Becoming an Advanced Nurse Practitioner

in Ireland

Emily Bury,ANP Candidate (Acute Medicine)

National Acute Medicine Programme

established in Ireland.

Background2010

June 2013 Acute Medical Unit/Acute Medical Assessment Unit opened in St. Vincent’s University Hospital, Dublin, Ireland.

March

2014 Business plan for ANP post approved and

ANP candidate commenced (Graduate

Certificate Advanced Nursing Practice)

2 clinical nurse managers appointed.

Nursing staff re-deployed from wards (58%

less than 5 years experience)

NAMP recommends the development of ANP

posts with emphasis on independent assessment

and development of treatment plans

SVUH business plan which stipulated ANP role,

acute medicine

A need for clinical nursing role models and

development of acute medical nursing as

speciality

Development of ANP posts in Ireland

Report of The Commission on Nursing (1998)blueprint for the future

“The Commission recommends the development of a three step clinical career pathway by the creation of clinical nurse or midwife specialist (CNS) posts and advanced nurse or midwife practitioner (ANP) posts.

Those with CNS or ANP status will be characterised by extensive relevant experience, appropriate post registration educational qualifications and an extended scope of

practice.”

p.4

Evaluation of the ANP role

NCNM (2005) - Qualitative study that found that the role has been successful and readily accepted by patients and staff

NCNM (2010) - Mixed method studyCare provided by CNSs and ANPs is safe, acceptable and cost-neutral while improving patient outcomes

Definition

‘Autonomous, experienced practitioners who are competent, accountable and responsible for their own practice.

Highly experienced in clinical practice and are educated to master’s degree level (or higher).

Utilise advanced clinical nursing knowledge and critical thinking skills to independently provide optimum patient care through caseload management of acute/chronic illness’

(NCNM, 2008 p.5)

Establishment of

ANP posts

Clearly defined process for role development and accreditation

Post - Site preparation

Person- Portfolio

(2008)

NMBI Assignment to ‘The Board’ of additional functions

In accordance with criteria set by the National Council

Determine applications for the accreditation of posts

Determine applications for the registration of nurses as Advanced Nurse Practitioners (ANPs)

To accredit ANP posts

To register an ANP who

Has been determined to meet the criteria

Has received an offer of employment

To remove name of any ANP who

No longer meets the criteria

Ceases employment in the ANP post

Pre-requisites to registration as an ANP

Be a

Registered

Nurse

(Active

Register)

Be

registerd

in the

appropriat

e division

of the

NMBI

Register

Masters

level or

above

Substan

tive

Clinical

Compo

nent

Clinical

supervis

ion (at

least

500

hours)

7 years post

registration

experience

5 years

experienc

e in the

chosen

area of

specialist

practice

Meets

core

concept

s and

associat

ed

compet

encies

Commitme

nt to

Continuing

Profession

al

Developme

nt

(Portfolio)

On-

going

clinical

supervis

ion

arrange

ments

Personal professional and academic

background

MSc Clinical Practice, UCD

Grad. Cert. Nursing-

Advanced Practice, UCD

Post. Grad. Emergency

Nursing, TCD

Professional Diploma

(Prescription of Medication)

7 years post

registration experience

Competency attainment

• Clinical and Professional Mentor

• All clinical cases discussed with Consultant/SpR

• Reflective accounts and formative based case discussions

• Clinical attachments

– Emergency - Stroke

– Cardiology - Neurology

– Respiratory - MedEl

Defining Scope of Practice

• Guided by Policy Documents -

An integrated career and competency framework for registered nurses in acute medicine

• Core competency standards • Specialist competency standards

• Liaised with Nurse Lead for SAM (Jan Christian)

• Site visits to Royal Bolton and Central Manchester

Local Need

0 5 10 15 20 25 30 35 40

TIA

Collape

Pneumonia

UTI

Migraine

Seizure

I/E COPD

CCF

Other

Number of presentations

Co

mm

on

Pre

sen

tati

on

s to

AM

U

Audit of common presentations to the AMAU/AMU at SVUH

Syncope algorithm

Stabilise ABC. Check capillary glucose and reverse hypolycaemia

Comprehensive health history/OLD CART Risk factors (CAD, CCF, syncope, valvular disease , family history of SADS, epilepsy)

Physical Examination, review of systems ECG, orthostatic BP measurements if tolerated

EvaluateCircumstance

ProdromeDuring T-LOCPostdrome

Medication History

Vital signs, Neurological observations

Are there features to suggest a structural or arrythmic cardiac

aetiology?

Are there features to suggest a benign aetiology?

Is there evidence to suggest that the T-LOC was a seizure?

Lightheadedness upon standing

Physical Findings

Vital signs: Low BP, sinus bradycariaCVS: HS normalResp:ClearNeuro: no focal neurology

Physical Findings

signs: ↓ systolic (20mmHg) and/or diastolic BP (10mmHg)on standing, sinus tachycardia on standing

CVS: HS normalResp:ClearNeuro: no focal neurology

Physical Findings

Vital signs: rapid or slow HR, low or high BPCVS: Added heart sound S3, mumers, Aortic stenosis. ↑JVP, ankle oedemaResp: CracklesNeuro: no focal neurology

Physical Findings

Vital signs: ↓GCS, normotensive, NSRCVS: HS normal Resp: ClearNeuro: focal neurological signs, diplopia, limb weakness

Investigations Labs: FBC, u&e, Orthostatic BP and HR measurements

CT Brain* 9

Investigations Labs: FBC, u&e, Orthostatic BP and HR measurements CT Brain*

Medication review

Investigations Labs: FBC, u&e,, TnT CXR 24 hour telemetry ECHO EST **

CT Brain*

Investigations Labs: FBC, u&e, Ca, glucose VBG: lactate, pH EEG 9,12

CT Brain +/- MRI Brain 9

Neurally mediated syncope

Orthostatic Hypotension

Cardiac Syncope Seizure

YESNO

YES YES

YES

Integrated DVT/AMAU Pathway

Confirmed DVT

Provoked DVT

- Known risk factor which will resolve

If no contraindications consider Rivaroxaban

- 15mg BD for 21 days followed by

- 20mg OD for remainder of 3 months

+ Compression stockings (grade 2) for 2 years

If contraindications to Rivaroxaban

- Warfarin therapy

- Low molecular weight heparin until therapeutic on Warfarin (consider CIT referral)

- Referral to Warfarin clinic

+ Compression stockings (grade 2) for 2 years

Unprovoked DVT

-No identified risk factor

If no contraindications consider Rivaroxaban

- 15mg BD PO for 21 days followed by

- 20mg OD PO ongoing

Thorough history and examination for malignancy – FBC, ESR, U&E, LFTs, Calcium, PSA (men>40), CXR. If abnormal refer for specific investigations

Discussion about life-long anticoagulation at this visit or a future OPD visit

+ Compression stockings (grade 2) for 2 years

If contraindications to Rivaroxaban commence Warfarin in LMWH

- Warfarin therapy

- Low molecular weight heparin until therapeutic on Warfarin (consider CIT referral)

- Referral to Warfarin clinic

Thorough history and examination for malignancy – FBC, ESR, U&E, LFTs, Calcium, PSA (men>40), CXR. If abnormal refer for specific investigations

Discussion about life-long anticoagulation at this visit or a future OPD visit

+ Compression stockings (grade 2) for 2 years

Current Process Post

• POST Accreditation NMBI

(resources, culture, leadership & management, policies, procedures, service

level agreements, memorandum of understanding, established referral

pathways, clinical governance, quality and risk management, continuous quality

improvement)

Following Post Accreditation

• ANPc must register as Advanced Nurse

Practitioner

• Currently based on submission of a Portfolio

– Must satisfy the Board that s/he has met criteria

set by the National Council and that s/he has offer

of employment in respect of the specified and

accredited Advanced Nurse Practitioner Post

concerned

Registration as RANP

PERSON Registered in relevant Division of the Register as

RANP

Registered Advanced Nurse Practitioner

National Strategy

for RANPs, Acute

Medicine

Expert advisory group established April 2016

Examine opportunities and make recommendations for RANPs in Acute Medicine

Standardised Job

description

Any Questions?