Development of the role of the Advanced Nurse Practitioner in Diabetes

1
Development of the role of theAdvanced Nurse
Practitioner in Diabetes

• Helen Burke
• Advanced Nurse Practitioner (Diabetes)
• University College Hospital Galway.

2
Historical Development ANP Roles Internationally

• Role of Nurse Practitioner developed in 60s by
  Loretto Ford in Colorado (Paediatric)
• CNS and NP programmes in the US ran parallel in
  mid 60s.
• These roles were quickly adapted throughout much
• of the U.S. and with the development of
  university based educational programmes delivered
  at masters degree level, this type of primary
  care role heralded the development of many
  similar roles in primary and more recently in
  acute care settings( Brown Grimes1995, Walsh
  2001,Guido 2004)

3
Defining Advanced Practice.

• ICN Defines advanced practice as The 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 country in which he/she is
  credentialed to practice. A Masters degree is
  recommended for entry level(ICN2002)

4
Origins of ANP Roles in Ireland

• Commission on Nursing 1998
• Commission on Nursing recognised that promotional
  opportunities should be made available for nurses
  wishing to remain in clinical practice and
  accordingly recommended a clinical career pathway
  leading from registration to clinical
  specialisation and to advanced practice.
• The development of this career pathway serves to
  develop clinical nursing and midwifery expertise
  in the interest of holism and excellence in
  patient care.
• National Council for the Professional Development
  of Nursing and Midwifery 1999.
• Framework for the development of ANP/AMP Posts
  2001 (revised 2004)

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Definition of Advanced Nurse/Midwife Practitioner
(Ireland)

• Advanced practice - autonomous, experienced,
  competent, accountable and responsible for own
  practice
• Highly experienced in clinical practice
• Educated to masters degree level (or higher)
• Promote wellness, offer healthcare interventions
  and advocate healthy lifestyle choices for
  patients/clients, their families and carers in a
  wide variety of settings in collaboration with
  other healthcare professionals, according to
  agreed scope of practice guidelines
• Utilise sophisticated clinical nursing/midwifery
  knowledge and critical thinking skills to
  independently provide optimum patient/client care
  through caseload management of acute and/or
  chronic illness

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Definition of Advanced Nurse/Midwife Practitioner
(Ireland)

• Grounded in the theory and practice of
  nursing/midwifery
• Incorporates other related research, management
  and leadership theories and skills
• To encourage a collegiate, multidisciplinary
  approach to quality patient/client care
• ANP/AMP roles developed in response to
  patient/client need and healthcare service
  requirements at local, national and international
  level
• ANPs/AMPs must have a vision of areas of practice
  that can be developed beyond the current scope of
  practice and a commitment to the development of
  these areas

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Criteria for Approval as ANP

• Have a minimum of 7 years post-registration
  experience, which will include 5 years experience
  in the chosen area of specialist practice
• Have substantive hours at supervised advanced
  practice level.
• Have the competence to exercise higher levels of
  judgement, discretion and decision making in the
  clinical area above that expected of the
  nurse/midwife working at primary practice level
  or the clinical nurse/midwife specialist
• Demonstrate competencies relevant to context of
  practice and
• Provide evidence of continuing professional
  development.

• Be a registered nurse or midwife on An Bord
  Altranais live register
• Be registered in the division of An Bord
  Altranais register for which application is being
  made (in exceptional circumstances which must be
  individually appraised, this criterion may not
  apply)
• Be educated to masters degree level (or higher).
  The post-graduate programme must be in
  nursing/midwifery or an area which is highly
  relevant to the specialist field of practice
  (educational preparation must include a
  substantial clinical modular component(s)
  pertaining to the relevant area of specialist
  practice)

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Approved ANP Posts

• Breast Care
• Cardiology
• Cardiothoracic
• Child Adolescent Mental Health Psychotherapy
• Diabetes
• Emergency
• Emergency Cardiology

• Gastroenterology
• Neonatology
• Oncology
• Palliative Care
• Primary Care
• Rheumatology
• Sexual Health
• Stroke Care

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Diabetes Mellitus

• It is estimated that 194 million people worldwide
  have diabetes with this figure expected to
  double by 2025.
• IDF (2003) described diabetes alongside global
  warming ,emerging diseases and environmental
  pollution as one of the worlds biggest
  environmental disasters.
• The effect of Aids in the last 20 years will be
  repeated by diabetes in this century

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• The alarming increase in diabetes is as a result
  of ageing populations, dietary changes, reduced
  physical activity and other unhealthy and
  behavioural patterns.
• A new trend of increasing cases of type 2
  diabetes in children and adolescents is emerging.
  These patients are likely to have kidney and
  cardiovascular disease much earlier in life,
  adding to the health economic burden (IDF 2003)
• The financial and social burden of diabetes will
  be intolerable if measures are not taken to
  address this disease.

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Irish Situation

• It is estimated that 200,000 people in Ireland
  have diabetes with a further 200,000 undiagnosed
  with the condition. The majority of these people
  will be diagnosed through an acute medical event
  due to the complications of long term untreated
  hyperglycaemia.
• A further 250,000 have impaired glucose tolerance
  or pre-diabetes of which 50 will develop
  diabetes in the next 5 years if lifestyle changes
  are not made.( Diabetes Care Securing the Future
  2002)
• In Ireland diabetes care accounts for 10 of the
  total health budget ( 350 million euro). More
  than half of this(59) is spent on treating
  complications.

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Diabetes Day Centre University College Hospital
Galway.

• Established in 2001.
• Services provided focus on diagnosis, treatment
  and patient education.
• The centre facilitates many sub-specialist
  clinics/services to enhance care for patients
  with diabetes.
• Specialist clinics. Young Adults clinic/Combined
  nephrology and diabetes service/Combined
  obstetric and diabetes service and pre-pregnancy
  service / Obesity clinic/Annual review/foot
  clinic.
• Services provided include. Podiatry, Dietetics
  ,Psychology, Phlebotomy ,DAFNE, ,Telephone
  support service, Group education and Retinal
  screening.
• Paediatric/Adolescent Diabetes services are
  provided from the Paediatric unit/outpatients
  department.
• Transitional service will be provided from June
  2007.

13
Getting Started
14

AIM

• To train a suitably qualified, experienced nurse
  to independently assess, diagnose, treat,
  discharge / refer patients with diabetes
  attending diabetes services at University College
  Hospital Galway.

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Rationale

• Develop clinical career pathway for experienced
  nurses
• Provide clinical leadership in critical area
• Enhance the quality of service delivered by the
  multi-disciplinary team to patients with diabetes
• Provide more timely, but safe, service leading to
  improved patient satisfaction
• Release physician time to deal with increasing
  acute workload

16
Process.

• The process for the establishment of an ANP
  service comprises two important parts.
• Service applies to have the post approved as an
  ANP/AMP post ( Job Description/Site Preparation)
• The nurse/midwife applies to be accredited as an
  ANP/AMP to the approved post( individual
  accreditation)

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My Journey.

• 2001-Establishment of the Diabetes Day Centre.
• 2001-Appointment of Professor of Medicine/
  Endocrinology
• 2002- The development of the ANP/Diabetes was
  discussed formally with nursing/medical
  management. The intention to develop the post was
  discussed with relevant stakeholders.
  (Consultants ,laboratory, nursing colleagues,
  dietitics, general practitioners).
• 2003- Commenced the Masters in Health
  Science/Advanced Practice at NUI Galway.
  Professor of medicine agreed to act as medical
  mentor ( supervised clinical practice hours)
• 2004- Approval for post for ANP/Diabetes included
  in service plan.

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• 2005- preliminary job description submitted to
  NPDU.
• 2005- Completed Masters in Health Science/
  Completed supervised clinical hours.
• Multidisciplinary Working group established for
  candidate ANPs in UCHG/Mayo general/Portiuncla
• Set Goals
• Specify action steps
• Establish timelines
• Identify indicators of success
• role development for the 3 sites/UCHG/Mayo
  General/Portiuncla Hospital
• Commenced work on site preparation.
• 2006- June/Site visit from National council.
  August- submitted Job portfolio. September
  received accreditation from the National Council.

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Site Preparation

• Review of National policy documents relevant to
  diabetes services.
• Review of research data pertaining to diabetes.(
  DCCT/UKPDS/ Diabetes Care Securing the Future).
• Review of service Adult and Paediatric need. (
  7,000 patient visits 2005).
• Audit current activity of service
• Service need established
• Client group caseload identified
• Identify outcome measurement
• Stakeholder BUY IN
• Demographics of region.( Fastest growing city in
  Europe, Student population, Tourism, 50 of
  boards population under 30 years, Higher
  percentage of people over 65 years 14 national
  average 11, Large rural population.
• Predictions for Future diabetes services based on
  demographics and epidemiology studies. (DfI 2002)
• Review of current roles and their effectiveness
  through audit. (Review similar roles and the
  effectiveness of these roles).

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Job description

• Detailed job description containing details of
  the role and responsibilities of the post,
  reporting relationships, reflecting the required
  experience and education as specified by the
  National council.
• Incorporate core concepts and definition of ANP
  role, together with core competencies for the
  role
• Developed in line with service plan and NMPDU

22
Clinical Supervision

• Major commitment required by clinical
  mentor/supervisors ( 1,400 supervised hours)
• Generates an environment conducive to learning
  for all

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Selling The Role.

• The integration of the ANP role into the practice
  setting has implications for patients, nurses and
  midwifes, medical colleagues, and other health
  care professionals.
• To ensure successful integration of the role
  employers and the ANP must give consideration to
  how best integrate the role in the context of
  the multidisciplinary team and the effect of the
  role on the work of other health care
  professionals.
• Talk to other health care professionals about the
  role. Liaise with departments that you will be
  referring patients to. Organise Meetings/
  articles re Advanced practice in hospital
  newsletter.

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Service needs addressed by post.

• Education- Need. Patients with diabetes and many
  primary and secondary health education needs. The
  health education component of the ANP role is
  central to the provision of this need.
• Response- ANP supports the empowerment of
  patients/families. Individualised care plans are
  developed for each patient incorporating holistic
  management.
• 2)Specialised Clinics-Need. The benefits of
  specialised clinics for complicated and
  specialised groups have been well established and
  demonstrated( NICE 2004) The ANP is central to
  the continued development and management of these
  clinics
• Response- Optimise care for patients
  attending young adults/annual review clinics
  attending to the special needs of these group of
  patients.

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• Paediatric/Adolescent Clinics. Need- The diabetes
  service at UCHG provides a structured
  multidisciplinary service to this cohort of
  patients and their families. Recommendations for
  paediatric diabetes care continue to be updated
  and implemented( NICE 2004/ISPAD 2004)
• Response- The ANP is actively involved in
  providing and optimising patient and family care
  .a) Involved in setting up transitional care for
  adolescents transferring to adult services .b)
  Service for schools. C) One home visit post
  discharge d) Implementation of NICE guidelines
  for the care of children/adolescents with
  diabetes e) Parent support workshops.

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• Linking Primary to secondary care Need- To
  foster and develop links between both services
  for people with diabetes.
• Response- The ANP is involved in the
  development process for a shared care scheme in
  the Galway area.
• Involved in the Development of guidelines for
  best practice which will be used throughout
  the HSE West/North West/Mid-West.
• Provide education programmes/workshops for
  GPS/Practice nurses/public health nurses.
• Involved in the development of the DESMOND
  Programme( hospital/community)
• Deliver the diabetes component of the
  Diabetes module for practice nurses NUI GALWAY/

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Advanced Nurse Practitioner

• Referral
• OPD
• IN-PATIENT Service. Adult/Paediatric.
• Maternity Services.
• dietetics
• Social Work Department
• Primary care
• Podiatry.
• Health Promotion.

• Caseload
• Patients with Type 1 and Type 2 Diabetes. New
  onset Diagnosis. Existing patients.
• New Type 2 clinic/GP referral.
• Children 0-13 years.
• Adolescents 13-18 years.
• Young Adults 18-26 years.
• Paediatric review clinic.
• Annual Review clinic.
• MDI Programmes.
• Group education programmes for Type 2 patients,

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Advanced Nurse Practitioner Scope of
Practice/Diabetes.

• Independent practice
• Assess patients with diabetes.
• Diagnose. Physical examination/Patient history/
  Laboratory investigations.
• Treat. Insulin Therapy/oral hypoglycaemic
  Therapy/antihypertensive agents/statins
• Discharge to GP or to other specialist clinics
• Referral pathway to appropriate service.
  Dietetics/ ophthalmology /nephrology/ vascular/
  podiatry/ health promotion.
• Education Patient/ other health care
  professionals involved in diabetes care.
• Consultancy

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Guidelines for Practice

• Collaboratively agreed (Nursing
  management/Consultants/ Paediatrician/Nurse
  Practitioner)
• Evidence based.
• Standard approach to managing clinical
  presentations for the diabetes department.
• Regularly reviewed by Consultants/ANP.
• Allow for safe innovation in practice
  Laboratory, Medication Management.
• Describes what the ANP does.

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Education Activity

• Clinical teaching clinical supervision
• Nurses ( hospital nursing staff, practice
  nurses/public health nurses/nursing students)
• Doctors (SHOs, Training SPRs, Med
  students-General Practitioners)
• Allied professionals (dietetics, podiatry,
  psychology, social work)
• In-service education medical nursing staff.
• Lecture on various post-graduate programmes in
  3rd level institutions.

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Consultancy

• Provide consultancy service to multi-disciplinary
  team members.
• Provide consultancy to primary care services
  (PHN, Practice Nurses, GPs).
• Provide Nursing consultancy on DSAG (Diabetes
  services advisory group, HSE WEST/North
  west/Mid-West)
• Authority/clinical nursing expertise for diabetes
  care
• Provide support to specialist areas outside
  diabetes engaged in ANP role development

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Research Audit

• Identified research priorities for role. A) MIND
  Study B) Evaluation of MDI Programmes C)
  Evaluation of paediatric education programmes. D)
  Type 2 Group education programmes.
• Clinical / Patient focus to research.
• Evidence for care
• Audit of service need ( case mix/Patient activity
  levels adult/paeds)
• Audit of quality.

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Case Scenario.

• Jane -21ys.
• Type 1 diabetes 10 years.
• Poor glycaemic control during adolescence, HBA1C
  10-12.
• June 2006- Hba1c 12.4.
• Complications- right background diabetic
  retinopathy, left pre-proliferative retinopathy.
• Microalbuminuria (Ramipril 10mg/nocte).
• Symptomatic of hyperglycaemia, tired, thirsty,
  weight loss ,irritable and fed up.
• Attending young adults clinic.

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ANP INPUT

• Empowered Jane to become involved in her care
  and decide on her treatment choices/ decisions.
• Changed insulin Therapy ( 4 injections/daily
  /novorapid/lantus)
• Twice monthly visits to ANP.
• 3monthly visits to young adults clinic.
• Telephone support weekly
• Referred to dietitian
• Psychologist.
• Referral to opthalmology. Will be followed up
  yearly. No laser treatment required.
• Hba1c September 9.1. December 7.8 February 7.8
  
• Jane feels much better, not symptomatic of
  hyperglycaemia and happier that she is assuming
  control and self managing her diabetes.
• Referred back to young adult service will be seen
  2 monthly.
• Continue telephone support/weekly.

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Case Study.

• Jack-Age 68 yrs.
• Diagnosis type 2 diabetes 1986.
• Attending G.P. Services.
• Treatment- Glucophage 850mgs/tds.
• Diamicron 80mgs/bd.
• Complications- Coronary Artery disease. MI 2003.
  Coronary Artery by-pass 2003.
• Diabetic Neuropathy.
• Diabetic Retinopathy
• Referred to Diabetes Service 2005.
• Attending annual review clinic.
• HBA1c 9.4.

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ANP Input.

• Commenced on Lantus once daily. Remains on
  Glucophage 850mgs /tds.
• Referred to dietitian.
• Referral to opthalmology.
• Referral to chiropody( Community chiropodist)
• Telephone support twice weekly x 2 weeks, then
  weekly x 2 weeks for advice on insulin dose
  adjustment.
• Group education.
• Continue telephone support weekly or Jack e-mails
  blood glucose readings.
• HBA1c March 8.0
• Referred back to annual review clinic.

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Putting things into perspective.

• The aim of diabetes care must be to ensure the
  best outcomes for patients, bearing in mind the
  risks associated with poor glycaemic control.
• Risk of complications associated with a 1 rise
  in HBA1c levels.
• Event
  Increase in risk of event.
• Diabetes related death.------------------------21
  .
• Myocardial infarction.--------------------------14
  .
• Peripheral vascular disease.------------------
  43.
• Microvascular disease.--------------------------37
  .
• Cataract extraction.-----------------------------1
  9.

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Benefits of an ANP Service

• High Quality
• Promotes Safe Care
• High Satisfaction
• Utilises competence of experienced nurses
• Improves recruitment and retention of workforce
• Improves risk management

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Career Pathway

• Structured
• Focused
• Not a cul de sac
• Rewards talent expertise in practice

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Job Satisfaction.

• The main reason I love my job is that I am
  dealing with and have time to spend with
  patients. I particularly like the fact that I
  have time to spend with children , adolescents
  and young adults who may be experiencing
  difficulties with their diabetes and this input
  may make a difference to their overall
  management. Patient empowerment is essential and
  I value and encourage patient input regarding
  their treatments choices. The fact that I can
  make decisions with patients about their care,
  assess, treat and discharge them satisfied and
  happy means a lot to me in terms of how I do my
  work

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ANY QUESTIONS ? THANK YOU