redesigning nurses work thomasine d. guberski, phd, crnp associate professor
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Providing Treatment, Restoring Hope
Redesigning Nurses WorkThomasine D. Guberski, PhD, CRNP
Associate ProfessorUniversity of Maryland School of Nursing
Track 1 MeetingSeptember 24, 2007
Slide 2
Scope of the Problem
Increasing number of patients Number of medical officers
Range is 4.1 (Tanzania) to 26.9 (Nigeria) MO per 100 000
Number of nurses Range is 11.3 (Zambia) to 108 (Kenya) per
100 000
World Bank, 2004
Slide 3
Current Care Paradigm
General Care Patients in Stable Condition
Providers Nurses and CO’s
General Care Patients in Unstable Condition
Providers Nurses and CO’s
Patients on ART in Unstable Condition
Providers MO’s and CO’s
Patients on ART in Stable Condition
Providers MO’s and CO’s
Slide 4
Breaking the paradigm
How do we effectively shift to new care paradigm, without losing quality of care? Break the paradigm that ART care must be given
only by MO and CO Implementation of the team model for HIV care Formally increase patient care responsibilities for
nurses The redesign of nursing roles and
responsibilities to more effectively care for patients with HIV/AIDS requires a different level of authority, responsibility and accountability
Slide 5
Current Initiatives
Strengthen community nursing care for all HIV+ patients
Nurses assume primary responsibility for patient triage in all settings
Follow stable patients on ARV therapy in a variety of settings
Train community health workers to assess symptoms
Facilitate transition from episodic to continuity care
Develop, implement and evaluate the nursing roles and responsibilities in the treatment plan for their institution.
Design, implement and evaluate clinic structure and flow for continuity care.
Slide 6
Slide 7
Current Initiatives
Establish nurse-run clinics in which the nurses will provide care to patients across the spectrum of HIV:
diagnose and manage common opportunistic infections assess and manage common signs and symptoms in HIV
infected patients provide community nursing for enrolled patients refer patients for and provide palliative care follow patients on ARV therapy recognize appropriate referral parameters refer patients to the MO/CO as appropriate
Slide 8
Successes and Challenges
Breaking the paradigm that only MO/CO can enroll patients
Improvements in patient flow Nurse run refill clinics Triage in home-based care Nurse run clinics in Rwanda Nurse run clinics in Mombasa Nurse practice acts Sustainability
Slide 9
Slide 10
Viral Suppression Rates on Therapy
92%
8%
Suppressed
Not Suppressed
Two nurse run clinics Rwanda
Slide 11
Percentage of Patients with a Documented OIs at ART Start
46%
24%
30%
None
One
Two or More
(Uganda & Kenya) Total 545 Patients with Documented OI
Number of OI/patient
None
one
2 or more
Slide 12
Shifting the paradigm
How do we effectively shift to new care paradigm, without losing quality of care?
Slide 13
How to Make Paradigm Shift a Reality
Include nurses in all phases of planning and implementation
Shift responsibility for stable ART patient care to nurses Increase MO responsibility for unstable general care
patients Implement nurse triage in all settings Improve recognition of potential OI’s by all nurses Community nurse referral required for all unscheduled,
non-emergency visits Increase education and responsibility of community
health workers Implement paradigm shifting protocols across all settings
Slide 14
Breaking the Provider Paradigm
General Care Patients in Stable Condition
Providers Nurses and CO’s
General Care Patients in Unstable Condition
Providers MO’s and CO’s
Patients on ART in Unstable Condition
Providers MO’s and CO’s
Patients on ART in Stable Condition
Providers Nurses and CO’s
Slide 15
Slide 16
Senior level nurse educators
Thomasine D. Guberski, PhD, CRNPAssociate Professor, UM School of Nursing
Yvelline Auguste, MS, FNP HaitiAmy Bositis, MS, CRM Zambia
Cara Endyke-Doran, MSN, MPH, ZambiaYvonne Henley, AS, RN TanzaniaAlphonse Kajiranga, RN RwandaNike Kehinde, RN, RM, Nigeria
Beatrice Kiama, RN KenyaMarik Moen, MSN, MPH, RwandaBarbara Smith, PhD, RN, FAAN
Professor and Associate Dean for Research UM School Of Nursing
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