Framework for the Nurse Practitioner Candidacy Program

Framework for the Nurse Practitioner Candidacy Program 0

This document was prepared by: Catherine Duck and Irene Murphy May 2014 Gippsland Region Palliative Care Consortium c/- West Gippsland Healthcare Group 41 Landsborough St, Warragul 3820 Tel: 03 5623 0684 www.grpcc.com.au 0

Table of Contents 1 Purpose... 1 2 Background... 2 Gippsland... 2 Palliative Care in Gippsland... 2 Specialist Palliative Care Consultancy Service in Gippsland... 3 The role of Nurse Practitioner a brief history... 4 Nurse Practitioner Candidate... 4 Nurse Practitioner Candidacy Program... 5 Palliative Care Nurse Practitioner Program in Gippsland... 5 3 Palliative Care Nurse Practitioner Candidacy Program in Gippsland... 6 Governance... 6 Appointment of sub-regional NPCs... 7 Obligations of the sub-regional NPC... 7 Steering Committee... 8 Sustainability... 9 Risk management... 9 Dispute resolution... 10 Complaints... 10 Performance Management... 10 4 Methodology of the Nurse Practitioner Candidacy Program... 12 The role of the NPC in Gippsland... 12 The knowledge, skills and attributes of the NPC in Gippsland... 12 Relationship network... 14 Referral and exit pathways... 15 Clinical internship... 16 Specialist clinical placements and supervision... 16 Nurse Practitioner Mentor... 17 Professional internship... 17 5 Reporting... 18 Statement of Intent... 18 Personal Learning Plan... 18 Candidacy Program Report... 19 Case Studies during the Program... 19 Case Study presentations to expert panel... 19 Logbook... 20 Timeline... 21 Program Logic... 22 Appendices... 23 Appendix 1. References... 23 Appendix 2. Abbreviations... 25 Appendix 3. Definitions... 26 Appendix 4. Palliative Care Nurse Practitioner Candidacy Program Steering Committee - Objectives... 28 Appendix 5. Risk Management Matrix... 29 Appendix 6. NPM - Key objectives, duties and responsibilities... 30 Appendix 7. Clinical Supervision Agreement... 31 Appendix 8. Mentorship Meetings: Agenda... 32 Appendix 9. Nurse Practitioner Candidate Activity Report... 33 Appendix 10. Nurse Practitioner Candidacy Clinical Mentor Report... 34 Appendix 11. Nurse practitioner standards for practice... 34 0

1 Purpose The purpose of this (Framework) is to: identify and articulate the clinical and professional components of the Palliative Care (PC) Nurse Practitioner (NP) Candidacy Program (Program) in Gippsland; identify and articulate the responsibilities of stakeholders in managing and supporting the Program; and to assist Nurse Practitioner Candidates (NPCs) in their clinical and professional preparation for successful endorsement as NPs by the Australian Health Practitioners Regulation Agency (AHPRA). The Framework aligns with: Nurse practitioner standards for practice (Nursing and Midwifery Board of Australia); and Safety and Quality Improvement Guide Standard 1: Governance for Safety and Quality in Health Service Organisations (Australian Commission on Safety and Quality in Health Care). See Appendix 11 for Nurse practitioner standards for practice (Nursing and Midwifery Board of Australia). 1

2 Background Gippsland The Gippsland region is extremely diverse and covers an area of 41,375 square kilometres (18.3% of Victoria), from metropolitan Melbourne to the New South Wales border in the east. The distance from Mallacoota to Melbourne CBD is approximately 516km. In 2011, the estimated resident population in Gippsland was 269,791 persons or 5% of Victoria s total population 1. The proportion of the population aged 65 or above is higher in Gippsland compared with Victoria as a whole 2, and it has a higher than average percentage of Aborigines 3. The number of immigrants is the lowest of all Victorian regions. Gippsland also rates the lowest of all regions on a number of health indicators, including smoking (highest rate in the state), male life expectancy, psychological distress, and rates of disability. The region has the highest rate of low birth weight babies and children at developmental risk, and the highest rate of drug and alcohol clients. The rate of inpatient separations is the highest of all regions and private hospital use is the lowest. GP attendances are slightly below average, while emergency department presentations and primary care type presentations are the highest of all regions 4. Palliative Care in Gippsland There are nine funded specialist community palliative care services in the Gippsland region, based at: Bairnsdale and Lakes Entrance in Eastern Gippsland; Sale and Yarram in Wellington; Morwell and Warragul in Central West; and Leongatha, Wonthaggi and San Remo in Southern Gippsland. Koo Wee Rup Health Service, Omeo District Health, Orbost Regional Health and South Gippsland Hospital all provide unfunded generalist palliative care services and there are also a number of smaller bush nursing services in the East Gippsland area. There are eleven designated palliative care inpatient beds in the region located at Bairnsdale (1), Sale (2), Traralgon (4), Leongatha (1), Wonthaggi (1) and Warragul (2). 1 Department of Planning and Community Development, State Government of Victoria Victoria in Future 2012 Data Tables 2 Ibid 3 Department of Health, State Government of Victoria Local Government Area Profiles, Gippsland Region 2012 http://www.dpcd.vic.gov.au/home/publications-and-research/urban-and-regional-research/census-2011/victoria-in-future- 2012/VIF-2012-One-page-Profiles Retrieved September 2013 pg. 101 4 Ibid, pg. 101 2

Map 1. Location of palliative care services Gippsland region Specialist Palliative Care Consultancy Service in Gippsland Since 2007-08 the Gippsland Region Palliative Care Consortium (GRPCC) has coordinated visits from metropolitan-based palliative medicine specialists (Calvary Health Care Bethlehem, Monash Health and Peninsula Health) to the region. The visiting palliative medicine specialists have also provided: secondary consultations; education for health professionals; training and support for the implementation of the end of life care pathway (PICD); and participation in multi-disciplinary team meetings at some local palliative care services. The GRPCC has enhanced the consultancy service by providing funding to lead member services to enable the employment of Nurse Practitioner Candidates (NPCs). With the supervision, support and clinical guidance of the regional Nurse Practitioner Mentor (NPM), they provide a sub-regional specialist palliative care service. 3

The role of Nurse Practitioner a brief history The first NP programs emerged in the 1960s in the United States and Canada in response to the limited access to health care services of specific populations and regions. The Australian movement began in New South Wales in 1998 after the introduction and amendment of state legislation. Other jurisdictions followed and NP roles are now being introduced in the delivery of health care across Australia 5. An NP is a registered nurse who is educated and authorised to function autonomously and collaboratively in an advanced and extended clinical role. The role includes assessment and management of clients and may include but is not limited to the direct referral of clients to other health care professionals, prescribing medications and ordering diagnostic investigations. The NP role is grounded in the nursing profession s values, knowledge, theories and practice and delivers evidence-based, innovative and flexible health care that complements that of other providers. The NP demonstrates dynamic practice, professional efficacy and clinical leadership 6. The NP s scope of practice is determined by the context for which the NP is endorsed and aligned with the needs of her/his employer and client base. The title Nurse Practitioner is protected, preventing its use by anyone not endorsed by the Nursing and Midwifery Board of Australia (NMBA) 7. As of December 2013, there were 1004 authorised NPs nationally, with 168 in Victoria 8. Nurse Practitioner Candidate A NPC is a highly experienced registered nurse employed by a service or organisation in an expanded role while they meet the academic and clinical requirements for endorsement as a NP 9. The preparation of a NPC requires the integration of theory with clinical practice as well as mastery and application of advanced skills in clinical assessment, diagnosis, symptom management, pharmacotherapy and other treatment options. NPCs further develop the psychosocial, spiritual and cultural domains of their practice, as well as their capacity to communicate, promote and market their role. In addition, they expand their research and leadership capabilities 10. 5 Government of Western Australia, Department of Health, Nursing and Midwifery Office 2012 Nurse Practitioner Candidacy Program Implementing nurse practitioner candidacy opportunities across WA Health pg. 2 6 Ibid pg. 5 7 Nursing and Midwifery Board of Australia (2013) Explanatory note and FAQ on title protection Retrieved 31 March 2014 from http://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/faq.aspx 8 Ibid Nursing and Midwifery Board Newsletter March 2014 9 Centre for Palliative Care. Victorian Palliative Care Nurse Practitioner Collaborative. (2014) What is a Nurse Practitioner 10 Nurse Practitioner Candidacy Program Implementing nurse practitioner candidacy opportunities across WA Health pg.3 4

Nurse Practitioner Candidacy Program A NP candidacy program is a structured and supported program of clinical and professional supervision and mentorship. The period of candidacy is flexible and depends, in part, on the NPC s clinical expertise and academic preparation. It may be taken concurrently with the required NMBA approved nurse practitioner qualification at Master s level 11. A candidacy program: Aligns with workforce planning; Aligns with the NPC s academic program; Supports the NPC s transition to practice as an endorsed NP; and is Individualised to ensure clinical competencies that meet service demands are developed during the candidacy 12. Palliative Care Nurse Practitioner Program in Gippsland In 2009 the GRPCC secured funding from the Victorian Government to develop a PC NP model. The model proposed that three NPs be recruited to the stand-alone community health services to enable sub-regional specialist palliative care services. There were difficulties in recruiting NPs to Gippsland so the GRPCC considered engaging NPCs. Implementation of this model began in late 2009. The development of the PC NP Candidacy Program (Program) was one of 11 recommendations of the Specialist Palliative Care Consultancy Service Plan for Gippsland and a key component of the Service Plan s implementation strategy endorsed by the Consortium Management Group in October 2011. The Program is integral to the provision of specialist palliative care when and where it is needed in Gippsland. In November 2012 GRPCC appointed an endorsed palliative care Nurse Practitioner Mentor (NPM) to provide mentorship, support and clinical guidance to the region s NPCs and to build the profile of the NP role in the region. In 2014 GRPCC is providing funding to three lead services to support the employment of four NPCs: West Gippsland Healthcare Group (two district nurses (DNs) based in Warragul); Latrobe Community Health Service (one DN based in Morwell); and Gippsland Lakes Community Health (one DN based in Lakes Entrance). This funding assists each of the lead services to employ a NPC to provide a fractional subregional service and to support training for the NPC to gain endorsement. GRPCC provides additional funding to assist with specialist clinical supervision and clinical placements at metropolitan based palliative care services. 11 Nursing and Midwifery Board of Australia (2013) Nursing and Midwifery Endorsement nurse practitioners Registration Standard Retrieved 31 March 2014 from http://www.nursingmidwiferyboard.gov.au/registration-standards.aspx 12 Nurse Practitioner Candidacy Program Implementing nurse practitioner candidacy opportunities across WA Health pg.5 5

3 Palliative Care Nurse Practitioner Candidacy Program in Gippsland The Program is based on: the NMBA Nurse practitioner standards for practice; the Clinical Diploma of Palliative Medicine Training Guidelines (Royal Australasian College of Physicians); and recent work of the Victorian Palliative Care Nurse Practitioner Collaborative (VPCNPC). The Program aims to: provide structures to promote the development of the required knowledge, skills and attributes; provide formalised supervision, mentorship and coaching; provide access to clinical expertise in diverse acute, sub-acute, residential aged care and community settings; provide timely, appropropriate and relevant experience" prepare NPCs so that they recognise the similarities and differences of the trajectories of cancer, organ failure and end stage dementia, as well as their associated physical and cognitive decline and frailty; prepare NPCs so they can develop effective careplans and interventions that align with the NMBA s Nurse practitioner standards for practice; enable NPCs to deliver comprehensive assessment and management of palliative care clients, caregivers and families across stable, unpredicted and/or complex situations within a clearly defined scope of practice that is underpinned by the best available evidence, and support the NPC to provide client-centred, safe, equitable and timely palliative care. Governance Sub-regional NPCs in Gippsland work within the corporate and clinical governance and performance management systems of their employing organisations. Employing organisations ensure that NPCs: have appropriate AHPRA registration; have current Police and Working with Children Checks; and adhere to their policies and procedures, including those related to Occupational Health and Safety. The GRPCC is responsible for establishing and maintaining this Framework which identifies, articulates, facilitates and guides the educational and professional components of the Program in Gippsland. NPCs who are financially supported by the GRPCC are required to undertake the Program. The Program can be tailored to meet the requirements of individuals and their employing health service however individual plans must be developed in conjunction with the GRPCC NPM. Completion of the Program will maximise the potential for endorsement as a PC NP. 6

Appointment of sub-regional NPCs It is the employing organisation s responsibility to credential and appoint NPCs and to provide the conditions that will enable them to progress to endorsement. The NPM participates in assessing the applicant at interview. In selecting the NPC the employing organisation should determine the applicant s suitability in line with NMBA requirements and by considering: Academic, professional and leadership skills; Quantity and quality of clinical experience; and Post-graduate qualifications in palliative care 13. The NMBA registration standard for endorsement as a NP states that an applicant seeking endorsement must be able to demonstrate: current general registration as a registered nurse with no conditions on the registration relating to unsatisfactory professional performance or unprofessional conduct; the equivalent of three years full-time experience in an advanced practice nursing role within the previous six years from date of lodgement of application; completion of a Board-approved nurse practitioner program of study at Master s level or equivalent as determined by the Board; compliance with the National Competency Standards for the Nurse Practitioner; and compliance with the Board s registration standard on continuing professional development as a registered nurse. Obligations of the sub-regional NPC The NPC s scope of practice is built on the platform of the registered nurses scope of practice and must meet the regulatory and professional requirements for Australia. They include the National competency standards for the registered nurse, Code of Ethics and Code of Professional Conduct for Nurses in Australia 14. NPCs are accountable for the care they deliver consistent with their defined roles and responsibilities 15. NPCs are also accountable, in collaboration with their clinical supervisors, for identifying, initiating, implementing and monitoring activities, and for assessing their clinical learning 16. 13 Nurse Practitioner Candidacy Program Implementing nurse practitioner candidacy opportunities across WA Health pg.9 14 Nursing and Midwifery Endorsement nurse practitioners Registration Standard 15 Department of Human Services (2009) Victorian clinical governance policy framework. A guidebook. State-wide Quality Branch, Rural and Regional Health and Aged Care Services, Victorian Government pg.4 16 Nurse Practitioner Candidacy Program Implementing nurse practitioner candidacy opportunities across WA Health pg.7 7

Steering Committee The Steering Committee s role is to oversee, advise, guide and support the planning, development, implementation and evaluation of the NPC Program in inpatient and community settings across Gippsland. Its objectives include: To oversee, advise, guide and support the NPC Program to meet the NMBA Nurse practitioner standards for practice; To oversee, advise, guide and support the progress of NPCs in the areas of clinical practice, research, education and leadership, both within their specific settings and in palliative care practice in general, to the achievement of endorsement; and To review the Program s progress against key milestones. See Appendix 4 for the full list of objectives. The Steering Committee s membership is multidisciplinary and includes senior practitioners in various aspects of palliative care as well as regional representatives: NPM; NPCs; Two palliative medicine specialists; Pharmacist; General practitioner (Gippsland); Two nurse managers (representing two Gippsland sub-regions and the Consortium Management Group); Allied health representative (Gippsland); and Academic (Federation University). Other relevant stakeholders may be invited, as required, to share expertise, knowledge and ideas. Figure 1. Governance structure "#$%"&' '(' )*"*+',+-./&"#$%' ) ) ) 0+-1&"*$23)) -) 42$5+//.$%"&' 0+61./.*+/' "#$%&'() ) ) *%(#%(+,') )-) )*$./.0+$) 1%2'(/+/0') 1A6**) ) ) B(+"'=%(C)%;) 840+7%/+$) )-) 6(%;'55.%/+$) *%"#%/'/,5) D,''(./<) *%"".E'') ) F2'(5.<>,?) 14.8+/0') )-) )982.0') 34(5')6(+077%/'()*+/8.8+,') ) 900%4/,+:$');%()0$.'/,)0+(')-)0$./.0+$)$'+(/./<)0%/5.5,'/,) =.,>)50%#')%;)#(+070'?)8'@/'8)(%$')-)('5#%/5.:.$.7'5) 789' ) 12/+' :2";##$%+2' /*"%<"2</' 5$2':2";#;+' 8

Sustainability The Program seeks to embed NPCs and NPs in Gippsland as an integral part the health workforce. To promote sustainability, the Program collaborates with, consults and assists relevant stakeholders, such as organisations employing NPCs, regarding the: Relevance, application and transference of the Program beyond individual NPCs and organisations; Alignment and/or integration of NP models of palliative care with existing service delivery models; Development of innovative NP models in palliative care with regional and state-wide application and transferability; Collaboration between regional private and public health services; Promotion and marketing of the Program across services and the region; Linking of employment with the Program; Identification of emerging clinicians with advanced practice; and Succession planning. Risk management The Program seeks to minimise risk and optimise the safety of clients, caregivers, families and NPCs by: Ensuring that all stakeholders recognise and acknowledge the elements of a successful PC NP model of care: autonomy, collaboration, innovation, organisational support, respect and recognition, role clarity and safety and quality 17 ; Aligning this Framework with the Safety and Quality Improvement Guide Standard 1: Governance for Safety and Quality in Health Service Organisations 18 ; Articulating that NPCs work within their scope of practice according to the NMBA s Nurse practitioner standards for practice and the requirements of their employing organisation; Identifying and articulating the responsibilities of stakeholders; Ensuring comprehensive stakeholder representation on the Steering Committee; Fostering a culture of open and robust communication through formal and informal means; Providing NPCs with several avenues of support and advice, including the dedicated role of NPM; Fostering a culture of trust, openness, respect and caring for NPCs; Monitoring of NPCs progress through several means of regular reporting; Identifying, assessing and prioritising risks; and Identifying actions to minimise and manage the probability and impact of adverse events. See Figure 2 for Elements of a successful nurse practitioner model of care See Appendix 5 for Risk Management Matrix. 17 Nurse Practitioner Candidacy Program Implementing nurse practitioner candidacy opportunities across WA Health pg.7 18 Australian Commission on Safety and Quality in Health Care Safety and Quality Improvement Guide Standard 1: Governance for Safety and Quality in Health Service Organisations (October 2012). Sydney. 9

Figure 2. Elements of a successful nurse practitioner model of care Dispute resolution In the event of dispute or grievance, representatives of each party will meet and endeavour to resolve the issue in an expeditious and informal manner. If resolution is not achieved and the issue is related to the NPC and/or the NPM, the matter will be managed according to: The employing organisation s dispute resolution system; and Clause 11 Dispute Settling Procedures of the Nurses and Midwives (Victorian Public Health Sector) (Single Interest Employers) Enterprise Agreement 2012 2016. If resolution is not achieved and the issue involves a specialist palliative care supervisor, the matter will be managed according to the Service Agreement for the Provision of Specialist Palliative Care Services. All other matters will be referred to the Steering Committee. Complaints In the event of a complaint against a NPC, the complaints management system of the NPC s employing organisation is followed. Complaints are also reported to the NPM to enable support, analysis, learning and improvement. Performance Management The NPC s performance is managed by the employing organisation. Input from the NPM and the Program s monitoring and reporting structures inform NPC appraisals. Should issues arise, 10

the NPM is involved in addressing them to enable support, analysis of the issues, learning and improvement. 11

4 Methodology of the Nurse Practitioner Candidacy Program The role of the NPC in Gippsland The role of the NPC is to provide: local specialist knowledge; build relationships with local GPs, nurses and allied health professionals to improve palliative care outcomes; a triage and referral service for complex patients throughout the sub-region; client assessment and consultation; participation and leadership in local multi-displinary team(mdt) meetings; advice about advance care planning; education to health professionals, clients and the community; initiation and implementation of quality improvement activities; and research. The knowledge, skills and attributes of the NPC in Gippsland Arising from a platform of highly developed clinical knowledge, skills and professional attributes, the NPC in Gippsland will deliver autonomous, collaborative, advanced and extended practice. Within the context of each employing organisation and its clients, such practice is exemplified by: Commitment to the nursing model; Communication skills that build collaborative and therapeutic relationships; Collaboration with health professionals and sub-regional health services; Navigation of the different cultures of sub-regional health services; Functioning autonomously and exhibiting advanced levels of decision-making; Applying advanced clinical knowledge, critical thinking and clinical leadership; Participating as a senior member of the MDT; Making and accepting appropriate referrals; Conducting comprehensive assessments, including physical examination, and the diagnosis of conditions where presentations are stable, unpredicted and/or complex; Recommending medications and diagnostics to GPs and medical consultants (within the NPC s scope of practice and the palliative care drug formulary); Managing and monitoring clinical and pharmaco-therapeutic regimens; Integrating the psychosocial, spiritual and cultural domains into assessment and care planning; Providing sophisticated therapeutic interventions that improve outcomes for clients, caregivers and families; Coordinating complex case management, including the main health issue and associated co-morbidities; Integrating research into evidence-based practice; Initiating and participating in quality improvement activities; 12

Participating in peer review; Being a role model and mentor to nursing colleagues and other health professionals; and Maintaining a life-long commitment to the professional development of self and other health professionals. Figure 3. Representation of how the education, research and leadership domains are couched within the clinically focused standards 19. 19 Nursing and Midwifery Board of Australia (2014) Nurse practitioner standards for practice Retrieved 31 March 2014 from http://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/codes-guidelines/nurse-practitioner-standards-ofpractice.aspx 13

Relationship network The NPC s relationship network includes: Governing bodies: Employing health service; GRPCC (funder); and Steering committee. Collaborative mentors/supervisors: NPM; Clinical supervisor/s (palliative care physician/s); and Allied health professionals, e.g. pharmacist, bereavement counsellor, occupational therapist. Collaborative partners: Clients, caregivers and families, physicians (palliative care and others), GPs, acute and community health services (CHSs) and residential aged care facilities (RACFs); and The Clinical Practice Group (CPG). The CPG is responsible for ensuring that decisions made by the GRPCC are based on good clinical practice and the best available evidence. Membership of this group offers NPCs opportunities to enhance their critical thinking and analytical and problem-solving skills. The CPG benefits from the NPC s contributions and activities. Professional affiliations: The NPC is required to develop collaborative professional relationships and networks. This includes: Regular participation in the activities of the VPCNPC; Membership of the Australian College of Nurse Practitioners; Development of and/or participation in peer reviews, reflective practice and clinical case studies and reviews; Attendance at conferences, seminars and workshops relevant to the context of their clinical practice; and Establishment and promotion of special interest groups (SIGs) and education and research groups related to their clinical practice. See Figure 4for a representation of the NPC s relationship network. 14

Figure 4. NPC s relationship network "#$%&'#()**+,%#&E%,0+#& ;44/%.&=%(408& 67'--& 1234+5%#& -4/,/)(4&>"3%#B/$+#& 9'(44/(*B%&-(#%&'85$/)/(,:& >0%%#/,A& -+22/D%%& "#$%&'#()**+,%#& -(,./.(0%$& -4/,/)(4&'#()*)%&6#+"3& G'-'-& ;"$0#(4/(,&-+44%A%&'$& >H6$& 6+B%#,/,A&C+./%$& -+44(C+#(*B%@2%,0+#/,A@$"3%#B/$/,A&&#%4(*+,$8/3$& -+44(C+#(*B%&#%4(*+,$8/3$& '#+<%$$/+,(4&(F4/(*+,$& '85$/)/(,$&93(44&)(#%:& '85$/)/(,$&9+08%#:& ;)"0%&<()/4/*%$& -=>$& 6'$& 7;-?$& -4/%,0$@)(#%A/B%#$& Referral and exit pathways There is a variety of ways in which the NPC will receive referrals. The NPC then triages, actions and/or refers clients and caregiver/family on to an appropriate service. NPCs may visit clients who are relatively stable in all domains for the purposes of teaching and modelling practice for other staff. In general, however, triggers for referral to the NPC indicate instability and/or complexity of clinical and/or psychosocial issues. They include: Phase of care: unstable and/or deteriorating or terminal; Frequent presentations to acute care; Frequent inpatient palliative care admissions; Refractory symptoms; Client/caregiver/family distress; Psychosocial/spiritual issues; Challenging family dynamics; Request for death at home; Facilitation of end-of-life care, choices and decision-making; Anticipated loss and grief issues; and Opportunities to educate and support other staff. 15

Acceptance of referrals is determined by the NPC s: Scope of practice; Clinical expertise; Employing health service s requirements; Current workload; and Academic work commitments. Clients may be referred via: The employing health service; The NPM; A palliative care physician; An acute health service; A community health service; A GP; A residential aged care facility; or A client and/or caregiver/family. Clients will exit the care of the NPC when: All symptoms are controlled; The client s condition is stable and/or deteriorating as expected; The client has been transferred out of the region; The client requests it; or The client dies. Clinical internship The NPC requires a minimum of six months (full time) supervised clinical practice but this can be extended to accommodate part-time positions (as in Gippsland). Supervised clinical practice is aligned with and complements the requirements of the Master of Nurse Practitioner. Specialist clinical placements and supervision Under the Specialist Palliative Care Consultancy Service Plan, the GRPCC has allocated funds to pay for specialist clinical supervision and clinical placements. A palliative care consultant, nominated by the NPC s employing health service, undertakes most of the clinical supervision while the NPM provides over-arching professional and clinical support that is both formal and informal. Supervision is developed and applied to clinical training through agreement between the NPC, the clinical supervisor and the NPM, and is tailored to the NPC s day-to-day clinical practice. As far as possible, clinical supervision is standardised across NPCs and sub-regions, ensuring similar levels of: primary and secondary consultation; collaboration in MDT meetings and video/case conferencing; opportunities for education, training and clinical placements; 16

clinical experiences in facilities, tertiary and other, outside the region; and exposure to related specialties, e.g. radiology and pathology. Ideally a senior pharmacist supervises the clinical therapeutics component. If this is not possible, the NPC develops a relationship with a local pharmacist. Other specialists, such as GPs, medical consultants, social workers and counsellors, provide additional support and supervision depending on the identified learning needs of the NPC. See Appendix 7 for Clinical Supervision Agreement Nurse Practitioner Mentor The role of the NPM is to: provide clinical leadership and expert advice to NPCs; model the way for Gippsland s PC NPCs and inspire a shared vision; and to be a trusted advisor and mentor. These objectives are achieved, in part, through: clinical supervision (regular and as required); structured support and guidance in areas such as clinical leadership, therapeutic communication and professional development; the structured Program and addressing individual training needs; providing clinical advice via telephone or in person on the assessment, care planning and management of complex clients; promoting and communicating information about the role and services of the NPCs; modelling expert skills and culturally safe nursing practice; demonstrating skilled mentoring/coaching and teaching; demonstrating and encouraging initiative, flexibility, creativity and resilience; and promoting teamwork. See Appendix 6 for the NPM s Key Objectives, Duties and Responsibilities. See Appendix 8 for Mentorship Meetings: Agenda Professional internship The NPM and clinical supervisor oversee the NPC s professional internship. The professional internship includes: development of leadership and management skills, including communication and relationship building; research, analytical and presentation skills; and development of the portfolio required for endorsement 20. 20 Cooper,D (2011) Implementation of Aged & Palliative Care Nurse Practitioner Role Melbourne Citymission pg.10 17

5 Reporting The NPC is required to prepare and submit a number of documents throughout the Program including: Statement of Intent; Personal Learning Plan; Candidacy Program Report; Case Studies during the Program; Case Studies presented to an expert panel towards the end of the Program; and Log Book. The NPC s employer is required to prepare and submit to the GRPCC twice per year: A Candidacy Clinical Mentor Report, demonstrating the progress of the NPC towards endorsement; and A Nurse Practitioner Candidate Activity Report. See Appendix 10 for the Candidacy Clinical Mentor Report. See Appendix 9 for the Nurse Practitioner Candidate Activity Report. The GRPCC undertakes an annual Service Satisification Survey of the Palliative Care Nurse Practitioner Program in May each year. The Survey investigates the delivery of the subregional pallative care specialist service. The Candidacy Clinical Mentor Report, Service Satisfaction Survey and Candidate Activity Report inform the GRPCC Annual Report to the Department of Health. Statement of Intent In consultation with their employing health organisation, clinical mentors and supervisors, the NPC prepares a Statement of Intent (Statement). The purpose of the Statement is to ensure that all professional development, clinical preparation and training requirements are met before application for endorsement as a NP. The Statement details: the NPC s commitment to fulfilling all the objectives of the Program; the responsibilities of the employing organisation, clinical supervisors and mentor/s in providing adequate supervision and opportunities for learning; the objectives of formal supportive structures; and the responsibility of the NPC to seek endorsement within a reasonable time of completing of the Program. Personal Learning Plan In consultation with the NPM and clinical supervisors, the NPC formulates a Personal Learning Plan (PLP). The PLP supports advanced practice and includes: supervised activities encompassing the holistic dimensions of palliative care: physical, psychosocial, cultural and spiritual; 18

the names and roles of allied health mentors who provide coaching and education in the holistic dimensions of palliative care; clinical placements in palliative care, sub-acute and community settings; self-directed learning activities; and timelines and milestones. Candidacy Program Report The NPC submits a Candidacy Program Report (Report) to the NPM and Steering Committee at six monthly intervals. The Report demonstrates the NPC s progress towards endorsement. It assists evaluation of the NPC s learning outcomes and identification of areas for further learning. The Report also flags barriers to development of the NPC s role and provides opportunities to address them. Case Studies during the Program The NPC develops and presents case studies during the Program to the clinical supervisor and/or the NPM. They occur within timeframes agreed to by the NPC, NPM and clinical supervisor. The case studies reflect the NPC s growing clinical capacity as well as the aims of the Program and the PLP. The NPC prepares at least three case studies. They reflect the intended scope of practice and extended practice, and include evidenced-based approaches, interventions and recommendations, literature reviews and reflective practice. This process is intended to be supportive, with the clinical supervisor and NPM giving constructive feedback and advice. Case Study presentations to expert panel The GRPCC requires the NPC, towards the end of the candidature, to present two case studies to an expert panel. These case studies draw together the NPC s learnings from the Program and include all the elements of the NMBA s Nurse practitioner standards for practice while focusing on clinical leadership and professional efficacy and effectiveness. They demonstrate the NPC s readiness to submit their portfolio for endorsement to the NMBA. This process is also intended to be supportive. It provides an opportunity for celebration of the NPC s achievements and showcasing of the individual s role and its impact 21. It also promotes consistency of practice in the NPCs supported by the GRPCC. The expert panel will consist of members from a range of areas. In addition to assessing the NPC against the Nurse practitioner standards for practice, the panel will take a broad perspective of the NPC s role and its innovation, flexibility and complementarity 22 to the NPC s employing health service. 21 Begbie, J. and Wheelhouse, A. The Nurse Practitioner Panel: A Crucial Step In The Endorsement Process? Retrieved 2 May 2014 from http://www.slideshare.net/informaoz/jo-begbie-and-alyson-wheelhouse-southern-health 22 Ibid 19

Logbook The NPC maintains a logbook of activities undertaken during the Program such as: reading of relevant articles; documentation of clinical discussions; clinical supervision and mentorship activities; peer reviews; and other professional meetings and clinical presentations. The logbook provides documented evidence of skill and knowledge acquisition, clinical outcomes and the variety of clinical and professional experiences gained through the Program. NPCs funded by the Victorian Nurse Practitioner Program NPC Support Package 23 are required to submit two six-monthly logbooks to the Department of Health. See Figure 5 for Timeline of reporting requirements 23Department of Health. Nursing in Victoria NP Candidate Support Packages Retrieved 31 March 2014 from http://www.health.vic.gov.au/nursing/furthering/practitioner/np-candidates 20

Timeline Figure 5. Timeline of reporting requirements Date By whom To whom Action Beginning of Program NPC Employer GRPCC Steering Committee Clinical supervisor/s NPM Statement of Intent Beginning of Program (evolving) NPC Employer GRPCC Steering Committee Clinical supervisor/s NPM Personal Learning Plan 6 monthly NPC NPM Steering Committee At least 3 units NPC NPM Steering Committee 6 monthly NPC NPM Steering Committee Department of Health 24 Candidacy Program Report Case Studies Logbooks End of Program NPC Expert panel Two Case Studies 1 June, 1 December Employer GRPCC Candidacy Clinical Mentor Report 1 June, 1 December Employer GRPCC Nurse Practitioner Candidate Activity Report

Program Logic A program-logic links the components of the Program and demonstrates how they flow through to the goals of NP endorsement and excellent palliative care in Gippsland. Figure 6. Program logic A2%;0: -)'8#::#: M;0%;0: A$%980: R9)3#0: "#$ %&'()*+*,$-&.+(/$ "#$%&'(#)* +,-..*/0##)123.'$$14##5 0(*1&)/2 345()'+/&)/$ "6-7*8&12189& :;%#)<1:'):5 #&6678&)79'($ "7)1*()/$"+-* =#9&0=:#)<18#:5 ")&:(//+&*76$ ;<6+79&*/$ ">-.6-.*?;:0)9&192.'&&#3# '@6-:*%##) 3)';%:5 #6+(*12 #7)(,+'()2=7>+6? 22 /090#$#20'@ A20#20 -#):'29&B#9)2123 -&92.92C1C98( -)'3)9$,#%')0.9:#/0;C1#: B'3D''E 345()'+/+&*$ $ 0(*1&)/@+5$ $ #&7A@+*,$ $ #6+*+A76$ "67A(>(*1/$ $ B.4A79&*$ $ C(/(7)A@$ $ C(D(A9&*$.)1F89&0=12E123.'$%)#=#2:1<# 9::#::$#20 G1932':1:.9)#%&922123 /'%=1:F890#C* 0=#)9%#;F8 120#)<#2F'2:.'&&9D')9F'2.'$%&#H89:# $9293#$#20 IC;89F'2'@ 8&1#20J 8'$$;210(J =#9&0= %)'@#::1'29& K;9&10( A$%)'<#$#20 -##))#<1#L?;0'2'$';:* #H0#2C#C* #<1C#28#ND9:#C %)98F8#.&1#208#20)#C* :9@#*#O;109D&#* %9&&19F<#89)# P'&1:F889)#.'2F2;10('@89)# 98)':::;DN)#31'2 A$%)'<#C ';08'$#:@') 8&1#20J89)#31<#)J @9$1&( A28)#9:#C %9&&19F<#89)# E2'L&#C3#Q 89%9810(,'&#$'C#& 7#20') G(29$18 -)98F8# -)'@#::1'29& IS#8F<#2#::Q IT898( B#9C#):=1% B*.&)/(>(*1$

Appendices Appendix 1. References Australian Commission on Safety and Quality in Health Care Safety and Quality Improvement Guide Standard 1: Governance for Safety and Quality in Health Service Organisations (October 2012) Sydney Begbie, J. and Wheelhouse, A. The Nurse Practitioner Panel: A Crucial Step In The Endorsement Process? Retrieved May 2014 from http://www.slideshare.net/informaoz/jo-begbie-and-alyson-wheelhouse-southern-health Centre for Palliative Care. Victorian Palliative Care Nurse Practitioner Collaborative (2014) What is a Nurse Practitioner Retrieved March 2014 from http://centreforpallcare.org/index.php/education/vpcnpc/ Cooper,D. (2011) Implementation of Aged & Palliative Care Nurse Practitioner Role Melbourne Citymission Department of Health. Nursing in Victoria NP Candidate Support Packages Retrieved March 2014 from http://www.health.vic.gov.au/nursing/furthering/practitioner/np-candidates Department of Health. State Government of Victoria Local Government Area Profiles, Gippsland Region 2012 http://www.dpcd.vic.gov.au/home/publications-and-research/urban-and-regionalresearch/census-2011/victoria-in-future-2012/vif-2012-one-page-profiles Retrieved September 2013 Department of Health, State Government of Victoria Strengthening palliative care: Policy and strategic directions 2011 2015 Department of Health, State Government of Victoria Strengthening palliative care: Policy and strategic directions 2011 2015 Implementation strategy Department of Human Services (2009) Victorian clinical governance policy framework. A guidebook. Statewide Quality Branch, Rural and Regional Health and Aged Care Services, Victorian Government Department of Planning and Community Development, State Government of Victoria Victoria in Future 2012 Data Tables Government of Western Australia, Department of Health, Nursing and Midwifery Office 2012 Nurse Practitioner Candidacy Program Implementing nurse practitioner candidacy opportunities across WA Health Lyth, GM. (2000) Clinical supervision: a concept analysis Journal of Advanced Nursing 31 (3): 722-729 Mills, J., Francis, K., Bonner, A. (2005) Mentoring, clinical supervision and preceptoring: clarifying definitions for Australian rural nurses. A review of the literature. Rural and Remote Health Journal 5:410 Retrieved January 2014 from http://www.rrh.org.au/articles/subviewnew.asp?articleid=410 23

Nursing and Midwifery Board of Australia (2013) Explanatory note and FAQ on title protection Retrieved March 2014 from http://www.nursingmidwiferyboard.gov.au/codes- Guidelines-Statements/FAQ.aspx Nursing and Midwifery Board of Australia Nursing and Midwifery Board Newsletter March 2014 Retrieved March 2014 from http://www.nursingmidwiferyboard.gov.au/news/newsletters/march-2014.aspx Nursing and Midwifery Board of Australia (2013) Nursing and Midwifery Endorsement nurse practitioners Registration Standard Retrieved March 2014 from http://www.nursingmidwiferyboard.gov.au/registration-standards.aspx Nursing and Midwifery Board of Australia (2014) Nurse practitioner standards for practice Retrieved March 2014 from http://www.nursingmidwiferyboard.gov.au/codes-guidelines-statements/codes- Guidelines/nurse-practitioner-standards-of-practice.aspx 24

Appendix 2. AH CHS CPG Framework GP GRPCC MDT NMBA NP NPM PC NPC PLP Program RACF Report SIG Statement VPCNPC Abbreviations Allied Health Community Health Service Clinical Practice Group Framework for the Palliative Care Nurse Practitioner Candidacy Program General Practitioner Gippsland Regional Palliative Care Consortium Multidisciplinary Team Nursing and Midwifery Board of Australia Nurse Practitioner Nurse Practitioner Mentor Palliative Care Nurse Practitioner Candidate Personal Learning Plan Palliative Care Nurse Practitioner Candidacy Program Residential Aged Care Facility Candidacy Program Report Special Interest Group Statement of Intent Victorian Palliative Care Nurse Practitioner Collaborative 25

Appendix 3. Definitions 25 Term Australian Health Practitioner Regulation Agency (AHPRA) Australian Nursing and Midwifery Accreditation Council Clinical governance Clinical Supervision Competence (or competency) Competency Standards (Nurse Practitioner) Credentialing Endorsement Internship and Clinical Placement Definition The organisation responsible for the implementation of the National Registration and Accreditation Scheme across Australia. The independent accrediting authority for nursing and midwifery under AHPRA. It sets standards for accreditation and accredits nursing and midwifery courses and providers. The system by which the governing body, managers, clinicians and staff share responsibility and accountability for the quality of care, continuously improving, minimizing risks, and fostering an environment of excellence in care for clients, caregivers and families 26. Clinical supervision offers a formal opportunity for a developing practitioner to share clinical, organisational, developmental and emotional experiences with an experienced clinician in a secure environment. Clinical supervisor and supervisee are both active roles. Clinical supervision: involves observation, evaluation, feedback, facilitation of supervisee self-assessment, and acquisition of knowledge and skills by instruction, modelling, and mutual problem solving; builds on the recognition of the strengths and talents of the supervisee; and encourages self-efficacy 27. The ability of an individual to do a job properly. A set of defined behaviours combined with knowledge and skills. There are three generic standards that define the parameters of NP clinical practice. These standards are defined by nine competencies, each with specific performance indicators. Standard 1: Dynamic practice that incorporates application of high level knowledge and skills in extended practice across stable, unpredictable and complex situations. Standard 2: Professional efficacy whereby practice is structured in a nursing model and enhanced by autonomy and accountability. Standard 3: Clinical leadership that influences and progresses clinical care, policy and collaboration through all levels of the health service. The process of verifying the qualifications, background and professional standing of a health professional for the purpose of forming a view about their competence and suitability to perform a specific role within a specific organisation. Refers to a category that a Registered Nurse (RN) may apply to the NMBA to have noted on their registration. Therefore a NP is an RN with an endorsement to practice as a NP. Supervised clinical practice undertaken, often as part of an academic course, to enhance and refine knowledge, skills and professional attributes required for safe and effective practice. 25 Nurse Practitioner Candidacy Program Implementing nurse practitioner candidacy opportunities across WA Health 26 Victorian clinical governance policy framework. A guidebook. 27 Lyth, GM. (2000) Clinical supervision: a concept analysis Journal of Advanced Nursing 31 (3): 722-729 26

Mentor/mentoring Nursing and Midwifery Board of Australia (NMBA) Standard Title Protection An experienced, skilled and trustworthy person who is willing and able to provide guidance and to share their knowledge, expertise and experience on career, technical, professional and cultural issues. The process is one-to-one, reciprocal and confidential. Nothing is reported except by mutual consent. The Board is responsible for: registering nursing and midwifery practitioners and students; developing standards, codes and guidelines for the nursing and midwifery profession; handlings notifications, complaints, investigations and disciplinary hearings; assessing overseas trained practitioners who wish to practice in Australia; and approving accreditation standards and accredited courses of study. A criterion, which is established by consensus, agreed upon and approved by a recognised body that provides for common guidelines and professional characteristics. The title Nurse Practitioner is legislated under section 95 of the Health Practitioner Regulation National Law (2009). Only a registered nurse who has successfully completed and approved NP master s level course of study and met the requirements of endorsement stipulated by the NMBA is legally permitted to use this title. 27

Appendix 4. Palliative Care Nurse Practitioner Candidacy Program Steering Committee - Objectives To oversee, advise, guide and support the NPC Program to meet the Nurse practitioner standards for practice (Nursing and Midwifery Board of Australia); To oversee, advise, guide and support the progress of NPCs in the areas of clinical practice, research, education and leadership, both within their specific settings and in palliative care practice in general, to the achievement of endorsement; To review the NPC Program s progress against key milestones; To recommend and/or facilitate opportunities for training and mentorship; To confirm that appropriate structures for clinical supervision and mentorship are in place; To oversee, advise, guide and support current and newly endorsed NPs in optimising their roles; To make recommendations for developing the capacity of the NP and NPC roles to improve and/or complement access to health services for clients, carers and families while enhancing diversity and flexibility; To make recommendations regarding the drug formulary for NPs in communitybased practice and any additional drugs required by specific client groups; To advise the NPC Program of the barriers and enablers to implementation of the NP role and strategies for managing same; To advocate for the NPC Program; To advise the NPC Program about strategies for collaborating with key stakeholders; and To advise and guide the NPC Program in developing a communication and marketing strategy for informing and educating stakeholders and the broader community of the program s progress and achievements. 28

Appendix 5. Risk Management Matrix Risks are listed, categorised and described. The consequence of each risk is rated high, medium or low. The probability of each risk is rated as unlikely, possible or likely. The overall risk score is derived from the two ratings, consequence plus probability (C+P): Description Impact Consequence Probability Score (C+P) Clinical incidents Complaints NPC operates outside scope of practice NPC is not achieving milestones NPC does not complete Program NPC leaves soon after completing Program Lack of GP and/or medical specialist engagement Strategy Client safety at risk. High Possible High Incidents management system of employer is followed; incidents, adverse events & near misses are reported to the NPM to enable support, analysis, learning & improvement. Program s reputation & credibility at risk. Client safety at risk; Program s reputation & credibility at risk. NPC is demoralised; the palliative care needs of clients & sub-region are not met; NPC is not endorsed. NPC is not endorsed; subregional palliative care needs are not met; Program s reputation & credibility at risk. The sub-region does not have an NP; the employer and GRPCC are at risk of losing the benefit of their investment. Lack of referrals; barriers to appropriate care of clients. High Possible High Complaints management system of employer is followed; complaints are reported to the NPM to enable support, analysis, learning & improvement. High Possible High Ensure position description is current; performance management system of employer is followed; performance is reported to the NPM to enable support, analysis, learning & improvement. High Possible HIgh Performance management system of employer is followed; the NPM works with the NPC to enable support, analysis of the issues, learning & improvement; the employer provides an alternate avenue of support if the NPC s relationship with the NPM is implicated. High Possible HIgh Detect and address issues early through maintenance of regular monitoring and reporting; consider flexibility in accommodating any personal or academic issues through the course of the Program. High Possible High As far as possible, when recruiting, seek the aspiring NPC s assurance of remaining in the region; acknowledge the benefit to the sub-region of the NPC during the Program; ensure succession planning. High Likely Very high NPC to enlist the assistance of the NPM and/or supervising palliative care physician for individual cases; focus initial energies on receptive GPs and medical specialists; promote and market the PC NP Program. 29