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July, 2006 Northeast
Health Background: The problem of recruitment and retainment of health workers outside metropolitan centres is well documented in the Australian literature. Coupled with this is the exponential increase in the incidence of chronic disease and the aging of our population. Initiatives that have been developed to plug gaps in service provision include offering clinical experience rotations to trainee doctors, nurses and allied health professionals, in the hope that they will appreciate the 'good life' that rurality has to offer and once they are fully qualified will return to the area in which they undertook their rural clinical placement rotation. Whilst undoubtedly this initiative has experienced some success, the fact remains that there still are not enough well qualified and experienced health care providers to go around and it is fair to say that this situation is not going to go away. An exciting initiative that has emerged within Australia, which addresses the health care provision crisis, is the advent of the role of nurse practitioner, which is seen as a pivotal and historic development in expanding the scope of professional nursing, and an important contribution to the health and well-being of the Australian community. The nurse practitioner role includes assessment and management of clients using nursing knowledge and skills and may include, but is not limited to, the direct referral of patients to other health care professionals, prescribing medications and ordering diagnostic investigations. The nurse practitioner role is grounded in the nursing profession's values, knowledge, theories and practice and provides innovative and flexible health care delivery that complements other health care providers. The scope of practice of the nurse practitioner is determined by the context in which the nurse practitioner is authorized to practise. Northeast Health Wangaratta (NHW) has undertaken significant capacity building in its nursing division over the past five to ten years in response to the evolving needs of health care in our rural context. As a result we now have many Division 1 & 3 nurses and midwives who are practising at an advanced level and who enjoy productive and innovative interdisciplinary relationships. Their involvement in the Department of Human Services (DHS) nurse practitioner funded projects has meant that significant work has also been undertaken in identifying service areas where patient care could be significantly enhanced by some of our nurses having the extended skills afforded by nurse practitioner endorsement. Built into this process has been a strategic emphasis on stakeholder education and engagement. While there remains substantial community confusion around nursing nomenclature there is strong agreement that many of our nurses undertake highly complex patient care and provide leadership in case management across a variety of health domains. Their most recent research has informed us that there are four key gaps in service delivery in our community and the likelihood of at least two other areas in the next few years:
Need for Extensions to Practice All of the above service areas have been piloted through various DHS funded nurse practitioner projects across Victoria and shown to demonstrate a clear argument for extension to practice. The exception being oncology. The situation at NHW is unique from the metropolitan experience in that our oncology nurses work in a unit at NHW geographically isolated from the Oncology physicians who work in Albury/ Wodonga. These nurses are highly skilled and practise with an advanced level of autonomy. This situation is enhanced by the close collaboration they have with our consultant general physicians. Endorsement as NPs would enable the oncology nurses to respond to their client needs in a much safer and timely fashion when our physicians are not immediately available. It would also identify these nurses as the advanced practitioners that they are and provide more scope for them to be involved in nursing clinical leadership. 1. Critical Care: NHW already has nurses functioning at advanced level in its Critical care Unit (CCU). Fifteen of their nurses have undertaken METS training and a PAR team is under development. NHW is a key partner in the University Of Melbourne Postgraduate Diploma Of Rural Critical Care. NHW nurses who hold this post graduate diploma are in a good position to move onto Masters Qualifications. Being a country hospital they do not have access to a full time intensivist therefore a strong collaborative approach is in evidence between the nursing staff and the medical team. Both these teams indicate that the capacity for a cohort of nurses to prescribe medication would result in a timely response to the changing physiological status of the patients in their care. In addition to this there is a strategic push in their organisation to better support the more junior members of the health team in the general wards particularly overnight and on weekends when the response to deteriorating physiological status can be delayed due to inexperience or lack of available senior medical officers. Having CCU staff who can leave their unit and respond to situations across the organisation with the capacity to prescribe and or admit to the critical care unit is seen to be a smart use of resources and something which in the long run can be sustained by our ready resource of CCU trained nurses coming through the postgraduate diploma course. There is a growing body of Australian and international literature to support this view. 2. Mental Health: Mirroring the experience of CCU the mental health team at NHW have responded to the paucity of specialist medical staff by developing the capacity of the nursing and allied health team. A key role for nurses in mental health is in community interventions and up stream health promotion activities. Many of our community based mental health nurses work at an advanced level providing specialist advice to GPs. The application of evidence based interventions by a multidisciplinary team has seen the development of innovative models of care such as our Integrated Primary Mental Health Team. These nurses work in a collaborative model in GP practices through out the region. Coupled with this NHW has developed a formal support system of education and research with strong linkages to the University of Melbourne. The mental health team have identified several areas of community practice where the capacity to utilise the extended practices of the nurse practitioner endorsement would lead to more timely and appropriate care for the clients. This view is supported by the regional division of GPs and the consultant psychiatrists. 3. Aged Care: NHW stakeholders consistently cite aged care as the domain most in need of nurse practitioners. The NE Division of GPs is quick to point out that the GP alone cannot cope with the demand associated with our aging population. There is much already written in the literature around NPs in aged care being able to respond to changing physical and mental states of community and residential facility based older people. The NE Victoria community is no different and in fact the ABS profile for age in our region shows higher than state average in persons over 65 years.
Benefits to the Community Rural communities are very much aware of the need for innovation and change. Often portrayed as people who resist progress, rural communities are pragmatic. The evolution of collaborative models of nurse practitioner care is seen to be a real and tangible way of maintaining quality health services where they are most threatened. While traditionally the GP has been the cradle to grave provider in country towns the community is only too aware that this is no longer the case. The NHW community is strong in its desire to grow its own skill base, provide local opportunities for its own people and alleviate some of the brain drain of our young and talented to the metropolitan centres. NHE has included local government in its nurse practitioner projects to date so they are aware of the positive possibilities of the role. In addition, its community advisory group are all participants of the current research project and have reported their ideas and support for growing the role of the nurse practitioner in their community. There is no question that the NP role has benefits from many perspectives to our community. In addition, a strong and skilled nursing workforce helps to retain and even attract specialist medical services in rural regions. Underpinning the prospective nurse practitioner roles is a robust population health focus. Working upstream and providing early intervention initiatives is key to any of our endeavours in community based mental health, aged care, wound care, palliative care and so on. As leaders and role models it is a key objective for the prospective NP candidates to acknowledge the social determinants of health as the most significant influence in achieving a well community. In addition to this we are confident that if we build a critical mass of NPs in the NHW organisation they can be used as mentors for growing NPs in some of the smaller district health services in the Hume region. They aim to build their capacity to provide educational support for the Masters studies and offer opportunities to other regional health services to access this. NHW has a strong field of nurses who have been working in an advanced capacity for some time and many of whom already hold post graduate diplomas. Some of its staff have local, regional and state leadership profiles. Many of their prospective NP candidates present their work at state and national conferences. They are mindful that their nurses need to develop their capacity to undertake research. To that end NHW is now a member of the Rural Health Academic Network (RHAN) and through this we hope to grow our research competence.
Education Fundamental to the development of nurse practitioners is the acknowledgement of the need for nurses to be working towards a Masters level qualification and to undertake a clinical internship in preparation for the extended practices inherent in their new role. NHW research has indicated that this is the single greatest barrier to nurses taking up the mantel of NP. The literature is also suggestive of the issue of isolation of individual NPs, burnout and tall poppy syndrome. For rural nurses, the tyranny of the distance, the expense of Masters level education both in dollar terms and time away from family and work is a substantive disincentive to them progressing to NP level. NHW acknowledges that it must address this reality if it is to achieve the Nurse Practitioner objectives.
Our plan • Establish a bank of NPs (three in each service area in order to provide a sustainable service and support each other from burnout and professional isolation). • Link closely with a provider university for online Masters study and work with that university to fund a joint academic appointment to support our cohort of NP candidates across the three/four identified immediate service areas. They have experienced great success with a similar model for the Postgraduate Diploma of Rural Critical Care. After some discussions and examination of particular masters' courses it is proposed that Deakin would be that university. • The enrolment of registered nurses into the course is local response to a national issue and will be a model for other rural communities to learn from. • The individuals who wish to enrol in the Master of Nursing Practice (Nurse Practitioner) course already live and work in Wangaratta and furthermore they intend to retire in this community. Hence, they do not have to rely on a hope that they will return to the area when they are qualified. • The individuals will be enrolling in a cohort group, so that they can study together. This is an important strategy that will enhance the likelihood that they will complete the course of study. • This initiative is a Victorian first, in that it is the first time that a large cohort of students, from a single organization have all enrolled together in a Nurse Practitioner course of study. The education model that NHW is proposing is a first, and if they are careful to document what they do and how they are doing it, it can be emulated by others. • Provide the mandatory clinical pharmacology modules of study by video conference- this has already been agreed to by the University of Melbourne providing they have a group enrolment of approximately twelve students.( Deakin does not proved the pharmacology component ) • Assist the nurses with identifying clinical mentors and provide the necessary resources for on site learning to supplement the theoretical learning. • Deakin will liaise closely with the NP candidates and NHW to develop the clinical practice guidelines (CPGs), which are mandatory for endorsement to practice in each domain. • The strength of this university /hospital partnership is to use a team approach to implement the Master of Nursing Practice (Nurse Practitioner) course in Wangaratta. Thus harnessing the talent and energy of leaders from both organizations, who are deeply committed to its success. • To achieve endorsement in a time frame consistent with our goals, the NP candidates require significant onsite clinical mentorship and support. They are mindful however that in some domains they do not have the capacity to provide this. Some buy in of mentorship and CPG development costs will be necessary.
Funding • NHW wishes to establish a generous funding model to underwrite the costs of this education to our nurses. The cost of a Masters degree sits at around $24,000 per student. Upon endorsement as a NP with the Nurses Board of Victoria, the Nurse Practitioner will be paid a base rate of approximately $36.00 per hour. They argue that the cost to an individual nurse is grossly inversely proportional with the gain to the health service and community of having those skills in the workforce. • NHW proposes to work with Deakin University to build a Public/ Private Partnership model to fund the course fees of the Masters program. To that end they have commenced deliberations with Deakin and the university fundraising department. The goal is to raise $1.5 million over five years. This initiative will have probative value for publicity purposes - the whole cohort can be followed over time, there could be opportunities for individuals to be followed over time, there will be opportunities for the management of Wangaratta to be seen as visionary, progressive, future oriented, and there is an opportunity for the Wangaratta community to be showcased etc. The success of the project will be built on getting our first cohort of NPs across the line, leading to them providing the next level of support for subsequent NPs from our organisation and from other health services in our region. The vision of 'The Champions of the Bush' has synergy with what NHW is trying to do in Wangaratta, and we therefore endorse the project in-principle.
Direct Contacts: Helen
Haines Dr
de Sales Turner
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