Nursing and Midwifery from Undergraduate to Advanced Practice: International

Dimensions and Outcomes

Croatian National Council International Conference

Professor Marie CarneyDean, Faculty of Nursing & Midwifery

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

2

Challenges of university nursing education in European Union

Aims:

• Discuss how nursing and midwifery is regulated and managed in the Republic of Ireland

• Highlight the various Models of Nursing used at all educational levels

• Explore outcomes that can be achieved from each of these Models

3

Introduction to nursing and midwifery education in Ireland

Population of 4.5 m people

1570 new nurses and midwives annually

There are approximately 35,000 WTE nursing and midwifery posts

Levels of Learning on the National Framework of Qualifications

4

Nursing and midwifery regulation in Ireland?

Public Protection

Midwifery Distinct

High Standards

Public Accountability

Professional Guidance

Context of healthcare delivery

Context

Political

Social

Economic

Technological

6

Models of midwifery education

Ireland: 4 Year Direct Entry BSc

Belgium, Denmark, Ireland, Italy, New Zealand: 3 Year Diploma or 4 Year Degree Direct Entry

USA: Certified nurse-midwives or certified midwives following BSc and specific science related courses

7

Models of nurse registration education

Two models exist internationally:

Generic model prepares nursing graduates for generic practice for multiple client groups in varied settings

Specialist model makes a distinction between branches of nursing and prepares for a graduate nurse with competencies for a specific client group e.g. children’s, psychiatric, intellectual disability, adult

nursing

Pre-registration nursing education

• European Union Directive 2005/36/EC

• Historically Certificate (Apprenticeship model)

• 1995 Diploma (Apprenticeship model)

• 2000 Degree (Graduate education)

8

European models of pre-registration nurse education

IRELAND•General•Psychiatry•Intellectual Disability•Integrated Children’s & General

Germany•General•Paediatric•Geriatric

UK•Adult•Children’s •Mental Health•Learning Disability

International models of nurse registration educationCountry Length of time

Denmark and Finland 3 .5 yr Degree

Australia, Italy and New Zealand 3 yr degree

United States 3 yr diploma2 /3 yr associate degree4 yr degree

Canada, the Netherlands and Ireland 4 yr degree

Denmark, Germany, New Zealand, Australia & United States offer

11 – 18 months Accelerated Programmes to graduates

Ireland 4.5 yr Integrated General & Children’s Degree

WHO regional strategy for nursing and midwifery education

• 2001: WHO Strategy identified the academic level of baccalaureate degree as the prerequisite for professional practice (WHO 2001a)

• 2005: Review of basic nursing and midwifery education programmes in Europe

• 2009: Published Global Standards for the Initial Education of Professional Nurses and Midwives (WHO 2009)

11

12

WHO standards

WHO Standards state that graduates should be able

to: Demonstrate established

competencies in nursing and

midwifery practice

Have a sound understanding

of the determinants

of health

Meet regulatory

body standards leading to

professional licensure/

registration as a nurse or a

midwife

Be a knowledgeable

practitioner who adheres to the code of

ethics and standards of

the profession

EU and Bologne Declaration

The Bologna Declaration aims to create a coherent, compatible and competitive European Health Education Area by 2010

Main objectives include: creation of comparable, uniform and easily readable degrees through a European Credit Transfer & Accumulation System (ECTS)

13

14

Tuning Educational Structures

Bologna DeclarationTuning Educational Structures emanated from the Bologna Process and its aims (47 Countries)

Implement student centred, outcome based and transparent higher educational programmes on the basis of three sequential cycles: the Bachelor, the Master and the Doctorate

15

Principles for undergraduate education programmes (Adapted from Tuning)

16

Unique features of the BSc undergraduate programme (Ireland)

An Bord Altranais (2007) Requirements and Standards for Educational Programmes for Nurses and Midwives. An Bord Altranais, Dublin.

17

Positive outcomes- BSc National Evaluation Review (2014)

BSc Review

Students Felt

Appreciated

Essential Role of Clinical Practice

Student confidence enhanced

Enhanced Student-Patient

Communication

18

Clinical career pathway models following registration

PG Certificate (Level 9)Three Core Modules Specialist Area of Practice

PG Diploma (Level 9)Three Anchor Modules

MSc Year 2 (Level 9)

Progression from BSc Degree to MSc programme (PG Cert + PG Diploma equates to year one of the MSc Programme)

Optimum Clinical Outcomes

• National Clinical Programmes Ireland eg Epilepsy

• Central to the development of clinical governance across the continuum of care in each national clinical programme

• Contain the same principles for all nurses who are working at every level from undergraduate to advanced practice level

19

Optimum Outcomes Achieved from

National Clinical Programmes

National clinical models of care- principles

Models• Patient first• Safety• Personal responsibility• Defined Authority• Clear accountability• Leadership• Inter-disciplinary working• Supporting performance• Open culture• Continuous quality improvement

20

21

Outcomes from care delivered: Research study Aiken et al. (2014)

Study: RN4CAST undertaken on nurse staffing and education and hospital mortality

Designed to inform decision making about hospital nursing operating expenses

Aimed to assess whether differences in patient to nurse ratio’s and nurses’ educational qualifications, in nine of the 12 RN4CAST countries with similar patient discharge data, were associated with variation in hospital mortality after common surgical procedures

22

Outcomes from care delivered: Research Study Methods (Aiken et al. 2014)

Researchers obtained discharge data for 422,730 patients, aged 50 years or older, who underwent common surgeries in 300 hospitals and they estimated 30 day in-hospital mortality by use of risk adjustment measures

Surveyed 26,516 nurses practising in study hospitals to measure nurse staffing and nurse education and assessed the effects of nursing factors on the likelihood of surgical patients dying within 30 days of admission

23

Results from Outcomes Study (Aiken et al. 2014)

Hospitals with more nurses with bachelor’s qualifications have lower mortality and fewer adverse patient outcomes than hospitals with fewer bachelors educated nurses

When there was an increase in a nurses’ workload by one patient this increased the likelihood of an inpatient dying within 30 days of admission by 7% and every 10% increase in bachelor’s degree nurses was associated with a decrease in this likelihood by 7%

Results imply that patients in hospitals in which 60% of nurses had bachelor’s degrees and when nurses cared for an average of six patients would have almost 30% lower mortality than patients in hospitals in which only 30% of nurses had bachelor’s degrees and nurses cared for an average of eight patients

24

Study on Nurses’ Reports (Aiken et al. 2009)

Study by Aiken et al. on Nurses’ Reports of working conditions and hospital quality of care for the RN4CAST Consortium

Obtained nurses’ assessments of their hospital work environments and quality of care in order to identify strategies to retain nurses in hospital practice and to avoid quality of care erosions related to cost containment

Sample of 33,659 hospital medical–surgical nurses in 12 European Countries providing care in 488 hospitals in Belgium, England, Finland, Germany, Greece, Ireland, the Netherlands, Norway, Poland, Spain, Sweden, and Switzerland

25

Outcomes

Clinical outcomes from advanced practice nursing are mainly focused on:

Patient satisfaction

Communication with patients

Length of stayComparisons between care provided in acute care and primary care

settings

Comparisons between care provided to vulnerable patients and older persons

Cost of care Outcome differences from care provided by doctors/physicians and that

provided by APN’s and by CNS’s

26

Outcomes from ANP/AMP and CNS Care (SCAPE Project (Begley et al. 2013)

Study: Begley et al. (2013) in a survey of 154 service users compared the roles and perceived outcomes CNS/CMS and ANP/AMP’s in Ireland

• Improved service delivery• Greater clinical , educational and professional leadership• Research active

ANP/AMP’s provide a higher level of care than CNS’s and is more evident at a strategic level

ANP’s provided

The SCAPE study concurs with others undertaken in Australia and New Zealand (Carryer et al. 2007) and in Finland (Fagerström 2009) in the area of clinical leadership where ANP’s were viewed as being positive role models in committee involvement, facilitating education for all team members, research and audits

27

Positive outcomes from ANP care

Research on the effects of advanced nursing care on quality of life and cost outcomes of women newly diagnosed with breast cancer found that these patients had improved quality of life compared to breast cancer patients receiving standard care (Ritz et al. 2000)

Positive outcomes from care delivered by Advanced Practice Psychiatric Nurses (APPN’s) in patients with major depression in USA (Parrish et al. 2013) and that clients were very satisfied with care (Feldman et al. 2003)

ANP’s are taking on responsibility for new service areas not previously provided by registered nurses, such as chronic disease management where reduction in length of stay by 2 days is reported (Koskinen et al. 2012)

References available at:

• Carney M. (2014) International perspectives on Advanced Nurse and Midwife Practice, regarding advanced practice, criteria for posts and persons and requirements for regulation of Advanced Nurse /Midwife Practice. Undertaken for Nursing and Midwives Board of Ireland (NMBI) (An Bord Altranais agus Cnáimhseachais na hÉireann) 2014.

http://www.nursingboard.ie/en/sponsored-project.aspx?article=2654b1a0-e36f-4706-a3b1-59e72bd59409

Research Dimensions Studied Related to:

Research Study Outcome Findings Delivered by ANP’s versus Physician

Mental Health in patients with major depression

Parrish et al. (2013) in USA by APPN’s Loescher et al (2011) Feldman et al. (2003)

APPN’s are highly effective in treating clients with depression and clients were very satisfied with this care

Access to care and quality of care delivered

Delamaire and Lafortune (2010) in OECD study.

Using APN’s can improve access to services, reduce waiting times, deliver the same quality of care as doctors for a range of patients, including those with minor illnesses and in routine follow-up

Range of activities carried out by ANP’s compared to those previously performed by doctors

Delamaire and Lafortune (2010), OECD Study

ANP’s were carrying out a range of activities that doctors previously performed incl. diagnostics screenings, prescribing of medication or medical tests, health prevention and education and monitoring of patients with chronic illnesses

Cost, quality of care, satisfaction and wait times in the ED

Carter & Chochinov (2007), in an Australian study

ANP led care resulted in higher patient satisfaction, decreased waiting times and equal quality of care, when compared to care delivered by mid-grade residents

If nurse practitioners working in primary care can provide equivalent care to doctors

Horrock et al. (2002) In a USA study

Patients are very satisfied with primary care provided by APRN’s and care is equivalent to that delivered by doctors

Reduction in length of stay Koskinen et al. (2012) in USA study

ANP’s were taking on responsibility for new service areas not previously provided by registered nurses, such as chronic disease management where reduction in length of stay by 2 days is reported

APN knowledge and collaborative practices

Ingersoll McIntosh & Williams (2006), & Sidani et al. (2006)

APN’s knowledge of patients and family were enhanced and collaboration among care providers was observed

Outcomes from care delivered by Advanced Nurse Practitioners

Research Dimensions Studied Researchers Outcome Findings

Roles and dimensions of the CMS’s in comparison to ANP’s and CNS’s

Begley et al. (2013) in Irish study

CMS’s were more involved in co-ordination of the multi-disciplinary team, integrated care planning and development of information resources for patients than were CNS’s or ANP’s.

Clinical leadership roles of CNS’s Elliott et al (2012) & Begley et al. (2013)

CNS/CMS’s continue to further develop their clinical leadership roles in teaching, consultancy, and practice development

Patients’ satisfaction with the care offered by APN’s

Bergman et al (2013) in a Swedish study with 340 APN’s

High level of satisfaction with APN led care and patients provided with information on the APN role prior to completing the survey were significantly more satisfied than those APN’s who did not highlight the importance of communication

Roles undertaken by CNS’s Mayo et al. (2010) in a USA study involving 947 Californian CNS’s

Even though CNS’s spent some time on clinical leadership and research, they preferred expert clinical practice

Role dimensions of CNS care versus CNC Roche et al. (2013)

CNC is equivalent to the CNS role in the UK and in the USA

Boundaries of NP and CNS practice intersection with Medicine

Cole (2003) in a UK study

Boundaries of NP practice intersect with medicine and CNS practice does not. The NP role is direct care giving providing a combination of nursing and medical care

Effects of advanced nursing care on quality of life and cost outcomes of women newly diagnosed with breast cancer

Ritz et al. (2000) in a US study

Patients had improved quality of life compared to breast cancer patients receiving standard care provided by the RN.

Outcomes from care delivered by Advanced Nurse Practitioners

RCSI Royal College of Surgeons in Ireland Coláiste Ríoga na Máinleá in Éirinn

35th Annual International Nursing & Midwifery Research & Education Conference  

March 2nd and 3rd 2016 

“Maintaining Professional Competence: Continuing Professional Development and Patient

Centred Outcomes”