1 Development of Advanced Nursing Practice in Hong Kong: a celebration of ten years work Frances Kam Yuet Wong Professor & Associate Head School of Nursing The Hong Kong Polytechnic University

2 Outline Factors that contribute to the development of Advanced Nursing Practice (ANP)Factors that contribute to the development of Advanced Nursing Practice (ANP) The scenario of practice by Nurse Specialists (NSs) in the early 1990sThe scenario of practice by Nurse Specialists (NSs) in the early 1990s The development of NS practice in the late 1990s to early 2000The development of NS practice in the late 1990s to early 2000

3 Factors Contributing to the Development of Advanced Nursing Practice (ANPs) Differentiation of nursing workDifferentiation of nursing work Nexus of work and profession in a cost containment environmentNexus of work and profession in a cost containment environment Specialization of patient groupsSpecialization of patient groups Enhancement of nursing educationEnhancement of nursing education (Wong, 1996)

4 (1) Differentiation of Nursing Work ProletarianizationProfessionalization Upgrading of nursing education and autonomy Nursing work less skilled worker

5 (2) Nexus of Work and Profession in a Cost Containment Environment

6 Human institution helps to mediate between Knowledge and Power

7 (3) Specialization of Patients Chronically ill patients become experts of their own illnessesChronically ill patients become experts of their own illnesses Increased level of educationIncreased level of education Increased availability of health knowledge in the mass media and the webIncreased availability of health knowledge in the mass media and the web

8 (4) Enhancement of Nursing Education Over 50% nurses possess a first degreeOver 50% nurses possess a first degree Many studying for masters degree and doctorate degreeMany studying for masters degree and doctorate degree

9 Scenario of Practice by NSs in the Early 1990s Identity searching Identity searching Being distinguished from RNs Being distinguished from RNs

10 Scenario of Practice by NSs in the Early 1990s The main work involvement of NSs: Client careClient care Patient educationPatient education Staff developmentStaff development Quality improvement and researchQuality improvement and research Hospital Authority, 1996 and Wong, 1997

11 NS vs RN Work is NOT subject to routinizationWork is NOT subject to routinization See clients by referralsSee clients by referrals

12 When I was working on the ward as an RN, if the patient in the next bed has a physical need, I needed to see him right away. This interrupted the health education session. Now I have the freedom to telephone the patients for follow up, and put time in cases which are of higher priority. The satisfaction is greater. (Wong 1998: 477) (1) Work is Not Routinized

13 (2) Consultation by Referrals Professional B Professional A Consultation

14 DMNS Notes... The patient demonstrated [basic skills in using the] Novopen … I would make an appointment to see her [in OPD]… To practice Novopen skill under supervision in ward. DMNS Notes... The patient demonstrated [basic skills in using the] Novopen … I would make an appointment to see her [in OPD]… To practice Novopen skill under supervision in ward.

15 DMNS Notes... The patient demonstrated [basic skills in using the] Novopen … I would make an appointment to see her [in OPD]… To practice Novopen skill under supervision in ward. DMNS Notes... The patient demonstrated [basic skills in using the] Novopen … I would make an appointment to see her [in OPD]… To practice Novopen skill under supervision in ward. Drs Notes … to practice [injection] skill on ward. Home until ready. Drs Notes … to practice [injection] skill on ward. Home until ready.

16 Scenario of Practice in NSs in the Early 1990s

17 Scenario of Practice in NSs in the Early 1990s

18 Scenario of Practice in NSs in the Early 1990s

19 Scenario of Practice in NSs in the Early 1990s 22 NSs appointed in 14 clinical areas in NSs appointed in 14 clinical areas in 1993 Definition of nursing specialties was somewhat arbitraryDefinition of nursing specialties was somewhat arbitrary No credentialing and regulatory body to scrutinize the qualifications of the NSs and monitor their clinical competenceNo credentialing and regulatory body to scrutinize the qualifications of the NSs and monitor their clinical competence

20 The Development of NS Practice in the Late 1990s to Early 2000s

21 The Development of NS Practice in the Late 1990s to Early 2000 Exemplary work of NS practice, with support of researchExemplary work of NS practice, with support of research Service well recognized by the nursing peers and doctorsService well recognized by the nursing peers and doctors Nurse-led clinicsNurse-led clinics The issue of regulationThe issue of regulation Room for the APN to be developed in the communityRoom for the APN to be developed in the community

22 Exemplary Work - Research Evidence From Senior NS (SNS) Scheme by HA, HKFrom Senior NS (SNS) Scheme by HA, HK Positive results of SNS from an independent evaluation (HA, 1996; Wong, 2001)Positive results of SNS from an independent evaluation (HA, 1996; Wong, 2001) Economic downturn position not establishedEconomic downturn position not established Examples on cost-effective and quality care by renal SNS

23 Cost-effective Care (1) Erythropoietin Self- injection Program 26 chronic renal failure patients Saving 225 nurse hours annually Erythropoietin Self- injection Program 26 chronic renal failure patients Saving 225 nurse hours annually Renal SNS

24 Cost-effective Care (1) Braunoderm Vs Betadine Spray Same effect Braunoderm costs HK$0.8 ( Hr) Betadine costs HK$6.0 (0.233 Hr) Braunoderm Vs Betadine Spray Same effect Braunoderm costs HK$0.8 ( Hr) Betadine costs HK$6.0 (0.233 Hr) Renal SNS

25 Cost-effective Care (2) Senior Diabetes NS Seeing 108 poorly controlled diabetic patients 10 (9%) physicians 98 (91%) managed by Senior Diabetes NS (HA, 1996; Wong 2001)

26 Leadership Care Engineer Clinical Leader

27 Nurse-led Clinic What is a nurse-led clinic See doctor To nurse for education Initial assessment by nurse See doctor

28 The Definition of A Nurse-led Clinic A NURSE CLINIC is a formalized and structured health care delivery mode formalized and structured health care delivery mode involving a nurse and a client. THE CLIENT is an individual and his/her family with health care needs that can be addressed by the nurse. THE CONSULTATION is initiated through referrals from nurses, doctors or other health care professionals. THE NURSE has demonstrated advanced competence to practice in the specific health area.

29 The Definition of A Nurse-led Clinic THE NURSE functions independently and/or interdependently with other health care team members for at least 80% of his/her work involvement. HE/SHE is supported by a multidisciplinary team, and can make referrals to other health care professionals to address the health care needs of the clients. THE MOST important and key interventions are nursing therapeutics which encompass assessment and evaluation, treatment and procedures, health teaching/counseling, and case management.

30 The Definition of A Nurse-led Clinic THE NURSE CLINIC differs from the doctor clinic in its less reliance on the use of medications, but the employment of a holistic approach in addressing the needs of the clients and their families. THE NURSE determines the duration of each consultation and the time lapse between consultations according to clients needs.

31 Future Development To link professional recognition with practice To expand the scope of practice of APN

32 Linking Professional Recognition with Practice To develop a certificate process to validate and standardize the qualifications and practice competencies of the advanced practice –To protect the public s health –To ensure the credibility of advanced practising nurses

33 Expanding Scope of APN Neoplasm 93,999 Respiratory system 121,637 Genitourinary system 119,720

34 Expanding Scope of APN Circulatory System 90,753 Digestive System 90,293 Pregnancy, childbirth and puerperium 90,753

35 Expanding Scope of APN ? Adequate coverage for high volume patient groups 10 NSs Hospice Neonatal ICU NSs Geriatric Operating theatre Renal 14 NSs Diabetic, ICU Obs & Gyn Total = 195 NSs in 38 specialties 8 NSs Stoma 4 NSs Coronary (4) 5 NSs Respiratory / pulmonary

36 Expanding Scope of APN Nurse practitioner (NP) in primary careNurse practitioner (NP) in primary care

37 Expanding Scope of APN NPs focus on primary care: family, adult, pediatric or obs & gyn -- life stagesNPs focus on primary care: family, adult, pediatric or obs & gyn -- life stages –Assessment, promotion of health and prevention of illnesses –Health areas: school, factory, community, GOPD and A&E NSs focus on well-defined health conditionsNSs focus on well-defined health conditions

38 Conclusions

39 Journey to the West Chapter 27

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