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Developing Critical Care Fellowship Program -Roadmap to fellowship for Critical Care Nurses

Dr. Esther WONG PhD; MSc; RM; RN President, HK College of Critical Care NursingAdjunct Professor, Girne American University14 November 2014

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CONTENT

I) An Introduction of PHKAN & Academy Colleges

II) Memberships under Hong Kong College of Critical Care Nursing (HKCCCN)

* Basic Critical Care Nursing Training * Higher Training * Competency Framework, APN(CC) *APCCN Certification Examination

III) APN to become a Fellow

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I) An Introduction of PHKAN & Academy College

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Hong Kong Academy of Nursing (HKAN)• At present, “Advanced Practice Nurse (APN)” is just a job title and

not yet a registered qualification in HK . The establishment of the HK Academy of Nursing (HKAN) is to regulate the nursing practice and to promote professional development of APNs in the specialty areas.

• As the new roles in advanced nursing practice emerge, we require

additional legislation and regulation because we want the “APN” title and the “APN” scope of practice to be protected

Reason: This regulation is intended to safeguard the public by ensuring that nurses meet the advanced standard levels of knowledge and education. The ultimate GOAL is to improve the health of people in Hong Kong.

• To achieve this legitimate coverage and protection under the legal system:

2008 – HKAN Preparatory Committee. 2011 - The Provisional HKAN established and has activated a task

force to draft relevant ordinance with the assistance of legal advisors recently.

• After the bill is passed, nurses with advanced practice nursing qualification will be registered as specialists - APNs.

In preparing for that, critical care nurses are required to follow the roadmap to fellowship.

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The PHKAN Founding Council in 2011

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Academy Colleges underThe Provisional Hong Kong Academy of Nursing (PHKAN)

1. Hong Kong College of Medical Nursing2. Hong Kong College of Surgical Nursing3. Hong Kong College of Community & Public Health Nursing4. Hong Kong College of Cardiac Nursing 5. Hong Kong College of Critical Care Nursing 6. Hong Kong College of Emergency Nursing7. Hong Kong College of Perioperative Nursing8. Hong Kong College of Mental Health Nursing9. Hong Kong College of Paediatric Nursing10. Hong Kong College of Gerontological Nursing11. Hong Kong College of Midwives12. Hong Kong College of Education & Research in Nursing13. Hong Kong College of Nursing & Health Care Management14. Hong Kong College of Orthopaedic Nursing

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The Provisional Hong Kong Academy of Nursing&

Hong Kong College of Critical Care Nursing

Processing its Bill to become Statutory HK Academy of Nursing

Academy College of the Provisional Hong Kong Academy of Nursing

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PHKAN Council Members pictured with advisors and guests prior to the

1st council meeting on 9th Nov. 2011

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Fellows of The Provisional Hong Kong Academy of Nursing – Critical Care

12 May 2012

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Milestone• A Grandfathering Scheme from 2012-2014.

• After 2014 – Pass examination to become a full member - APN.

• A full member with contribution to be recommended, then go through assessment to become a fellow.

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Fellows Under Grandfathering Scheme by 2014

Year * PHKAN * HKCCCN 2012 --------- 1489 ------------109 2013 --------- 796 ------------ 47 2014 --------- 1040 ------------ 46------------------------------------------------------ 3325 202 Remarks: 193 in 2014 because 9 retired

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What is an Advanced Practice Nurse?

International Council of Nurses (ICN) defines an Advanced Practice Nurse / Nurse practitioner (APN/NP) as “a registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which s/he is credentialed to practice” and requires education at a master’s level. (http://www.icn-apnetwork.org/)

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Background InformationNursing Manpower & Career Progression Model

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ICU Statistics

No. of Beds under HA Over 27,800

Staff and organization 53,000 staff in 7 Clusters & all part of a single organization

No. of ICU Beds >220 under HA (+Private250-260 )No. of ICU/HDU nurses under HA & in private hospitals in early 2011

Over 860 in HA (+ Private - 950 )

Annual ICU admissions under HA 12000-13000

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New Career Progression Model (2008)New Career Progression Model (2008) TThe 3-tiers career pathway for a critical care nurse

Nurse Consultant Department Operations Manager

Advanced Practice Nurse

Ward/Unit Manager

Registered Nurse(Specialty Nurse)

Registered Nurse (Pre-Specialty)

Registered Nurse (Beginner)

Clinical Management

Career

Tier 3ANP Level

Tier 2ANP Level

Tier 1

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CGM(N)CGM(N) RewardReward

GM(N)GM(N)

Additional Additional Increment/ Increment/ PromotionPromotion

Specialty Specialty NurseNurse

7 7 –– 10 Years 10 Years

1) Specialty 1) Specialty QualificationQualification

2) Experience2) Experience3) Performance3) Performance

3r3rdd

4 4 –– 6 Years 6 Years Practice NursePractice Nurse(Pre-Specialty(Pre-Specialty))

Additional Additional IncrementIncrement

1) Generic 1) Generic CompetencyCompetency

2) Specific 2) Specific CompetencyCompetency

3) Experience3) Experience4) Performance4) Performance

2nd2nd

3 3 YeaYearsrs

Practice Practice NurseNurse(Beginner)(Beginner)

Annual Annual IncrementIncrement1st1st 1) 1)

PreceptorsPreceptorshiphip

2) 2) PerformanPerformancece

Nurse Nurse ConsultantConsultant**

PromotionPromotion1) Clinical Mgt 1) Clinical Mgt

Leadership ExpertiseLeadership Expertise2) Experience2) Experience3) Performance3) Performance

5th5th

18 18 Years Years ++

Advanced Advanced Practice Practice NurseNurse**

PromotionPromotion1) Sub-Specialty/Mgt 1) Sub-Specialty/Mgt

QualificationQualification2) Higher Academic 2) Higher Academic

QualificationQualification3) Experience3) Experience4) Performance4) Performance

4th4th

12 12 Years Years ++

* * Management allowance for designated positionsManagement allowance for designated positions

MilestonesMilestones

Career Progression

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II) Memberships under Hong Kong College of Critical Care Nursing

(HKCCCN)

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Only Grandfather Fellow Members in 2012 - 2014They are also fellows of PHKAN

From 2014 onward, categories of memberships:(1) Associate Member(2) Full Member(3) Fellow Member(4) Honorary Fellow Member

Hong Kong College of Critical Care Nursing(HKCCCN)

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1. Associate Membership:

Criteria for RN to apply for an Associate Membership:

• RN who has registered with the Nursing Council of Hong Kong (NCHK)

• RN who is currently practicing in the Intensive Care setting at time of application;

• RN who is recommended by two Fellows of HKCCCN.

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Trainees

Registered Nurses who are interested in Critical Care Nursing may apply to be trainees

(1) Basic Critical Care Nursing Training - within 2 years

(2) Higher Critical Care Nursing Training - within 4-6years

Hong Kong College of Critical Care Nursing

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Basic Critical Care Nursing Training• 100 Hours Theoretical Input 19 Topics included:

- Elementary Critical Care Nursing (ECG, Resp., CVS, RNT) - ACLS - Patient documentation

- Workplace violence - Nursing standard & audit- Pain management - Health information system- Wound management - Basic infection control- Incident / accident reporting - Crisis management- Pharmacology for nurses - Legal aspects- Team management - communication skill- Occupational Safety and Health

• Logbook with at least 90% of the items listed signed by HKCCCN ‘s Nursing Fellow / Advanced Practice Nurse or above in the clinical care area

Hong Kong College of Critical care Nursing

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Eligibility for Advanced Practice Critical Care Nurse (APCCN ) Certification Examination

(Refer to HKCCCN Policy Handbook):

• Holder of a valid RN license certified by the NCHK.• RN who has worked in critical care area for at least 5 years, i.e. in direct bedside care of acutely and/or critically ill adult patients

in the most recent 5 years uninterruptedly.• RN who has completed a recognized critical care nursing program..• An associate member who can provide evidence of supervised training

in ICU setting (in form of Basic Log Book – 90% signed) to demonstrate that the core contents stipulated by HKCCCN are covered.

• RN who has fulfilled the requirement of a minimum of 2000 clinical practice hours as stipulated by HKCCCN within the previous 3 years period, of which 1000 hours accrued in the most recent one year.

• Holder of a Master’s Degree in Nursing or related practice.

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Higher Critical Care Nursing Training

• Specialty Training – structured critical care program. • Logbook with items listed signed by an Academy Fellow,

Member (APN) or above in the clinical specialty area• Successfully passed the Full Membership Examination set

by HKCCCN.• May apply to be registered as Advanced Practice Nurse

(APN).

Hong Kong College of Critical Care Nursing

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Higher Training Proposed Nursing programs – Theory input

1. Master in Nursing 2 years (360 hrs), include a Specialty-related Certificate or Diploma Course (120-150

Hrs.) e.g. IANS PRCC ICU Course CUHK ICU Diploma Course HKU ICU Diploma Course 2. Advanced Health Assessment Module (50 Hrs.) e.g. Physical assessment course for all nurses 3. Advanced Specialty-related Enhancement Module(50 Hrs.) e.g. Advanced Critical Care Nursing (ACCN) Course) for

ICU nurses4. Clinical Skill Enhancement Course (50 hours) e.g. IANS – Clinical Skill Enhancement Course for APNs. Total – 510 hours

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Basically 500 Hrs Theory & 500 Hrs. Practicum

The 500 Hrs Theory Input includes:1/3 Basic Core1/3 Advanced Practice Core1/3 Specialty Core

HKCCCN requires >500 Hrs. RN has to fulfil the requirement of a minimum of 2000

clinical practice hours as stipulated by HKCCCN within the previous 3 years period, of which 1000 hours accrued in the most recent one year.

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• Program aims to develop the competence of registered nurses in intensive care nursing in order to ensure a high standard of specialized care for critically ill patients.

• Academic level equivalent to Qualification Framework (QF) level 6 as defined by the Hong Kong Council for Accreditation of Academic & Vocational Qualifications (HKCAAVQ)

• Duration:– 18 study days– 14 weeks of clinical practicum

Highlights of the Post Registration Certification Course (PRCC-Intensive Care Nursing)

offered by Employer

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Key Contents of PRCC(ICU)

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:•Pathophysiology and critical illnesses of major organ /systems•Psychosocial perspectives associated with critical care•Pharmacology•Evidence based practice •Quality management•Legal & ethical issues in critical care

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Nursing Specialty (Intensive Care Nursing)

Specialty Standards

Scope of Practice

ProfessionalKnowledge

Specialty Training

Specialty Nurse Model

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HKU Master of Nursing (Part-time)

• A 2-year program with 6 core modules (120 hours), 4 elective modules (80 hours) and either a clinical practicum or dissertation (200 hours), A total of 400 hours

• Example of available track:– Critical Care Nursing – Public Health– Health Services Development & Planning

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HKU Master of Nursing (Critical Care

• Advanced Practice Nursing Roles in Critical Care

• Managing clients with complex critical care problems

• Therapeutic Nurse-client relationship in Critical Care

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Characteristics of Each Module

• Advanced Practice Nursing Roles in Critical Care:– Focus on professional role development

• Managing clients with complex critical care problems:– Focus on management of complete episode of care

independently with the multidisciplinary healthcare team

• Therapeutic Nurse-client Relationships in Critical Care:– Focus on therapeutic interaction to effect client’s change in

health behaviour, counseling, emotional support to clients and their families and empowerment

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Contents of the Examination -The

Competencies Framework (APN – Critical Care)

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What are included in the framework?

The framework embraces a full range of skills, which are the generic features of advanced nursing practice: They are clinical skills with the use of sound clinical knowledge in practice; critical thinking; clinical judgment and decision making skills; coaching and mentoring skills; research skills; changing practice skills; and clinical/professional leadership.

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6) Enhancing professional

and personal attributes of general and

advanced practice

5) Managing and negotiating innovative and effective

approaches to care delivery

4)Enhancing quality

assurance and improvement

3) Demonstrating effective

leadership and teamwork

2)Enhancing therapeutic

nurse-client relationships

1) Managing clients

with complex conditions

Six Domains

Six Domains of Competency Framework APN(CC)

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Hong Kong College of Critical Care NursingThe Competency framework of APN(CC) consists of six domains:1) Managing clients with complex conditions;

2) Enhancing therapeutic nurse-client relationships;

3) Demonstrating effective leadership and teamwork;

4) Enhancing quality assurance and improvement;

5) Managing and negotiating innovative and effective approaches to care delivery; and

6) Enhancing professional and personal attributes of general and advanced practice.

SIX domains (A total of 72 statements)

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APCCN Certification Examination*Format and presentation of the examination questions - MCQ (150 Questions) in 3 hours Cover all (6) domains of the Competency Framework

for Advanced Practice Nurse (Critical Care)

1) scenario-based or independent formats (35-40%), and independent questions (60-65%).

2) Taxonomy for questions – 3 Cognitive Ability level : knowledge/comprehension (Around 25%), application Around 25%; and critical thinking (Around 50%).

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Examples of Critical Thinking• Ability to judge the relevance of data.• To deal with abstraction and to solve problem e.g.

identifying priorities of care or evaluating the effectiveness of intervention.

• To identify cause-and-effect relationships.• To distinguish between relevant and irrelevant

data.• To formulate valid conclusions• To make judgments about the needs of patients.

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2. Full Membership of HKCCCN & PHKAN(Earned membership)

1) A Master’s Degree holder who can2) pass the APCCN Certification

Examination will become a full member

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3. Fellow Membership of HKCCCN & PHKAN(Earned fellowship)

Requirements for a Full Member to become a Fellow Member:

• A Full member of HKCCCN & PHKAN;• conduct of his/her practice has been consistently

good;• who has demonstrated significant contributions in

nursing practice and/or service development .• has passed the assessment stipulated by HKCCCN. • Recommended by HKCCCN to be fellow member

of PHKAN as well.

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III) An APN to Become a Fellow

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Earned fellowshipRecommended by HKCCCN to be fellow member of

PHKAN: • APN- A Full member of HKCCCN & PHKAN;• with significant contributions; • has passed the assessment stipulated by HKCCCN.

Honorary Fellow (By Recommendation)• Eminent figure who has made a tremendous

impact on: - clinical services; or - art or science of nursing ; or - HKCCCN/PHKAN

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Nurses in ICU

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Same as countries overseas, the scope of the clinical roles & functions of RN(CC) in HK can be summarized as follows:

1) Perform continuous patient assessments. 2) Provide patient physical care. 3) Administer and manage patient medication. 4) Manage technical equipment. 5) Assist in performing special procedures. 6) Advocate client (patient and/or family included) needs 7) Collaborate with multidisciplinary healthcare team members.8) Maintain safe environment for patient and staff. 9) Document medical and nursing management10) Promote professional development.

10 Functions/Duties and tasks performed by critical care RNs

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Extended & Expanded Roles

• Extended roles were viewed as tasks previously performed by medical staff which had been delegated down to nurses.

'Extendect roles relate back to what nurses had been handed down from medical staff,

something which nurses have done beyond basic training. (N)

• Expanded roles were viewed as a growth of the nurses' role according to the needs of the patients, technological advances and the increasing experience and expertize of the nurse.

Expanded roles are something more nebulous, something which has grown as nursing and patients needs have grown'. (N)

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ICU NursingAshworth (1990) suggested that nurses in ICUmay use the technology available to benefitpatients, whilst emphasizing that the majorattribute of nursing in this field is the humanizinginfluence, conveyed by constant presence withthe patient. This presence renders the nurse thestaff member best placed to carry out the closemonitoring, psychological support and coordinatingaspects that were all listed as important to produce

holistic care from the ICU team.

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»What are the

specialized Skills?

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A study in UK on Expanded Roles

• The UK Study revealed that:Substantial support for developing the roles of

critical care nurses in the following activities:1 - Cannulation;2 - venepuncture;3 - ordering blood tests and x-rays;4 - performing physiotherapy;5 - inserting arterial lines;6 - performing elective cardioversion;7 - thrombolysis treatment;and8 - intubation.

Source: Exploring the expanded roles of nurses in critical care(1999)

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Skills actively undertaken by nurses, by site in another UK Survey (1)

Helen G. Goldman (1999),Participants of a survey were asked whether the following skills were

considered to be part of the nurses’ role in the unit where they worked - reflected that 63% - 100% said they did for each skill.

1 – Weaning patients from ventilators.2 – Extubation of patients.3 – Pulmonary capillary wedge pressure measurements.4 – Cardiac output studies.5 – Emergency defibrillation.6 – Management of haemofiltration. Source: Role expansion in intensive care: survey of nurses’ views

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Other extended role skills

Cont’d Helen G. Goldman (1999),• obtaining specimens;• ordering blood tests;• arterial blood gas sampling;• venepuncture;• limited prescribing; and• administering boluses from epidural infusions.

Source: Role expansion in intensive care: survey of nurses’ views.

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Expanded & Extended Roles of Nurses in Hong Kong

• How far nurses can go in Hong Kong?

1 - What are the Specialized Skills?2 - Any specific role expansion activities?3 - Do both doctors and nurses in favour of

nursing role developments?4 - How to maintain the competence?5 - Are these need-driven roles or they are

nurses’ desire to meet the needs of patients?

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ANP & APNAdvanced Nursing

Practice &Advanced Practice

Nurses

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What is an Advanced Practice Nurse?

The seven thematic units that formed the generic features of the advanced nursing practice developed by Mintzoukas & Watkinson S. in 2007 (p.32) after extensive systematic review of literature were:

1 - the use of knowledge in practice; 2 - critical thinking; 3 - clinical judgment and decision-making skills; 4 - professional leadership and clinical inquiry; 5 - coaching and mentoring skills; 6 - research skills; and 7 - changing practice. Advanced Practice Nurses are expected to be able to

master all the skills.

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The Operational definitions

of APN

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The Nursing and Midwifery Council (NMC) (2005) in U.K. published the operational definition of APN

APNs are highly skilled nurses who can perform the following:• take a comprehensive patient history;• carry out physical examinations;• use their expert knowledge and clinical judgment to identify potential diagnosis;• refer patients for investigations where appropriate;• make a final diagnosis;• decide on and carry out treatment, including the prescribing of medicines, or refer

patients to an appropriate specialist;• use their extensive practice experience to plan and provide skilled and competent

care to meet patient’s health and social care needs, involving other members of the healthcare team as appropriate;

• ensure the provision of continuity of care including follow-up visits;• assess and evaluate, with patients, the effectiveness of the treatment and care

provided and make changes as needed;• work independently, although often as part of a healthcare team;• provide leadership; and• make sure that each patient’s treatment and care is based on best practice.

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Operational Definition of APNs in HKHKAN will work on the operational definition for APNs in

Hong Kong basing on the competencies stipulated, it will not be identical to other very well developed countries in which their Nurse practitioners diagnose, prescribe and refer.

NURSING as a body of knowledge changes according to the development in science and technology.

Nursing is striving to change from medical model of giving care to nursing model, where the emphasis is on the patient as a person and not only on the disease.

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Types of APNs in HK

To be in line with the global specialization trend • NS - HA had Nurse Specialist piloted in ICU in 1992 The Chinese University of Hong Kong organized the first tertiary level

Diploma Course in acute care nursing in 1995.

• APN - HA had Advanced Practice Nurse piloted from 2003 to January 2006. HKACCN pioneered a commissioned Program (The program was conducted

by Australian critical care nursing experts) on Advanced Critical Care Nursing in 2001 through 2007 with the last 4 years being a program conducted in collaboration with HA.

By 2014 – about 170 NS/APN/NO (Critical Care)

• Nurse Consultants (NC) –positions were first appointed in 2009

(Pilot Study). By 2014 – a total of 6 NC (Critical Care).

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As at October 2012 in HA

• There are altogether 171 APN/NO/NS working in ICU and only 3 NC (Critical Care) appointed.

• 4000 APNs & 60 NCs in all specialties of all hospitals.

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Intensive Care Nursing : 3 tiers Service Care Model

We focus on provision of timely care to critically ill patients and their relatives with expert preventive and resuscitative interventions. The ultimate goal is to sustain life and aid recovery

although transition to facilitation of peaceful death will be included if condition indicates.

Differentiation of ranksLevels of Service delivery Complexity of interventionsComplexity of interventionsIdentification of improvement opportunities with influences to cluster level

• Be sensitive to professional service development globally and to benchmark to local practice.

• Initiate and evaluate changes based on evidence to enhance quality of service

• Initiate clinical protocol and monitor their effects

Expert care to enhance clinical outcomes• Manage complex ICU cases and difficult situations e.g.

patients with multi-organs failure & appropriate use of technology to achieve optimal care.

• Initiate and accept nursing referrals e.g. patients with high MEWS score, wound care, & endo-tracheal tube care etc.

• Proactive out-reach support to specific and complex cases.• Lead cluster specialty trainings and hospital critical care

knowledge and skills training to optimize patient cares.• Empower APNs to assure quality critical care standards.

Implementation of continuous improvement

• Participate in changes actively

• Adopt team cohesion measures

• Conduct quality improvement process

Coordination of complex critical care • Act as a resource person and mentor to staff• Assure holistic care with appropriate staff

allocation matching skill level and patient complexity

• Organize and participate in cross-disciplinary care

• Participate in organization of staff training

• Monitor provision of care standards in the unit.

Implementation of safe practices

• Be compliant with practice guidelines and protocols

• Be assertive to clarify doubtful practices.

Individual holistic patient care

• Provide holistic cares to critically illpatients to enhance recovery.

•Act as trainer to novice and student.

NC(DOM-

Managementsupport &

shared governance)

NS/NO/APN(WM-Management support)

Specialty RN

A Three Tiers Service Care Model for Nurse Consultant Service Model in Intensive Care

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Nurse Consultants

Key Roles

* Manage complexities.

* Lead changes in traditional care process

* Empower staff – facilitate staff competency in delivering complex patient care.

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NC

APN

Nurse Consultant (NC)

1. Be an expert consultant on complex care2. Initiate and participate in Service

planning and development3. Establish mechanism for evaluating

service quality4. Lead specialist education development5. Cultivate a spirit of inquiry to support

knowledge development and transfer.6. Direct research utilization & EBNP

implementation.

Service Outcomes

Patient Outcomes

Advanced Practice Nurse (APN)

1. Offer individual and direct specialty care

2. execute service initiatives3. provide specialist education4. maintain service quality5. Implement and transfer specialty

knowledge

Roles, scope of practice and level of expertise between NC and APN

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Nurse Consultant PilotBackgroundBackground

NC emerged in HK in early 2009 NC emerged in HK in early 2009

Pilot Study - 7 NCs have been appointed in 5 Pilot Study - 7 NCs have been appointed in 5 clinical specialties : clinical specialties :

Community Psychiatric, Community Psychiatric, Continence, Continence, Diabetics, Diabetics, Renal, and Renal, and Wound and Stoma Care. Wound and Stoma Care.

An evaluation study of the pilot implementation of the new NC An evaluation study of the pilot implementation of the new NC post in HA was conducted by CU from post in HA was conducted by CU from July and July and September 2009.September 2009.

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Findings from the Evaluation Study

The Review and Evaluation of the Pilot Implementation of the new NC post in the HA conducted by the Chinese University of Hong Kong (2009) has delineated:

• the clinical work involvement of the NCs with expert practice (47.7%), and

• service development (35.0%) ranked the top in terms of time involvement, followed by

• education (8.7%), • continuous quality improvement (5.0%)

and • research (3.6%).

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Continuous Quality Improvement (5.0%) quality control of service standard, protocol development and implementation

Research (3.6%) promote & implement evidence-based practice

Education (8.7%) staff supervision, in-service education, community education

Service Development (35.0%) Development of care delivery model, facilitating intra- and inter-disciplinary and cluster service collaboration, initiating new service projects, strengthening hospital-community interface

% = observed time spent in each role

Expert Practice

Education

Research

Service Development

Continuous Quality Improvement

Expert Practice (47.7%) expert clinician / consultant, complex patient care patient risk identification /stratification, care coordination

NCs’ Roles and Scope of Practice

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RN: ‘Doing things well’Specialist: ‘Doing things better’NC: ‘Doing better things’ Maylor (2005)

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The Way Ahead

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The way ahead

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Through innovation, collaboration and regulation

…….. our dreams come true.

Excellence in Nursing

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Both the medical and nursing discipline need to grow. Critical care doctors and nurses are team mates in the ICU. With the changing roles of nurses, it’s hoped that:WE can workcollaboratively, complementarily and harmoniouslyfor the care of our critically ill patients.

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REFERENCES• Ashworth P 1990 High technology and humanity for intensive care.

Intensive Care Nursing 6 (3): 150-160• Goldman H.G.(1999) Role expansion in intensive care:survey of

nurses’ views. Intensive and Critical Care Nursing (1999) 15, 133-323.• Bowler S. & Mallik M. (1998) Role extension or expansion : a

qualitative investigation of the perceptions of senior medical and nursing staff in an adult intensive care unit. Intensive and Critical Care Nursing (1998) 14, 11-20.

• Baggs J G 1989 Intensive care unit use and collaberation between nurses and physicians. Heart and Lung 18 (4):332-338

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Welcome to visit our websiteWelcome to visit our websitewww.hkcccn.org.hk

Dr. Esther WONG e-mailDr. Esther WONG e-mailestherwongyeehing@yahoo.comestherwongyeehing@yahoo.com

Thank YouThank You

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