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
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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
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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
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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
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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
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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)
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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)
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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)
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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
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Principles for undergraduate education programmes (Adapted from Tuning)
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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.
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Positive outcomes- BSc National Evaluation Review (2014)
BSc Review
Students Felt
Appreciated
Essential Role of Clinical Practice
Student confidence enhanced
Enhanced Student-Patient
Communication
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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
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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
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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
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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
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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
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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
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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
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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
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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”