Advancing Nurses Contribution Through a Clinical Career Pathway
Transcript of Advancing Nurses Contribution Through a Clinical Career Pathway
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Advancing Nurses
Contribution Through a
Clinical Career Pathway
What’s to be covered
Background to the development of a clinical nursing career pathway in Hospital Authority (HA)
The development journey
Current situation
Looking into the future
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Hospital Authority
Established in 1990
Now Managing 41 Public Hospitals
49 Specialist Out-Patient Dept
74 Out-Patient Department
16 Chinese Medicine Clinic
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Hospital Authority Cluster Hospitals Map
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HA’s Performance in 2011/12
No. of Hospital Beds (as of end March 2012) 27,054
In-Patient
Services
No. of Discharges & Deaths 1,004,326
No. of Patient Days 7,217,755
Bed Occupancy Rate 83%
Ambulatory
Diagnostic &
Therapeutic
Services
Day Patient: Discharges & Deaths 496,640
A&E Services - No. of Attendance 2,241,176
No. of Specialist Out-patient
attendances 6,731,155
No. of General Out-patient
attendances 5,316,486
Rehabilitation
& Outreach
Services
No. of Home Visits by Community
Nurses 838,896
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Nursing Manpower (As at 31 Oct 2013)
Others 17,970 (27.0%)
Medical 5,734 (8.6%)
Nursing 22,446 (33.7%)
Allied Health 6,578 (9.9%) Mgt Admin
2,180 (3.3%)
Supporting (Care-Related)
11,761 (17.6%)
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Back in 1993
Was it an obvious answer?
What’s the HA context?
How can it be built on existing developments?
Why a clinical nursing career pathway?
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HA was established to improve the MANAGEMENT of public hospitals in Hong Kong
New Management Initiatives – new structure focusing on management
An emphasis on efficiency as oppose to effectiveness
The Context
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Chief Nursing Officer (CNO)
Senior Nursing Officer (SNO)
Senior Nursing Officer (Education) [SNO(E)]
Nursing Officer (NO)
Nursing Officer (Education) NO(E)
Registered Nurse (RN)
Enrolled Nurse (EN)
General Manager (Nursing) [GM(N)]
Departmental Operations Manager (DOM)
School Principal (SP)
Ward Manager (WM)
Nurse Specialist (NS) - 1993
Pre HA HA New Positions
Structural Changes Needed
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Issues
Management oriented structure
No clear clinical career option
Lack of focused clinical development
Lack of clear direction for profession
and career development
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From Nursing Officer to
Advanced Practice Nurse
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Critical Timeline
1993 2000 2003 2010 2006 2008 2011-13
•Nurse Specialist
•Health Care Assistant
•Joint Liaison Group
• Introduction of Nurse Clinic
•Advanced Practice Nurse pilot
• Introduction of Primary Nursing Model
Consolidation of Nurses
Career Progression Model
and Implementation of
Nurse Consultant
Report of Advanced
Practice Nurse pilot
•Nurses Career Progression Model & Retention Strategy
•Nurse Consultant pilot
Nurse Consultant
Pilot Report
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Characteristics of a Profession Four Criteria
(Encyclopedia of Sociology, NY: Macmillan, 1992. p1554)
Esoteric knowledge
Autonomy on the job
Authority over clients
Altruistic
Underlying these four characteristics is a fifth: the
public must recognize the occupation as a profession.
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Building the Career Structure
Guiding Principles
a) Focus emphasis on direct patient care;
b) Conceptual and system change;
c) Professional participation in the review;
d) Accountability follows authority; and
e) Remuneration follows quality patient-centred care.
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New Nursing Career Structure and
Progression Model in HA
The new clinical structure has 3 functional
groups of nurses:
Registered Nurse (RN)
Advanced Practice Nurse (APN)
Nurse Consultant (NC)
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Objectives of the New Career Structure
to provide better role delineation of
nurses;
to strengthen the clinical focus and
accountability of nursing practice; and
to enable nursing specialization in line
with health care developments.
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Nursing Professional Development –
Clinical Nursing Model – Building
an Enabling Environment
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Primary Nursing
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Primary nursing is a system of delivering care in which each patient is assigned to the care of a primary nurse. This nurse, in collaboration with the patient, family and other members of the health care team assesses, plans, implements and evaluates the patient’s nursing care from admission to discharge.
Primary Nursing
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Advantages of Primary Nursing Approach
Includes:
A better organization of nursing care delivery;
Enhance autonomy in nursing practice; and
Increase professional accountability
Primary Nursing Care Practice Model
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Four Elements for Primary Nursing
Decision making
Work allocation and/or patient assignments
Communications with health care team members
Management
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Nurse Clinics developed in 2000
Nurse Clinic
A&E Nurse Clinic
Cardiology Nurse Clinic
Clinical Oncology Nurse Clinic
Continence Nurse Clinic
Endocrinology Nurse Clinic
Enterostomal & Wound Nurse Clinic
Geriatric Nurse Clinic
Gynaecology Nurse Clinic
Haematology Nurse Clinic
Medical Nurse Clinic
Midwife Clinic
Neurology Nurse Clinic
Obstetric Nurse Clinic
Nurse Clinic
O&T Nurse Clinic
Paediatric Nurse Clinic
Palliative Nurse Clinic
Primary Health Care (Hypertension)
Primary Healthcare Nurse Clinic (Community Care)
Psychiatric Nurse Clinic
Renal Nurse Clinic
Respiratory Nurse Clinic
Rheumatology Nurse Clinc
Special Medical Nurse Clinic
Surgical Nurse Clinic( Breast Care)
Wound Nurse Clinic
No. of Nurse Clinics : 151 (as at 31 July 2013)
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From Novice to Expert
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Nurses Career Progression Model
Career
Nurse Consultant Department Operations Manager
Advanced Practice
Nurse
Ward/
Unit Manager
Registered Nurse (Specialty Nurse)
Registered Nurse (Pre-Specialty)
Registered Nurse (Beginner)
Clinical Management
Tier 3
Tier 2
Tier 1
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Career Progression
Specialty Nurse
1) Specialty Qualification 2) Experience 3) Performance
3rd
Registered Nurse (Pre-Specialty)
1) Generic Competency 2) Specific Competency 3) Experience 4) Performance
2nd
Registered Nurse (Beginner)
1st 1) Preceptorship 2) Performance
Nurse Consultant
1) Clinical Managerial Leadership Expertise
2) Experience 3) Performance
5th
Advanced Practice Nurse
1) Sub-Specialty/Mgt Qualification 2) Higher Academic Qualification 3) Experience 4) Performance
4th
Milestones
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The Path to the New Career Structure
Commence discussion with staff in 2000
HA Board meeting on 28 February 2008
HA Human Resources Committee meeting on 15 April 2008
Revised Strategies & Package presented at AOM on 17 April 2008 for decision
Package endorsed by HA Board in May 2008
Implementation commenced in June 2008
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2008 Strategies for Retention of Nurses
Pilot Nurse Consultant posts – subsequently reported in 2010
Restructure the management related allowance (MRA) of the Department Operations Manager to differentiate increased responsibilities and management duties
Move the pay package of APN (W&UM) in line with the existing Ward Managers (WM) – 170+ converted and increased by 36 WMs
Increase the number of APNs (>450) in clinical units to enhance supervisory support and senior coverage
Increase the number of APNs to take on emerging roles through the establishment of more nurse-led clinics – more nurse clinics established
Flexible contract structure - implemented with success
Offer 6-years contract with contract gratuity at the end of each 3 years
Offer of conversion to permanent employment for eligible contract full-time RNs after 3 years of full time service.
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Nurse Consultant in HA
Scope of NC Practice
Consultation service
Ensure Care
Standard
Nurse Consultant
Direct care and
management of
complex and high
risk cases
Strategic plan
Enhance clinical
patient care, monitor
standard & outcomes
of care
Community care
development &
networking
Care delivery model/ care
pathway/ guidelines
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Roles of Nurse Consultant and Scope of Practice
Continuous Quality Improvement (5.0%) Quality control of service standard, protocol development and implementation
Research (3.6%) Promote and implement evidence-based practice
Education (8.7%) Staff supervision, in-service education, community education
Service Development (35.0%) Development of care delivery model, facilitating intra- and inter-disciplinary and cluster service collaboration, initiating new service projects, and strengthening hospital-community interface % = observed time spent in each role
Expert Practice (47.7%) Expert clinician / consultant, complex patient care & patient risk identification / stratification, care coordination
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Contributions of Nurse Consultants NCs have made major contributions as identified by
triangulation of the qualitative and quantitative data in the
study:
Achieve significant reductions in hospital admission (p<.001), A&E visit
(p<.001) and length of hospital stay (p<.001) between patients who were
under NC care and those who were not.
Achieve significant improvements in specialty-specific indicators (such
as improved urea level, improved HbA1c level, and decreased number of
dressing changes in the respective renal, wound/ stoma specialty) (p<.05)
between patients who were under NC care and those who were not.
Facilitate patients’ earlier and timely access to specialty care.
Innovate practice to improve/ reform existing procedures/ care
processes.
Strengthen cross-specialty collaboration to improve service delivery.
Secure continuous quality improvement and care standardization.
Enhance patient satisfaction and empowerment.
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Professional Development
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A Model of Building Specialty
Qualification in HA
Core Clinical Competencies (Web-based)
Basic Life
Support
Wound Mgt
Patient Edu-
cation
Patient Safety & Infection Control
Occupa-tional Safety And
Health
Legal And
Ethical Issues
Communi- cation Skills
Pain Mgt
Multi-disciplinary Collabora-
tion
Advanced specialty Competencies (option)
Focused Nursing Assess-
ment
Advanced Cardiac
Life Support
Patient Empower
ment Rehabili-tation
Thera-peutic
Communi-cation
Discharge Planning & Service
Co-ordination
Evidence Based
Practice
Specialty certification
Post-basic Certificate in
Specialty Nursing e.g.
Emergency nursing,
Intensive care,
Paediatrics, etc.
Nursing Assess-
ment
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Specialty Nursing Certificate Courses conducted by HA
Course Title
1. Advanced Medical Nursing
2. Advanced Surgical Nursing
3. Anaesthetic and Recovery Nursing
4. Cardiac Care Nursing
5. Cardiac Surgical Nursing
6. Community Nursing
7. Community Psychiatric Nursing
8. Continence Nursing
9. Diabetes Nursing
10. Emergency Nursing
11. Gerontological Nursing
12. Haematological & Bone Marrow
Transplant Nursing
13. Intensive Care Nursing
Course Title
14. Neonatal Intensive Care Nursing
15. Paediatric Intensive Care Nursing
16. Peri-operative Nursing
17. Primary Health Care Nursing
18. Psychiatric Rehabilitation Nursing
19. Rehabilitation Nursing
20. Renal Nursing
21. Respiratory Nursing
22. Rheumatology Nursing
23. Substance Abuse Nursing
24. Breast Care
25. Orthopaedics & Traumatology
Nursing
26. Advanced Paediatric Nursing
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Training Framework for Advanced Practice Nurses (APN)
People Management Leadership skill
Team work
Motivation
Communication skills
Performance Management & SDR
Supervisory skills development for first-line leaders
Service Management Managing difficult complaints
Conflict Management
Quality and risk management
Service development
Change management
Advanced Nursing Practice including ACLS 34
Nurse Consultant Development
Navigating Change Enabling Change Managing Change
Corporate essentials in
Spearheading Services
The Next of Nursing
Management
Research: You & I
Bringing change
through Project
Management
Presenting to
Audience’s wants
Writing to Readers’
Wants
Influencing for
success
1st - 2nd month 5th - 6th month 3rd - 4th month
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A Clear Direction for Education, Training and Development
Coordination between service and
education
Clinical practice
Learning culture
Continuing education
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The Complete Picture
Practice
Environment
Education &
Continuing
Development
Role and Role
Development
Policy
&
Structure
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Critical Timeline
1993 2000 2003 2010 2006 2008 2011-13
•Nurse Specialist
•Health Care Assistant
•Joint Liaison Group
• Introduction of Nurse Clinic
•Advanced Practice Nurse pilot
• Introduction of Primary Nursing Model
Consolidation of Nurses
Career Progression Model
and Implementation of
Nurse Consultant
Report of Advanced
Practice Nurse pilot
•Nurses Career Progression Model & Retention Strategy
•Nurse Consultant pilot
Nurse Consultant
Pilot Report
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What’s the future?
Current Issues Opportunities for Nursing
Ageing population
Primary Health Care
Non-communicable Diseases
Hospital accreditation
Health Care Financing & Insurance
Health system pressure - waiting list and waiting time
Professional advancement - Academy
Tertiary education for nurses
Prevention/early prevention; health maintenance
Enhancing care in the community
Independent practice
Enhanced scope of practice and credentialing
Refine and redefine of health professional boundaries – service needs and pressure from patients
Relevancy of nursing education and practice – basic and post basic
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Reflections
Be prepare and think ahead
Be opportunistic
Be patience and never lose sight of the
patient
There is always a way out
Don’t lose the big picture
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(William Jennings Bryan)
Destiny is not a matter of chance.
It is a matter of choice!
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References
Chan, E (2006) Evaluation of Advanced Practice Nurse Pilot
Scheme, Hospital Authority Head Office, 2006
Lee, D; Chan, C; Chair, SY; & Chan, D (2010) A report on Study on
the review of clinical nursing career structure, CUHK, 2010
Lee DTF, Choi KC, Chan CWH, Chair SY, Chan D, Fung SYK, Chan
ELS (2013) The impact on patient health and service outcomes of
introducing nurse consultants: a historically matched controlled
study. BMC Health Services Research 2013; 13(1): 431. doi:
10.1186/1472-6963-13-431
Hospital Authority (2008), Career Structure and Retention Strategies
for Nurses, Hospital Authority AOM paper No. 540, 2008
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