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Development of the role of the Advanced Nurse Practitioner in Diabetes


Role of Nurse Practitioner developed in 60's by Loretto Ford in Colorado ... and midwifery expertise in the interest of holism and excellence in patient care. ... – PowerPoint PPT presentation

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Title: Development of the role of the Advanced Nurse Practitioner in Diabetes

Development of the role of the Advanced Nurse
Practitioner in Diabetes
  • Helen Burke
  • Advanced Nurse Practitioner (Diabetes)
  • University College Hospital Galway.

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)

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)

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)

Definition of Advanced Nurse/Midwife Practitioner
  • Advanced practice - autonomous, experienced,
    competent, accountable and responsible for own
  • 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

Definition of Advanced Nurse/Midwife Practitioner
  • Grounded in the theory and practice of
  • 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
  • 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

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
  • 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
  • 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

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


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

  • 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.

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
  • 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
  • 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

Diabetes Day Centre University College Hospital
  • 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
  • Services provided include. Podiatry, Dietetics
    ,Psychology, Phlebotomy ,DAFNE, ,Telephone
    support service, Group education and Retinal
  • Paediatric/Adolescent Diabetes services are
    provided from the Paediatric unit/outpatients
  • Transitional service will be provided from June

Getting Started

  • 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.

  • Develop clinical career pathway for experienced
  • 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

  • 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

(No Transcript)
My Journey.
  • 2001-Establishment of the Diabetes Day Centre.
  • 2001-Appointment of Professor of Medicine/
  • 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.

  • 2005- preliminary job description submitted to
  • 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.

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).

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
  • Developed in line with service plan and NMPDU

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

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
  • 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

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
  • 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
  • Response- Optimise care for patients
    attending young adults/annual review clinics
    attending to the special needs of these group of

  • 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.

  • 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/

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,

Advanced Nurse Practitioner Scope of
  • 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

Guidelines for Practice
  • Collaboratively agreed (Nursing
    management/Consultants/ Paediatrician/Nurse
  • 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.

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.

  • 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
  • Authority/clinical nursing expertise for diabetes
  • Provide support to specialist areas outside
    diabetes engaged in ANP role development

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.

Case Scenario.
  • Jane -21ys.
  • Type 1 diabetes 10 years.
  • Poor glycaemic control during adolescence, HBA1C
  • 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.

  • Empowered Jane to become involved in her care
    and decide on her treatment choices/ decisions.
  • Changed insulin Therapy ( 4 injections/daily
  • 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.

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.

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
  • Group education.
  • Continue telephone support weekly or Jack e-mails
    blood glucose readings.
  • HBA1c March 8.0
  • Referred back to annual review clinic.

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.------------------
  • Microvascular disease.--------------------------37
  • Cataract extraction.-----------------------------1

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

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

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