Peter Godor MN, NP ICU NP Royal Alexandra Hospital, Edmonton, AB DYNAMICS 2010: Edmonton, AB September, 2010
Nurse Practitioners in Alberta Protected title under the Health Professions Act (HPA) One of the first in Canada to address NP practice To date, leading the way in protecting NP practice in our health care delivery system CARNA s NP Roster: ~ 300 Acute Care NPs: ~ 200 ICU NPs in Edmonton: 7 RAH: 4 GN: 2 MH: 1 UofA: 0
Nurse Practitioner Basics Completion of advanced nursing education/training MN (typically) with NP specific content Some jurisdictions require only diploma Licensed and governed by a nursing organization with Roster placement, as an advanced practitioner Various category divisions Acute Care vs. Primary Care Adult vs. Paediatric vs. Neonatal
ICU Nurse Practitioner Preparation In Alberta Graduate level education MN or MH (not restrictive) NP specific course content U of A, U of C, and Athabasca Licensing examination for entry to Roster Requirement since 2009 Educational inclusions Physical assessment, diagnostics, pathophysiology, and pharmacology
Nurse Practitioner History: Safety and Efficacy NP practice has been researched extensively for the last 40+ years Generally NPs quality of care is comparable Analogous to Fellows ; Attendings (in certain settings) NP care is associated with decreased costs Diagnostic Imaging Pharmacy Length Of Stay Readmissions and Complications Narrower the scope, the more efficacious the NP practice
Nurse Practitioner vs. Physician Assistants Nurse Practitioners Preferred in Canada U of M PA program (only) Independent practitioners Based within legislature, authority to prescribe, consult, be consulted, and order/interpret diagnostics Long standing history Distinguished track record within the health care delivery system Governed by independent professional bodies Not practiced under an MD s license
ICU Nurse Practitioner Role Role = What we do Collaborate with interdisciplinary team members Comprehensive assessment Planning of care Monitoring progress Altering plan of care, as needed Discharge planning Facilitate end of life care
ICU Nurse Practitioner Scope Scope = How we do things Consult with the interdisciplinary team members Daily rounding on patients Ordering and interpreting diagnostic tests and procedures Ordering pharmacologic agents Ordering plan of care Perform invasive diagnostic procedures Perform invasive therapeutic procedures Order discharge/transfer instructions
Royal Alexandra Hospital Experience History First NP 10 years ago Currently, 4 NPs in total Dr Rick Johnston established the first role Role and scope of NPs expanded over the years Subsequent MD hires were based, partially, on their willingness to work with NPs
Royal Alexandra Hospital Experience Role and Scope RAH 24 bed closed unit A-Side and B-Side (12 per side) Day NP Responsible for B-Side with one attending MD NP sees half the patients preceding rounds with MD Day NP (Post Rounding) NP assists A-Side, while maintaining responsibility for B-Side Night and Weekend NP Works collaboratively with residents to meet the needs of the unit: A-Side and B-Side Admits patients Resuscitate codes from outside of ICU Actively manages ICU patients, as needed
Royal Alexandra Hospital Experience Schedule and unit coverage is continuously assessed and changed to meet the unit s needs 12H shifts (7-19, 12-00, 19-07) One NP on unit at a time 24 hr coverage Impossible with 4 FTE; thus, coverage from 12-00H predominates Planning for implementation to ensure at least one, Attending, Fellow, or NP physically on unit at any given time
Creating a Role Identify Need Working Group Proposal Role and Scope Preparation Implementation
Creating a Role: Identifying Need Identify Need It would be cool to have ICU NPs Not a valid reason Examine the needs of the unit and/or organization Are care providers needed? Is quality of care suffering due to lack of care providers? Is patient flow suffering? What do the stakeholders say? How is the unit morale? How is the MD-RN relationship? How does the interdisciplinary team function?
Creating a Role: Working Group Working Group: Purpose Facilitating assessment of needs Writing a proposal Selling the proposal Developing the role and scope Implementing and maintaining the role Working Group: Inclusions Stakeholders Decision Makers Eloquent/Articulate Individuals Respected Individuals
Creating a Role: Proposal Proposal Proposal writing is an art Follow organizational standard formatting The less fluff, the better EB literature Remember, individuals within the decision making roles are, most likely, AT LEAST as smart as you! Emphasize measurable improvements and benefits Emphasize cost savings, where possible Have a solid financial breakdown Build in outcomes which are measurable and can be monitored
Creating a Role: Role and Scope Role and Scope Preparation Realistic Achievable Specific Key stakeholders involved Ensure unanimous buy-in MDs, nursing management, organization at large Consistent with legislature and laws, at various levels
Creating a Role: Implementation Implementation If not done correctly, the role will fail! Select the RIGHT NP Especially, the initial position Lots of preparation from all involved Unit and/or organization-wide Allow time Allow flexibility and alteration of role/scope Frequent reassessment and modification during implementation
Barriers to Success Lack of unanimous buy-in by key stakeholders Inappropriate NP selection Lack of flexibility Lack of leadership Competing interests Funding climate changes Lack of appropriate revision and maintenance of the role
Role Ongoing Maintenance Promote NP growth Facilitate ongoing education NP practice Involve NPs in committees, working groups, and initiatives Reassess NP Role and Scope Changes in needs Changes in culture Modify NP hours Meet needs of unit/organization NP scope Keep up with advancements in care and technology
Key Points Nurse Practitioners are great in the ICU The Royal Alexandra Hospital ICU is an excellent example of a successful NP Program Develop the role and scope with care Choose the appropriate NPs for the role Implement the role with attention Ensure all stakeholders are content Frequent reassessment is imperative
Thank You for you Attention Any Questions, Any Comments?
References Canadian Institute for Health Information. The supply and regulation of nurse practitioners in Canada. Ottawa, On: CIHI; 2005 Canadian Nurse Practitioner Initiative. Canadian nurse practitioner initiative technical report: Legislative and regulatory framework. Ottawa, On: CNA; 2006 Canadian Nurse Practitioner Initiative. Nurse practitioners: The time is now. Ottawa, On: CNA; 2006 Considine J, Martin R, Smit D, Jenkins J, Winter C. Defining the scope of practice of the emergency nurse practitioner role in a metropolitan emergency department. International Journal of Nurse Practitioners 2006;12(4):205-13 Green J. Growing ranks: Benefits of collaboration with nurse practitioners. In: American Medical Association Online: AMA; 2001 Government of Alberta. Health Professions Act 2000 (with amendments current to 2010) Published by Alberta Queen s Printer National Panel for Acute Care Nurse Practitioner Competencies. Acute care nurse practitioner competencies. Washington, DC: NONPF; 2004 van Soeren MH, Micevski V. Success indicators and barriers to acute nurse practitioner role implementation in four Ontario hospitals. AACN Clinical Issues 2001;12(3):424-37 Vincent D. Using cost-analysis techniques to measure the value of nurse practitioner care. International Nursing Review 2002;49(4):243-9. Herrmann LL, Zabramski JM. Tandem practice model: a model for physician-nurse practitioner collaboration in a specialty practice, neurosurgery. Journal of American Academy of Nurse Practitioners 2005;17(6):213-8