· PDF fileChronic Kidney Disease Model of Care 11 Overview ... Preparing the Nursing Workforce 26 8. ... patients and the renal service plan

CONTENTS _____________________________________________________________

Page

1. Executive Summary 6

Background 7

Project aims and Objectives 9

The Development Phase 9

2. Chronic Kidney Disease Model of Care 11

Overview of CKD Model of Care- the continuum of care 12

3. Nurse Practitioner Model of Care at Southern Health 13

Southern Health Nurse Practitioner Strategic Framework 15

4. Positioning the Renal Nurse Practitioner in the CKD Model of Care 16

Shaping the Renal Nurse Practitioner Model of Care 17

Hospital Based Renal Nurse Practitioner 19

Community-Based Stage 5 CKD Renal Nurse Practitioner

- satellite units 20

5. Continuity and Sustainability of the Renal Nurse Practitioner 23 6. Nurse Practitioner Candidate Recruitment 24 7. Preparing the Nursing Workforce 26 8. Closing Thoughts 32 9. Acknowledgements 33 10. Abbreviations 34 11. Bibliography 36

Part B

Page

11. Appendices

Appendix 1: VNPP Submission for Funding 37

Appendix 2: Renal Nurse Practitioner Steering Committee 43

Appendix 3: Southern Health Nurse Practitioner Strategic

Framework 46

Appendix 4: Renal Model of Care & the Nurse Practitioner 85

Appendix 5: Current Nursing Positions & How the Renal Nurse

Practitioner Will Affect These 90

Appendix 6: Renal Nurse Practitioner Candidate Advertisement 92

1. EXECUTIVE SUMMARY ________________________________________________

• Chronic Kidney Disease (CKD) is a significant and growing public health problem

responsible for a substantial burden of illness and premature mortality. In 2003,

kidney failure was associated with 11.3% of all deaths making it the seventh most

common cause of death. In Australia annual spending on CKD Stage 5 is

estimated to be at least $570 million, increasing each year by $30million.

(Southern Health Renal Service Plan 2007)

• The Nurse Practitioner (NP) role is at the apex of clinical nursing practice. To

ensure NP roles are developed with the consideration and planning they deserve,

a strategic approach is required. The establishment of a Nurse Practitioner

position in a site/service within Southern Health is to be guided by the

collaborative planning, practice, implementation and evaluation within the

specialty area. All Nurse Practitioner roles within Southern Health require

development within the Nurse Practitioner Strategic Framework.

• In an endeavour to improve care of renal patients within the Renal Service

Program, Southern Health applied for, and was successful in obtaining funding in

Round 4.3 from the Department of Human Services to develop two Nurse

Practitioner roles in this specialty.

• The key aims of developing the renal Nurse Practitioner roles are to support renal

patients within Southern Health from pre-dialysis through to successful renal

transplant or palliative care. When implemented, the impact on the current model

of care will be an extension and a re-design of existing services allowing new

service capacity to be delivered.

VNPP 4.3 Renal Round 1: Implementation Report 6

Background In Victoria the role of the NP has been supported by the State Government since 1998,

with the first NPs endorsed in 2004. This coincided with the development of the National

Competency Standards for the Nurse Practitioner by the Australian Nursing and

Midwifery Council (ANMC) in 2004/2005. The title of Nurse Practitioner is legally

protected in Victoria.

The Victorian NP Project has been undertaken since this time by the Department of

Human Services (DHS). To date, 42 individuals have successfully obtained their NP

endorsement. Southern Health was involved in the third phase of this project, which

resulted in one being endorsed in 2006 by the Nurses Board of Victoria (NBV) in the

Emergency Department at Dandenong Hospital. Since this time, there have been no

further Nurse/Midwife Practitioners endorsed within the organisation. (Southern Health

Nurse Practitioner Strategic Framework 2008)

The Manager of Advancing Nursing and Midwifery Practice at Southern Health in

consultation with renal services secured funding in 2008 round 4.3 for Renal Nurse

Practitioner development. This funding was primarily used to employ a project officer to

support the development of a model of care for renal NP and Nurse Practitioner

candidates at Southern Health. At this time there are only two Renal Nurse Practitioners

at St. Vincent’s Hospital in Victoria.

The scope of practice of dialysis roles has been clearly defined in North America and

includes the following components (table 1):

Table 1 – Scope of practice of dialysis nurse practitioners Address social issues Kt/V, PCR assessment Admission Medical declotting of venous catheters Adjust medications Pre-ESRD education - blood pressure Preventive medical evaluations - vitamin D Referrals for procedures and - anticoagulants consultations - EPO Rounds on dialysis patients Clinical studies Routine periodic physical examinations Counselling Set dialysis parameters, target weight Deal with patient medical complaints Triage problems Drop-ins in clinics CKD teaching (Stage 3-5) Adapted from: Bolton, 1998b


Renewed interest and debate about NP roles is occurring worldwide. The main reason

for this is the significant increase in renal failure in western society, which has been

estimated to be in the range of 7–9% per annum (Steinman, 1999; Suki, 1999). This is

further supported by ANZDATA figures specific to Australia. It has been estimated that

there is a ratio of 40-60 end stage renal disease patients per nephrologist currently, but

this is predicted to increase to 120 (Hoffart & Nissenson, 1998). At Southern Health

nephrologists currently have 158 CKD patients.

“Nephrologists generally recognise the large defacto nurse practitioner practice that occurs in units daily around Australia. Many experienced dialysis nurses, anaemia coordinators, pre dialysis and transplant nurses are using extended practices facilitated through local arrangements sometimes in the form of standing orders.

There is also an informal practice occurring particularly in the area of ordering pathology where nurses frequently use pre-signed pathology forms. Nephrologists in Australia are beginning to show an interest in NP roles because they have worked with nurses who use NP skills and they wish to acknowledge and formalise existing arrangements.” (St Vincent’s Final Report 2003)

The Australian Nursing and Midwifery Council define a NP as:

A nurse practitioner is a registered nurse educated and authorised to function autonomously and collaboratively in an advanced and extended clinical role. The nurse practitioner role includes assessment and management of clients using nursing knowledge and skills and may include but is not limited to the direct referral of patients to other health care professionals, prescribing medications and ordering diagnostic investigations. The nurse practitioner role is grounded in the nursing profession’s values, knowledge, theories and practise and provides innovative and flexible health care delivery that complements other health care providers. The scope of practice of the nurse practitioner is determined by the context in which the nurse practitioner is authorised to practise (ANMC, 2005)

This definition has been accepted by the Nurses Board of Victoria.

Nurses who are employed by a health service to be working towards the Nurse

Practitioner title are called Nurse Practitioner candidates (NPc).


Project Aims and Objectives The overall aim of the project was for the development of the Nurse Practitioner role

for Renal Services as described in the Victorian Nurse Practitioner Project (VNPP)

Round 4.3 funding round application. (Appendix 1)

The Project incorporated the following:

• Responsibility for elements/stages of the project, including ensuring DHS timeframes are met.

• Development of briefs in consultation with stakeholders as directed by the

Director of Nursing, and Manager of Advancing Nursing and Midwifery Practice.

• Development of detailed project plans, including methodologies, timelines, report writing and evaluations.

• Development and management of effective collaboration with internal and

external stakeholders.

• Development of implementation and communication models for Nurse Practitioner roles.

The Development Phase The development of the project ran from July till December 2008. The project was limited

by this timeframe to determining the NP role within renal services and the benefit to

patients and the renal service plan. The major achievement of the development phase

was the setting up of the renal NP Steering Sub-Committee in August 2008. This

committee directly reports to the NP Strategic Steering

Committee at Southern Health.

The role of the Renal NP Sub-Committee is to: • design, implement and evaluate the Renal Nurse Practitioner Roles within Southern

Health: and • support and inform the development of a renal model of care. This committee acted as the major decision-making and problem solving body and met

on a monthly basis. The group operated under the direction of the Director of Nursing

(Chair) with the Project Manager as Secretary.


Members are listed below:

• The Operations Director and Director of Nursing and Specialty Program Director- Kym Forrest (Chair)

• Manager of Advancing Nursing and Midwifery Practice- NSU Naomi Dobroff • Professor of Nephrology- Dr Peter Kerr • Associate Professor of Nephrology- Dr John Kanellis • Renal Nurse Practitioner Project Manager- Petra Spiteri (Secretary) • Renal NUM Representative- Tracy Beatty • Renal Satellite NUM Representative- Ann Marie Corradini • Dialysis Co-Ordinator- Penny Paton • Peritoneal Dialysis NUM- Francine Lynn • Pharmacy Representative • Diagnostic Imaging Representative • Pathology Representative • Others as co-opted as need

For Terms of Reference see Appendix 2


2. CHRONIC KIDNEY DISEASE MODEL OF CARE __________________________________________ The Chronic Kidney Disease (CKD) Model of Care provides a framework for

comprehensive, accessible and efficient treatment of CKD and its complications.

Key objectives of the CKD model of care are to ensure that renal services are optimally

configured to:

1. prevent or delay the onset of CKD.

2. prevent and slow progression of CKD and its complications, particularly end-

stage renal disease, heart disease stroke and peripheral vascular disease.

3. improve the quality of life of people who have CKD.

4. reduce CKD-related presentations to tertiary hospitals.

Identification of early CKD is critical to ensure appropriate management, so as to delay

and minimise or halt the disease progression. CKD is irreversible and there are 5 stages

to the disease. Stage 5 end stage kidney disease (ESKD) is fatal unless treated by

dialysis or kidney transplantation.

A CKD Model of Care can encompass seven key action areas: 1. Prevention strategies – primary, early detection and secondary prevention 2. Appropriate and timely referral to a nephrologist 3. Establishment of multi-disciplinary clinics in the metropolitan and regional areas 4. Early evaluation and management of patients with advanced CKD, where renal

replacement therapy is anticipated 5. Preparation and care of patients suitable for kidney transplantation 6. End of life and palliative care 7. Appropriate number of renal workforce personnel to provide high quality service.

(Renal Diseases Health Network WA, 2007)


Overview of CKD Model of Care. The Continuum of Care Responsibility Primary

Prevention (Stage 1)

Early Detection (Stage 2)

Secondary Prevention (Stage 3)

Specialist Nephrology Services (Stage 4)

End-Stage (Stage 5)

Kidney damage with normal kidney function (eGFR 90)

Kidney damage with mild decreased kidney function (eGFR 60-89)

Moderate decrease in kidney function (eGFR 30-59)

Severe decrease in kidney function (eGFR 15-29)

End-stage kidney disease (eGFR <15)

Population Health

Services for people to reduce preventable causes of CKD

Primary Care Services for people at risk of developing CKD

Services for people with early stable CKD.

Primary Care + Chronic Disease Management

Services for people with stage advanced CKD

Tertiary and secondary hospital services

Services for people with end-stage disease

Table 2 (Renal Diseases Health Network WA 2007) The challenge for tertiary and secondary hospital services is to provide education and

information regarding chronic disease management for people with advanced stage CKD

(stage 3 and 4) to delay the progression to ESKD (stage 5) for as long as possible.

Renal NPs in all areas of the Continuum of Care in the CKD Model of Care would make

significant health improvement outcomes for patients at Southern Health.


3. NURSE PRACTITIONER MODEL OF CARE AT SOUTHERN HEALTH

_______________________________________________ A Patient-Centred Approach The Nurse Practitioner Model of Care at Southern Health uses a patient-centred

approach. The model of care includes the concept of growing nurses into NP roles. A

flower can represent this. The stem and leaves of the flower demonstrate the scaffolding

that needs to take place to become an endorsed NP. This involves endorsement from

the Nurses Board of Victoria (NBV) and support from Southern Health (SH) as per the

SH NP Framework The patient is at the centre of the care model which is represented by

the centre of the stigma. Each petal represents a fundamental component of the role of

the NP.

Figure 1: A Patient – Centred NP Model of Care


The first petal represents the first standard of practice for a NP which is a dynamic practice that incorporates application of high-level knowledge and skills in extended

practice across stable, unpredictable and complex situations (NBV).

The second petal represents the second standard of practice for a NP which is

professional efficacy whereby practice is structured in a nursing model and enhanced by

autonomy and accountability (NBV).

The third petal represents the third standard of practice which is clinical leadership that

influences and progresses clinical care, policy and collaboration through all levels of

health care (NBV).

The fourth petal represents the Southern Health icare values.

Figure 2: SH icare values

The fifth petal represents the collaborative approach by NP to guide their practice,

working together with all members of the healthcare team including patients, their

families , doctors including GPs, all members in the allied health-care team, radiology,

pharmacy and diagnostic imaging.

The sixth and last petal represents the support systems the nurse practitioner may

access to assist them in their practice. For example their mentor, research and the

Centre of Clinical Effectiveness, Health Clinicians, Drugs and Poisons Act etc.


Southern Health Nurse Practitioner Strategic Framework Nurse Practitioner Definition and Role

The Australian Nursing and Midwifery Council define a Nurse Practitioner as:


The NP is a Registered Nurse who has expert knowledge base in their clinical area, is

able to make complex clinical decisions and is prepared to further their role to include an

expanded scope of practice. The NP role ‘is grounded in the nursing professions’ values,

knowledge theories and practice and provides innovative and flexible health care

delivery that complements other health care providers’ (NBV Nurse Practitioner

Information Sheet).

Southern Health has a Nurse Practitioner Strategic Framework that was endorsed in July

2008. The strategic framework identifies:

1. The strategic approach to NP role development and aligns to government and SH

plans.

2. Governance of the NP Steering Committee

3. The process for development of NP roles at Southern Health.

4. Educational requirements for NP and NPC.

5. Evaluates the NP role.

See Appendix 3 for the Southern Health Nurse Practitioner Strategic Framework.


4. POSITIONING THE RENAL NURSE PRACTITIONER IN THE CKD MODEL OF CARE ________________________________________________ When considering the expansive size of the renal program within Southern Health, it is

difficult to place only two NP positions. It is clear there are currently three high priority

need areas in the development of renal NP roles.

The three priority areas include Stage 3-4 CKD, and Stage 5 CKD-d (meaning ‘on

dialysis’) in the satellite setting and the home dialysis setting. A fourth NP role within the

renal program is also evident in the transplant specialty. Following review of the renal

plan, the gaps in the service, and discussions with key stake holders in the renal

program the following plan was decided:

The priority areas for NP service development and timeframes include:

• Within 1 year – two nurse practitioner candidates working towards endorsement

at the Nurses Board of Victoria in the area of Stage 3 / 4 CKD in the acute setting

and Stage 5 CKD in the satellite units for Southern Health (metropolitan and

rural.)

- A third Div 1 Registered Nurse to begin Masters study for the development of a

NP (Stage 5 CKD) in the area of home dialysis.

• 3 year plan – endorsement of third renal NP supporting home dialysis patients.

- A fourth Div 1 Registered Nurse to begin Masters study for the development of a

NP in the transplant specialty.

• 5 year plan – endorsement of a fourth renal NP supporting transplant patients.

A table (Appendix 4) was created which represents the Chronic Kidney Disease Model of

Care and concepts where a NP can fill gaps in the renal service at Southern Health. The

gaps a NP can fill and goals for the NP are identified. Expanded scopes of practice the

NP needs to care for a patient in that stage of CKD is also identified. In addition, issues

that need to be overcome for the NP to function successfully are also identified.


Shaping the Renal NP Model of Care Figure 3: Renal NP Model of Care

Initially one renal nurse practitioner candidate role will be in a hospital based setting

primarily looking after CKD Stage 3/4 patients. The second role is a community-based

setting supporting both metropolitan and rural satellite units looking after CKD Stage 5

patients.

The NPc’s would rotate regularly between these two settings. This ensures continuity of

care for the patients and a sustainable nursing role.

As more renal NPc roles develop, for example in home dialysis and transplant, the NP

would rotate through all these areas. Continuity, sustainability and expansion of the renal

NP roles are discussed more in depth later in this report.

The two initial renal NP roles to be developed are described below:

Acute Care

Home Dialysis

CKD Stage 3 / 4 CKD Stage 5

Community Based Nurse Practitioner

Hospital

Based Nurse Practitioner

Satellite

Transplant


Table 3: The Hospital Based and Community Based NP

Hospital Based (CKD Stage 3-4 ) Community Based (CKD Stage 5- Satellite)

CKD clinics- glomerulonephritis (stage 3-4) - renal failure (stage 4-5)

CKD clinic - Clayton - The Bays - Berwick - Wonthaggi - Cranbourne - Warragul - Moorabbin - Traralgon - Dandenong

A&E triage of presenting renal patients Support satellite units both metropolitan

and rural Renal NP consultant for CKD/Dx patients admitted to wards other than the renal ward

Follow up/monitor/assess patient if changes made to patient’s treatment between clinic appointments (Eg EPO, iron, Ca/PO4)

Pre-admission clinics- work in collaboration with access nurse

Work with home training patients currently situated in a satellite unit.

Uncomplicated post-operative access patient care.


Hospital-Based Renal NP The renal NP in Stage 4 of the renal model of care has two potential growth areas. Firstly the renal NP can have significant input in the patient decision making regarding their future dialysis options and setting up supports so that home dialysis becomes the first option and the use of satellite services is for patients who cannot manage at home. This ties in perfectly with the Southern Health renal service plan. Refer to dialysis forecasts below.

-

100

200

300

400

500

1999 2001 2003 2005 2007 2009 2011 2013 2015 2017Year

Patie

nt

Satellite

Home

Hospital

Proposed scenario forecast

-

100

200

300

400

500

1999 2001 2003 2005 2007 2009 2011 2013 2015 2017Year

Patie

nt

Satellite

Home

Hospital

Base case forecast

s

Figure 4: Southern Health base case and revised scenario dialysis forecasts 2005-17 Scenarios have been developed of estimated patient numbers and the required facilities to service the demand. The base case forecast reflects the continuation of historical treatment patterns. The base case scenario has been modified to include a greater emphasis on home based dialysis modalities. (Renal Service Plan 2007)


The second area the hospital-based renal NP can have a major impact is in the

management of patients within the acute care setting. There are two identified areas:

1. renal patients presenting to A&E: and,

2. the placement of renal patients who are admitted to Southern Health that are

admitted for a problem other than renal but are currently admitted to the renal

ward.

The renal NP could impact on how renal patients that present to the Emergency

Department (ED) are managed. Any patient who presents to ED could be triaged by the

renal NP regarding their problem. The renal NP could assess how the renal problem is

best managed in the A&E department, make autonomous and collaborative decisions

regarding treatment options and involve the GP in the follow up care to prevent

unnecessary hospital admissions.

The renal NP could also impact on how elective admissions for renal patients are

managed. Currently all renal patients are admitted under the renal medical unit

regardless of their primary admission diagnosis. With the renal NP in the acute care

setting, renal patients could be admitted under the medical unit of the primary diagnosis

and the renal NP could support any pre-renal, peritoneal, haemodialysis and transplant

patients throughout their inpatient stay. The biggest impact this would have is the

availability of renal beds in the renal unit for patients who are acutely unwell due to a

renal-related problem.

The renal NP role will impact on the workload and work dynamics of some existing roles

within the renal program at Southern Health. These roles will work collaboratively with

the NP. These are discussed further in Appendix 5.


Community Based Stage 5 CKD Renal NP – Satellite Units Even though there is a push for patients to be dialysed at home, the demand on satellite

units will increase by projected 100 patients by the year 2017 (Southern Health Renal

Service Plan, 2007).

The current haemodialysis capacity and forecast can be identified in Table C. The Nurse

Unit Managers are currently attempting to manage extra dialysis sessions for patients

such as twilight times to maximise use of machines and meet demands on the service.

The renal NP managing Stage 5 CKD patients would have a significant impact on patient

care management and follow up. The overall aim is to:

1. manage patients in a more timely fashion: and,

2. to prevent admissions into the acute care setting.

Currently 2% of patients in satellite units are also an inpatient in the acute service due to

a renal-related problem. The renal NP candidate could identify the reasons for admission

and address these issues in the scope of their practice therefore maintaining a stable

renal patient in the satellite units by closely monitoring and adjusting medications

depending on blood results in a timely manner. The aim would be to decrease acute

hospital admissions of patients in satellite units.

Table 4: Satellite haemodialysis capacity – current and forecast

Site Existing and planned chair capacity

Forecast chair capacity – 2017

Additional chairs required

Southern Health sites Casey Hospital 9 9 - Cranbourne ICC 12 12 - Dandenong LGA 9 18-21 9-12 MMC Moorabbin 15 15 - Sub total 45 54 9-12 Non SH – satellite sites The Bays Private Hospital – Hastings 8 6 - Latrobe Regional Hospital – Traralgon 9 9 - West Gippsland Health Service – Warragul 6 (4 operational) 6 - Bass Coast Health Service – Wonthaggi 9 (6 operational) 9 - Sub total 30 30 - Grand total 75 841 9-12

1 Note that the 84 satellite chairs managed by Southern Health does not equal the required capacity for Southern Health patients. This is because some Southern Health managed patients will continue to receive satellite care at non-Southern Health sites. Southern Health also provides satellite capacity for some patients from other hubs. (Renal Service Plan, 2007)


A major factor to be considered is the age and the multiple medical conditions of the

patients who access satellite units. Future forecasts predict that patients requiring

dialysis will become older, some over 85 years of age, with many medical co-morbidities.

Refer to graph below.

Figure 5: Prevalent Age Groups of Dialysis Patients in Australia


5. CONTINUITY AND SUSTAINABILITY OF THE RENAL NURSE PRACTITIONER ROLE ________________________________________________ Long term, any new renal NPc’s who are recruited will be mentored by existing endorsed

renal NP. Endorsed renal NPs would mentor the NP candidates in the hospital based

and community based settings as well as provide leadership in developing support in the

new area of NP development, for example home dialysis or transplant.

As these new roles grow the current NPs would rotate though the developed renal areas.

This would achieve the following:

- Continuity of care for the patient, due to constant communication between

the renal nurse practitioner group at SH.

- The NP role would be a unique nursing role in renal services because the

NP is qualified and experienced in all aspects of renal care within the CKD

model of care.

- Develop senior nursing staff to their maximum potential.

- The role would be sustainable because all practising renal NPs are

constantly rotating between all areas therefore annual leave, sick leave

etc would be covered by a person who can perform the role.

- Nurse practitioner candidates would be supported by existing NP and

would mentor further renal NP roles.

- The roles could also be developed in different renal specialty areas such

as transplants in a supported sustainable environment.

- This would also give more job satisfaction to the renal NP because a

system is in place where they work autonomously and as a team.

- The renal NP role developed would be more ‘transferable’ than one that is

role specific.

- Less “burn-out” particularly in areas where extensive travel is involved.

I.e. CKD Stage 5 Satellite NP


6. NURSE PRACTITIONER CANDIDATE RECRUITMENT ________________________________________________ From the commencement of the renal NP project, all key stake holders have been

informed and visited on their respective sites about the project. Throughout the project

‘think tank’ sessions were held with staff as a forum to discuss ideas, ask questions,

work through issues and raise awareness within the organisation about two upcoming

nurse practitioner candidate roles. The ‘think tank’ sessions were held at different sites to

allow a variety of nursing staff members to attend.

Two renal NPc positions were advertised in several internal and external media forums,

including the Southern Health internal advertising paper, the Purple Peril, The Age, and

the Renal Society of Australasia.

Formal and informal discussion and enquiries was generated from this. Four Division 1

Registered nurses all currently enrolled in tertiary studies at Masters Level applied for

these positions.

Interviews took place on Friday 14 November 2008. The two successful applicants were

notified the following week. See Appendix 6 for the advertisement for the Renal Nurse

Practitioner Candidates.

A time-line has been developed for potential NPc dependant on where they are in their

educational journey to becoming an endorsed NP.


Sep-08 Oct-08 Jan-09 Apr-09 Jul-09 Oct-09 Jan-10 Apr-10 Jul-10 Oct-10 Jan-11 Apr-11 Jul-11 Oct-11NPc roles advertisedNP candidates appointed (substantive salary) in current role NPc requires 20% non - clinical time (cost implication)NPc enrol at UniTherapeutic Medication management subject 1 semesterNPc requires mentors and pharmacy assistanceNPc requires internal/external education program with medical staff and other NPsNPc moves into NPc developed role away from current workplace - substantive salary (cost implication depands on current salary)NPc moves into NP role as fully paid (approx. $90,000 per year with oncosts) and functional NP

Sep-08 Oct-08 Jan-09 Apr-09 Jul-09 Oct-09 Jan-10 Apr-10 Jul-10 Oct-10 Jan-11 Apr-11 Jul-11 Oct-11NPc roles advertisedNP candidates appointed (substantive salary) in current role

NPc requires 20% non - clinical time (cost)NPc enrol at UniMasters of Nursing Practice (Nurse Practitioner)NPc requires mentor and pharmacy assistanceNPc requires internal/external education program with medical staff and other NPs

NPc moves into NPc developed role away from current workplace - substantive salaryNPc moves into NP role as fully paid (approx. $90,000 per year with oncosts) and functional NP

NPc an existing Master of Nursing

NPc an existing Master of Nursing

Implementation and Financial Implication Plan Nurse Practitioner Roles Renal Services

Implementation and Financial Implication Plan Nurse Practitioner Roles Renal Services

with DRAFT

without DRAFT


7. PREPARING THE NURSING WORKFORCE ________________________________________________ Expanded clinical practice requires formal educational preparation at the Masters level

with relevant clinical experience to ensure that the Renal Nurse Practitioner is

academically and clinically prepared for practice.

The Renal Nurse Practitioner must have outstanding interpersonal communication skills,

and demonstrate leadership, advanced assessment skills, clinical skills and diagnostic

abilities and be politically astute.

In order to facilitate the development of advanced clinical practice skills, the need for

exposure to the clinical aspects of the role has been recognised. The literature identifies

that whilst formal educational preparation is a prerequisite, NPs develop many of their

clinical skills through on the job training and attendance at continuing education

programs and conferences (Cole and Ramiz, 2000).

Ongoing education utilising ‘on the job’ training such as clinical mentorship, specific skills

workshops, attendance at in-service and outpatient clinics provide opportunities to

acquire the required knowledge and gain valuable skills. This education is often provided

by medical professionals, and more recently NPs.

Educational framework of the Renal Nurse Practitioner It has been recognised that the education of the Nurse Practitioner candidates

and ongoing education of the endorsed Nurse Practitioner has been previously

identified as one of the most challenging areas of role implementation at

Southern Health. The nature and amount of education required for each NPc and

NP will be dependant on the needs of the individual practitioner, their prior

experience, the context of the role and the specific scope of the role.

Additionally, as these roles progress, it is expected that the Master of Nurse

Practitioner degrees offered by relevant Universities, will close the theory-practice

gap further supporting the Nurse Practitioner candidate. The internship module

that applicants must now undertake will support this.

All NPc and NP roles must have at least 20% of their Effective Full Time (EFT) as

“non-clinical” time. This equates to 1 day per week for full time NP and NPc. This

must be built into the budget as an ongoing component of any NP and NPc role.


An education plan is required for all Southern Health NPc and NP. This plan

needs to recognise that NP/candidates will require significant initial and ongoing

education to undertake their role and identify potential areas where education can

be accessed. (Southern Health Nurse Practitioner Strategic Framework 2008)

The ongoing sustainability of the renal NP role requires the development of a formalised

educational process that is supportive, and which strengthens the NP’s role.

Clinical education for the renal NPc is available from many resources such as clinical

tutorials, case presentations, renal meetings and other forums which will be discussed in

more detail later. While it is recognised that the majority of learning takes place within the

clinical environment, structured education sessions are required to address the detailed

learning needs of the individual to practise clinical skills (such as fistulagrams,) prior to

the clinician introducing them to their clinical practice.

It is also recognised that candidates will have come from varied educational

backgrounds, and as adult learners will not only bring a wealth of past experience, but

will also have developed their own distinctive learning style. Education needs to be

learner focused, flexible and brought into the program from a variety of sources to meet

the needs, and the structure of the clinical education program will similarly need to be

based on various learning methods.

Learning Opportunities available within Southern Health The learning opportunities identified below will be developed into an educational

framework for NPc’s at Southern Health. These will align with the “National Competency

Standards for the Nurse Practitioner” as described by the Australian Nursing & Midwifery

Council.

Clinical Tutorials

Dr. Robyn Langham (Nephrologist) and Dr. Ann Allenby from St. Vincent’s Hospital,

Melbourne have designed a curriculum and specialist education for dialysis nurse

practitioner candidates. A nephrologist was the main provider of the clinical component

of the program with contributions from a dietician, pharmacist, surgeon, radiologist and

other nephrologists.


The aim of the renal NP curriculum is to divide it between the main hospitals within the

collaborative. Logistical organisation of this is yet to be determined. Currently the renal

collaborative is waiting to see how the renal NP curriculum from St. Vincent’s could be

distributed.

Southern Health is investigating the possibility of employing designated medical staff to

provide clinical tutorials to the NPc. Links with and attendance to clinical tutorials already

provided to medical staff and students will also be a viable option which needs further

investigations until endorsed renal NP can provide their own clinical tutorials.

The topics presented will be evaluated for their relevance and application to clinical

practice. Candidates will have every opportunity to request new or varied topics.

Throughout their candidacy, candidates will be expected to address their own learning

needs. Intermittent tutorials will be designed for candidates to support them in meeting

these needs in an open forum style tutorial. Learners may also address these needs in a

more private forum. Self-directed learning is expected from candidates prior to attending

the tutorial for each topic.

As the experience of endorsed renal NP at Southern Health grows, it is envisaged that

the renal NPs will contribute to and provide much of the education required by new

candidates, while continuing to foster the invaluable input from other disciplines.

The ongoing education sessions of endorsed renal NP will be provided over half and full

study days where possible, avoiding interrupted clinical days, and will be provided on a

consistent basis. The renal collaborative will take ownership of this.

Case Presentations

Each renal NPC would be expected to present a case study for discussion within a

tutorial group. Tutorials enable candidates to refine their ability to consult with physicians

about individual patients, and provide an invaluable learning opportunity to all group

members. These case presentations could take place at the Friday morning renal

meeting.

Interdisciplinary Collaborative Learning and Mentorship

In recognition of the multidisciplinary approach to the renal NP role and the nature of the

renal program, interdisciplinary education is an objective of the education program. The

candidate is expected to utilize sessions presented by other disciplines that are relevant

to learning, and to embrace the opportunity to invite others to attend the renal NPc

sessions.


A model of collaborative learning centred on clinical mentorship provided by a ‘clinical

coach’ needs to be established to assist with the acquisition of advanced clinical skills by

the renal NPc. Initially this support will be provided by a Senior Renal Physician-

mentors, yet to be determined. Once there are endorsed renal NP in Southern Health,

they will take on the role of ‘clinical coach.’

An initial, two-week supervisory role period is necessary to introduce the renal NPc to

their new role. The ‘mentoring’ function with supporting medical staff, is integral to the

renal NPc’s successful role transition. Specific key skills, in particular history and

physical assessment are a major focus during this period. This period also facilitates the

interdisciplinary liaison and referral process, as the new candidates assimilate their role

and are introduced to other members of the health care team, intra- and inter-

departmentally.

Outpatient Clinic Attendance

Outpatient clinic attendance provides excellent learning opportunities and activities for

the renal NPc. The renal NPc would be expected to utilise outpatient clinics as a

resource for acquiring and practising clinical skills. The outpatient department was

extremely supportive of this with the Emergency Nurse Practitioner Project in 2005.

Attendance must be organised with relevant Nurse Unit Managers and Senior Medical

Staff prior to attendance. Clinics such as CKD clinics which includes the

glomerulonephritis clinic, the Stage 3-4 renal failure clinic, preadmission clinic and

satellite outpatient clinic at Traralgon are all educational opportunities for the renal NPC.


Renal Meetings

The renal program holds weekly meetings that all medical staff and renal NPc are invited

to attend. These meetings are held every Friday morning from 8 until 9am and cover a

range of learning opportunities including biopsy results, case presentations, conference

presentations, haematology, peritoneal dialysis, transplant and death audit results.

Radiological issues are also discussed every two months.

Journal Club

The renal program holds a Journal Club meeting every fortnight from 1-1:30pm on a

Monday. Attending journal reviews will help to guide best practice and also give the renal

NPc opportunities to present their own literature review that guides their practice.

Small Group Ward Rounds

Small group ward rounds are excellent learning and practice opportunities for the renal

NPc to put theory into practice regarding patient decision making and care management

in a supported learning environment.

Victorian Renal Nurse Practitioner Collaborative

During the project phase, the participating project teams formed a renal NP collaborative.

The Collaborative’s purpose is to assist health services to implement NP models in renal

care by sharing information, knowledge and experiences that impact on the

implementation of services. Renal NP candidates, potential candidates and endorsed

renal NPs are encouraged to participate. Other people including representatives from

Nurses Board Victoria, Department Human Services and the Renal Health Clinical

Network are involved to provide support and two-way information sharing.

It is envisaged that the collaborative will provide strong support to hospitals and NPc

introducing the role in 2009.

Australia, New Zealand, Society of Nephrology Conference

The annual ANZSN Conference is a high-quality educational opportunity for NPc to

attend and present the extent their level of knowledge pertaining to current renal

practice.


Other Learning Opportunities Available to Renal NP Candidates www.kidney.primed.com.au

This is a website from Kidney Health Australia that contains education for health care

professionals on CKD patient care management. There are currently eight KCAT

Workshop modules currently available:

• Early detection of Chronic Kidney Disease (CKD)

• CKD and Diabetes

• CKD and Cardiovascular Disease

• Management of Stage 3 CKD in General Practice

• Issues in CKD – 4 different case studies

• Using the CKD Management in General Practice Resource

• Haematuria and urinary tract infection

Each two-hour workshop generally consists of a didactic presentation, small group work

using case studies, as well as a plenary discussion. A general practitioner chairs the

workshop, whilst a nephrologist (organised by KCAT) facilitates and provides expert

advice to address questions raised by participants. All educational materials are provided

and include a PowerPoint slide show and relevant support material.

Kidney Health Australia also has many educational resources available to the Renal NP

candidate which could be incorporated into their practice. For example ‘Living With

Reduced Kidney Function - A Handbook for self management of Chronic Kidney

Disease’.

Renal Society of Australasia (RSA)

Being a member of the RSA provides the renal NP Candidate with up to date

information. Moreover, attendance of the annual conference that the RSA organises is

another excellent learning opportunity for renal NP. NPC could attend and present a

poster, whereas endorsed renal NP could present.

There is a website, www.rsa.org.au

On this website there are regular publications in The Communiqué and the Renal

Society of Australasia Journal.


http://www.kidney.primed.com.au/

8. CLOSING THOUGHTS ________________________________________________

• The Nurse Practitioner Role is the pinnacle of clinical nursing. The introduction of

additional Nurse Practitioner roles to Southern Health aligns with the Southern

Health goal in developing our people, knowledge and skills. It is a positive

forward step for the nursing profession at Southern Health.

• Careful planning prior to implementation of the Renal Nurse Practitioner role is a

critical step towards the successful implementation and integration of this new

role into existing health services.

• This project enabled Southern Health to develop a readily transferable plan to

implement the Renal Nurse Practitioner role at a large metropolitan hospital that

also services a community health setting.

• Renal nurse practitioners clearly have a future. As a result of this project two

renal nurse practitioner candidates were appointed. They will be working towards

endorsement to make a significant difference to the delivery of healthcare to renal

patients at Southern Health in the future.

• The most important infrastructure, the Southern Health Nurse Practitioner

Strategic Framework 2008 is already in place.

• Educational programs and ongoing support for the renal NPc are also partially in

place at and partly in progress. The aim is to ensure that the candidates are

ready to assume the Nurse Practitioner role in its fullest capacity once they are

endorsed by the Nurses Board of Victoria.

• The case for ongoing development and further Renal Nurse Practitioner roles

within the renal program at Southern Health has been discussed and strongly

recommended for the sustainability of the renal NP role and to service the renal

program at Southern Health to the extent it requires.


9. ACKNOWLEDGEMENTS ________________________________________________ The renal service providers are a community high functioning, highly motivated, vibrant

team. Most of the information gathered for this project was from discussion, networking

and sharing of ideas and information with a range of people.

People and organisations engaged included:

Internationally Ms Tricia McCarley- Nephrology Nurse Practitioner USA Nationally Australian Nurse Practitioner Association Kidney Health Australia Renal Society of Australasia Amgen Nephrology Department of Health WA- Renal Diseases Health Network Armadale Health Service- Casey Light (Renal NP) Lesley Salem- Renal NP Hunter New England Hospital NSW Mr Graeme Turner- Renal NP Lismore, NSW Ms Bettina Douglas – Renal NP Princess Alexandra Hospital, Q’land State Department of Human Services, Nurse Policy Branch Nurses Board of Victoria St. Vincent’s Health – Renal NP’s (Melissa Stanley and Margaret Morris) Annette Rose- Bairnsdale Regional Health Southern Health Renal Service Plan Renal Nurse Practitioner Collaborative


10 ABBREVIATIONS ________________________________________________ A/L Annual Leave ANMC Australian Nursing and Midwifery Council ANZDATA Australia and New Zealand Dialysis and Transplant Association AVF Arteriovenous fistula AXR Abdominal X-ray Ca Calcium Ca/PO4 Calcium/phosphate product CARI Caring for Australians with Renal Impairment Chol Cholesterol CKD Chronic Kidney Disease CMV Cytomegalovirus CT Computer Tomography CXR Chest x-ray DHS Department of Human Services ECG Electro cardiogram EFT Equivalent Full Time eGFR Glomerulo-Filtration Rate EPO Erythropoietin ESKD End stage kidney disease FBE Full blood examination FT Full time GN Glomerulonephritis GP General Practitioner HD Haemodialysis MC&S Microscopy, culture and sensitivity MMC Monash Medical Centre MO Medical Officer


MSU Mid stream urine NBV Nurses Board of Victoria NPC Nurse Practitioner Candidate NP Nurse Practitioner NSU Nursing Support Unit NUM Nurse Unit Manager PD Peritoneal dialysis PO4 Phosphate QOL Quality of life SH Southern Health Tx Transplant U&E Urea and electrolytes VNPP Victorian Nurse Practitioner Project


9. BIBLIOGRAPHY ________________________________________________ Bendigo Health, A Service Plan for implementation of the Nurse Practitioner Role in Bendigo Health and Bendigo Community Health Services Inc 2006-2008 Bolton, W. (1998b). The role of the nephrologist in ESRD/pre- ESRD care: a collaborative approach. American Journal of Kidney Diseases. 9:S90-S95 Cole, F.L., Ramirez, E. (2000) Activities and procedures performed by nurse practitioners in emergency care settings. Journal of Emergency Nursing. Vol 26 (5) pp:455-463 Department of Health, Western Australia. (2008) Chronic Kidney Disease Model of Care. Perth: Health Networks Branch Edwards. L, Morgan. K & Clothier. (2005) The Emergency Nurse Preactitioner Model of Care. Southern Health Hoffart, N. & Nissenson, A. (1998). The future of end-stage renal diseases care: nephrology enters a new millennium. Advances in Renal Replacement Therapy. 5(4):257-266. Kidney Health Australia www.kha.org.au National Competency Standards for the Nurse Practitioner: Australian Nursing and Midwifery Council 2005 Nurses Board of Victoria www.NBV.org.au Renal Society of Australasia www.rsa.org.au Southern Health Renal Service Plan 2007 St. Vincent’s Health Melbourne 2003. Nurse Practitioner Project Final Report of the Project and Evaluation Suki, W. (1999). Are physicians assistants the answer to a shortage of nephrologists? American Journal of Kidney Diseases. 33(4): 796-797.


http://www.nbv.org.au/

APPENDIX 1 PART A RENAL Questions 1.1 to 2.9 (inclusive) must be completed in support of any application for Round 4.2 or 4.3 funding elements. If you are seeking funding for both rounds, complete Part A separately for both models.

Whilst recognising that service development is an iterative process, to be able to assess submissions for funding under Rounds 4.2 and 4.3, Nurse Policy Branch requires information on the proposed model of service delivery, the role of the NP and the anticipated outcomes needs to be provided.

1. OVER VIEW OF PROPOSED MODEL

1.1 Briefly describe the proposed model of care that a NP role will support.

To support renal patients within Southern Health from pre-dialysis through to palliative care or a successful renal transplant. These patients would include :

Pre dialysis patients both Haemodialysis & Peritoneal Dialysis patients. Pre transplant, transplanted & post transplanted patients. Some “medically” managed patients who may not have commenced renal replacement therapy eg.

Haemodialysis / Peritoneal dialysis but may require regular I.V. Iron management / Erythropoietin medication etc.

All Satellite Haemodialysis patients by visiting the satellite clinics weekly To support patients commencing in home training following through to home dialysis either Haemodialysis or Peritoneal Dialysis. This could move to the Dandenong Super Clinic. Referrals could be made by self referral, carer’s, Nephrologists, GP, nurses & others.

1.2

When implemented, what will be the impact on the current model of care – i.e. will it be an extension of existing services, allow new service capacity to be delivered or is it a re-design of services.

Provide an extension of existing services within the Department of Nephrology at Monash Medical Centre, Clayton.

Provide a NP role which functions between the acute and home renal services interface via an outpatient/home visit model of care. This would be a redesign of existing services. This will ensure easier access for these renal patients to be seen or reviewed in a more timely fashion

Criteria’s could include problematic access / fistula’s that NP could arrange investigations and intervention

Change of medications would be addressed for this group of patients

1.3 When fully implemented, what will be the NP role? Describe how an NPs specific advanced and extended skills will be used in delivery of services (e.g. assignment of independent clinical load, case management or other model, what will be the key responsibilities of NP.

Provide an expert and advanced assessment of patients in the acute hospital/clinic including:

• Assess patients for their fluid status • Assess patients for Fistulagrams / Ultrasound on their access’s. • Assess patient’s anemia management and increase / decrease medication appropriately eg Erthyopoietin / Aranesp

or initiate Blood Transfusions. • Assess for requiring a Chest X-ray or other related diagnostic imaging tests for issues like : Pulmonary Odeama,

Blocked or ? movement of Peritoneal Catherter which may require further investigation.

VNPP Round 4.2 or 4.3 - Submission for funding


• Assess for ? Peritonitis on patients at home on Peritoneal Dialysis and initiate treatment at home instead of patients

having to go and wait for hours in the Emergency Department. • Insert Vascaths which would be for temporary Haemodialysis To be able to manage the Chronic / End Stage Renal Patient

To hold renal clinics. Dose Erthyopoietin / Aranesp appropriately. Change medications eg. Phosphate Binders. Dialysis Prescriptions eg. Hours of Dialysis, Dialyser, Concentrate.

1.4

What specific service gaps does the proposed model and specific NP role address?

The development of a model of provision within the acute and satellite and home renal services interface would ensure patients are able to be:

• treated in a more timely manner • have timely medication management • regular review of Dialysis adequacies and deficits • Patients / clients not could be seen in an outpatient NP clinical rather then waiting in Emergency departments • Satellite and home dialysis patients / clients to be seen or reviewed on a regular basis eg. weekly or more if

required depending on individual patients. • Provide an improved service for the renal staff in that the frustrations could be alleviated by not having to wait for

clinic appointments for their patients eg. 3months. • patients seen / reviewed by NP for full assessments at home / satellite units instead of having to sent them to the

acute sites

1.5

How is it anticipated that service continuity be managed when the model is fully implemented?

Initial discussions and consultation across Southern Health has lead to the possibility of developing 2 separate NP roles in Renal Services:

Position should be an EFT of 1.0 / 1.5 and beneficial to have two NP. • One NP could review and oversee the care of the patients/clients in the satellite units. • A second NP could cover pre-dialysis through to home dialysis , transplant patients & palliative care patients.

These roles would work collaboratively with each other and senior medical staff to ensure service continuity.

2. SPECIFIC DHS SELECTION CRITERIA

2.1 Provide information about the extent to which the proposed model aligns with the Stroke Care Strategy (DHS 2007) and contemporary stroke management

As recommended in the Southern Health Renal Service Plan November 2007 the following issues were recognized in regard to a NP in the renal satellite units they were : • Page vi / Recommendation 16

“Establishing advanced practice nursing positions in satellite centre to provide enhanced clinical care to patients.”

• Page 25 / Section 8.4 Workforce – point 8.4.1 Ensuring sustainability of the Workforce “Southern Health should

investigate new workforce roles and responsibilities such as introducing Nurse Practitioner roles for Division 1 Registered Nurses”.

If the above was implemented it could provide a holistic service to all renal patients under the care of Southern Health from pre – dialysis to palliative care or a successful renal transplant. This person would work and communicate with all health professionals for the welfare of all renal patients.

2.2

Provide information that demonstrates your organisation’s capacity to successfully manage workforce initiatives of this size/type or previous experience in service development initiatives.


Southern Health has previously managed many workforce initiatives. Firstly, the VNPP Phase 3, Round 5 Emergency Department NP project which was undertaken in 2005. Secondly, and at a strategic level, Southern Health were highly commended at the 2007 Victorian Public Healthcare Awards for our Southern Health Nursing Workforce Innovations. Section of abstract from Awards submission: In early 2006, the Nursing Executive (Directors of Nursing – DONs) and Nursing Support Unit (NSU - senior nursing staff specialising in Workforce Planning, Casual Nursing Workforce Management and Nursing Informatics) embarked on a workforce development plan to address this issue and to reduce the 150 vacancies and the large agency use. This workforce development plan included a number of strategies and involved collaborating with both Deakin University and Chisholm Institute of TAFE. The workforce plan included:

• identifying wards which could employ more Division 2 RNs • seeking Department of Human Services funding for a coordinated education and support program for integrating Division 2 RNs

into acute wards; and • recruiting Division 2 RNs into the selected wards.

The plan also aimed to integrate Division 1 RNs into high dependency areas. This transition was supported by providing Deakin University postgraduate scholarships and a career development year in the high acuity areas of Intensive Care, Coronary Care, Nephrology and Emergency. The outcomes of the workforce plan have included reductions in:

• the use of agency nursing staff from 112 to 54 positions a month; • nursing vacancies from 150 to 66 positions; and • agency staffing costs if $1.7 million.

The plan also provides an excellent model for workforce development that has improved recruitment and retention of nurses. This workforce plan has been further developed and it currently being updated through the Nursing and Midwifery Executive at Southern Health. The Nursing Support Unit, who directly reports to the Executive Director of Nursing and Midwifery, have extensive experience leading portfolios from a strategic perspective.


2.3 Provide information about your organisational commitment to develop and expand NP services.

A Decision Memorandum was approved by the Executive Management Team at Southern Health in February 2008. This Decision Memorandum was for the Executive Management Team to approve and support the commencement of a strategic framework for Nurse Practitioner Implementation in 2008 (please see attached). The second draft of the above mentioned Strategic Framework has now been circulated for comment across the organisation, and a steering committee has been formed which will have its first meeting on 12 May 2008. This steering committee is chaired by the Executive Director of Nursing and Midwifery, and membership includes the Executive Director of Medical Services, 2 Directors of Nursing from within Southern Health, Directors of Pharmacy, Diagnostic Imaging, and Pathology Services, the NP portfolio manager, and a Nurse Practitioner. External membership includes senior representatives from DHS, NBV, and the ANF. A NP portfolio manager has been established within current resources (ADON) within the Nursing Support Unit. This manager directly reports to the Southern Health Executive Director of Nursing and Midwifery.

2.4 Describe the level of support at both executive level and the specific clinical sponsors (who are considered clinical leaders in stroke care) and their roles within the organisation for this initiative.

As described above the development of NP roles across Southern Health has support from the Executive Management Team at Southern Health. The Executive Director of Nursing and Midwifery is the chair of the Steering Committee and the executive sponsor for all NP strategic development. The Nurse Practitioner Decision Memorandum was approved by the Executive Management Team at Southern Health in February 2008. The Director of Renal Services has been consulted and engaged in the development of the Renal NP roles. He is very supportive of the development of these roles. Other medical staff have not yet been consulted but will be approached as soon as funding is granted.

Describe to what extent your organisation is committed to collaborating with other health services including participating in a stroke NP collaborative in the course of developing the stroke NP model 2.5

Southern Health will actively collaborate with other health services when developing the renal model of NP, though the current networks and other formed from this VNPP round, i.e. a renal NP collaborative. The Renal Nurse Unit Managers and Renal Assess Manager of Southern health already have close ties to the Renal NPs at St Vincent’s Hospital Melbourne. This would be further enhanced when deriving the NP model for Southern Health.

2.6 Briefly describe the processes that will be used (existing or new) to engage stakeholders, consumers and community in model development

Stakeholder engagement has already commenced with senior medical and nursing staff working in renal medicine across Southern Health. Further stakeholder engagement will include the:

• Southern Health Nurse Practitioner Steering Committee, • current consumers via survey/invitation to current patients, • community members by making contact with the Community Participation Executive Officer for Southern Health,

and • Southern Health nursing, allied health, support services staff and medical staff

2.7 Describe how you will recruit/appoint/deploy appropriate project support such as, project coordinator, to enable the work to commence within period.


A project manager/coordinator would be employed for a six (6) month period to develop model of NP in Renal Services. This position would be advertised internally within Southern Health, and will be appointed by the 30th May 2008. This project manager/coordinator would report to the NP portfolio manager within the Nursing Support Unit, who directly reports to the Executive Director of Nursing and Midwifery.

Provide macro budget estimates of costs for key activities that you will be undertaking (up to $35,000). 2.8

VNPP Round 4.3 Budget $35,000

Cost On-costs RN Grade 4B Yr 1 (YZ7) (0.6 EFT) $20,930.52 $3,558.19

$2,000 Computer (lap top) $1,000 Travel costs within SH

$500 Stationary $600 Phone

$1,000 Printed matter Consumer/Community Travel etc $1,000 Benchmarking (study tour to relevant states within Australia) $3,000

Total $30,030.52 $3,558.19 $33,588.71


Describe the proposed governance arrangements for this project including project management roles and governance structures (including roles and responsibilities for all sites if collaborative model) 2.9

The governance model for Nurse Practitioner role development is with the Southern Health Nurse Practitioner Steering Committee (Terms of Reference attached). The project manager would report to the Nurse Practitioner portfolio manager who directly reports to the Executive Director of Nursing and Midwifery.

2.10 Is there any other information you would like to present in support of this submission?

Please find attached the Decision Memorandum which was endorsed by the Executive Management Team at Southern Health

Please find attached the Nurse Practitioner Steering Committee Terms of Reference


APPENDIX 2

Renal Nurse Practitioner

Steering Sub-Committee

TERMS OF REFERENCE August 2008

Background Southern Health was successful in obtaining VNPP Round 4.3 funding from DHS to develop two Renal Nurse Practitioner roles. The Southern Health Nurse Practitioner Strategic Framework has been developed has been developed and endorsed by the Southern Health Nurse Practitioner Steering Committee. All roles developed must align with this document. Furthermore a sub-committee has been established for the development of any new Nurse Practitioner Role, beginning with the Renal Nurse Practitioner. In Victoria the role of the Nurse Practitioner has been supported by the State Government since 1998, with the first Nurse Practitioners endorsed in 2004. This coincided with the development of the National Competency Standards for the Nurse Practitioner by the Australian Nursing and Midwifery Council (ANMC) in 2004/2005. The Victorian Nurse Practitioner Project has been undertaken since this time by the Department of Human Services (DHS). Many individuals have successfully obtained their Nurse Practitioner endorsement since 2004. Southern Health was involved in the fourth phase of this project, which resulted in funding for two Nurse Practitioners in the Renal Program. The Australian Nursing and Midwifery Council define a Nurse Practitioner as:

A registered nurse educated to function autonomously and collaboratively in an advanced and extended clinical role….. The role is grounded in the nursing profession’s values, knowledge, theories and practice and provides innovative and flexible health care delivery that complements other health care providers

(ANMC, 2005) A Nurse Practitioner must undergo competency standards developed by the ANMC. In addition, they undertake the process for Nurse Practitioner Endorsement established in July 2006 by the NBV. This is a comprehensive assessment process, which ensures that the Nurse Practitioner has the skills and knowledge to undertake their role.

Role The role of the Renal NP Sub-Committee will be to: • Design, implement and evaluate the of Renal Nurse Practitioner Roles within

Southern Health • Support and inform the development of a renal model of care


Membership The steering committee members will include:

• The Operations Director and Director of Nursing and Specialty Program Director- Kym Forrest (Chair)

• Assistant Director of Nursing- NSU Naomi Dobroff • Director of Nephrology- Dr Peter Kerr • Renal and Transplant Physician- Dr John Kanellis • Renal Nurse Practitioner Project Co-Ordinator- Petra Spiteri (Secretary) • Renal NUM Representative- Tracy Beatty • Renal Satellite NUM Representative- • Dialysis Co-Ordinator- Penny Paton • Pharmacy Representative • Diagnostic Imaging Representative • Pathology Representative • Others as co-opted as need

Responsibilities • Identify priority areas for Nurse Practitioner which aligns with Southern Health

strategic direction, service plans and DHS directives/funding. • Describe the impact on the current model of care and describe which are extensions

of existing services or a re-design of services. • Describe the specific service gaps the proposed model of the Renal NP will address. • Oversee a communication and information technology strategy. • When fully implemented, describe what the Renal NP role will be and the key

responsibilities of the Renal NP. • Facilitate evidence and information to inform strategic development and

implementation of the Renal Nurse Practitioner role • Ensure that the Renal Nurse Practitioners have defined their role and that this is

evidence based and in accordance with Southern Health Policy • Endorse completed Model of Care that the Nurse Practitioner will support. • Ensure the Southern Health Medication Safety Committee is aware of the drugs that

are identified for use by the Renal Nurse Practitioner in the formulary, and ensure clinical appropriateness and consistency with local policy.

• Feed back to the Southern Health Nurse Practitioner Steering Committee Reporting

Minutes and actions from the Renal Nurse Practitioner Steering Sub-Committee will be provided to the Nurse Practitioner Strategic Steering Committee.

Conduct of Meetings

I. The Operations Director and Director of Nursing and Specialty Program Director is the chair of the Southern Health NP steering sub-committee.

II. Quorum: the quorum will be fifty percent of listed members, plus one. Where a quorum is not reached, a meeting may still proceed, but decisions made must be ratified at the next meeting having a quorum,

III. Voting: all members will have an equal vote. The chairperson may cast the deciding vote

IV. Frequency of meetings: meetings to be held monthly V. Duration of meetings: meetings are to be for a maximum of one (1) hour

VI. Location of meetings: meetings are to be held at a time and place decided by the


chairperson.

VII. Frequency of attendance to meetings: 70% attendance is required by all members VIII. Proxy attendance is available if committee member is unable to attend

Safe and Effective care Support 1.2 SH Strategic Policy ACHS Function Executive Director of Nursing and Midwifery

Feb 2008 Reviewer Last review date

Executive Director of Nursing and Midwifery

Feb 2009 Authoriser Next review date

Acknowledgments Sydney West Area Health Service Nurse/Midwife Practitioner Information (Rhonda Day, draft 5) Bayside Nurse Practitioner Service Plan Development Project Report June 2006


Southern Health Strategic Framework Nurse Practitioner


Appendix 3

NURSE PRACTITIONER STRATEGIC FRAMEWORK

2008

This guide has been developed using ideas and information from the: o Bayside Nurse Practitioner Service Plan Development Project 2006, o Eastern Health Victorian Nurse Practitioner Project Service Plan Development

Report 2006, o Nurse Practitioner Project: Service Plan Development Northern Health,

November 2006 o Southern Health Emergency Department Nurse Practitioner Model of Care and

Final Project Report 2005 o Sydney West Area Health Service Nurse/Midwife Practitioner Information Guide

2007



CONTENTS

1. General Overview Glossary Background Definition and Role Endorsement by the Nurses Board of Victoria Preparation to be a Nurse Practitioner

45

6-78

9-10

2. Strategic Approach Nurse Practitioner Role Development Alignment to Government and Southern Health

Plans Nurse Practitioner Endorsement Process Standardisation of Position Description across

Southern Health

11

11-12

1212

3. Governance Nurse Practitioner Steering Committee Manager with Nurse Practitioner portfolio

responsibility Nurse Practitioner and Nurse Practitioner

Candidate meetings

13-14

15

15

4. Process for the Development of Southern Health Nurse Practitioner Roles

Flow Chart Review of Services and Role Development Submission to Steering Committee

• Expression of Interest

• Submission for a NP role

• Approval process by

1617

1818-19

19

5. Education requirements for Nurse Practitioner and Nurse Practitioner candidate

20

6. Evaluation of the Nurse Practitioner Role Evaluation Tools Performance Appraisal

21

21-22

Appendices 1. Position Description – Nurse Practitioner candidate 2. Position Description – Nurse Practitioner

24-2930-35



3. Expression of Interest to Nurse Practitioner Steering Committee

4. Full submission to Nurse Practitioner Steering Committee

5. Evaluation Framework

36-37

38-40

41



1. GENERAL OVERVIEW

Glossary ANMC – Australian Nursing and Midwifery Council

DHS – Department of Human Services

DON – Director of Nursing

EDNM – Executive Director of Nursing and Midwifery

HPRA – Health Professionals Registration Act

NBV – Nurses Board of Victoria

NP – Nurse Practitioner

NPc – Nurse Practitioner candidate

SH - Southern Health

VNPP – Victorian Nurse Practitioner Project



Background In Victoria, the role of the Nurse Practitioner (NP) has been supported by the State

Government since 1998 when work began on the legislative and professional framework

to support the new role. The initial Nurse Practitioners were endorsed by the Nurses

Board of Victoria in 2004 and were the first to use the protected title of Nurse

Practitioner. To date, 40 individuals have successfully obtained their Nurse Practitioner

endorsement in Victoria and there are about 260 nurses nationally authorised as NPs by

their respective registration bodies.

In 2004/2005, work began on developing National Competency Standards for the Nurse

Practitioner by the Australian Nursing and Midwifery Council (ANMC) and a framework

for educational standards for NP programs. This work was to provide nationally agreed

core competency standards for all state and territory nursing and midwifery regulatory

authorities to adopt.

The Victorian Nurse Practitioner Project (VNPP) was established by the Department of

Human Services (DHS) to progress the implementation of the NP role in Victorian public

health services. Initially the VNPP provided the focus for the policy and legislative

framework to support the implementation of the NP role and to fund demonstration

projects. Since 2004, the VNPP has been assisting public health services with funding

for establishment projects and NP service planning as well as scholarships to support

nurses undertaking the academic preparation to become endorsed as NPs.

Southern Health was involved in the third phase of the VNPP and was funded to

implement an Emergency NP model at Monash Medical Centre Clayton and Dandenong

Hospital Emergency Departments. The outcomes of that project include the successful

preparation and endorsement of a NP (endorsed in 2006) who is currently employed in

the Emergency Department at Dandenong Hospital. Since this time, there have been no

further Nurse Practitioners endorsed within Southern Health.



Definition and Role The Australian Nursing and Midwifery Council define a Nurse Practitioner as:


This definition has been accepted by the Nurses Board of Victoria.

The national competency standards for the nurse practitioner build on the core

competency standards for registered nurses and midwives, as well as the advanced

nursing practice competency standards. These have now been accepted by all the state

and territory nursing and midwifery regulatory authorities.

The following assumptions underpin use of the competency framework:

1. The nurse practitioner is a registered nurse whose practice must first meet the

following regulatory and professional requirements for Australia and New Zealand

and then demonstrate the additional requirements of the nurse

practitioner:

● National Competency Standards for the Registered Nurse

● Code of Ethics for Nurses

● Code of Professional Conduct for Nurses

2. The nurse practitioner standards build upon the existing Advanced Nursing

Practice Competency Standards used respectively in Australia and New Zealand.

3. The nurse practitioner standards are based on the findings from the Nurse

Practitioner Standards Research Project. They are developed to ensure safe

nurse practitioner practice that relates to a specific field of health care.

4. The nurse practitioner standards are core standards that are common to all

models of nurse practitioner practice. They can accommodate specialty

competencies that are designed to meet the unique health care needs of specific

client/patient populations.



5. The nurse practitioner standards will be used by nurse practitioner education

providers to develop the content and process requirements for a nurse

practitioner education program.

6. The nurse practitioner standards will be used by regulatory authorities to

determine the eligibility of nurse practitioners seeking authorisation as nurse

practitioner in Australia and New Zealand.

Nurse/Midwife practitioners must demonstrate competence across three standards that

are:

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 health care

Further information regarding the AMNC competency standards can be viewed at

http://www.nbv.org.au/media/51813/anmc%20national%20competancy%20standards%2

0np.pdf

http://www.nbv.org.au/media/51813/anmc%20national%20competancy%20standards%20np.pdf

http://www.nbv.org.au/media/51813/anmc%20national%20competancy%20standards%20np.pdf



Endorsement by the Nurses Board of Victoria (NBV) The title of Nurse Practitioner is legally protected within Victoria, and as such only those

nurses who are endorsed by the NBV may call themselves Nurse Practitioners. As of

June 2008, there were 40 Nurse Practitioners authorised in Victoria.

Under the Health Professional Registration Act (HPRA) 2005, (enacted July 1 2007)

relevant boards need to establish a Prescribing Practice Advisory Committee (PPAC) to

advise the board on matters including:

• the categories of nurse practitioner for which a nurse's registration may be

endorsed

• the curriculum, content and standard of courses of study required of a NP

• the content and standard of clinical experience required of a NP

• the Schedule 2,3, 4 or 8 poisons2 that each NP category has prescribing

rights to and should be authorised to obtain and have in his or her possession

and use, sell or supply under the Drugs, Poisons and Controlled Substances

Act 1981

• the guidelines for health practitioners with endorsement of registration, and

• the requirements of the on-going education for NPs

The NBV requirements (including academic) for endorsement as an NP (and the

associated procedures and processes) under the HPRA are currently being finalised and

then will be submitted to the Minister for Health for approval.

To date, NBV has sought the Ministers approval to establish 12 categories of NP

practice and received approval for the categories and the associated list of drugs

associated with each category. Under HPRA, the NBV is reviewing the categories for

NP practice and will be recommending a framework for future NP practice areas and the

associated scope of prescribing practice. This work and the revised NBV process for

endorsement is anticipated to be agreed in 2008.

2 “Poisons” is used in this context as this is the terminology used by the relevant legislation i.e. the Drugs, Poisons and Controlled Substances Act (date). A more consumer friendly term would be medicines.



Preparation to be a Nurse Practitioner

This can be viewed in detail on the NBV webpage:

http://www.nbv.org.au/media/43422/current%20process%20nurse%20practitioner%20en

dorsement.pdf

The entry to practice level for NP in Victoria is generally accepted as a Masters level of

educational preparation including pharmacology studies also at Masters level. This

includes courses of study designed to ensure graduates meet the NP competency

Standards e.g. Masters of Advanced Nursing Practice (Nurse Practitioner) and other

clinically based Masters degrees.

Courses accredited by the NBV which may lead to endorsement as a Nurse Practitioner

can be found on the NBV website at

http://www.nbv.org.au/media/43419/accredited%20courses%20nurse%20practitioner%2

0feb2008.pdf

The preparation for NP includes the NBV requirements as well as other specific

employer requirements of the role that may be determined by the specific clinical area or

model of care or NP role requirements. It is therefore critical that the preparation of the

NP be seen as partnership between the nurse, the employer and where relevant the

educational provider(s).

Nurses who are employed by a health service to be working towards the Nurse

Practitioner title are called Nurse Practitioner candidates (NPc). A Nurse Practitioner

candidate is paid at their substantive salary (Australian Industrial Relations Commission,

2005) until they become endorsed as a Nurse Practitioner, when they are reclassified as

a Grade 6 Registered Nurse as per the Deed and Schedules between ANF, HSU1 and

VHIA dated 25 October 2007 in relation to General Nurses2.

2 This document requires submission to the Workplace Authority once agreed to by a majority of staff. It will be then known as "Nurses (Victorian Public Health Sector) Multiple Business Agreement 2007 - 2011".

The NPc title can only be used by a Nurse Practitioner candidate in Southern Health if

they are in a role supported by the health service, and have a letter confirming their

appointment into this role from their site/program DON.

http://www.nbv.org.au/media/43422/current%20process%20nurse%20practitioner%20endorsement.pdf


http://www.nbv.org.au/media/43419/accredited%20courses%20nurse%20practitioner%20feb2008.pdf

http://www.nbv.org.au/media/43419/accredited%20courses%20nurse%20practitioner%20feb2008.pdf



2. STRATEGIC APPROACH

The Nurse Practitioner role is at the apex of clinical nursing practice. To ensure NP roles

are developed with the consideration and planning they deserve, a strategic approach is

required. The establishment of a Nurse Practitioner position in a site/service within

Southern Health is to be guided by collaborative planning, practice, implementation and

evaluation within the service/area the nurse will be employed within.

All Nurse Practitioner roles within Southern Health require development within the

framework set out within this document.

Nurse Practitioner Role Development The Southern Health Nurse Practitioner Steering Committee will identify and prioritise

areas for the development of all Nurse Practitioner roles within the health service. As

such, a two stage process has been developed to ensure adequate understanding of the

advanced practice role of a Nurse Practitioner, role planning, stakeholder analysis and

resource allocation have been put in place for Nurse Practitioner role development. The

two stages are:

1. Expressions of Interest for developing Nurse Practitioner roles must be

submitted to the Nurse Practitioner Steering Committee, via the Executive

Director of Nursing and Midwifery, who is the committee Chair,

2. These Expressions of Interest will be reviewed, and if approved, an invitation will

be extended to complete a detailed submission to the Southern Health Nurse

Practitioner Steering Committee.

Alignment to Government and Southern Health Plans Establishment of NP positions will be in alignment with specific Government Health

Plans, where appropriate, including those developed by the:

Federal Department of Health and Ageing

Victorian Department of Human Services

Local Government

Establishment of NP positions will be in alignment with Southern Health plans including,

where appropriate:

1. Strategic Plan including the

Strategic Direction of the organisation



Southern Health goals

Southern Health values

2. Southern Health Clinical Service Plan 2005-2010

3. Specific Service Plans for the area

Nurse Practitioner Endorsement Process The Nurse Practitioner endorsement process is completely separate from Southern

Health developing and supporting Nurse Practitioner positions. The Nurse Practitioner

endorsement process is undertaken by the Nurse Board of Victoria. This process is

discussed on page 8 of this document; it can also be viewed at

http://www.nbv.org.au/media/43422/current%20process%20nurse%20practitioner%20en

dorsement.pdf

As with all professional roles, the obligation is on Southern Health to ensure that nurses

practising in Nurse Practitioner roles have access to the resources needed to deliver

services to the public that are safe and of acceptable quality. Nurse Practitioners are

covered by the Southern Health Insurance Policy as per any other nurse or midwife

employed within the organisation.

Standardisation of Position Description across Southern Health The purpose of the standardisation of NPc and NP Position Descriptions is to provide a

consistent strategic approach within Southern Health regarding the recognition, job

summary and responsibilities/accountabilities of these positions.

Specific Key Performance Indictors would then need to be developed for each NPc and

NP which takes into consideration the context and the specifics of their role. These

would need to be reviewed no less than yearly in line with the performance appraisal of

the NPc and NP.

Please see the positions descriptions on Appendix 1 (Nurse Practitioner candidate) and

Appendix 2 (Nurse Practitioner) of this framework.





3. GOVERNANCE

Southern Health Nurse Practitioner Steering Committee The role of the steering committee is to:

• Provide governance and oversight of the design, implementation and evaluation of

Nurse Practitioner Roles within Southern Health

• Support and inform the development of the strategic framework

The responsibilities of the steering committee will be to:

• Endorse the completed strategic framework including generic Position Descriptions

• Identify priority areas for Nurse Practitioners which align with Southern Health

strategic direction, service plans and Government directives/funding

• Have responsibility for overseeing the Nurse Practitioner’s safety and improvement

systems, assessed against the Southern Health strategic and operational/service

plans, and Government requirements and community expectations

• Oversee a communication and information technology strategy

• Ensure that there is effective review and an accountability and governance structure

of Nurse Practitioner roles

• Facilitate evidence and information to inform strategic development and

implementation of the Nurse Practitioner role

• Review applications from Program Directors/Service Directors/Managers developing

Nurse Practitioner roles

• Ensure that the Nurse Practitioner have defined their role and that this is evidence

based and in accordance with Southern Health Policy

• Ensure the Southern Health Medication Safety Committee is aware of the drugs that

are identified for use by the Nurse Practitioner in the formulary, and ensure clinical

appropriateness and consistency with local policy

• Ensure an education plan is in place for each authorised position, and made explicit

within the position plan



The NP steering committee members will include

• Executive Director of Nursing and Midwifery

• Manager of Southern Health Nursing and Midwifery Advancing Practice

• Manager - Nurse Workforce Policy and Programs, Department of Human Services

• Manager - Policy Research and Practice Standards, Nurses Board of Victoria

• Professional Officer – Australian Nursing Federation, Victorian Branch

• Executive Director of Medical Services

• Nurse Practitioner Representative

• Director of Nursing Representative

• Program Director of Nursing Representative

• Pharmacy Representative

• Diagnostic Imaging Representative

• Pathology Representative

• Other co-opted by need

Conduct of Meetings

IX. The Executive Director of Nursing and Midwifery is the chair of the Southern Health

NP strategic steering committee.

X. Quorum: the quorum will be fifty percent of listed members, plus one. Where a

quorum is not reached, a meeting may still proceed, but decisions made must be

ratified at the next meeting having a quorum,

XI. Voting: all members will have an equal vote. The chairperson may cast the deciding

vote

XII. Frequency of meetings: meetings to be held bi-monthly

XIII. Duration of meetings: meetings are to be for a maximum of one (1) hour

XIV. Location of meetings: meetings are to be held at a time and place decided by the

chairperson

XV. Frequency of attendance to meetings: 70% attendance is required by all members

XVI. Proxy attendance is available if committee member is unable to attend



Manager with Nurse Practitioner portfolio responsibility The Manager of Southern Health Nursing and Midwifery Advancing Practice, a role

directly accountable to the Executive Director of Nursing and Midwifery, will have

responsibility for the Nurse Practitioner portfolio. This includes:

• providing assistance and expertise in NP role development,

• being the secretary of the Southern Health Nurse Practitioner Steering

Committee,

• chairing the Nurse Practitioner and Nurse Practitioner candidates meeting

monthly,

• chairing open forums to present and discuss the NP strategy, and

• reporting progress and outcomes of the above mentioned meeting to the EDNM

monthly, and the NP Steering Committee Bi-monthly, as appropriate

Nurse Practitioner and Nurse Practitioner Candidate meetings Monthly meetings will be held to bring together all the Nurse Practitioners and supported

Nurse Practitioner candidates from across Southern Health. This meeting will be a forum

to discuss various issues and themes particular to the Nurse Practitioner role. The

meeting will be chaired by the Manager of Southern Health Nursing and Midwifery

Advancing Practice. Strategic matters from this meeting may be reported back to the

Steering Committee if deemed appropriate by the members of this meeting.

Open forums will also be held across Southern Health for all staff interested in Nurse

Practitioner roles and may also be attended by those NPc who are not in supported

Southern Health roles. These forums will be advertised across all sites and services, and

chaired by the Manager of Southern Health Nursing and Midwifery Advancing Practice,

and may at times be attended by the Executive Director of Nursing and Midwifery and

other persons on the Nurse Practitioner Steering Committee.



4. PROCESS FOR THE DEVELOPMENT OF SOUTHERN HEALTH NURSE PRACTITIONER ROLES

Identify service gap and review relevant plans including Service

Plans, Strategic Plan, and Government Plans

Does the role being developed need: 1. a registered nurse educated and authorised to

function autonomously and collaboratively in an advanced and extended clinical role,

2. to use nursing knowledge to assess and manage clients,

3. to have skills that may include but are not limited to the direct referral of patients to other health care professionals, prescribing medications and ordering diagnostic investigations,

4. to be grounded in the nursing profession’s values, knowledge, theories and practice, and

5. to provide innovative and flexible health care delivery?

Yes, Nurse Practitioner role development recommended

No, not a Nurse Practitioner role Consider other senior clinical nursing role, e.g. Clinical Nurse Consultant

Submit an Expression of Interest for an NP role to the Nurse Practitioner Steering Committee via chair (see appendix 3)

Complete a submission for a NP role and forward to Nurse Practitioner Steering Committee via Chair (see appendix 4)

Review role and submission notes as received from NP steering to determine appropriate course of action

Put submitted plan into action: Including employment process for an Nurse Practitioner candidate or Nurse Practitioner

Resubmit with detail as requested from the NP Steering Committee

Not approved

Approved

ApprovedNot approved



Review of Services and Role Development When considering a NP within a service it is important to establish this role in the same

manner as other health worker positions. The facility, program or service manager will

undertake the services review, which may lead to the development of a Nurse

Practitioner position in line with the SH framework outlined within this document.

Investigation and planning should occur to understand:

1. what the service needs or service gaps are,

2. what skills or knowledge a health worker should have to fit this need, and

3. then what are the potential roles that could be employed

4. the proposed role redesign

5. the clinical governance model for the role

6. specific stakeholder consultation

Specific attention is required as to whether a Nurse Practitioner role or another role such

as a Clinical Nurse Consultant is better suited for the role. A Nurse Practitioner is:

1. a registered nurse educated and authorised to function autonomously and

collaboratively in an advanced and extended clinical role

2. able to use nursing knowledge to assess and manage clients

3. has skills and may include but are not limited to the direct referral of patients to

other health care professionals, prescribing medications and ordering diagnostic

investigations

4. grounded in the nursing profession’s values, knowledge, theories and practice

and

5. able to provide innovative and flexible health care delivery



Submission to Steering Committee Once this role analysis has been undertaken, and it has been determined that a NP role

is required, a two staged process as described below is required:

1. Expressions of Interest for developing Nurse Practitioner roles must be submitted to

the Nurse Practitioner Steering Committee, via the Executive Director of Nursing and

Midwifery, who is the committee Chair,

2. These Expressions of Interest will be reviewed, and if approved, an invitation will be

extended to complete a detailed submission to the Southern Health Nurse

Practitioner Steering Committee.

Stage 1. Expression of Interest (Overview of the proposed model) An expression of interest must be submitted to the Southern Health Nurse Practitioner

Steering Committee, in no more than 2 pages. The following areas need to be addressed

in the Expression of Interest (please see complete form in Appendix 3)

1. Describe the proposed model of care that a NP role will support

2. When implemented, what will be the impact on the current model of care?

3. When fully implemented, what will be the NP role?

4. What specific service gaps does the proposed model and specific NP role

address?

5. Provide information about the extent to which the proposed model aligns to the

Southern Health Strategic Plan, and other plans (i.e. DHS, local Government, service

plans etc)

6. Describe the level of support at the executive level and specific clinical level for

this role

7. Show approval (signature) from the Operations Manager/Director of Nursing and

the program Director of Nursing as appropriate.

Stage 2. Submission for a Nurse Practitioner Role To be completed only at the invitation of the Southern Health Nurse Practitioner Steering

Committee. This document will detail the following criteria:

1. There is a demonstrable need

2. There is a clearly definable scope of practice

3. There is demonstrated support for the role from key stakeholders

4. The role can be funded within the existing budget or has approval for addition

budget from the Operations Director/Director of Nursing



5. The requirements for an education program and other resources have been

identified

6. Other considerations

Please see appendix 4 for completion and submission.

Approval Process by Steering Committee If the document is complete and aligns with all of the appropriate plans, the steering

committee may then:

• authorise the establishment of the role as either a Nurse Practitioner or a Nurse

Practitioner candidate

ensure governance structure in place for Nurse Practitioner role

ensure they incumbent is supported within the NP and NPc monthly meetings,

and

ensure there is an effective review and accountability structure for the NP or NPc



5. EDUCATION REQUIRMENTS FOR NURSE PRACTITIONER CANDIDATES AND NURSE PRACTITIONERS

It has been recognised that the education of the Nurse Practitioner candidates and

ongoing education of the endorsed Nurse Practitioner has been previously identified as

one of the most challenging areas of role implementation at Southern Health. The nature

and amount of education required for each NPc and NP will be dependant on the needs

of the individual practitioner, their prior experience, the context of the role and the

specific scope of the role. Additionally, as these roles progress, it is expected that the

Master of Nurse Practitioner degrees offered by relevant Universities, will close the

theory-practice gap further supporting the Nurse Practitioner candidate. The internship

module that applicants must now undertake will support this.

All NPc and NP roles must have at least 20% of their Effective Full Time (EFT) as “non-

clinical” time. This equates to 1 day per week for full time NP and NPc. This must be built

into the budget as an ongoing component of any NP and NPc role.

An education plan is required for all Southern Health NPc and NP. This plan needs to

recognise that NP/candidates will require significant initial and ongoing education to

undertake their role and identify potential areas where education can be accessed.

All education plans for NP and NPc roles at Southern Health must include:

1. Development of a specific clinical education plan as per the context of role

1.1. Ensure two medical mentors have been identified

1.2. Ensure one nursing mentor has been identified

1.3. Alignment with any relevant state-wide NP collaborative

1.4. Attendance at monthly Southern Health NP/NPc meetings to ensure collegiality,

nursing context and strategic alignment

1.5. Attendance at relevant conferences/seminars in both the NP, nursing and

medical arena

2. NPc and NP keep a progressive log regarding all of their non-clinical activities

(including education)

3. An outline of how education of NPc will be assessed/evaluated to ensure it is

relevant to the context of the NPc role



6. EVALUATION OF NURSE PRACTITIONER ROLE

Evaluation of the Nurse Practitioner Role is required to ensure quality of health care

delivery and responsiveness to the community/patient needs. It is a requirement that

each area that a NP and NPc practices within can demonstrate the outcomes of their NP

role. This includes the use of evaluation tools and individual annual performance

appraisal.

Evaluation Tools Within Southern Health evaluation tools have been developed in the initial Emergency

NP role implementation. These tools have been validated via research, and as such

provide a good basis for evaluating all NP and NPc roles. These tools are able to be

adapted to local need and used by other disciplines to help evaluate their role and audit

many of their skills.

An Evaluation Framework is outlined in Appendix 5 of this document. It is advised that

this framework is used to ensure consistency across Southern Health. Examples of

these tools for these are also attached.

Further evaluation can be undertaken specific to the Nurse Practitioner role, and the

context of the position.

Performance Appraisal An annual appraisal is required for all Southern Health staff including NP and NPc. The

model for performance appraisal for NP and NPc is as follows (and in accordance with

the NP and NPc position description):

• The Director of Nursing (site or program depending on context of role) will

oversee the performance appraisal

• The Manager who holds the budget under which the NP or NPc is employed

(may be a NUM or service director)

As with any senior role at Southern Health there is an expectation that a 360 degree

feedback model may be used, or information may be sort from other health professionals

working with the NP to provide feedback re performance to the performance planning

process.



Specific Key Performance Indictors would then need to be developed for each NPc and

NP which takes into consideration the context and the specifics of their role. These

would need to be reviewed within the performance appraisal of the NPc and NP.

Current Southern Health Human Resource procedures will be undertaken if the NP or

NPc is not performing in their role.



Appendix 1

Southern Health Position Description

Position Title: Nurse Practitioner candidate

Classification: Substantive salary until endorsement as NP with NBV

Reports to:

Operationally:

Cost Centre Manager (may be a NUM or service director)

Professionally:

Operations Manager / Director of Nursing

or

Program Director of Nursing depending on the context of the appointment

Department/ Cost Centre:

Southern Health wards/ units (depending on location)

1. Southern Health

Southern Health is the largest health service in Melbourne and provides comprehensive

integrated health care services to over 750,000 people in the south-eastern suburbs of

metropolitan Melbourne and nearby catchment populations.

Southern Health has a commitment to good practice, planned health promotion with a view to

addressing the broader determinants of health, in all areas of professional practice. Our services

include public hospital services; aged in-patient, community and home care services; and in-

patient and community mental health services.

As the largest public healthcare employer in Victoria, Southern Health employs approximately

11,200 employees and has an annual turnover in excess of $850 million. In 2006/2007 we

treated more than 170,000 patients in our hospitals, performed 36,500 operations and provided in

excess of 762,000 episodes of care including outpatients, emergency attendances and other

services.



Southern Health is affiliated with several Universities for teaching undergraduate and

postgraduate: medical, midwifery and nursing students. Southern Health also provides extensive

postgraduate study and medical research.

Further information on Southern Health is available at www.southernhealth.org.au

2. Job Summary

The Nurse Practitioner candidate must be working towards their endorsement as a Nurse

Practitioner by the Nurses Board of Victoria. This involves ensuring that all the Key Selection

Criteria set by the NBV are being addressed to ensure endorsement. It is expected that most

NPc’s will be endorsed within 24 months of their candidature commencing. Any potential

exceptions must be discussed by the candidate and their managers. The Southern Health NP

steering committee must be given at least 4 months notice if this time frame is not anticipated to

be met.

The Nurse Practitioner candidate is working towards being

1. a registered nurse educated and authorised to function autonomously and collaboratively

in an advanced and extended clinical role

2. able to use nursing knowledge to assess and manage clients

3. has skills and may include but are not limited to the direct referral of patients to other

health care professionals, prescribing medications and ordering diagnostic investigations

4. grounded in the nursing profession’s values, knowledge, theories and practice and

5. able to provide innovative and flexible health care delivery

The specific scope of practice of the Nurse Practitioner candidate is determined by the context in

which the nurse practitioner is authorised to practice.

The Nurse Practitioner candidate will become recognised as an expert practitioner and clinical

leader with advanced knowledge, skills and recognised competence. The Nurse Practitioner

candidate promotes nursing and explores the boundaries of nursing practice through the use of

evidence based and best practice literature.

The Nurse Practitioner candidate will be actively engaged in their own professional development,

ensuring they are working towards the NBV requirements for endorsement as an NP and the

National Competency Standards for NPs. They will also be committed to the professional

development of others and with their expert knowledge and skills, influence and direct policy

within their area of employment and expertise.

http://www.southernhealth.org.au/



They will also ensure that the vision, purpose and values of the organisation are understood and

integrated into daily practice. A commitment to their own professional development and

achievement of unit and organisational performance indicators is also required.

The Nurse Practitioner candidate will be cognisant of the scope of practice for the position and

function in accordance with this. They will develop competence in the domains identified by the

Australian Nursing and Midwifery Council (ANMC).

The NPc will be directly involved in research and leadership both at a departmental and

organisational level. In addition, it is expected that the NPc will be representing SH outside of the

organisation through activities such as (but not limited to): conference presentations, contributing

to the body of nursing research, and being actively involved in professional associations.

Work Area

This section must include a summary of the specific work area of the Nurse Practitioner

candidate.

3. Nature and Scope of the Position

Dimensions Employment status and hours of Nurse Practitioner candidate

positions will be determined according to individual program, unit,

ward requirements.

Direct reports None

Work relationships Internal:

Clients, patients and professionals linked to the specific Nurse

Practitioner candidate role

4. Responsibilities/Accountabilities

Operational / Clinical

• Progressing towards autonomous and independent practice with respect to individual

competencies and scope of practice, with appropriate supervision, consultation and

collaboration with other members of the health care team to ensure the delivery of patient

centered care.

• Combines developing assessment skills to move towards understanding the clinical,

physical, psychosocial assessment findings, interpretation of health history, diagnostic



test results, and appropriate consultation with and referral to other health care providers

that would become part of a comprehensive, high quality, problem focused patient

centered management plan

• Communication of health care findings, diagnosis, prognosis and options for management

with the patient, family and other relevant health care providers in a language that is

clearly understood

• Promotes nursing and explores the boundaries of nursing practice through the use of

evidence based literature.

• Undertakes education towards developing the ability to initiate and request relevant

diagnostic investigations (diagnostic imaging and/or pathology) based on the patient’s

identified health care needs.

• Undertakes an approved Therapeutic Medication Module, and further develops/informs

the Southern Health formulary and the scope of prescribing practice for their specified

area of practice (defined by the approved NP formulary)

• Is an integral part of the senior multi-disciplinary health care team

• Establishes relationships and liaises with relevant inpatient / other specialty medical /

multidisciplinary health care providers to meet the patient’s identified health care needs

• Initiates, contributes and facilitates research and quality improvement activities relevant to

clinical practice, as an individual, and in collaboration with other members of the health

care team to improve service delivery

• Delivers patient education as required

• Assist with policy development within their area of employment and expertise.

• Commitment to submitting for endorsement with the NBV as a Nurse Practitioner within

24 months of commencement of the candidacy, or as negotiated with DON.

Financial Management

• Demonstrate effective and efficient use of resources in the delivery of services

• Initiate and implement actions to improve the financial effectiveness of all functions, under

the positions control

Human Resources Management

• Become a leader in their field through facilitating the professional development of

colleagues, through the use of their expert knowledge and skills,

• Influence policy within their area of employment and expertise.

• Assist in orientation of all new staff to area ensuring an understanding of the Nurse

Practitioner candidates role and responsibilities

• Participate in orientation, preceptorship and mentoring of new staff and students

• Participate in mentorship program (as described in education plan)

• Understand separate and interdependent roles and functions of the health care team



• Demonstrate a commitment to organisational change

• Accept responsibility for own continuing professional development

• Undertake annual performance appraisal and identify learning needs

• Demonstrates comprehensive knowledge and understanding of, and practices according

to, professional standards, codes of ethics and conduct, relevant legislation and

regulations as established by the Nurses Board of Victoria and professional

organisations, for the advanced practice role

Adherence to Privacy/Confidentiality Requirements

• Adhere to Victorian privacy laws – Information Privacy Act 2000 and the Health Records

Act 2001, as well as other laws that regulate the handling of personal information

5. Key Behavioural Requirements

The incumbent will undertake the role in a manner that demonstrates commitment to the

positive leadership behaviours of Southern Health, to the principles of working together

and to Southern Health’s Vision, Purpose and Values.

Southern Health Values:

Integrity Honesty, open and transparent, admit mistakes, maintains confidentiality,

fairness, builds trust.

Compassion Empathy, sensitivity, concern for others, interacts with dignity, tolerance,

anticipates needs

Accountability Understands roles, uses resources wisely, delivers on time, timely decision

making, achieves stretch goals, takes responsibility for performance

Respect Builds relationships, courteous, listens and understands, gives & receives

feedback, sensitivity & understanding, values difference & individual worth

Excellence Supports creativity & innovation, proactive & solution focused, seeks out

opportunities, embraces quality improvement, professionalism

6. Qualifications/ Memberships/ Licenses

Registered Nurse (Division 1, 3 or 4) within State of Victoria (NBV)

Membership of professional nursing bodies/organisations

7. Key Selection Criteria

• Extensive clinical practice working in area of practice

• Working towards a Masters of NP knowing that this must be completed prior to

applying for endorsement with NBV



8. Other Position Requirements

It is the responsibility of the Nurse Practitioner candidate to ensure that he/ she meets all

criteria identified as mandatory by the NBV and organsiation within the 2 year from

commencement as a NPc

The NPc is expected to contribute to the development of the service model they will be

operating within, particularly where a new role is under development

To participate in continuous improvement activities as required using EQuiP accreditation

program.

Appointment is subject to a satisfactory police check prior to commencing, unless the

applicant is already a staff member currently employed in a direct care position.

Approved (Job Title)

Date



Appendix 2

Southern Health Position Description

Position Title: Nurse Practitioner

Classification: RN Grade 6 Nurse Practitioner Year 1 (NO1)

RN Grade 6 Nurse Practitioner Year 2 (NO2)

Reports to:

Operationally:

Cost Centre Manager (may be a NUM or service director)

Professionally:

Operations Manager / Director of Nursing

or

Program Director of Nursing depending on the context of the appointment

Department/ Cost Centre:

Southern Health wards/ units (depending on location)

1. Southern Health

Southern Health is the largest health service in Melbourne and provides comprehensive

integrated health care services to over 750,000 people in the south-eastern suburbs of

metropolitan Melbourne and nearby catchment populations.

Southern Health has a commitment to good practice, planned health promotion with a view to

addressing the broader determinants of health, in all areas of professional practice. Our services

include public hospital services; aged in-patient, community and home care services; and in-

patient and community mental health services.

As the largest public healthcare employer in Victoria, Southern Health employs approximately

11,200 employees and has an annual turnover in excess of $850 million. In 2006/2007 we

treated more than 170,000 patients in our hospitals, performed 36,500 operations and provided in

excess of 762,000 episodes of care including outpatients, emergency attendances and other

services.

Southern Health is affiliated with several Universities for teaching undergraduate and

postgraduate: medical, midwifery and nursing students. Southern Health also provides extensive

postgraduate study and medical research.



Further information on Southern Health is available at www.southernhealth.org.au

2. Job Summary

The Nurse Practitioner must be endorsed by the Nurses Board of Victoria. The Nurse Practitioner

role includes assessment and management of clients using nursing knowledge and skills and may

include but is not limited to the direct referral of patients to other health care professionals,

prescribing medications and ordering diagnostic investigations.

The role is grounded in the nursing profession’s values, knowledge, theories and practice and

provides innovative and flexible health care delivery that complements other health care

providers.

The scope of practice of the nurse practitioner is determined by the context in which the nurse

practitioner is authorised to practice.

The Nurse Practitioner is a recognised expert practitioner and clinical leader with advanced

knowledge, skills and recognised competence. The Nurse Practitioner promotes nursing and

explores the boundaries of nursing practice through the use of evidence based and best practice

literature.

The Nurse Practitioner will facilitate the professional development of colleagues, and with their

expert knowledge and skills, influence and direct policy within their area of employment and

expertise.

They will also ensure that the vision, purpose and values of the organisation are understood and

integrated into daily practice. A commitment to professional development and achievement of unit

and organisational performance indicators is also required.

The Nurse Practitioner will be cognisant of the scope of practice for the position and function in

accordance with this. He/ she will demonstrate competence in the domains identified by the

Australian Nursing and Midwifery Council (ANMC).

The Nurse Practitioner will be directly involved in research and leadership both at a departmental

and organisational level as well as outside of this arena. It is expected that the NP will be

representing SH outside of the organisation through activities such as (but not limited to):

conference presentations, contributing to the body of nursing research, and being actively

involved in professional associations.

http://www.southernhealth.org.au/



Work Area

This section must include a summary of the specific work area of the Nurse Practitioner.

3. Nature and Scope of the Position

Dimensions Employment status and hours of Nurse Practitioner positions will

be determined according to individual program, unit, ward

requirements.

Direct reports None

Work relationships Internal:

Clients, patients and professionals linked to the specific Nurse

Practitioner role

4. Responsibilities/Accountabilities

Operational / Clinical

• Combines autonomous and independent practice with respect to individual competencies

and scope of practice, with appropriate consultation and collaboration with other members

of the health care team to ensure the delivery of patient centered care.

• Combines clinical, physical, psychosocial assessment findings, interpretation of health

history, diagnostic test results, and appropriate consultation with and referral to other

health care providers as part of a comprehensive, high quality, problem focused patient

centered management plan

• Promotes nursing and explores the boundaries of nursing practice through the use of

evidence based literature.

• Initiates and requests relevant diagnostic investigations (diagnostic imaging and/or

pathology) based on the patient’s identified health care needs.

• Autonomously prescribes medications as per agreed Southern Health formulary

• Consultation with and referral to relevant inpatient / other specialty medical /

multidisciplinary health care providers to meet the patient’s identified health care needs

• Communication of health care findings, diagnosis, prognosis and options for management

with the patient, family and other relevant health care providers in a language that is

clearly understood

• Is an integral part of the senior multi-disciplinary health care team



• Provision of effective education and counselling to individuals, families or groups to meet

the patient’s identified health care needs, including health promotion, health protection

and disease presentation

• Ongoing reassessment, evaluation and monitoring of the patient’s response to

intervention and treatments prescribed using a process of critical appraisal of information

collected to alter, continue or change management as the patient’s conditions requires

• Initiates, contributes and facilitates research and quality improvement activities relevant to

clinical practice, as an individual, and in collaboration with other members of the health

care team and improve service delivery

• Facilitate the professional development of colleagues, and with their expert knowledge

and skills,

• Influence and direct policy within their area of employment and expertise.

• Ensure compliance with Nurses Board of Victoria and specialty practice standards.




organisations, for the advanced practice role.

Financial Management

• Demonstrate effective and efficient use of resources in the delivery of services

• Initiate and implement actions to improve the financial effectiveness of all functions, under

the positions control

Human Resources Management

• Facilitate the professional development of colleagues, and with their expert knowledge

and skills,

• Influence and direct policy within their area of employment and expertise.

• Assist in orientation of all new staff to area ensuring an understanding of the Nurse

Practitioner role and responsibilities

• Participate in orientation, preceptorship and mentoring of new staff and students

• Understand separate and interdependent roles and functions of the health care team

• Demonstrate a commitment to organisational change

• Accept responsibility for own continuing professional development

• Undertake annual performance appraisal and identify learning needs



• Ensure compliance with Nurses Board of Victoria and specialty practice standards




organisations, for the advanced practice role

Adherence to Privacy/Confidentiality Requirements

• Adhere to Victorian privacy laws – Information Privacy Act 2000 and the Health Records

Act 2001, as well as other laws that regulate the handling of personal information

5. Key Behavioural Requirements

The incumbent will undertake the role in a manner that demonstrates commitment to the

positive leadership behaviours of Southern Health, to the principles of working together

and to Southern Health’s Vision, Purpose and Values.

Southern Health Values:

Integrity Honesty, open and transparent, admit mistakes, maintains confidentiality,

fairness, builds trust.

Compassion Empathy, sensitivity, concern for others, interacts with dignity, tolerance,

anticipates needs

Accountability Understands roles, uses resources wisely, delivers on time, timely decision

making, achieves stretch goals, takes responsibility for performance

Respect Builds relationships, courteous, listens and understands, gives & receives

feedback, sensitivity & understanding, values difference & individual worth

Excellence Supports creativity & innovation, proactive & solution focused, seeks out

opportunities, embraces quality improvement, professionalism

6. Qualifications/ Memberships/ Licenses

Registered Nurse (Division 1, 3 or 4) within State of Victoria (NBV)

Endorsed as a Nurse Practitioner by the Nurses Board of Victoria (NBV)



7. Key Selection Criteria

• Extensive clinical practice working in area of practice

• Postgraduate Diploma in area of specialty (as appropriate)

• Completed Master Degree of Nurse Practitioner or equivalent

• Completion of a NBV recognised and approved Therapeutic Medication Management

Module

• Endorsed as a Nurse Practitioner by the Nurses Board of Victoria (NBV)

8. Other Position Requirements

To participate in continuous improvement activities as required using EQuiP accreditation

program.

Appointment is subject to a satisfactory police check prior to commencing, unless the

applicant is already a staff member currently employed in a direct care position.

Approved (Job Title)

Date


Appendix 3

Expression of Interest to the Executive Director of Nursing and Midwifery (Chair of Steering Committee)

Name of Service:

Contact Name for Submitting Expression of Interest:

Position/Title:

Phone/Fax:

Email Address:

For the proposed Nurse Practitioner Role please describe (in no more than 2 pages):

1. Describe the proposed model of care that a NP role will support

2. When implemented, what will be the impact on the current model of care?



3. When fully implemented, what will be the NP role (including which of the extensions of practice which will be utilised)?

4. What specific service gaps does the proposed model and specific NP role address?

5. Provide information about the extent to which the proposed model aligns to the Southern Health Strategic Plan, and other plans (i.e. DHS,

local Government, service plans etc)

6. Describe the level of support at the executive and specific clinical level for this role

7. Show approval (signature) from the Operations Manager/Director of Nursing

Signature Name/Title Date



Appendix 4

Please do not proceed with this section, unless invited by the Southern Health Nurse Practitioner Steering Committee

Criteria for Submission to Nurse Practitioner Steering Committee (all evidence to be included or attached)

Evidence (either included or attached) Signature/Date

There is a demonstrable need, evidence of requirement for Nurse Practitioner role including:

• An overview of current service model • What are the service gaps/needs • What are the overall benefits to establishing a NP

role in line with the NP definition:

o a registered nurse educated and

authorised to function autonomously and

collaboratively in an advanced and

extended clinical role

o able to use nursing knowledge to assess

and manage clients

o has skills and may include but are not

limited to the direct referral of patients to

other health care professionals, prescribing

medications and ordering diagnostic

investigations

o grounded in the nursing profession’s



values, knowledge, theories and practise

and

o able to provide innovative and flexible

health care delivery

• An overview of new model of care proposed,

including workplace context and NP role within

that context

• Overview of Key Stakeholder Consultation and

Analysis

• Evidence of alignment with DHS and SH plans

• When implemented, what will be the impact on the

current model of care?

There is a clearly definable scope of practice

• workplace context and

• NP role within that context

There is demonstrated support for the role from key stakeholders

• Nursing (including clinical staff, Nurse Unit

Manager, DDON of area, program)

• Medical (including clinical staff and medical head

of unit)



• Allied Health (including clinical staff)

• Executive (including Director of Nursing site and

program, where appropriate)

• Consumers

The role can be funded within the existing budget or has approval for addition budget from the Operations Director/Director of Nursing

• Provide documented support from the Director of

Nursing/Operations Manager

The requirements for an education program and other resources have been identified

Further infrastructure supports which are in place to

ensure the NP service is able to function according to the

roles and responsibilities established

Outline succession planning and role sustainability plans for this role

All submission paperwork required Southern Health logo, and date of submission




Appendix 5

Evaluation Framework

Southern Health has evaluation tools for NP and NPc roles which were developed for the

Emergency NP role implementation. These tools have been validated via research, and

as such provide a good basis for evaluating all NP and NPc roles.

It is an expectation that all NP roles will use this evaluation framework, which can be

modified for the context of the NPc or NP role.

1. Pre implementation Staff perception survey and

2. Post implementation Staff perception survey

3. Decision making audit

4. Documentation Audit

5. Patient Phone Follow-up

6. Patient satisfaction survey

APPENDIX 4 Renal Model of Care and the Nurse Practitioner The following table represents the Renal Model of Care and concepts where a NP can fill gaps in the renal service at Southern Health. The gaps and goals a NP can fill are identified in the 2nd column. The 3rd column identifies the monitoring the NP would need to do to care for a patient in that stage of CKD. The last column also identifies any issues that need to be overcome for the NP to function successfully. Model of Care Concept Goals and Gaps Monitoring and Issues

Chronic Kidney Disease- • One –three monthly clinical review • Outcome: patient informed choice for

dialysis or no dialysis and suitability of patients for home dialysis.

Stages 3 – 4 (eGFR 30-59mL/min/1.73m2) • Clinical assessment of blood pressure,

weight, urine dipstick. o Pre-renal replacement therapy o Education and treatment

options for renal replacement therapy

• A NP in this area will impact on pt decision making re. home HD, home PD and satellite dialysis option.

• Laboratory assessment of: - biochemistry (urea, creatinine, and

electrolytes o Access for renal replacement • Reduce progression of kidney disease - eGFR

- fasting glucose - fasting lipids • Reduce cardiovascular risk - full blood count (anaemia

management)

• Early detection and management of complications- especially anaemia and mineral metabolism

- iron stores - calcium and phosphate (bone

management) - parathyroid • Avoidance of renally-excreted and

nephrotoxic medications • Medication review: - dosage reduction or cessation of

renally excreted medications and avoidance of nephrotoxic medications in people with CKD.

• Adjustment of medication doses to levels appropriate to kidney function

• Appropriate referral to a nephrologist

for conservative management, pre- - Hepatitis B vaccine


Model of Care Concept Goals and Gaps Monitoring and Issues

emptive transplantation or preparation of renal replacement therapy (CARI guidelines- 12 months prior to anticipated commencement of dialysis and/or kidney transplantation- referral when eGFR <30mL/min/1.73m2)

• Prior to referral to nephrologist ensure: - recent kidney ultrasound - current blood chemistry - quantification of proteinurea

• Early referral to surgeon- for fistula.

Order CXR/AXR and mapping

• NP to maintain contact with GP to ensure coordination of whole patient care, routine screening, health promotion and psychosocial support.

• Advanced care planning directives to

outline wishes for future health and personal care, including conservative treatment.

• Liaison with community services and

supports; - chronic disease management

program - aboriginal health - palliative care - diabetes coordination and

assessment service (renal flag?)



Chronic Kidney Disease • Reduce cardiovascular risk • Weekly/Monthly clinical review. Stage 5 (eGFR ,15mL/min/1.73m2) • Clinical assessment of blood pressure,

weight, urine dipstick. Not yet on dialysis • Early detection and management of complications

• Weight and fluid management • Avoidance of renally-excreted and

nephrotoxic medications • Laboratory assessment of:

- biochemistry (urea, creatinine, and

electrolytes - eGFR • Adjustment of medication doses to

levels appropriate to kidney function - fasting glucose - fasting lipids - full blood count (anaemia

management)

• Support in emergency situation and admitting rights into hospital if required with doctor consultation

- iron stores - calcium and phosphate (bone management)

- parathyroid (quarterly) • NP to maintain contact with GP to

ensure coordination of whole patient care, routine screening, health promotion and psychosocial support.

• Medication review: - dosage reduction or cessation of

renally excreted medications and avoidance of nephrotoxic medications in people with CKD.

- Review current medications with pathology results

• Gap identified in patient care management plan communication between acute setting, community setting, patient and GP.

- Anaemia (EPO) and bone

management • Advanced care planning directives to

outline wishes for future health and personal care, including conservative

• Referrals to supports for patients including:



- S/Wand OT treatment (no dialysis or transplantation) and palliative care arrangements.

- Dietetics - Diabetes management - Podiatry

• Access review at satellites and outpatient clinics- use of portable ultrasound

• Metropolitan satellites service 200 patients currently.

Satellite Units

• Rural satellites service 50 patients

currently. • Support rural areas (Warragul, Traralgon, Wonthaggi and Hastings as these units follow Southern Health protocols and Southern Health receives capitation grants.)

• Projected total number in 2017 is

351patients with the main increase in home haemodialysis.

• Visit satellite units with ultrasound to

trouble shoot difficult access issues • Standardise process and frequency for review for metropolitan and rural services.

• Assess patient’s fluid status.

• No cover when nephrologist on A/L • Communication of patient care

management plan between acute care, community care setting and GP

• Variations in how often a patient is

reviewed by a nephrologist • TRANSPORT- use of a car for satellite

NP and home dialysis NP


The renal model of care and the NP table is useful for renal nurse practitioner candidates as it will guide them in the development of their expanded

scope of practice and also extend on the renal drug formulary. This will evolve through the renal NP collaborative. The table also helps identify

learning gaps where medical input will be necessary.


APPENDIX 5 Current Nursing Positions and How the Renal NP Will Affect These Currently there are two nurses working in Stage 4 of the renal model of care at Southern

Health- a renal access nurse and a dialysis co-ordinator.

Below is a list of the tasks their jobs entail. The bolded writing represents the areas

where a renal NP would impact.

Access Coordinator (No succession or A/L cover)

Operational

• Bed management- access to renal beds

- elective renal surgical patients (renal and vascular)

• Elective surgery waiting lists

• Pre admission clinic and surgery date

• Transplant patients- end up on elective waiting list- r/o stents, transplant

nephrectomy, return to theatre.

• Post op follow up of access monitoring- day of surgery, 1week and 6 weeks post

surgery

Database for renal program

• FAVOUR trial submission (attracts funding) Effect of fish oil and aspirin in

preventing thrombosis of AV fistula

• Data for infection rates

• 10 key performance indicators where data is collected

• CARI (attracts funding) Data collection for vascular access

Dialysis Access

• Phone access for any renal patients with access issues- including predialysis,

dialysis- haemo or PD. To discuss issues with access. Includes metropolitan and

rural patients. NP to support dialysis access nurse by ordering necessary radiological and other investigations prior to referral to surgeon if necessary.

• Pre-dialysis patients- patient informed choice for dialysis or no dialysis and suitability of patients for home dialysis.

• Advance care planning (Planning care in advance – respecting patient choices)

• Patient education regarding dialysis. NP to establish suitability of patients for home haemo.


• Dialysis access- referral to surgeons for dialysis access and investigations

eg. Venous and arterial mapping. - referrals from Traralgon, Cranbourne and Clayton renal clinic (NP to

attend these existing clinics)

• Visit satellite units with ultrasound to trouble shoot difficult access issues

(satellite NP)

• Education for rural (Traralgon) patients regarding dialysis (The satellite NP could address the above two areas.)

Dialysis Coordinator (No succession or A/L cover)

• Receive new patient referrals into acute care setting from nephrologists –

different from patients coming from clinic.)

• Assessment day- every 2nd month patients are assessed for dialysis.

• Waiting lists and access to satellite units. (Patients placed on waiting lists and

slotted into places as they come available.)

• Patient education days (as a group) every 2 months including PD and HD (60%

of patients starting dialysis have attended education day) With emphasis on above role, % of patients attending education days to increase.

• Transplant patient education days occur every 3 months.

• Database for every patient that starts on dialysis (DHS-capitation grant) Currently

the only overall DATA base is the ANZDATA (based in Adelaide) There is no

overall database for Southern Health renal.

(Note; all bolded writing is areas where a renal NP will make a difference or take on that responsibility.)


APPENDIX 6 Renal Nurse Practitioner Candidates (2 roles) Full Time Permanent Southern Health Renal Service The Nurse Practitioner candidate is a Registered Nurse who has an expert knowledge base in their clinical area, is able to make complex clinical decisions and is prepared to further their role to include an extended scope of practice. In this instance the roles (2) are in Renal Services. The Nurse Practitioner candidate is working towards being

• a registered nurse educated and authorised to function autonomously and collaboratively in an advanced and extended clinical role

• able to use nursing knowledge to assess and manage clients • has skills and may include but are not limited to the direct referral of patients to

other health care professionals, prescribing medications and ordering diagnostic investigations

• grounded in the nursing profession’s values, knowledge, theories and practise and

• able to provide innovative and flexible health care delivery The Nurse Practitioner Candidates will be supported by Southern Health in receiving one study day per week, undertaking specific renal education, participating in the Southern Health Nurse Practitioner and Nurse Practitioner candidate meetings, and by being part of the Victorian Renal Nurse Practitioner Collaborative. It is expected that the Nurse Practitioner candidates will be endorsed as Nurse Practitioner within 24 months of their candidature commencing. As such the Nurse Practitioner candidates must be working towards their endorsement as a Nurse Practitioner by the Nurses Board of Victoria, including commencing/undertaking a Master Degree in Nursing. The endorsement process with the Nurses Board of Victoria can be viewed at www.nbv.org.au. Once the Nurse Practitioner Candidates are endorsed they will automatically commence a Nurse Practitioner role within Renal Services at Southern Health. Please see Southern Health Nurse Practitioner Strategic Framework for further detail of the Nurse Practitioner candidate role. Generic Position Description attached. Queries to: Naomi Dobroff, Manager for Southern Health Nursing and Midwifery Advancing Practice, Nursing Support Unit, Corporate Services, 9594 7629, Locked Bag 29, Clayton 3169 or [email protected] Applications including a CV and addressing the Key Selection Criteria to: Kym Forrest, Operations Manager/Director of Nursing, MMC Clayton and Speciality Program [email protected] Closing Date: 6th October 2008


http://www.nbv.org.au/

mailto:[email protected]

mailto:[email protected]


Documents

· PDF fileChronic Kidney Disease Model of Care 11 Overview ... Preparing the Nursing Workforce 26 8. ... patients and the renal service plan