Nurse Practitioners as part of your General Practice … · A comparative of the scopes is supplied below: ... A focus was placed on services moved closer to home; ... economic and

Nurse Practitioners as part of your General

Practice Team: a toolkit

2 CCL/WPHO NPs as part of your GPT: a toolkit, final (2013)

Contents Part I ........................................................................................................................................................ 3

Introduction ........................................................................................................................................ 3

Background ......................................................................................................................................... 5

Part II ....................................................................................................................................................... 7

The benefits of Nurse Practitioners in the general practice team. ..................................................... 7

In brief: ................................................................................................................................................ 8

Clinical Benefits: .................................................................................................................................. 9

Economic Benefits and Considerations ............................................................................................ 11

Other economic considerations: ....................................................................................................... 11

Capitation ...................................................................................................................................... 11

Financial impacts for the practice ................................................................................................. 12

To employ or to contract .............................................................................................................. 12

Variables........................................................................................................................................ 13

Other Benefits ................................................................................................................................... 16

Part III .................................................................................................................................................... 17

Employing a Nurse Practitioner ........................................................................................................ 17

Considerations .................................................................................................................................. 18

Capitation Funding ............................................................................................................................ 19

Potential Employment models for NPs working in Primary Care: .................................................... 20

Profile 1: General Practice NP employment (traditional business model) ................................... 20

Profile 3: Integrated DHB/PHO NP contract employment ............................................................ 21

Appendix 1: ........................................................................................................................................... 22

NP working group members ............................................................................................................. 22

Appendix 2: ........................................................................................................................................... 24

Nurse Practitioner position description ............................................................................................ 24

Appendix 3 ............................................................................................................................................ 34

New Zealand NP profiles relevant to primary health care. .............................................................. 34

Acknowledgements ........................................................................................................................... 39

References ........................................................................................................................................ 40


Part I

Introduction

This document has been compiled by the Waitemata PHO working group to point the

lens on advanced nursing roles and nurse practitioners. This group (appendix 1) was

established in mid 2012 to examine the challenges and issues facing the primary

care workforce and specifically expert nursing roles. By taking a focussed approach

to harnessing and enabling role development in this area we aimed to address one

aspect which could impact the current and future demands of primary care services.

This document draws on a variety of literature specific to the role and functionality of

the nurse practitioner. It is directed towards general practice owners, primary health

care service providers, district health board planners and funders, practice

managers, and teams of professionals working within the primary health care arena.

It provides information, and highlights the opportunities to serve the needs of our

populations and meet health and quality performance targets via a future model of

service delivery that incorporates Nurse Practitioners (NP) into the general practice

setting.

In essence, NP’s may be considered to be bilingual in that they borrow and use

some of the skills and techniques of medicine to deliver high level comprehensive

care as nurses. They can deliver a significant proportion of the services the average

person may require in terms of minor, acute illness and long term conditions. As

such, through NPs general practices can be equipped to offer the public a whole new

access arrangement in healthcare.

This document provides an essential source of information or toolkit for general

practice thinking about employing or contracting a NP. It aims to highlight the

opportunities available to a practice and a population associated with employing or

contracting a NP, particularly where there is a gap in service provision, a high clinical

need or a growing care demand.

It is important to distinguish nurse practitioners from registered nurses. The

registered nurse scope of practice defines a broad range of settings and function

available to nurses. This may include a variety of contexts where the registered


nurse performs general functions and comprehensive assessments. This is in

contrast to the nurse practitioner scope which requires expertise in a defined scope:

A comparative of the scopes is supplied below:

A Nurse Practitioner is:

Nurse Practitioners are expert nurses who work within a specific area of practice incorporating advanced knowledge and skills.

They practise both independently and in collaboration with other health care professionals to promote health, prevent disease and to diagnose, assess and manage people’s health needs.

They provide a wide range of assessment and treatment interventions, including differential diagnoses, ordering, conducting and interpreting diagnostic and laboratory tests, and administering therapies for the management of potential or actual health needs.

They work in partnership with individuals, families, whanau and communities across a range of settings.

Nurse Practitioners may choose to prescribe medicines within their specific area of practice. Nurse Practitioners also demonstrate leadership as consultants, educators, managers and researchers, and actively participate in professional activities, and in local and national policy development.

A Registered Nurse is:

Registered nurses utilize nursing knowledge and complex nursing judgment to assess health needs and provide care, and to advise and support people to manage their health.

They practise independently and in collaboration with other health professionals, perform general nursing functions and delegate to and direct enrolled nurses, healthcare assistants and others.

They provide comprehensive assessments to develop, implement, and evaluate an integrated plan of health care, and provide interventions that require substantial scientific and professional knowledge, skills and clinical decision making. This occurs in a range of settings in partnership with individuals, families, whanau and communities. Registered nurses may practise in a variety of clinical contexts depending on their educational preparation and practice experience.

Registered nurses may also use this expertise to manage, teach, evaluate and research nursing practice. Registered nurses are accountable for ensuring all health services they provide are consistent with their education and assessed competence, meet legislative requirements and are supported by appropriate standards. There will be conditions placed in the scope of practice of some registered nurses according to their qualifications or experience limiting them to a specific area of practice.

Nursing Council of New Zealand (2008)


Background

The Nurse Practitioner (NP) was a new scope of practice launched by the Ministry of

Health and the Nursing Council of New Zealand in May 2001. Since the regulations

for NPs in New Zealand were announced, more than 120 nurses have received

endorsement from the Nursing Council of New Zealand including 77 with prescribing

authority. However there is clearly additional opportunity for the development of the

NP role in primary health care which is currently not being realised. We currently

have 54 NP’s working in primary health care in New Zealand. Of interest and note is

the premise that New Zealand has drawn on experience from other countries in

advancing nursing practice roles and likewise met a number of challenges along the

way. NPs have been well established in the US and Canada from 1965 onwards with

the role providing expertise and supplementation when physician supplies have been

low. The growth of advanced nursing roles in the UK was visible in the early 1990s

and late 2000s into Australia. Key drivers were to improve access to healthcare

services, incorporate a flexible, innovative, regulated and integrated service and

promote continuity for care at an advanced practice level.

Many countries, including New Zealand have regulatory frameworks related to the

NP role and scope of practice. These frameworks serve to:

Define the scope of practice

They serve as a means for determining competence

They protect the public

The scope definitions generally describe what it is an NP can do within the regulatory

framework that exists in any particular country. This is a useful ‘fit for purpose’ check

for the practitioner themselves, the employer and members of the public. The New

Zealand nursing council requirements for nurse practitioner approval include:

Academic preparation to a level of clinical masters’

Clinical training of 4-5 years at an advanced level in a specific scope of

practice

Clinical competency assessment by the NZ regulatory body


(Hughes & Carryer, 2002)

Added to this is the completion of an approved advanced assessment,

pathophysiology and pharmacology courses as well as prescribing practicum as

mandatory for nurse practitioners as prescriber’s.

Further to these requisites, is the importance of considering what it is the population

needs. The response to community, the growing demands for healthcare and the

increasing complexities faced by the health workforce are additional and significant

considerations when looking at the NP as part of the general practice team. A key

notion of NPs is that they have the potential and capability to lead services across

the traditional boundaries of specialties and settings. They likewise can free up

doctors to focus on what they do best. Our GPs have the expert skills to work on

complex diagnosis and pathologies. Having more NPs in general practice will mean

they can relieve the GPs load and an approach to working in partnership can more

adequately serve the needs of our people in a timely and focused fashion.

With the implementation of the Governments Better Sooner More Convenient

(BSMC) policy agenda and principles underway from 2008 onwards, to reframe

primary health care services, a more personalized primary health care system was

forecast. A focus was placed on services moved closer to home; a reduction in

demand on hospitals and a package of services centred on integrated family health

centres. A signal was made to nurses to take a key role in shifting services from the

secondary to primary care needs of patient to improve care an management. A

clinically led, integrated workforce where NP’s are part of primary care practices and

service provision would support this policy directive, not only to deliver on target

areas of health but to enable quality advanced nursing practice to manage and meet

need and outcomes for patients.


Part II

The benefits of Nurse Practitioners in the general practice team.

Nurse practitioners can enhance general practice teams in a number of ways,

including clinical, economic and other benefits. These benefits are clearly

demonstrated in an Australian report by King, Corter, Brewerton and Watts (2012)

and are used here to explore in terms of the New Zealand context.

The flexibility and fit with the service need or gap will be dependent on the context of

the general practice team (i.e. a larger integrated family health centre, or a smaller

solo practice).

Economic benefits

Other benefits

Clinical benefits


In brief:

Clinical benefits

Economic benefits Other benefits

Improved/additional access Opportunities for new revenue streams

Shared patient outcomes, and improved organisational culture

Increased choice

Cost efficiencies Patient satisfaction

Improved continuity

Skill mix of staff matches patient need

Addresses workforce issues and potential shortages

Longer consults

Potential reduction in hospital admissions due to improved primary care efficiencies

NP services may be commissioned to practices where there is an identified need.

Case management and care coordination

High productivity/profitable Work/life balance for practice owners

Interdisciplinary decisions and team-work is fostered and enabled.

Can provide additional up-skilling services to RN’s in the workplace

Education and training portal/support for new nurses

New services for patients

Role modelling for RN’s considering NP candidacy.

GP time is freed up and increased volume of patients able to be seen

High standard of competency/professionalism

Clinical leadership/clinical innovations leadership

Holistic Generalist approach centred on supplementation to the GPT not substitution. Quality interventions.


Clinical Benefits:

Clinical benefits may be determined by clinical or population need. In seeking to

determine local gaps and population need and then align roles to meet these, a

benefit or win-win situation is more likely to be achieved. Generalist, Rural and Older

Adult NP scopes would seem to align most favourably with the Waitemata region

and population that we currently serve. Additionally by identifying this alignment the

best fit for our general practice teams can then offer care provision that may be

otherwise unavailable.

Once an identified gap is established, the practice team or the PHO/network has the

opportunity to choose how to maximise the potential of their nursing roles and their

team by:

Offering a new access arrangement for patients at a cost effective rate, which

will result in comprehensive patient assessment and management that

includes:

o Clinical and critical thinking skill

o Prescribing

o Diagnostic testing and referral

o A role that complements the medical services available within the

practice.

Offering increased choice for patients

Gaining the potential to increase enrolment and provide additional and

complimentary services, this may be problem or population specific, as a

response to community need. Clinics may include diagnostic acute care

management; a long term condition focus; wound clinics; diabetes clinics;

cardiovascular disease management clinics; women’s-men’s health clinics;

dementia assessment and management.

Improving or maintain clinical flow by easing bottlenecks through skilled

responsive NP focussed activity.

Target achievement which is significant in terms of New Zealand policy

directives.

Quality NP care coordination and case management that has the potential to

improve patient self care behaviour and minimise care seeking behaviour.


Interdisciplinary working which means decision making is a joint process and

enrolments can be spread between the GP and NP within the team setting.

This would include the requirement to ensure after hours coverage for the

enrolled population and to share the workload between GP and NP.

NP clinical leadership which will provide up-skilling and training for RN’s within

the practice; this will support growth of new leadership and support clinical

succession planning of practice/network teams.


Economic Benefits and Considerations

Economic benefits include opportunities to:

Generate new revenue streams through clearly defined fee scheduling, use

of flexible funding and by reviewing the practice team configuration and skill

mix. This will ensure the right skill is delivered by the right person at the right

time.

Realise cost efficiencies, by increasing practice capacity while reducing the

average cost per consultation, (this relies on a team philosophy and

interdisciplinary decision making)

Avoid unnecessary duplication of work in situations where patients might

otherwise see a GP or a practice nurse concurrently, a NP may be the first

port of call which will serve the holistic needs required and importantly free up

the GP and practice nurse to deal with other patient loads (raises productivity

which in turn will reap a greater return on investment see examples page 14-

15).

An NP’s time can be sold to up-skilling RN’s and providing primary care

education to the wider PHC workforce to grow new nurses with new skills and

raise workforce capability (educator and revenue sources).

Other economic considerations:

Capitation

The PHO (Alliance agreement V.1 DOES NOT prohibit Nurse Practitioners from

enrolling in a Primary Health Organisation (PHO). In order for a nurse practitioner to

enrol people in a PHO, the NP must be a contracted provider of the PHO and must

be able to give enrolees access to the full range of First Level Services set out in

clause H.3, just as there is an expectation for general practitioners to meet this

requirement.

This means for example the NP would need to have arrangements with other

providers so enrolled patients have access to the full range of services described in

the PHO agreement. Of note is the current situation where NP’s can claim capitation

with General Medical Services (GMS) currently under review.


Financial impacts for the practice

These are influenced by:

The employment or contracting arrangement with the nurse practitioner

Additional practice income associated with the nurse practitioner and with

other changes in practice configuration and activity.

Cost effective and client efficient use of funding streams such as ‘care-plus’ to

maximise client self care behaviour and minimise care seeking behaviour

(hospital presentation/admission).

Number of consultations per hour undertaken by an NP and a GP.

To employ or to contract

Employment Contracting

Summary

Practice earns income from NP activity, pays the NP a salary or a wage, and covers the costs of employing the NP. NPs enrol patients

PHOs or Networks become budget holders for nurse practitioner services. Utility of joint appointments Practice earns income from NP activity. NP employment related costs are met by the PHO.

Practice income

NPs attract capitation as funding goes to the practice not the GP. PHOs using first level services, this can be used in flexible ways.

NPs attract capitation as funding goes to the practice not the GP. PHOs using first level services, this can be used in flexible ways.

Practice costs

Rooms and equipment NP salary Stat days Annual leave Sick days Professional development

Rooms and equipment NP salary Stat days Annual leave Sick days Professional development

Nurse income

Salary % capitation

Hourly fee % capitation

Nurse costs APC Professional indemnity Kiwisaver

APC Professional indemnity Kiwisaver


In considering the economic benefits alone, patient demands and the requirement to

ensure productivity as a General Practice business is important and cannot be

negated. If the practice owner can maximise productivity by meeting demands and

ensure the workforce provides comprehensive, quality and targeted care, this is a

win-win situation. It is worth considering the scenario:

General Practitioner:

“I need more patient appointments due to increasing demands”:

To increase screening coverage

To offset an increase in acute demand

To improve long term condition management

To increase practice enrolment (capacity)

So that my GP colleagues can:

Reduce their weekly hours

Attend Professional Development

Maximise their work-life balance.

If the NP is able to work >2.5 consultations in 1 hour, the saving is 24% per consult.

If the NP works 3 consultations in 1 hour the saving is 37% per consult

So with 3 NP consultations per hour, the saving is $18 per consult.

Example 1 Dr FTE and Example 2 NP FTE demonstrate a cost analysis on the two

roles with locum cover, clinical hours and cost. This provides just one indication of

how productivity alone may be addressed via the NP role as a cost efficient

measure.

Variables

The different arrangements, i.e. employment or contracting, will have an impact on

roles, responsibilities and incentives within the practice. Whereas a fee schedule for

an NP may motivate the NP to build up their own enrolment numbers (whilst working

within a GPT), an NP who works within a flexible funding stream may be best utilised

to fulfil a specific service gap or population health focus. For both options volume

based activity and non volume based activity with nurse sensitive measures may

provide the best blend of role activity required to achieve target and quality health

outcomes.


Example 1 Dr FTE

DR FTE Days Hours FTE Adjusted

FTE 1

Annual Days 260 2080 2080

Stats 11 88 88

Leave 25 200 200

Sick 5 40 40

Mandatory Study 5 40 40

Clinical Availability 214 1712 1712

Productivity Loss 10% 21 171 171

Administrative Component 20% 39 308 308

Total Face to Face Clinical Hours Available 154 1233 1233

Annual Base Salary 195,000$ 195,000$

Overhead Allocation % 20% 39,000$

Total Cost 234,000$

Face to Face Patient Cost per Hour 189.84$

Locum

Is Absence Locum Covered Yes

Hours Required for Cover 280

Productivity Loss 28

Administrative Component 50

Total Face to Face Clinical Hours Available 202

Locum Hourly Rate 150.00$

Locum Cover Cost 42,000$


Total Clinical Hours and Cost


Dr FTE 1233

Locum 202

Total Cost 276,000$


Consults per Hour 4

Available Consults 5737

Cost per Consult 48.11$


Example 2 NP FTE

NP FTE Days Hours FTE Adjusted

FTE 1

Annual Days 260 2080 2080

Stats 11 88 88

Leave 20 160 160

Sick 5 40 40

Mandatory Study 5 40 40

Clinical Availability 219 1752 1752

Productivity Loss 10% 22 175 175

Administrative Component 20% 39 315 315

Total Face to Face Clinical Hours Available 158 1261 1261

Annual Base Salary 95,000$ 95,000$

Overhead Allocation % 20% 19,000$

Total Cost 114,000$


Locum

Is Absence Locum Covered Yes

Hours Required for Cover 240

Productivity Loss 24

Administrative Component 43


Locum Hourly Rate 70.00$

Locum Cover Cost 16,800$


Total Clinical Hours and Cost


Nurse FTE 1261

Locum 173

Total Cost 130,800$


Consults per Hour 3

Available Consults 4303

Cost per Consult 30.40$


Other Benefits

A holistic generalist intervention, consider a maxi nurse role rather than a mini

doctor. An NP can deliver similar outcomes to that of a medical practitioner, although

consultations tend to take more time and cost efficacy indicators may not be so well

reported IF DEFINED by medically associated indicators. Their work is delivered

according to the context and philosophy of nursing values, knowledge and practice.

Potential to increase patient satisfaction and health outcomes, as a result of

advanced nursing clinical input and expertise; practice staff up-skilling, coaching and

training opportunities and importantly improved access arrangements for patients to

enable timely and responsive care.

General Practice Team reconfiguration: right skill right person, right time. An

opportunity to work within a multidisciplinary team and support decision making that

is interdisciplinary. Accountability for actions is individually observed and jointly

agreed upon in many instances. Enrolment numbers can be increased and workload

assigned to a practitioner with the identified expertise.

A long term workforce development approach to support the whole GPT,

workload and workforce issues are addressed through more efficient use of skill-

sets, the patient is afforded greater choice and an extra point of access. Bottle necks

and workflow may be enhanced by freeing up GP and RN time.


Part III

Employing a Nurse Practitioner

It is acknowledged that District Health Boards have a responsibility for health care

planning and delivery across their specific geographical area and that a significant

focus concerns secondary care provision and the need to deliver quality in patient

care within budgetary limitations. However it is worth noting in this context that

international evidence would suggest that augmentation of general practice services

through the development of the NP role makes a significant contribution to the

management of ill health and promotion of wellness in the community. This is of

course with the added benefit of reducing demand on DHB secondary care services.

District Health Board planners and funders, general practice owners, primary health

care teams, employers and networks or PHOs are encouraged to consider the

opportunities and identify priority areas for developing their capacity and capability

through an NP role.

Useful questions for the planners, the general practice team or PHO/ network

to consider:

1. How through cross working or joint working can we meet the needs of our

community, our hapu and iwi?

2. Are we delivering enough services to meet the needs of our community?

3. Do we have high need groups in hard to reach areas we are not currently

accessing?

4. Where are these service gaps and how could a suitably skilled NP in primary

health care fill this?

5. What are our population demographics/health gaps and could a NP role

support this with quality care?

6. What is our infrastructure requirement? (Technology

enablement/relationships/authorisation and accountabilities)

7. Would this responsive service meet the needs of our patients in a

comprehensive way?

8. Would employing an NP complement the current access arrangements for

patients we have and the services and skills we are currently offering?


Considerations

NPs attract higher rates of pay than registered nurses due to their advanced

preparation and level of clinical expertise; alongside the unique role they can

play within a practice/team (refer to scopes earlier)

Funding mechanism/stream or fee for service

NP’s will generate revenue

Position description to fit the role (example-Appendix 2)

Ongoing professional development and appraisal framework in place.

Promotion of the NP role, the fit with the current practice team/staff and the fit

with the practice population/patients.

Provision of office space, furniture, equipment and IT resource.

Recruitment process

Ongoing coaching and support via a nursing leadership structure.


Capitation Funding

Capitation is an index of funding to enable access and services for our

populations, not a source of funding for any one individual provider.

Fact vs. Fiction (Nursing Review series Summer Edition, 2012/2013 p. 9)

Fact

1. There is no barrier to anyone holding a provider or capitation contract. The

contract states that a “practitioner, general practitioner, or medical

practitioner” can be contracted by a PHO and goes further to define GPs and

RNs as ‘practitioners’ eligible to be contracted with if the hold appropriate

registration and a current annual practicing certificate. Some DHBs and PHOs

may have placed various restrictions around who they will allow to hold a

contract. However the contract holder can make their own arrangements

about how the specifications are met and there is leeway for how this can be

done. This means a non GP can hold a contract and ‘buy in’ or partner with a

GP for the medical and other services that are required by patients, and to

meet contract specifications.

2. While capitation funding is paid to subsidise the cost of general practitioner

consultations, it is not paid for each consultation with a GP. It is paid as a

lump sum every month based on the number of enrolled patients at the

practice. Therefore the capacity and capability of the team in terms of skill and

knowledge potentially determines the workload and services that can be

delivered, and the numbers of enrolled patients that can be accommodated.

You can therefore pose that nurses attract capitation to a practice.

3. The capitation contract is not just about capitation. It also covers services like

clinical programmes, services to improve access and health promotion. The

bulk of a practices income is not via capitation, this allows for great scope in

non capitated services to generate income. These are just reliant on GP

providers and allow opportunities for non GP practitioners to provide and

invoice for services.


Potential Employment models for NPs working in Primary Care:

Profile 1: General Practice NP employment (traditional business model)

Funding mechanism Employed by the General Practice Original funding came via DHB for an NP rural role to be developed in General Practice. Careplus management funding is utilised as much as possible (the NP sees mostly patients with chronic care issues, rather than acute presentations).

FTE 28-30 hours per week. Some of which is ‘protected’ time to manage PMP work.

Scope of Practice Adult family NP with prescribing

Population focus/identified gap/need for service delivery

Focus on chronic care management and act as clinical team leader. Also coordinate CMECNE/quality improvement programme.

Salary Level 8 on DHB Meca Range: $92,724-$107,792

Place in the team/practice/organisation

Responsibility to practice manager (nurse) and partners (GPs).

Outcomes focus Share GP workload Reduce ED presentations/hospital admissions Improve targets Quality care


Profile 3: Integrated DHB/PHO NP contract employment

Funding mechanism DHB/PHO agreed via alliance contracting due to identified need/gap in service to meet community requirements

FTE 1.0

Scope of Practice (determined by identified gap)

Older adult/Generalist/Rural

Population focus (determined by identified gap/need for service delivery)

Older adult; Gerontology/Birth to end of life.

Salary Level 8 on DHB Meca Range: $92,724-$107,792

Place in the team/practice/organisation

Reports to PHO Director of Nursing. Connected to relevant specialty DHB teams. Clinical review and supervision determined and ensured.

Outcomes focus Reduce older adult /specific scope related ED presentations and hospital admissions Demonstrate innovative approaches to integration specific to a primary care intervention Educate and up-skill GPT Share GP workload


Appendix 1:

NP working group members


Rachael Calverley WPHO Director of Nursing and

workforce development

Gabrielle Graham Practice manager, Massey University

Health

Jen Hardcastle

RN on NP Pathway

Elly Dagley

Gerontology NS on NP pathway

Adrienne Carter

Nurse Manager

Dr Alison Sorley

GP

Jackie Flemming

RN, CCL/WPHO Practice Liasion

Andrea Ryan WDHB Nursing Development Team,

Nurse Leader Career Development

Sandy Oster Professional Teaching Fellow,

Coordinator NP Pathway, University

of Auckland

Michal Boyd Nurse Practitioner in aged care

primary health, Waitemata DHB and

Senior Research Fellow at the

University of Auckland

Jean McQueen

WDHB PHC Nursing Director


Appendix 2:

Nurse Practitioner position description


Nurse Practitioners as part of your General Practice Team: a toolkit


Date:

Job title WPHO Nurse Practitioner (NP)

Location Waitemata PHO/Comprehensive Care,

42 Tawa Drive, Albany, Auckland

Reporting to WPHO Director of Nursing and CEO

Direct reports

Functional relationships with Internal

Will be required to interact on a regular basis with a range of

Waitemata PHO staff members including:

General Practice Teams (GPT)

Clients

WPHO nurse reference group

External

WDHB PHC providers

Medical specialists and staff

Clinical Nurse Specialists

Clinical networks

Iwi/Maori Health providers

Nurse Practitioners

Secondary care staff

Purpose

The primary purpose of the role of the Nurse Practitioner is to provide advanced nursing expertise

for family/whanau. The context of the care delivery will be within the general practice setting and

the provision of services will be in collaboration with the GPT. The NP will prioritize, initiate and

provide effective ongoing care for individual clients, based on patient need, including case

management of patients with long term conditions. The NP will take a leadership role within the

team in complex clinical situations supporting the provision of effective LTC management.

The Nurse Practitioner (NP) will work collaboratively with the General Practice Team,

family/whanau, community based support services and other health professionals to ensure goals

are met and best outcomes are achieved within the available resources. Assessment, clinical

management and coordination of care across primary settings will ensure appropriate, safe and

timely care delivery. In addition, this leadership role will further the development of professional

expertise and capacity within the nursing and interdisciplinary workforce that will enable them to


proactively facilitate timely, responsive, and effective care to the family/whanau enrolled in the

Waitemata region.

Key result area Measurable outcomes

Works within the Family/whanau scope of

Practice and the context of care

The scope of this role and how it is positioned within the two services is confidently and accurately articulated

Clinical expertise is maintained and contemporary specialty knowledge is continually updated

The impact of the wider determinants of health, and changes to health policy and funding models are considered and incorporated into practice as required

Limitations to practice within the articulated Nurse Practitioner scope are recognised. Interdisciplinary consults are requested and referrals made accordingly

The candidate utilizes a nursing model/framework underpinned by the values and knowledge of Best Practice principles and congruent with the values of the three organizations

The Health & Disability Sector Standards, DHB contractual requirements and other relevant legislation are understood and adhered to

Referrals and requests for advanced nursing assessment /intervention are responded to in a timely manner and prioritised according to the identified level of clinical risk and complexity

Ongoing assessment and care provision is organised in a proactive, time-conscious manner through the scheduling of regular Nurse Practitioner clinics and outreach visits.

Provides Clinical Expertise to the defined

client group,

Provides culturally safe practice based on the principles of the Treaty of Waitangi – protection, partnership and participation.

Provides advanced contemporary clinical assessment and advanced clinical decision making processes to assess, make differential diagnosis, plan care, implement interventions, inclusive of prescribing, and evaluate outcomes

Initiate case management for individual patients based on:


physical examination and assessment

differential diagnoses

diagnostic results

sound clinical judgment. Data collection and assessment processes are

appropriate for the client’s immediate and/or on-going needs

Accurate information and education is provided to the client, their whanau and staff to enable their participation in - support planning including goal setting

- self management as able

Differential diagnoses, care planning and interventions are determined utilising a full range of data including appropriate laboratory and diagnostic tests

Creative and innovative solutions to complex situations are developed from a critical thinking and problem solving approach.

Maintains professional development and

clinical competence

Proactively participates in own performance development and review

o Establishes annual goals, objectives, performance targets and strategies to meet these.

o Attends relevant negotiated educational opportunities and conferences.

o Participates in regular professional supervision

o Maintains and develops clinical competence according to Nursing Council competencies.

o Maintains a professional portfolio annually and submits for formal assessment 3 yearly

o Prescribing evidence is presented annually

Participates in clinical practice review, including case reviews. Action plans are implemented to address any issues

Opportunities for clinical mentorship and support are identified, negotiated and completed.

Stakeholder relationships are developed

and maintained in a professional collegial

manner to provide a sound base for

Contributes to relevant sector networks Communicates, collaborates and coordinates

care with General Practice Teams, Acute and Specialist Services and other health


seamless service provision and

improvement by promoting continuity of

care.

professionals to ensure best outcomes Promotes and role models effective

teamwork and collaborative relationships within the interdisciplinary team

Facilitates and participates in relevant interdisciplinary team meetings

Works within internal and external teams in a collaborative relationship

Provides clinical and professional

leadership and consultancy

Nursing consultancy and advice consistent with best practice interventions for family/ whanau are provided to interdisciplinary team members, key stakeholders and regional and national agencies across the continuum

Works alongside General Practice, WPHO and PHC staff to provide clinical assessment, differential diagnosis, plan care, evaluate and improve outcomes through Nurse Practitioner clinics.

Takes a leadership role working alongside the nursing staff in the general practice team to support effective LTC management

Takes a leadership role in complex situations across settings and disciplines.

Facilitates interdisciplinary case review Formulates working relationships across the

primary/secondary interface to promote continuity of care

Opportunities to improve clinical practice

and service delivery are identified and

focus on service development and

participation in quality improvement is

evident

Uses databases to document caseload, leadership/consultation activities to aid in future service development

Barriers to service delivery/client satisfaction are identified and appropriate action taken.

Evidence of contribution to change to service delivery through the use of current research and best practice is present.

Health outcomes are evaluated and information utilized to contribute to local and national policy development.

Contributes to local and national health/socio-economic policy through membership and participation in sector groups.

Participates in formal research related to service development and clinical area of


Provides Education and Clinical Teaching

practice when opportunities arise Intervention effectiveness is evaluated and

support plans updated as required Participates in national benchmarking and

auditing programmes Documentation is professional, accurate and

timely, captures the provision of education and client involvement in decision making is visible.

Practice is acceptable as evidenced by client satisfaction surveys

Clinical enquiry, critical thinking and research skill acquisition is fostered among the nursing workforce to advance nursing practice and resident care

Nurses in the General Practice and PHC/secondary care ( e.g. ED) receive expert advice and best practice recommendations, skilled mentoring, coaching and teaching.

Contributes to the WPHO nursing workforce development plan including:

o Provision of clinical education for multidisciplinary teams across the continuum.

o Provision of teaching for tertiary students

Contributes to the business requirements

of WPHO

Reports against position description and contractual requirements are timely, accurate and add value to the business processes

Actively participates in auditing and benchmarking

Contributes to Business planning processes to promote innovative practice and continuity of care delivery

Undertakes project work as negotiated

Risk Management

Clinical and non clinical risks are identified, addressed and reported in a timely manner, utilising the systems of the organisation concerned, ensuring safe environment for clients, whanau and staff

Complies with policies, procedures and safe


systems of work

Health and Safety Contributes to organisational health and safety programme.

Actively supports health and safety initiatives

Hazards are identified, addressed and reported

Behavioural Competencies

Adheres to Waitemata PHO and Comprehensive Care organisational values of Dynamic,

Accountable, Respect, Trust

Behavioural competencies Behaviour demonstrated

Communicates and works

co-operatively Actively looks for ways to collaborate with and assist others to

improve the experience of the workforce, patients and their

families, the community and Iwi

Is committed to learning Proactively follows up development needs for self and direct

reports

Is transparent Communicates openly and engages widely across the

organisation

Enacts agreed decisions with integrity

Is customer focused Responds to people’s needs appropriately

Identifies opportunities for innovation and improvement

Person specification and position competencies

Position title:

Qualifications and experience Minimum of 5 years recent experience in the clinical care of family/ whanau

Experience in successfully mentoring and educating nurses and other health professionals

Experience of leading and managing teams

NZ Registered Nurse Practitioner (Prescribing) with Family/ whanau related scope.

Current NZ NP APC and portfolio

Skills and attributes Committed to improving the quality of care and service delivery for family/ whanau in a client centred, culturally


safe, creative and innovative manner Articulates an understanding of ,and a

compelling vision for how this role will be operationalised including an awareness of boundaries both organisational and professional

Presents a professionally mature, confident and solution oriented persona

A “grower” of others knowledge and skills

High level computer literacy including use of clinical information systems

Emotionally Intelligent Proactively utilises own strengths and

self develops areas of deficit Excellent written and verbal

communication skills. Excellent time management and

prioritisation ability Comfortable with ambiguity and able to

adapt readily to different work environments and requirements

Able to work effectively both autonomously and within a team

Nurse Practitioner scope of practice (under the Health Practitioners Competence Assurance Act

2003)

Nurse Practitioners are expert nurses who work within a specific area of practice incorporating advanced

knowledge and skills. They practise both independently and in collaboration with other health care professionals

to promote health, prevent disease and to diagnose, assess and manage people’s health needs. They provide a

wide range of assessment and treatment interventions, including differential diagnoses, ordering, conducting and

interpreting diagnostic and laboratory tests and administering therapies for the management of potential or

actual health needs. They work in partnership with individuals, families, whanau and communities across a

range of settings. Nurse Practitioners may choose to prescribe medicines within their specific area of practice.

Nurse Practitioners also demonstrate leadership as consultants, educators, managers and researchers and actively

participate in professional activities, and in local and national policy development.

The Nursing Council competencies for Nurse Practitioners describe the skills, knowledge and activities of Nurse

Practitioners.

Required Qualifications

a) Registration with the Nursing Council of New Zealand in the Registered Nurse Scope of Practice, AND

b) A minimum of four years of experience in a specific area of practice, AND

c) Successful completion of a clinically focused Masters Degree programme approved by the Nursing Council

of New Zealand, or equivalent qualification, AND

d) A pass in a Nursing Council assessment of Nurse Practitioner competencies and criteria. Nurse Practitioners

seeking registration with prescribing rights are required to have an additional qualification: Optional -

Successful completion of an approved prescribing component of the clinically-focused Masters’ programme

relevant to their specific area of practice.



Appendix 3

New Zealand NP profiles relevant to primary health care.


Rosemary Minto RN NP Adult Family Nurse Practitioner with prescribing, working within a Tauranga general practice team

After many years working in general practice in NZ my clinical pathway has culminated in my registration in 2008 as an adult family health nurse practitioner with a focus on long term conditions. I am currently employed by a general practice and see patients who are referred to me by the GP team or who elect to see me. I have a daily appointment template. I also see patients in their homes who for many reasons are unable to come into the practice. These are generally the older more infirm adults. I utilise care plus funding and other PHO driven funding streams, for example, diabetes incentive programme funding, to subsidise patient appointment costs and generate income for the practice. I also see patients for their regular three monthly reviews and prescription repeats. Other aspects of my role is as the quality programme coordinator, assisting the practice manager in ensuring our performance management programme targets are reached, and arranging regular ongoing education for the practice team.


Sharon Hansen RN NP Primary Health Care semi rural small town

I have been a registered nurse practitioner in rural south Canterbury for the last five years, and during that time have worked in small rural practices. I have done on call work in different practices and will be participating in an on call roster for the area in the future. My weekday role entails working alongside a general practitioner in a sole practice. I see people across the life span for both acute and chronic conditions. The gp and I work quite closely sharing the patient load, if I see someone who has complex medical needs, I will refer to the gp. If he sees someone who he thinks might benefit seeing me he refer them to me. I tend to do a lot of women's health and mental health and the doctor has real strength in cardiology, and cancers. It depends on who has a gap as to who sees the acute sick same day patients. We both have our followers who no matter what they are there for, will ask for either the doctor or for me. Working in this way has made economic sense as well as providing a wider approach to patient care. My salary is paid for from capitation and the fee for service that is charged. My service fee is five dollars less than the gp, and I have worked in practice where the fee was the same as the gp. Patients accept the nurse practitioner service and have been accepting of the charges. I am expected to see a similar number of patients to the gp, however with a number of patients requiring mental health support the consultations can be longer. Despite many patients having no idea what a nurse practitioner was able to do, they have become very supportive of the role. The gp I work with has stood up at conferences and defended his decision to employ a nurse practitioner, he can't understand why others don't.


Dr Karen Hoare PhD

NP Children and Youth Primary Health Care

Senior Lecturer University of Auckland in the School of Nursing and the

Department of General Practice and Primary Health Care

My role in general practice is to provide a strategic overview for child and youth health. I am a business partner with six general practitioners. My role has included linking with midwives to ensure seamless care of the pregnant woman and early newborn enrolment. This initiative entitled ‘Best for baby’ has resulted in a 100% timeliness and rate of immunisation since 2009. In the period we have been collecting statistics, we have never dropped below 94% for timeliness and rate of immunisation. Additionally I facilitated collaboration with three local High Schools, working with the school nurses to ensure they have access to essential medicines for the children through the MPSO system. The GP registrar and I provide a two hour clinic for two of the High Schools weekly and for all three high schools we act as a repository and second checking system for lab test results. We see students at the practice who the school nurses would like a second opinion on. Having collected rigorous statistics over the last 2 years, we have seen the teenage pregnancy rate in Manurewa drop from 29 in 2012 to 2 so far this year. In an attempt to reduce hospitalisation rates of children with skin infections, we commenced an age sex register of all of our children with eczema. One of our practice nurses runs a nurse-led clinic for children with eczema and we regularly review the register together to ensure children with moderate and severe eczema are seen and have sufficient creams to manage their condition. Last year we implemented our ‘999’ register of vulnerable children. I maintain an overview of this register and ensure that the children are seen regularly. Additionally we also have a record of children with special needs in the practice. My vision is that all general practices have access to a ‘child champion’ who is either a Nurse Practitioner or Clinical Nurse Specialist for children and young people and who can help general practice staff develop systems to provide a population approach to caring for children and young people. I envisage that one nurse per 5-10,000 enrolled population would be enough for this role. Our New Zealand children need and deserve this level of primary health care


Janet Parker RN NP

Older Adult Nurse Practitioner with prescribing working for Waitemata DHB

Older Adult Services

I registered as an NP in 2010 following a Nurse Practitioner Intern programme developed through the DHB. Prior to becoming a Nurse Practitioner I was a Gerontology Nurse Specialist working in the community. I work within the DHB Older adult team and work closely with the geriatricians. I currently lead the Community Gerontology Nurse Specialist team on the assessment/treatment and rehabilitation unit at Waitakere hospital. I work in the community with high needs older people providing comprehensive geriatric assessment, care coordination and gerontology education. I liaise with primary care through our work with residential aged care facilities and with high needs people living in the community.


Acknowledgements

Thank you to all working group members for your commitment, discussion and ongoing support. Thank you to all the profiled Nurse Practitioners involved in the compilation of this information toolkit. Thank you to the Comprehensive Care Ltd/Waitemata PHO Executive Leadership Team, Clinical Directorate and Board members for your ongoing support of this role and its potential within General Practice.


References

Hughes, F. & Carryer, J. (2002). Nurse Practitioners in New Zealand, Wellington. Ministry of Health.

King, J., Corter, A., Brewerton, R., Watts, I. (2012). Nurse Practitioners in primary care: benefits for your practice. Australian General Practice Network, Auckland: Julian King & Associates Limited; Kinnect Group.

Minto, R. (2011). Nurse Practitioner Video. Accessed 4/3/2013 from http://www.screencast.com/t/PXeSVJNck5

Nursing Council of New Zealand. (2008). Scopes of practice. Wellington. Ministry of Health.

Documents

Nurse Practitioners as part of your General Practice … · A comparative of the scopes is supplied below: ... A focus was placed on services moved closer to home; ... economic and