Development of Advanced Nursing Practice in Hong Kong: a celebration of ten years ’ work

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Development of Development of Advanced Nursing Advanced Nursing

Practice Practice in Hong Kong:in Hong Kong:

a celebration of ten a celebration of ten years’ workyears’ work

Frances Kam Yuet WongFrances Kam Yuet WongProfessor & Associate HeadProfessor & Associate Head

School of NursingSchool of NursingThe Hong Kong Polytechnic The Hong Kong Polytechnic

UniversityUniversity

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OutlineOutline• Factors that contribute to the development of Factors that contribute to the development of

Advanced Nursing Practice (ANP)Advanced Nursing Practice (ANP)• The scenario of practice by Nurse Specialists (NSs) The scenario of practice by Nurse Specialists (NSs)

in the early 1990sin the early 1990s• The development of NS practice in the late 1990s The development of NS practice in the late 1990s

to early 2000to early 2000

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Factors Contributing to the Factors Contributing to the Development ofDevelopment of

Advanced Nursing Practice Advanced Nursing Practice (ANPs)(ANPs)

• Differentiation of nursing workDifferentiation of nursing work• Nexus of work and profession in a Nexus of work and profession in a

cost containment environmentcost containment environment• Specialization of patient groupsSpecialization of patient groups• Enhancement of nursing educationEnhancement of nursing education

(Wong, 1996)

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(1) (1) Differentiation of Differentiation of Nursing WorkNursing Work

ProletarianizatioProletarianizationn

ProfessionalizatiProfessionalization on

Upgrading of nursing education and autonomy

Nursing work less skilled worker

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(2) (2) Nexus of Work and Nexus of Work and Profession in a Cost Profession in a Cost

Containment EnvironmentContainment Environment

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(2) (2) Nexus of Work and Nexus of Work and Profession in a Cost Profession in a Cost

Containment EnvironmentContainment EnvironmentHuman institution helps to Human institution helps to

mediate between mediate between Knowledge and PowerKnowledge and Power

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(3) (3) Specialization of Specialization of PatientsPatients

• Chronically ill Chronically ill patients become patients become experts of their own experts of their own illnessesillnesses

• Increased level of Increased level of educationeducation

• Increased availability Increased availability of health knowledge of health knowledge in the mass media in the mass media and the weband the web

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(4) (4) Enhancement of Nursing Enhancement of Nursing EducationEducation

• Over 50% nurses Over 50% nurses possess a first possess a first degreedegree

• Many studying for Many studying for masters degree masters degree and doctorate and doctorate degreedegree

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Scenario of Practice Scenario of Practice by NSs by NSs

in the Early 1990sin the Early 1990s Identity searchingIdentity searching

Being distinguished Being distinguished from RNsfrom RNs

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Scenario of Practice by NSs Scenario of Practice by NSs in the Early 1990sin the Early 1990s

The main work involvement of The main work involvement of NSs:NSs:

• Client careClient care• Patient educationPatient education• Staff developmentStaff development• Quality improvement and research Quality improvement and research

Hospital Authority, 1996 and Wong, 1997

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NS vs RNNS vs RN

• Work is NOT subject to Work is NOT subject to routinizationroutinization

• See clients by referralsSee clients by referrals

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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

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(2) (2) Consultation by Consultation by ReferralsReferrals

Professional

BProfessional

AConsultatio

n

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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.

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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.

Dr’s Notes

… to practice [injection] skill on ward.

Home until ready.

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Scenario of Practice in NSs Scenario of Practice in NSs in the Early 1990sin the Early 1990s

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Scenario of Practice in NSs Scenario of Practice in NSs in the Early 1990sin the Early 1990s

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Scenario of Practice in NSs Scenario of Practice in NSs in the Early 1990sin the Early 1990s

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Scenario of Practice in NSs Scenario of Practice in NSs in the Early 1990sin the Early 1990s

• 22 22 NSs appointed in 14 clinical areas in NSs appointed in 14 clinical areas in 19931993

• Definition of nursing specialties was Definition of nursing specialties was somewhat arbitrarysomewhat arbitrary

• No credentialing and regulatory body No credentialing and regulatory body to scrutinize the qualifications of the to scrutinize the qualifications of the NSs and monitor their clinical NSs and monitor their clinical competencecompetence

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The Development The Development of NS Practice in of NS Practice in the Late 1990s to the Late 1990s to

Early 2000sEarly 2000s

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The Development of NS The Development of NS Practice in the Late 1990s to Practice in the Late 1990s to

Early 2000Early 2000• Exemplary work of NS practice, with Exemplary work of NS practice, with

support of researchsupport of research• Service well recognized by the nursing Service well recognized by the nursing

peers and doctorspeers and doctors• Nurse-led clinicsNurse-led clinics• The issue of regulationThe issue of regulation• Room for the APN to be developed in Room for the APN to be developed in

the communitythe community

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Exemplary Work - Research Exemplary Work - Research EvidenceEvidence

• From Senior NS (SNS) Scheme by HA, HKFrom Senior NS (SNS) Scheme by HA, HK• Positive results of SNS from an Positive results of SNS from an

independent evaluation (HA, 1996; Wong, independent evaluation (HA, 1996; Wong, 2001)2001)

• Economic downturn Economic downturn position not position not establishedestablished

Examples on cost-effective Examples on cost-effective and quality care by renal SNS and quality care by renal SNS

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Cost-effective Care (1)Cost-effective Care (1)

Erythropoietin Self-injection

Program• 26 chronic renal failure patients• Saving 225 nurse hours annually

Renal SNS

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Cost-effective Care (1)Cost-effective Care (1)

Braunoderm Vs Betadine Spray

• Same effect• Braunoderm costs HK$0.8 (0.0067 Hr)•Betadine costs HK$6.0 (0.233 Hr)

Renal SNS

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Cost-effective Care (2)Cost-effective Care (2)• Senior Diabetes NSSenior Diabetes NS• Seeing 108 poorly Seeing 108 poorly

controlled diabetic controlled diabetic patientspatients

• 10 (9%) 10 (9%) physicians physicians

• 98 (91%) 98 (91%) managed by Senior managed by Senior Diabetes NSDiabetes NS

(HA, 1996; Wong 2001)(HA, 1996; Wong 2001)

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Leadership Leadership

Care Engineer

Clinical Leader

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Nurse-led ClinicNurse-led Clinic

What is a nurse-led clinic What is a nurse-led clinic

See doctor See doctor To nurse for education

Initial assessment by nurse See doctor

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The Definition of A Nurse-The Definition of A Nurse-led Clinicled Clinic

A NURSE CLINIC A NURSE CLINIC is ais a formalizedformalized and and structured structured health care delivery mode health care delivery mode

involving a nurse and a client. involving a nurse and a client.

THE CLIENT THE CLIENT is an individual and his/her family is an individual and his/her family with health care needs that can bewith health care needs that can be addressed by the addressed by the

nursenurse. .

THE CONSULTATION THE CONSULTATION is initiated is initiated through through referrals referrals from nurses, doctors or other health from nurses, doctors or other health

care professionals.care professionals.

THE NURSE THE NURSE has demonstratedhas demonstrated advanced competenceadvanced competence to practice in the specific health area.to practice in the specific health area.

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The Definition of A Nurse-The Definition of A Nurse-led Clinicled Clinic

THE NURSETHE NURSE functions functions independently independently and/orand/or interdependently interdependently with other health care team members with other health care team members

for at least 80% of his/her work involvement. for at least 80% of his/her work involvement.

HE/SHE HE/SHE is supported by a multidisciplinary team, is supported by a multidisciplinary team, and can make and can make referralsreferrals to other health care professionals to other health care professionals

to address the health care needs of the clients. to address the health care needs of the clients.

THE MOSTTHE MOST important and key interventions are important and key interventions are nursing therapeutics which encompass nursing therapeutics which encompass

assessmentassessment and and evaluationevaluation, , treatmenttreatment and and proceduresprocedures, , health teaching/counselinghealth teaching/counseling, and , and case managementcase management. .

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The Definition of A Nurse-The Definition of A Nurse-led Clinicled Clinic

THE NURSE CLINIC differs from the doctor clinic in THE NURSE CLINIC differs from the doctor clinic in its less reliance on the use of medications, its less reliance on the use of medications,

but the employment of but the employment of a holistic approacha holistic approach in addressing the needs of the clients and their in addressing the needs of the clients and their

families. families.

THE NURSE determines the THE NURSE determines the duration of each duration of each consultationconsultation and the time lapse between and the time lapse between

consultations consultations according to clients’ needs.according to clients’ needs.

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Future DevelopmentFuture Development

To link professional recognition To link professional recognition with practicewith practice

To expand the scope To expand the scope of practice of APNof practice of APN

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Linking Professional Linking Professional Recognition with PracticeRecognition with Practice

To develop a certificate process to To develop a certificate process to validate and standardize the validate and standardize the qualifications and practice qualifications and practice competencies of the advanced competencies of the advanced practicepractice

– To protect the public’s health To protect the public’s health – To ensure the credibility of advanced To ensure the credibility of advanced

practising nursespractising nurses

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Expanding Scope of APNExpanding Scope of APN

Neoplasm93,999 Respiratory system

121,637

Genitourinary system119,720

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Expanding Scope of APNExpanding Scope of APN

Circulatory System90,753

Digestive System 90,293

Pregnancy, childbirth and puerperium

90,753

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Expanding Scope of APNExpanding Scope of APN

? ? Adequate coverage for high volume Adequate coverage for high volume patient groupspatient groups

10 NSsHospice

Neonatal ICU

11-12 NSsGeriatric

Operating theatreRenal

14 NSsDiabetic, ICUObs & Gyn

Total = 195 NSs Total = 195 NSs in 38 specialtiesin 38 specialties

8 NSsStoma

4 NSs Coronary (4)

5 NSsRespiratory / pulmonary

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Expanding Scope of APNExpanding Scope of APN

• Nurse practitioner (NP) in primary Nurse practitioner (NP) in primary carecare

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Expanding Scope of APNExpanding Scope of APN

• NPs focus on primary care: NPs focus on primary care: family, adult, pediatric or obs & family, adult, pediatric or obs & gyn -- life stagesgyn -- life stages– Assessment, promotion of health Assessment, promotion of health

and prevention of illnessesand prevention of illnesses– Health areas: school, factory, Health areas: school, factory,

community, GOPD and A&Ecommunity, GOPD and A&E• NSs focus on well-defined health NSs focus on well-defined health

conditionsconditions

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ConclusionsConclusions

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Journey to the WestChapter 27

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