Questionnaire to accompany applications for the following Postgraduate Nursing Courses NS86 Master of Nursing Science (Nurse Practitioner) Section 1

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1 Questionnaire to accompany applications for the following Postgraduate Nursing Courses NS86 Master of Nursing Science (Nurse Practitioner) Section 1 Name of applicant: (print) First Name Last Name Meta Specialty: (te: this is the broad area in which you practice; may choose more than one) Sub Specialty (if any): Organisation (or hospital): Location (City and State): Present position: Ward/Unit/Department: Aged and palliative care (APC) Primary health care PHC) Emergency and acute care (EmAc) Long term conditions care (ChC) Child and family health care (CFH) Mental health care (MHC) Years experience in specialty: Employment status (chose one): Full time Part time (if part time, number of hours per week): Ward/Unit Manager Contact details: Student Checklist*: Name: Telephone: 1. I am registered as a nurse with the Nursing and Midwifery Board of Australia with no restrictions (evidence attached). 2. I have a minimum of five years full time equivalent clinical practice experience as a Registered Nurse (evidence attached). 3. My recent clinical practice experience includes a minimum of three years full time equivalent experience as a Registered Nurse in the nominated specialty area (evidence attached). 4. My recent clinical practice experience includes a minimum of two years full-time equivalent experience at an advanced practice level in the nominated specialty area (evidence attached e.g. statement of service). 5. I have earned a graduate certificate (or higher) qualification that was obtained within the past 10 years in the nominated specialty area (evidence attached). 6. I am actively involved in professional organisations and contribute to the ongoing development of the profession e.g. active membership of professional committees, publications related to professional activities, additional professional roles and activities such as mentoring, etc. (brief 2 page CV and supporting evidence attached). 7. I have attached a Letter of Support from my Executive Director of Nursing (or equivalent) and each member of my nominated clinical support team (at least one member must be a nurse practicing in an advanced practice role) in support of my QUT Master of Nursing Science (Nurse Practitioner) application. 8. I have attached current brief resumes (2-3 pages) for each member of my nominated clinical support team, including evidence of current AHPRA registration where relevant. 9. I have attached Evidence of Advanced Practice from a senior nurse, nurse manager or approved delegate (supported by employers statements of service; see point (4) above. 10. If there are any changes to my circumstances (e.g. place of employment, clinical support team members, level of support) I will notify the Study Area Coordinator as soon as practicable. Applicant Signature: Date: *Submit checklist and required supporting evidence as required with your application. te: original documents required as per instructions on postgraduate application. PG NS86 Nursing Questionnaire NS86, v

2 Section 2 To be completed by applicants applying for NS86 (Nurse Practitioner) Please give details of your Executive Director of Nursing (or equivalent) and your clinical support team members^ below: Executive Director of Nursing (or equivalent): Name: Position: Organisation: Phone: Clinical Support Team member 1 (attach 2-3 page brief resume of experience and skills) Name & Title: AHPRA registration no.: Position: NP Advanced Practice Nurse Phone: _ Clinical Support Team member 2 (attach 2-3 page brief resume of experience and skills) Name & Title: AHPRA registration no.: Position: NP Advanced Practice Nurse Phone: _ Clinical Support Team member 3 (optional) (attach 2-3 page brief resume of experience and skills) Name & Title: AHPRA registration no,: Position: NP Advanced Practice Nurse Phone: _ (add additional pages if necessary) ^The clinical support team will consist of an advanced health practitioner currently practising the relevant extended clinical skills in your specialty field of practice (for example, an experienced and qualified nurse practitioner or medical practitioner) and an advanced practice nurse (for example, Master s prepared nurse practitioner or clinical nurse consultant or clinical nurse specialist). Other relevant health professionals can also form part of the clinical support team (for example, senior dietician or pharmacist). The composition of your clinical support team will be determined and approved on application to the course and re-confirmed before you undertake each semester of your internship. In addition to the local clinical support team, the unit coordinator will formally link you with a qualified, practising nurse practitioner as clinical academic facilitator for the duration of the internship component of the course. PG NS86 Nursing Questionnaire NS86, v

3 Certification must be obtained before application will be considered for entry into NS86 Master of Nursing (Nurse Practitioner). Queensland University of Technology (QUT) will retain this form for its records. Certification is to be by handwritten signature on this form. Please keep pages together. Signatures must be provided by: (a) Student, (b) Executive Director of Nursing (or equivalent), and (c) two Clinical Support Team members (as per criteria). Each Clinical Support Team member must provide a brief resume outlining clinical experience and skills (2-3 pages). STUDENT COMMITMENT I, (first and last name), CERTIFY THAT I have three of the past six years experience as a Registered Nurse in (Clinical specialty) I am currently working as a(n) I currently work at (Advanced Practice Nursing role) (Organisation/Facility) in the specialty, and. I CERTIFY THAT I am applying to undertake the NS86 Master of Nursing Science (Nurse Practitioner) course at Queensland University of Technology, Faculty of Health, School of Nurse and Midwifery, in preparation for Nurse Practitioner endorsement. I CERTIFY THAT I have read the attached Course Expectations Related to the Clinical Learning Environment and Clinical Support Team and I am aware of my clinical learning requirements if I am accepted into the course. I anticipate I can meet the expectations in terms of time and resources required, while I am undertaking the required two semesters of professional practice experience. I CERTIFY THAT I have kept a copy of this letter of support for my records. Signed Date My contact address is: City, State, Postcode: My daytime phone number is: My address is: page 1 of 6

4 SUPPORT FROM EXECUTIVE DIRECTOR OF NURSING OR EQUIVALENT I, _, (Print first and last name) in the position of (Executive Director of Nursing or equivalent) _, on behalf of, (Organisation/facility name) agree to support the Nurse Practitioner studies of (Student s first and last name) if he/she is accepted into NS86 Master of Nursing Science (Nurse Practitioner ) at Queensland University of Technology, Faculty of Health, School of Nurse and Midwifery. I CERTIFY that I have read the attached Course Expectations Related to the Clinical Learning Environment and Clinical Support Team and I am aware of the student s clinical learning requirements. I anticipate the organisation can meet the expectations of the student in terms of time and resources required while the student is undertaking the required two semesters of professional practice experience. The organisation is committed to supporting the student in undertaking the required studies and learning activities to support the timely completion of studies required. I CERTIFY THAT I have kept a copy of this letter of support for my records. Signed Date My contact address is: City, State, Postcode: My daytime phone number is: My address is: page 2 of 6

5 SUPPORT FROM CLINICAL SUPPORT TEAM MEMBER 1 I, _, (Print first and last name) in the position of located at (Position) (Organisation/facility name) _, _, agree to support the Nurse Practitioner studies of (Student s first and last name) if he/she is accepted into NS86 Master of Nursing Science (Nurse Practitioner ) at Queensland University of Technology, Faculty of Health, School of Nurse and Midwifery. I CERTIFY THAT I have read the attached Course Expectations Related to the Clinical Learning Environment and Clinical Support Team and I am aware of the student s clinical learning requirements. I anticipate I can meet the expectations of the student in terms of time and resources required while the student is undertaking the required two semesters of professional practice experience. I am committed to supporting the student in undertaking the required studies and learning activities to support the timely completion of studies required. I CERTIFY THAT I have kept a copy of this letter of support for my records. Signed Date My contact address is: City, State, Postcode: My daytime phone number is: My address is: page 3 of 6

6 SUPPORT FROM CLINICAL SUPPORT TEAM MEMBER 2 I, _, (Print first and last name) in the position of located at (Position) (Organisation/facility name) _, _, agree to support the Nurse Practitioner studies of (Student s first and last name) if he/she is accepted into NS86 Master of Nursing Science (Nurse Practitioner ) at Queensland University of Technology, Faculty of Health, School of Nurse and Midwifery. I CERTIFY THAT I have read the attached Course Expectations Related to the Clinical Learning Environment and Clinical Support Team and I am aware of the student s clinical learning requirements. I anticipate I can meet the expectations of the student in terms of time and resources required while the student is undertaking the required two semesters professional practice experience. I am committed to supporting the student in undertaking the required studies and learning activities to support the timely completion of studies required. I CERTIFY THAT I have kept a copy of this letter of support for my records. Signed Date My contact address is: City, State, Postcode: My daytime phone number is: My address is: This page may be duplicated if there are other members on the student s clinical support team. page 4 of 6

7 COURSE EXPECTATIONS RELATED TO THE CLINICAL LEARNING ENVIRONMENT AND CLINICAL SUPPORT TEAM 1. The student must have a minimum of five years fulltime-equivalent clinical practice experience as a registered nurse, which includes a minimum of three years fulltimeequivalent experience as a registered nurse in the nominated clinical area and two years fulltime-equivalent experience at an advanced practice level in the nominated specialty area of practice prior to enrolment in the course. In addition, the student must be working at an advanced practice level for the duration of the course, at least 0.6 fulltime- equivalent. 2. While undertaking the professional practice experience (or internship) component of the Master of Nursing Science (Nurse Practitioner), which comprises two semesters, the student must be working in an advanced practice nursing role, of which 0.4 FTE hours constititutes the clinical internship (over two semesters). Hence, the clinical component for the internship comprises a minimum of 390 formal and supernumerary clinical learning hours (15 hours per week x 13 weeks x 2 semesters). 3. The NP student will be transitioning into the role of nurse practitioner through the internship, whereby the NP student will be practising clinical activities that are an extension of the scope of practice of the registered nurse. These extended practice areas include referral of patients to other health care professionals, requesting diagnostic tests, prescribing medication and performing specific interventions that are relevant to their specialty field of practice. 4. The student must have ready access to the nominated clinical support team during their supernumerary clinical learning days. The NP student s clinical support team will provide teaching support through supervision, monitoring, supporting and reviewing these extended practice aspects of the candidate s role. 5. The clinical support team must consist of an advanced health practitioner considered an expert in, and currently practising the relevant extended clinical skills in, the student s nominated specialty field of practice (for example, a medical practitioner or an authorised nurse practitioner) and an advanced practice nurse (for example, an authorised nurse practitioner, senior clinical nurse consultant, clinical nurse specialist or nurse educator). Other relevant health professionals can also form part of the clinical support team (for example, senior dietician, pharmacist, psychologist). 6. The student is responsible for identifying and obtaining support from a suitable clinical learning environment and an appropriate clinical support team. The composition of the clinical support team will be determined and approved by the School on application to the course. 7. The clinical support team members will be re-confirmed by the Unit Coordinator prior to the start of each semester in which the internship is undertaken. It is the student s responsibility to notify the Unit Coordinator of any changes to the clinical support team members or clinical learning environment as soon as practicable. 8. During the internship, the student is expected to manage, under appropriate supervision, at least two complete episodes of care per week during the semester for typical patients/clients in the student s case load. page 5 of 6

8 9. The clinical support team will conduct clinical practice reviews on the student s management of these patients/clients. These reviews will be held weekly in the first half of the semester and at least fortnightly towards the end of the semester and will be the formal mechanism for teaching and learning. The practice reviews will draw upon documented care in the medical record, observation of practice and the student s case reporting and are a process for monitoring safety of practice. The reviews are an important teaching, learning and assessment strategy, but they also provide opportunities for the team to monitor the quality of patient care. 10. The student will also be matched with an experienced nurse practitioner, external to the clinical support team, who functions as a clinical academic facilitator. The student will communicate weekly with their QUT-appointed clinical academic facilitator for feedback. These meetings can occur through a variety of media: face-to-face contact, telephone, video conference, synchronous online chat or synchronous conversation. 11. The student is encouraged to develop a learning plan and discuss this plan and their learning goals with their clinical support team and their clinical academic facilitator early in the semester. In addition, they should make time throughout the semester to discuss their progress and make amendments to their plan, to ensure they meet the unit requirements before the end of the semester. 12. Specific details of assessment of clinical and academic performance during the internship are outlined in the Unit Information and Student Support Handbook. It is the student s responsibility, in consultation with the clinical support team, the clinical academic facilitator and the Unit Coordinator, to organise the processes for this assessment. 13. The clinical support team s role in assessment of the candidate will include ongoing monitoring and evaluation of the candidate s clinical performance through weekly/fortnightly clinical practice reviews on the student s management of cases in their case load and the provision of feedback on required learning and assessment activities. 14. The clinical academic facilitator s role in the assessment process is to review the candidate s written cases and provide feedback. 15. Each member of the clinical support team and the clinical academic facilitator will also be required to contribute to, and sign off, on the Clinical Activity and Practice Assessment Records for both internship units and to contribute to and sign off as a panel member/chair in a formal clinical viva at the end of the internship. For more information regarding the course, contact: Dr Sonya Osborne, Senior Lecturer, Nurse Practitioner Study Area Coordinator Queensland University of Technology, School of Nursing and Midwifery Victoria Park Road Kelvin Grove, QLD 4059 phone: page 6 of 6

9 NS86 Master of Nursing Science (Nurse Practitioner) LETTER SUPPORTING ADVANCED PRACTICE Employer/Colleague Testimonial Purpose of this form: Applicants must supply evidence of advanced practice knowledge and skills within an area of clinical practice before their application for entry into the program will be considered. Additional entry requirements: Applicants to the NS86 Master of Nursing Science (Nurse Practitioner) program at Queensland University of Technology must demonstrate at least three years fulltime-equivalent (FTE) experience as a registered nurse in a clinical area, including at least two years FTE experience at an advanced practice level in the relevant clinical area of practice. In addition, applicants must currently be working at least 0.6 FTE at an advanced practice nursing level while enrolled in the course, with at least 50% of their time spent in direct client care. Definition of advanced practice: The Nursing and Midwifery Board of Australia (NMBA) defines advanced practice as a level of nursing practice that utilises extended and expanded skills, experience and knowledge in the assessment, planning, implementation, diagnosis and evaluation of [nursing] care required. Nurses practising at this level are educationally prepared at postgraduate level and may work in a specialist or generalist capacity. However, the basis of advanced practice is the high degree of knowledge, skill and experience applied in the nurse- patient/client relationship to achieve optimal outcomes through critical analysis, problem solving and accurate decision-making 1. Applicant instructions: This form should be completed by a senior nurse, nurse manager or other nursing delegate (approved by the Postgraduate Course Coordinator or Study Area Coordinator) who can testify to the applicant s level of practice. Sections 1 and 2 must be completed. Verification must include handwritten signatures on this form. Applicant must also attach employers statements of service on organisation letterhead. Please keep pages together and forward the completed Evidence of Advanced Practice with application. Section 1: Applicant s Advanced Practice Employment Experience I,, verify that (Print first and last name) has worked as an RN at an advanced practice level (Student s first and last name) (Organisation/facility name) from to in a full time / part time position. Where part-time, (date) (date) (circle one) this required the applicant to work hours per week, which is approximately a total of years / months of advanced practice. (circle one) In regard to the applicant s current practice responsibilities, I confirm that at least 50% or more of their current nursing role involves direct client care. YES NO. Signature: Date: Letter of Advance Practice, v

10 NS86 Master of Nursing Science (Nurse Practitioner) LETTER SUPPORTING ADVANCED PRACTICE Employer/Colleague Testimonial Section 2: Applicant s Advanced Knowledge and Skills I verify that the above applicant has demonstrated knowledge and skills at an advanced practice level 2 as follows: 1. Uses best available evidence, observations and experience to plan, conduct and evaluate practice in ways which incorporate complexity and/or a multiplicity of elements 2. Uses health and/or nursing models as a basis for practice 3. Manages outcomes in complex clinical situations 4. Anticipates and meets the needs of individuals and groups with complex conditions and/or in high risk situations 5. Integrates and evaluates knowledge and resources from different disciplines and health care teams to effectively meet the health care needs of individuals and groups 6. Seeks out and integrates evidence from a range of sources to improve health care outcomes 7. Safely interprets and modifies guidelines and practice to meet the health care needs of individuals and groups 8. Leads and guides the nursing team to promote optimum standards of care 9. Shares information and resources to initiate improvements and/or innovation in nursing practice 10. Fosters and initiates research based nursing practice 11. Acts as a mentor and role model for nurses and other health professionals 12. Contributes to development of nursing knowledge, standards and resources through active participation at the broader professional level 13. Facilitates education of individuals and groups, students, nurses and other members of the health care team 14. Acts as a resource for other nurses and members of the health care team 15. Provides nursing as a resource to others through their capacity to practice outside single contexts and episodes of practice Signature: Date: Please provide your contact details below: Name: Organisation/Facility: City, State, Postcode: My daytime phone number is: My address is: 1 NMBA (2014). Nurse Practitioner Standards of Practice (as of 1 Jan 2014). Available from the AHPRA website 2 adapted from Australian Nursing Federation, Competency Standards for the Advanced Registered Nurse, Letter of Advance Practice, v

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