International Nurse Practitioners

     The role of an advanced practice Nurse (APN) or Nurse practitioner (NP) is becoming familiar in an international level. Two main reasons for many countries to start developing the role of NPs are the shortage of physicians and the need to cut cost in healthcare spending (Kroezen, van Dijk, Groenwegen, & Francke, 2011). The International Council of Nurses (ICN) has defined the role of the Nurse Practitioner (NP) in the following statement.

A Nurse Practitioner-advanced practice Nurse as a registered nurse who

 has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice. A master’s degree is recommended for entry level (Pulcini, Jelic, Gul, & Loke, 2010, p. 32).

     There are vast variations in the scope of practice and education of the APN. In the following, the author will discuss the history, regulations, education and attitude of the public towards the APN/NP for a select few English speaking countries.

 

Nurse Practitioners in the United Kingdom and the Republic of Ireland

 

 

Belfast, Northern Ireland

 

     The United Kingdom (UK) medical system is ran by the government under the guidance of the National Health Service (NHS). Advanced practice Nurses in the UK are called Nurse Practitioners. The role of the NP was established in 1998 to create efficiency of use of nurses, cut cost in the NHS and to ease the deficit of physicians (known as General Practitioners [GP]) in community practice, primary care clinics and acute care settings. They are mainly highly specialized and specifically trained in roles that they are filling such as Endoscopy, Primary Care, Critical Care or Emergency. There are three main levels of prescriptive authorities in Great Britain, Independent, Supplemental, and use of Patient Group Directives (PGD) or Medical Directives (protocols). Independent NPs have full prescriptive authority and full liability whereas supplemental NPs collaborate with independent prescribers. British NPs enjoy full prescriptive authority and access to the full British Formulary including controlled and experimental drugs, access to the NHS prescribing budget for reimbursement and support from the British Medical Association (Kroezen et al., 2011). However, some of the setbacks in the role are the British nursing body’s lack of explicit description of the APN role and highly variable training. British NPs can have a bachelor degree, a post graduate diploma or a master degree. Pharmacology training for prescriptive authority is provided at a degree level and NPs only require three years of clinical experience. Also, NPs in the UK are not required to be licensed or registered. Therefore, the British public does not always embrace NPs due to their lack of confidence that NP training is adequate. Forty four percent of British NPs have had diagnostic request denied. As the NHS is cutting the budget but still demanding high quality care, there is a demand in the UK for NPs to fill positions of GPs at a cheaper price. Morgan (2010) recognized that the NPs in the US are better prepared and that the UK needs time to catch up with the US. The Nurse Practitioner United Kingdom (2010) has been lobbying since 2005 for the government to set a standard of regulation for all advanced practice nurses. This group is seeking to learn from other countries such as USA and Australia on how to regulate advanced practice in nursing.

                                         Cliffs of Moher, Republic of Ireland

     The Republic of Ireland (ROI) has a two-tier health care system; the public health care ran by the government under the Health Service Executive (HSE) and the private health care system. All citizens are entitled to use of the public health care system but only 80% utilize it. The private health care system is more attractive to the public because of the belief that it gives faster access to services and better services than the public health care system (Carney, 2010). The role of the Registered Nurse Prescriber (RNP) was established in the ROI in 2007. RNPs enjoy a vast prescriptive authority much like the UK but require registering under the Nurse Prescriber Division of Register and having a written collaborative practice agreement with a medical practitioner. More information on the RNP scope of practice can be found in the An Bord Altranais website (An Bord Altranais, 2012; Carney, 2010; Kroezen, 2011).

 

An interesting fact: NPs in the United States (US) make on average 51,000 pounds ($81,400) as British nurses make at maximum 43,335 pounds ($69,449) (Morgan, 2010).

Nurse Practitioners in Canada

                                                    Niagara Falls, Canada

      Until the 1990’s, NPs in Canada were trained only to fill position gaps in northern parts of Canada.  Now legislation has been implemented to allow NPs to work in areas outside of the Northern Provinces (Alden-Bugden, 2007). There are 3000 NPs in Canada today. Nurse practitioners in Canada can provide quality care, order tests, prescribe medications, diagnose and manage chronic diseases, and refer to specialists as needed. They work in doctor’s offices, community clinics, nursing homes, private homes, Emergency Departments and Critical Care Units. Canadian NPs are certified by passing the Canadian Nurse Practitioner Exam. However, not all provinces require NPs to take this exam. The Canadian Nurses Association is launching a campaign to educate the population about how NPs can improve access of care for Canadians as close to five million Canadians do not have a primary care provider and those who do have one have a hard time accessing care (NPCanada.ca, 2011).

     Although there are currently no colleges in Canada that has a Doctorate of Nursing Practice (DNP) program, the advent of its southern neighbors requiring their entry level NPs to have a DNP by the year 2015 is putting some pressure on nurse leaders in Canada. All entry level registered nurses in Canada are required to have a bachelor degree however advanced practice nurses can have a bachelor or master degree (Joachim, 2008).

Nurse Practitioners in Australia and New Zealand

     Australia introduced the role of NP in 2000 to relieve the burden of physician shortages. Australian NPs require a master degree, ability to demonstrate clinical assessment and clinical decision making skills and at least five years of clinical experience in order to receive prescriptive authority and endorsement as NPs. However, Australian prescriptive authority is limited compared to British NP prescriptive authority (Kroezen et al., 2011). Since Australia has various states and territories, laws and regulations for NPs vary in each one. The Nurses Registration Board of New South Wales was one of the first states to begin regulation and licensing criteria for NPs. Now Australia is in the process of forming a national regulation (Pulcini et al., 2010).

New Zealand began the role of NP in 2001. Nursing prescriptive authority was historically limited to specialized roles but was just recently expanded to all NP roles. It has similar education requirements and regulations as Australia except New Zealand require only four years of clinical experience and must maintain continuing education in order to maintain their prescriptive authority. NPs in New Zealand get reimbursed the same amount for their services as physicians (Kroezen et al., 2011).   

References

Alden-Bugden, D. (2007, May 25). Welcome to NPCanada.ca. Retrieved from http://www.npcanada.ca/portal/

An bord Altranais (2012). Collaborative practice agreement (CPA) for nurses and midwives with prescriptive authority (third edition). Retrieved from www.nursingboard.ie

An Bord Altranais (2012). An Bord Altranais flowchart for application and registration process for the registered nurse prescribers division [Flowchart]. Retrieved from www.nursingboard.ie

Carney, M. (2010). Challenges in healthcare delivery in an economic downturn, in the Republic of Ireland. Journal of Nursing Management, 18, 509–514. doi: 10.1111/j.1365-2834.2010.01078.x

Joachim, G. (2008). The practice doctorate: Where do Canadian Nursing leaders stand? Nursing Leadership, 21(4), 42-51

Kroezen, M., van Dijk, L., Groenwegen, P. P., & Francke, A. L. (2011).Nurse prescribing of medicines in Western European and Anglo-Saxon countries: a systematic review of the literature. Bio Central Health Services Research, 11(1), 127. doi:10.1186/1472-6963-11-127

  

Morgan, S. (2010). What are the differences in nurse practitioner training and scope of practice in the US and UK? Nursing Times.net. Retrieved from http://www.nursingtimes.net/what-are-the-differences-in-nurse-practitioner-training-and-scope-of-practice-in-the-us-and-uk/5017012.article

NPCanada.ca (2011, October 17). Canadian Nurses Association says ‘it’s about time’ [Press release]. Retrieved http://www.npcanada.ca/portal/

Nurse Practitioner United Kingdom (2010). Regulation [Fact sheet]. Retrieved from http://www.nursepractitioner.org.uk/Regulation.html

Pulcini, J., Jelic, M., Gul, R., & Loke, Y. (2010). An international survey on advanced practice nursing education, practice, and regulation. Journal of Nursing Scholarship,42(1), 31-39. doi: 10.1111/j.1547-5069.2009.01322.x

 

The Research-Focused Doctorate versus the Practice-Focused Doctorate

The Doctor of Nursing Practice (DNP) degree is defined as a "practice focused" doctorate terminal degree in nursing (Chism, 2010).  So what is the difference between this DNP degree and a Doctor of Philosophy (PhD) degree?  The two are compared below:

                                DNP                                    PhD                     
Program               prepares for advanced practice               prepares for nurse research     

Competencies     AACN Essentials                                        Indicators of Quality in
                                                                                                    Research-Focused 

Students              Oriented towards improving                  Oriented towards developing
                              outcomes                                                    new knowledge

Faculty                High level of expertise in                         High level of expertise in
                             speciality area                                            research 

Resources         Access to diverse practice                         Access to research settings;
                            setting; financial aid                                   dissertation support dollars

Program            Health care improvements                     Health care improvement via
Assessment       via practice, policy change                        development of new knowledge
                      
Reference
Chism, L. A. (2010).  The doctor of nursing practice: A guidebook for role development and professional issues. Sudbury, MA: Jones and Bartlett Publishers.

Malpractice Insurance

As nurse practitioners (NPs) assume more autonomy and take on more responsibility, they increase their legal liability. NPs are now being held accountable to their scope of practice. The resulting dilemma is that as scope of practice and autonomy increase so does susceptibility to malpractice exposure.

Professional liability insurance (PLI), also known as malpractice insurance, is an insurance policy that provides financial protection in the event of a malpractice claim. PMI is sold in two forms:

Claims-made policy – covers claims made while the policy is in force but not if a claim is made after the policy expired.

Claims-occurrence policy – covers claims made at the time the policy was in effect regardless of when the claim is made.

How much malpractice insurance is enough?

The best answer is: As much as you can get and afford.

To Avoid a Malpractice Lawsuit

• Do not establish a duty to a patient when you do not have to
• Do not offer advice, diagnosis, or treatment outside of your scope of practice and expertise
• Base your diagnosis and therapy on guidelines and references commonly accepted in your area of practice
• Order a consultation or refer a patient if the history and examination suggest a differential which includes a deadly condition, and you have not ruled out or treated that condition
• If you order a test or consultation, follow through to be sure it was done and that the results were dealt with appropriately
• If the standard of care calls for screening for disease due to your patient’s age, gender, or risk facts, conduct the screening and follow through if the results are positive
• Document carefully so that your actions are justified and your process for medical decision making is discernable to an outside evaluator
• If you cannot practice safely in your current work situation, for whatever reason, leave that situation and find somewhere you can practice safely
• Purchase your own “occurrence” malpractice insurance policy

Picking a Policy

• Ask these questions of companies from which you are considering purchasing malpractice insurance:
• What does the policy cover?
• What is excluded from coverage?
• What are the policy limits?
• How long have you been in business?
• How long have you been writing policies for NP’s?
• What is your financial stability rating?

What questions should I ask my employer about their policy?

• Am I protected individually under the policy? (i.e., am I specifically named as an insured?)
• Does my insurance include License Protection to help defend me in an administrative or disciplinary situation
• If I leave my employer, will its policy cover me for an incident that occurred while I was still employed? (i.e., is my employer’s policy “Occurrence”?)
• Do I have my own individual limits of liability?
• What level of coverage do I have?
• May I see the policy?
• Do I have coverage 24 hours a day

References

ACNP (2012). Frequently Asked Questions about NP Liability Insurance. Retrieved from

http://www.acnpweb.org/frequently-asked-questions-about-np-liability-insurance

Buppert, C. (2008). Frequently asked questions, and answers, about malpractice insurance. Dermatology Nursing, 20(5), 405-406.

The Role of the Hospitalist Nurse Practitioner

     The hospitalist role is a new role for all healthcare providers. It was first termed in 1996 to describe a physician who devotes his or her time to the care of a hospitalized patient. The role of a hospitalist focusing on the hospitalized patient helps relieve the burden on the Primary Care Provider (PCP) so that the PCP can focus on his or her outpatient population (Sullivan, 2008). The hospitalist coordinates a team of healthcare professionals consisting of physicians, nurse practitioners, physician assistants, pharmacists, case managers, social workers, and physical therapists to manage the care of the hospitalized patient (Sheridan, 2011). 
 

 

      A Hospitalist Nurse Practitioner is a nationally certified nurse practitioner who has no primary care or tertiary care practice outside the hospital. He or she is usually trained and certified as an Acute Care Nurse Practitioner but can also be a Family Nurse Practitioner, Adult Nurse Practitioner, Geriatric Nurse Practitioner and Pediatric Nurse Practitioner. The primary duty of a Hospitalist Nurse Practitioner is to admit and discharge patients, manage the hospitalized patient's care with the collaboration of a Hospitalist Physician, make rounds and write orders as needed, interpret laboratory values, make simple diagnosis, plan and coordinate discharges and rehabilitation, and perform procedures within the scope of practice (Sullivan, 2008). The salary of a Hospitalist Nurse Practitioner ranges from $70,000 to $100,000.

 

     The Hospitalist Nurse Practitioner specialty is rapidly growing to help close the gap between the large demands for but lack of available Hospitalist physicians (Sheridan, 2011). I work as a Hospitalist Nurse Practitioner in a small 20-bed rural hospital that sees an average of 6-7 patients a day. I work during the night and admit around 1-2 patients during my shift. I work closely with my collaborating physician and learn a lot from him things that are unique to the hospitalist experience that were not taught in The Doctorate of Nursing (DNP) program or even in medical school. I have learned a lot about how various acute care patients with diagnoses of pneumonia, chronic obstructive pulmonary disease, colitis, acute renal failure, pancreatitis, congestive heart failure, angina, transient ischemic accident and various other medical problems are managed in an acute care setting. Our service only sees patients with medical problems and we have to be careful to not accept a patient with an issue that may require surgical intervention as the surgeon in our hospital would manage those patients. We also only accept patients that are 18 years old or older. We also have to be careful to not accept patients that may require services that are not provided in our hospitals such as critical care, neurosurgery or cardiac catheterization. These patients would be transferred to a bigger hospital that has these services available. The position of a Hospitalist Nurse Practitioner can be challenging but is very rewarding as well.

 

Reference

Sheridan, T. (2011). Hospitalist: An emerging choice for nurse practitioners (Online Exclusive). Health Callings. Retrieved November 10, 2012 from http://career-news.healthcallings.com/2011/08/15/hospitalists-an-emerging-job-choice-for-nurse-practitioners/

Sullivan, L. (2008). The role of nurse practitioners- The hospitalist (Online Exclusive). StudentNurse.com. Retrieved November 10, 2012 from http://www.stunurse.com/features/new-role-nurse-practitioners-hospitalist

Recognizing “Burnout”

Nurse practitioners are at high risk for burnout. It is important to recognize the warning signs of burnout. Burnout is described as specific psychological condition brought on by excessive, prolonged and unrelieved work-related stress.

Burnout occurs when enthusiasm is replaced by frustration and disappointment. If left unaddressed, it can lead to irritability and resentment, productivity drops, behavior changes, confidence and passion are lost.

Risk factors include:

Job-related stressors:

• Unclear Requirements
• High-Stress Times with No “Down” Times
• Big Consequences for Failure
• Lack of Recognition
• Impossible Requirements
• Poor Communication
• Insufficient Compensation
• Poor Leadership

 Personal characteristics:

• Perfectionist Tendencies
• Type A Personality
• Pessimistic
• Poor Fit for the Job
• Lack of Belief in What You Do
• Feel they must always give “110 percent”
• Personalize failure for outcomes beyond their control

Common warning signs:

• Increased absenteeism
• Rushed patient care
• “By the book” approaches
• Emotional outbursts
• Boredom
• Tend to procrastinate
• Withdraw from friends
• Self medicate with alcohol
• Physical symptoms can include:
• chronic headaches
• sleep disturbances
• fatigue/exhaustion
• stress/anxiety
• overall sadness
• irritability
• forgetfulness
• GI upsets
• Cardiac arrhythmias 

Transition to full-blown burnout:

• Can be rapid, or...
• Can be progressive and insidious
• Progressive pessimism
• Dissatisfaction and increased absenteeism
• Low work productivity
• Withdrawal and depersonalization from relationships leads to desire to                                  disappear, and potentially, to thoughts of suicide

Preventing burnout:

• Realize that self care is not selfish
• Take care of yourself first
• Create relaxation time, even at work
• Take a few minutes during the day to meditate, read or go for a walk
• Go out to lunch, or get out of the office
• Be realistic of your expectations
• Create balance in your life
• Talk to others
• Ask for support when you feel the need  

Reducing Stress in the Health Care Workplace

• Build group cohesiveness through regular training, discussions, and in-services.
• Encourage peer support
• Offer recognition for success and excellence
• Vary professional responsibilities
• Create a monthly newsletter with updates an kudos
• Let staff know it is all right to ask for a “stress break”
• Watch for signs of significant stress in staff, and offer them help.

Self-Care Tips to Prevent Burnout

• Take care of you. It will relieve some of your stress and allow you to take better care of others
• Treat yourself with the same care you give to your patients
• Allow yourself to say no. Offer alternatives if you feel unable to say no
• Develop a routine to help ease the transition from work to home (Do not use alcohol to unwind)
• Avoid over-identification with patients
• Recognize and accept your own feelings
• Practice stress-reduction techniques (exercise, relaxation, meditation, distraction)
• Plan for regular breaks, conferences, and vacations
• Know when to say “enough”. If necessary, change to another practice environment

Life needs to be approached from the preventive perspective. We need to live what we have been preaching to our patients. Create relaxation time, even at work. Create balance. Take care of yourself first!

  

References

Duffy, V.J. (2012). Beating burnout. Advance for Nurse Practitioners and Physician Assistants. Retrieved from http://nurse-practitioners-and-physician-assistants.advanceweb.com/Article/Beating-Burnout.aspx

Nadan, R.J. (2012). Dousing burnout. Advance for Nurse Practitioners and Physician Assistants. Retrieved from http://nurse-practitioners-and-physician-assistants.advanceweb.com/article/dousing-burnout.aspx