded) International Survey on Advanced Practice Nursing: Education, Practice and Regulatory Issues: 2008 Pulcini et.al

20 Considerations for Advanced Practice Must not expand beyond legislative framework Usually operates under medical supervision Incorporates expanded autonomy and decision making Scope of Practice has evolved in response to nurses career expectation (Wilson et.al 2004) APN stops experienced RNs from leaving the clinical area (Wilson et.al 2004) APN role is fraught with ambiguity (Lyon 2004, Jamieson & Williams 2002, Daly & Carnwell 2003, Bryant-Lukosius et al.2004) Must be able and willing to show leadership in clinical practice. communication/collaboration/education. active in membership of peak body and/or recognised authoritative specialist organisation.

21 Considerations for Advanced Practice in Australia CNS role? New research (2010) Published paper: The Perioperative Nurse Surgeons Assistant: Issues and challenges associated with this emerging advanced practice nursing role in Australia. (Lynn & Brownie 2010). International perspective of APN. CNS only international with Masters degree. Justifies allocation of role into APHRA s APN designation. Identifies reasons for experienced Periop RN s for advancing practice Establishes platform for ongoing research into APN roles in Aust. (cite me!)

22 Strong Model of Advanced Practice (Ackerman et al 2000) Domain Direct comprehensive care Support of systems Education Research Publication and Professional leadership Description procedures, assessment, interpretation of data, patient counselling professional contribution to optimal functioning of the institutional nursing service enhancement of caregiver, student, and public learning related to health and illness supports a culture of practice that challenges the status quo and seeks better patient care through scientific inquiry. promote dissemination of nursing and health care knowledge beyond the individuals practice setting

23 Validation of the APN What is needed is a generic description of the core features of the practice of advanced nursing that is grounded in research and tested for validity and stability across diverse advanced practice nursing roles. (Gardner, Chang, Duffield 2006)

24 The role of Perioperative Nurse Surgical Assistant (PNSA) Full scope of practice involves pre-operative examination workup and patient education Intra-operative patient care and technical skills of assisting Post-operative care in hospital and/or rooms Peak body: Australian Association of Nurse Surgical Assistants (AANSA) More than 80 members Australia wide Define a Scope of Practice Lobby government and other healthcare agencies Assist both the clinician and healthcare institution with credentialing Provide information, education and networking

25 RACS Position Statement on Surgical Assistants 2009 Assistants must be appropriately trained and maintain professional development The Choice of an Assistant 1. The decision as to whether an assistant will be required and the level of knowledge and skill required of the assistant is the responsibility of the operating surgeon. This decision should be made in advance so that the appropriate arrangements can be made. 2. The assistant must be covered by appropriate medical indemnity insurance.

26 Task Transfer: the view of the Royal Australasian College of Surgeons Important Considerations: Impact on training of future surgeons Training and supervision Importance of medical training Responsibilities of care Public right and perceptions Conclusion: The RACS supports the evolution of new health care roles in surgery provided a clear need is identified, a proper curriculum and standards are developed, and provided these health professionals work under supervision as part of a surgical team and in situations where clinical outcomes are monitored continuously. Collins, J; Hillis,D; Stitz, R. The Medical Journal of Australia. 2006

27 Difference between a PNSA and a second scrub May be employee of hospital, employee of the surgeon or a surgical practice, contracted by an institution, selfemployed (accredited with healthcare facility) Carries PI & PL Insurance PNSAs can have a wide Scope of Practice - pre, intra and post-operative Intra-operative tasks involve all those of a second scrub assistant In addition to these a PNSA may make incisions, maintain hemostasis with use of diathermy, ligature, hemoclips etc, dissection of tissue, infiltration of LA, suture

28 My role as an Advanced Practice Nurse Currently Gradate Diploma in Clinical Science - PNSA (working toward Masters - 1 year to go!) Work in the private sector in many surgical specialties including orthopaedics, robotics - urology, gynae, cardiac and colorectal/general, cardiac & vascular surgery. Self Employed Carry Professional Indemnity & Public Liability Insurance Credentialed at 8 private healthcare facilities in Sydney Metropolitan area and 1 regional (Bowral) as a PNSA Current NSW Executive for AANSA Inc.

29 Questions??