Framework
for the
This document was prepared by: Catherine Duck and Irene Murphy May 2014
Gippsland Region Palliative Care Consortium c/- West Gippsland Healthcare Group 41 Landsborough St, Warragul 3820 Tel: 03 5623 0684
Table of Contents
1! Purpose ... 1!
2! Background ... 2!
Gippsland ... 2
!
Palliative Care in Gippsland ... 2!
Specialist Palliative Care Consultancy Service in Gippsland ... 3!
The role of Nurse Practitioner – a brief history ... 4!
Nurse Practitioner Candidate ... 4
!
Nurse Practitioner Candidacy Program ... 5!
Palliative Care Nurse Practitioner Program in Gippsland ... 5!
3! Palliative Care Nurse Practitioner Candidacy Program in Gippsland ... 6!
Governance ... 6!
Appointment of sub-regional NPCs ... 7!
Obligations of the sub-regional NPC ... 7!
Steering Committee ... 8! Sustainability ... 9! Risk management ... 9! Dispute resolution ... 10! Complaints ... 10! Performance Management ... 10!
4! Methodology of the Nurse Practitioner Candidacy Program ... 12!
The role of the NPC in Gippsland ... 12
!
The knowledge, skills and attributes of the NPC in Gippsland ... 12!
Relationship network ... 14!
Referral and exit pathways ... 15!
Clinical internship ... 16
!
Specialist clinical placements and supervision ... 16!
Nurse Practitioner Mentor ... 17!
Professional internship ... 17!
5
!
Reporting ... 18!
Statement of Intent ... 18!
Personal Learning Plan ... 18!
Candidacy Program Report ... 19!
Case Studies during the Program ... 19
!
Case Study presentations to expert panel ... 19!
Logbook ... 20! Timeline ... 21! Program Logic ... 22
!
Appendices ... 23! Appendix 1.! References ... 23! Appendix 2.! Abbreviations ... 25! Appendix 3.! Definitions ... 26!Appendix 4. Palliative Care Nurse Practitioner Candidacy Program Steering Committee - Objectives ... 28!
Appendix 5.! Risk Management Matrix ... 29!
Appendix 6.! NPM - Key objectives, duties and responsibilities ... 30!
Appendix 7.! Clinical Supervision Agreement ... 31!
Appendix 8.! Mentorship Meetings: Agenda ... 32!
Appendix 9.! Nurse Practitioner Candidate Activity Report ... 33!
Appendix 10.! Nurse Practitioner Candidacy Clinical Mentor Report ... 34!
1
1 Purpose
The purpose of this Framework for the Palliative Care Nurse Practitioner Candidacy Program (Framework) is to:
• identify and articulate the clinical and professional components of the Palliative Care (PC) Nurse Practitioner (NP) Candidacy Program (Program) in Gippsland; • identify and articulate the responsibilities of stakeholders in managing and
supporting the Program; and to
• assist Nurse Practitioner Candidates (NPCs) in their clinical and professional
preparation for successful endorsement as NPs by the Australian Health Practitioners Regulation Agency (AHPRA).!
The Framework aligns with:
• Nurse practitioner standards for practice (Nursing and Midwifery Board of Australia); and
• Safety and Quality Improvement Guide Standard 1: Governance for Safety and Quality in Health Service Organisations (Australian Commission on Safety and Quality in Health Care).
See Appendix 11 forNurse practitioner standards for practice (Nursing and Midwifery Board of Australia).
2 Background
Gippsland
The Gippsland region is extremely diverse and covers an area of 41,375 square kilometres (18.3% of Victoria), from metropolitan Melbourne to the New South Wales border in the east. The distance from Mallacoota to Melbourne CBD is approximately 516km. In 2011, the
estimated resident population in Gippsland was 269,791 persons or 5% of Victoria’s total population1.
The proportion of the population aged 65 or above is higher in Gippsland compared with Victoria as a whole2, and it has a higher than average percentage of Aborigines3. The number of immigrants is the lowest of all Victorian regions.
Gippsland also rates the lowest of all regions on a number of health indicators, including smoking (highest rate in the state), male life expectancy, psychological distress, and rates of disability. The region has the highest rate of low birth weight babies and children at
developmental risk, and the highest rate of drug and alcohol clients. The rate of inpatient separations is the highest of all regions and private hospital use is the lowest. GP attendances are slightly below average, while emergency department presentations and primary care type presentations are the highest of all regions4.
Palliative Care in Gippsland
There are nine funded specialist community palliative care services in the Gippsland region, based at:
• Bairnsdale and Lakes Entrance in Eastern Gippsland; • Sale and Yarram in Wellington;
• Morwell and Warragul in Central West; and
• Leongatha, Wonthaggi and San Remo in Southern Gippsland.
Koo Wee Rup Health Service, Omeo District Health, Orbost Regional Health and South
Gippsland Hospital all provide unfunded generalist palliative care services and there are also a number of smaller bush nursing services in the East Gippsland area.
There are eleven designated palliative care inpatient beds in the region located at Bairnsdale (1), Sale (2), Traralgon (4), Leongatha (1), Wonthaggi (1) and Warragul (2).
1 Department of Planning and Community Development, State Government of Victoria Victoria in Future 2012 Data Tables 2Ibid
3 Department of Health, State Government of Victoria Local Government Area Profiles, Gippsland Region 2012
http://www.dpcd.vic.gov.au/home/publications-and-research/urban-and-regional-research/census-2011/victoria-in-future-2012/VIF-2012-One-page-Profiles Retrieved September 2013 pg. 101
3
Map 1. Location of palliative care services – Gippsland region
Specialist Palliative Care Consultancy Service in Gippsland
Since 2007- 08 the Gippsland Region Palliative Care Consortium (GRPCC) has coordinated visits from metropolitan-based palliative medicine specialists (Calvary Health Care Bethlehem, Monash Health and Peninsula Health) to the region.
The visiting palliative medicine specialists have also provided: • secondary consultations;
• education for health professionals;
• training and support for the implementation of the end of life care pathway (PICD); and
• participation in multi-disciplinary team meetings at some local palliative care services.
The GRPCC has enhanced the consultancy service by providing funding to lead member services to enable the employment of Nurse Practitioner Candidates (NPCs). With the supervision, support and clinical guidance of the regional Nurse Practitioner Mentor (NPM), they provide a sub-regional specialist palliative care service.
The role of Nurse Practitioner – a brief history
The first NP programs emerged in the 1960s in the United States and Canada in response to the limited access to health care services of specific populations and regions. The Australian movement began in New South Wales in 1998 after the introduction and amendment of state legislation. Other jurisdictions followed and NP roles are now being introduced in the delivery of health care across Australia5.
An NP is a registered nurse who is educated and authorised to function autonomously and collaboratively in an advanced and extended clinical role. The role includes assessment and management of clients and may include but is not limited to the direct referral of clients to other health care professionals, prescribing medications and ordering diagnostic
investigations. The NP role is grounded in the nursing profession’s values, knowledge, theories and practice and delivers evidence-based, innovative and flexible health care that
complements that of other providers. The NP demonstrates dynamic practice, professional efficacy and clinical leadership6.
The NP’s scope of practice is determined by the context for which the NP is endorsed and aligned with the needs of her/his employer and client base.
The title ‘Nurse Practitioner’ is protected, preventing its use by anyone not endorsed by the Nursing and Midwifery Board of Australia (NMBA)7. As of December 2013, there were 1004 authorised NPs nationally, with 168 in Victoria8.
Nurse Practitioner Candidate
A NPC is a highly experienced registered nurse employed by a service or organisation in an expanded role while they meet the academic and clinical requirements for endorsement as a NP9.
The preparation of a NPC requires the integration of theory with clinical practice as well as mastery and application of advanced skills in clinical assessment, diagnosis, symptom management, pharmacotherapy and other treatment options. NPCs further develop the psychosocial, spiritual and cultural domains of their practice, as well as their capacity to communicate, promote and market their role. In addition, they expand their research and leadership capabilities10.
5 Government of Western Australia, Department of Health, Nursing and Midwifery Office 2012 Nurse Practitioner Candidacy Program Implementing nurse practitioner candidacy opportunities across WA Health pg. 2
6 Ibid pg. 5
7 Nursing and Midwifery Board of Australia (2013) Explanatory note and FAQ on title protection Retrieved 31 March 2014 from
http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/FAQ.aspx
8 Ibid Nursing and Midwifery Board Newsletter March 2014
5
Nurse Practitioner Candidacy Program
A NP candidacy program is a structured and supported program of clinical and professional supervision and mentorship. The period of candidacy is flexible and depends, in part, on the NPC’s clinical expertise and academic preparation. It may be taken concurrently with the required NMBA approved nurse practitioner qualification at Master’s level11.
A candidacy program:
• Aligns with workforce planning;
• Aligns with the NPC’s academic program;
• Supports the NPC’s transition to practice as an endorsed NP; and is
• Individualised to ensure clinical competencies that meet service demands are developed during the candidacy12.
Palliative Care Nurse Practitioner Program in Gippsland
In 2009 the GRPCC secured funding from the Victorian Government to develop a PC NP
model. The model proposed that three NPs be recruited to the stand-alone community health services to enable sub-regional specialist palliative care services. There were difficulties in recruiting NPs to Gippsland so the GRPCC considered engaging NPCs. Implementation of this model began in late 2009.
The development of the PC NP Candidacy Program (Program) was one of 11
recommendations of the Specialist Palliative Care Consultancy Service Plan for Gippsland and a key component of the Service Plan’s implementation strategy endorsed by the Consortium Management Group in October 2011. The Program is integral to the provision of specialist palliative care when and where it is needed in Gippsland.
In November 2012 GRPCC appointed an endorsed palliative care Nurse Practitioner Mentor (NPM) to provide mentorship, support and clinical guidance to the region’s NPCs and to build the profile of the NP role in the region.
In 2014 GRPCC is providing funding to three lead services to support the employment of four NPCs:
• West Gippsland Healthcare Group (two district nurses (DNs) based in Warragul); • Latrobe Community Health Service (one DN based in Morwell); and
• Gippsland Lakes Community Health (one DN based in Lakes Entrance).
This funding assists each of the lead services to employ a NPC to provide a fractional sub-regional service and to support training for the NPC to gain endorsement. GRPCC provides additional funding to assist with specialist clinical supervision and clinical placements at metropolitan based palliative care services.
!
11Nursing and Midwifery Board of Australia (2013) Nursing and Midwifery Endorsement nurse practitioners Registration Standard Retrieved 31 March 2014 from http://www.nursingmidwiferyboard.gov.au/Registration-Standards.aspx
3 Palliative Care Nurse Practitioner Candidacy Program in Gippsland
The Program is based on:
• the NMBA Nurse practitioner standards for practice;
• the Clinical Diploma of Palliative Medicine Training Guidelines (Royal Australasian College of Physicians); and
• recent work of the Victorian Palliative Care Nurse Practitioner Collaborative (VPCNPC). The Program aims to:
• provide structures to promote the development of the required knowledge, skills and attributes;
• provide formalised supervision, mentorship and coaching;
• provide access to clinical expertise in diverse acute, sub-acute, residential aged care and community settings;
• provide timely, appropropriate and relevant experience"!
• prepare NPCs so that they recognise the similarities and differences of the trajectories of cancer, organ failure and end stage dementia, as well as their associated physical and cognitive decline and frailty;
• prepare NPCs so they can develop effective careplans and interventions that align with the NMBA’s Nurse practitioner standards for practice;
• enable NPCs to deliver comprehensive assessment and management of palliative care clients, caregivers and families across stable, unpredicted and/or complex situations within a clearly defined scope of practice that is underpinned by the best available evidence, and
• support the NPC to provide client-centred, safe, equitable and timely palliative care.
Governance
Sub-regional NPCs in Gippsland work within the corporate and clinical governance and performance management systems of their employing organisations.
Employing organisations ensure that NPCs: • have appropriate AHPRA registration;
• have current Police and Working with Children Checks; and
• adhere to their policies and procedures, including those related to Occupational Health and Safety.
The GRPCC is responsible for establishing and maintaining this Framework which identifies, articulates, facilitates and guides the educational and professional components of the Program in Gippsland.
NPCs who are financially supported by the GRPCC are required to undertake the Program. The Program can be tailored to meet the requirements of individuals and their employing health service however individual plans must be developed in conjunction with the GRPCC NPM. Completion of the Program will maximise the potential for endorsement as a PC NP.
7
Appointment of sub-regional NPCs
It is the employing organisation’s responsibility to credential and appoint NPCs and to provide the conditions that will enable them to progress to endorsement. The NPM participates in assessing the applicant at interview.
In selecting the NPC the employing organisation should determine the applicant’s suitability in line with NMBA requirements and by considering:
• Academic, professional and leadership skills; • Quantity and quality of clinical experience; and • Post-graduate qualifications in palliative care13.
The NMBA registration standard for endorsement as a NP states that an applicant seeking endorsement must be able to demonstrate:
• current general registration as a registered nurse with no conditions on the registration relating to unsatisfactory professional performance or unprofessional conduct;
• the equivalent of three years’ full-time experience in an advanced practice nursing role within the previous six years from date of lodgement of application;
• completion of a Board-approved nurse practitioner program of study at Master’s level or equivalent as determined by the Board;
• compliance with the National Competency Standards for the Nurse Practitioner; and • compliance with the Board’s registration standard on continuing professional
development as a registered nurse.
Obligations of the sub-regional NPC
The NPC’s scope of practice is built on the platform of the registered nurses’ scope of practice and must meet the regulatory and professional requirements for Australia. They include the National competency standards for the registered nurse, Code of Ethics and Code of Professional Conduct for Nurses in Australia14.
NPCs are accountable for the care they deliver consistent with their defined roles and
responsibilities15. NPCs are also accountable, in collaboration with their clinical supervisors, for identifying, initiating, implementing and monitoring activities, and for assessing their clinical learning16.
13 Nurse Practitioner Candidacy Program Implementing nurse practitioner candidacy opportunities across WA Health pg.9 14 Nursing and Midwifery Endorsement nurse practitioners Registration Standard
15 Department of Human Services (2009) Victorian clinical governance policy framework. A guidebook. State-wide Quality
Branch, Rural and Regional Health and Aged Care Services, Victorian Government pg.4
Steering Committee
The Steering Committee’s role is to oversee, advise, guide and support the planning, development, implementation and evaluation of the NPC Program in inpatient and community settings across Gippsland. Its objectives include:
• To oversee, advise, guide and support the NPC Program to meet the NMBA Nurse practitioner standards for practice;
• To oversee, advise, guide and support the progress of NPCs in the areas of clinical practice, research, education and leadership, both within their specific settings and in palliative care practice in general, to the achievement of endorsement; and
• To review the Program’s progress against key milestones. See Appendix 4 for the full list of objectives.
The Steering Committee’s membership is multidisciplinary and includes senior practitioners in various aspects of palliative care as well as regional representatives:
• NPM; • NPCs;
• Two palliative medicine specialists; • Pharmacist;
• General practitioner (Gippsland);
• Two nurse managers (representing two Gippsland sub-regions and the Consortium Management Group);
• Allied health representative (Gippsland); and • Academic (Federation University).
Other relevant stakeholders may be invited, as required, to share expertise, knowledge and ideas.
Figure 1. Governance structure
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9
Sustainability
The Program seeks to embed NPCs and NPs in Gippsland as an integral part the health workforce. To promote sustainability, the Program collaborates with, consults and assists relevant stakeholders, such as organisations employing NPCs, regarding the:
• Relevance, application and transference of the Program beyond individual NPCs and organisations;
• Alignment and/or integration of NP models of palliative care with existing service delivery models;
• Development of innovative NP models in palliative care with regional and state-wide application and transferability;
• Collaboration between regional private and public health services; • Promotion and marketing of the Program across services and the region; • Linking of employment with the Program;
• Identification of emerging clinicians with advanced practice; and • Succession planning.
Risk management
The Program seeks to minimise risk and optimise the safety of clients, caregivers, families and NPCs by:
• Ensuring that all stakeholders recognise and acknowledge the elements of a successful PC NP model of care: autonomy, collaboration, innovation, organisational support, respect and recognition, role clarity and safety and quality17;
• Aligning this Framework with the Safety and Quality Improvement Guide Standard 1: Governance for Safety and Quality in Health Service Organisations18;
• Articulating that NPCs work within their scope of practice according to the NMBA’s Nurse practitioner standards for practice and the requirements of their employing organisation;
• Identifying and articulating the responsibilities of stakeholders;
• Ensuring comprehensive stakeholder representation on the Steering Committee; • Fostering a culture of open and robust communication through formal and informal
means;
• Providing NPCs with several avenues of support and advice, including the dedicated role of NPM;
• Fostering a culture of trust, openness, respect and caring for NPCs;
• Monitoring of NPCs’ progress through several means of regular reporting; • Identifying, assessing and prioritising risks; and
• Identifying actions to minimise and manage the probability and impact of adverse events.
See Figure 2 for Elements of a successful nurse practitioner model of care See Appendix 5 for Risk Management Matrix.
17 Nurse Practitioner Candidacy Program Implementing nurse practitioner candidacy opportunities across WA Health pg.7 18 Australian Commission on Safety and Quality in Health Care Safety and Quality Improvement Guide Standard 1: Governance for Safety and Quality in Health Service Organisations (October 2012). Sydney.
Figure 2. Elements of a successful nurse practitioner model of care
Dispute resolution
In the event of dispute or grievance, representatives of each party will meet and endeavour to resolve the issue in an expeditious and informal manner.
If resolution is not achieved and the issue is related to the NPC and/or the NPM, the matter will be managed according to:
• The employing organisation’s dispute resolution system; and
• Clause 11 Dispute Settling Procedures of the Nurses and Midwives (Victorian Public Health Sector) (Single Interest Employers) Enterprise Agreement 2012 – 2016.
If resolution is not achieved and the issue involves a specialist palliative care supervisor, the matter will be managed according to the Service Agreement for the Provision of Specialist Palliative Care Services.
All other matters will be referred to the Steering Committee.
Complaints
In the event of a complaint against a NPC, the complaints management system of the NPC’s employing organisation is followed. Complaints are also reported to the NPM to enable support, analysis, learning and improvement.
Performance Management
The NPC’s performance is managed by the employing organisation. Input from the NPM and the Program’s monitoring and reporting structures inform NPC appraisals. Should issues arise,
11 the NPM is involved in addressing them to enable support, analysis of the issues, learning and improvement.
4 Methodology of the Nurse Practitioner Candidacy Program
The role of the NPC in Gippsland
The role of the NPC is to provide: • local specialist knowledge;
• build relationships with local GPs, nurses and allied health professionals to improve palliative care outcomes;
• a triage and referral service for complex patients throughout the sub-region; • client assessment and consultation;
• participation and leadership in local multi-displinary team(MDT) meetings; • advice about advance care planning;
• education to health professionals, clients and the community; • initiation and implementation of quality improvement activities; and • research.
The knowledge, skills and attributes of the NPC in Gippsland
Arising from a platform of highly developed clinical knowledge, skills and professional attributes, the NPC in Gippsland will deliver autonomous, collaborative, advanced and extended practice.
Within the context of each employing organisation and its clients, such practice is exemplified by:
• Commitment to the nursing model;
• Communication skills that build collaborative and therapeutic relationships; • Collaboration with health professionals and sub-regional health services; • Navigation of the different cultures of sub-regional health services;
• Functioning autonomously and exhibiting advanced levels of decision-making; • Applying advanced clinical knowledge, critical thinking and clinical leadership; • Participating as a senior member of the MDT;
• Making and accepting appropriate referrals;
• Conducting comprehensive assessments, including physical examination, and the diagnosis of conditions where presentations are stable, unpredicted and/or complex; • Recommending medications and diagnostics to GPs and medical consultants (within
the NPC’s scope of practice and the palliative care drug formulary); • Managing and monitoring clinical and pharmaco-therapeutic regimens;
• Integrating the psychosocial, spiritual and cultural domains into assessment and care planning;
• Providing sophisticated therapeutic interventions that improve outcomes for clients, caregivers and families;
• Coordinating complex case management, including the main health issue and associated co-morbidities;
• Integrating research into evidence-based practice;
13 • Participating in peer review;
• Being a role model and mentor to nursing colleagues and other health professionals; and
• Maintaining a life-long commitment to the professional development of self and other health professionals.
Figure 3. Representation of how the education, research and leadership domains are couched within the clinically focused standards19.
19Nursing and Midwifery Board of Australia (2014) Nurse practitioner standards for practice Retrieved 31 March 2014 from http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines/nurse-practitioner-standards-of-practice.aspx
Relationship network
The NPC’s relationship network includes: Governing bodies:
• Employing health service; • GRPCC (funder); and • Steering committee.
Collaborative mentors/supervisors: • NPM;
• Clinical supervisor/s (palliative care physician/s); and
• Allied health professionals, e.g. pharmacist, bereavement counsellor, occupational therapist.
Collaborative partners:
• Clients, caregivers and families, physicians (palliative care and others), GPs, acute and community health services (CHSs) and residential aged care facilities (RACFs); and • The Clinical Practice Group (CPG). The CPG is responsible for ensuring that decisions
made by the GRPCC are based on good clinical practice and the best available evidence. Membership of this group offers NPCs opportunities to enhance their critical thinking and analytical and problem-solving skills. The CPG benefits from the NPC’s contributions and activities.
Professional affiliations:
The NPC is required to develop collaborative professional relationships and networks. This includes:
• Regular participation in the activities of the VPCNPC;
• Membership of the Australian College of Nurse Practitioners;
• Development of and/or participation in peer reviews, reflective practice and clinical case studies and reviews;
• Attendance at conferences, seminars and workshops relevant to the context of their clinical practice; and
• Establishment and promotion of special interest groups (SIGs) and education and research groups related to their clinical practice.
15
Figure 4. NPC’s relationship network
Referral and exit pathways
There is a variety of ways in which the NPC will receive referrals. The NPC then triages, actions and/or refers clients and caregiver/family on to an appropriate service.
NPCs may visit clients who are relatively stable in all domains for the purposes of teaching and modelling practice for other staff. In general, however, triggers for referral to the NPC indicate instability and/or complexity of clinical and/or psychosocial issues. They include:
• Phase of care: unstable and/or deteriorating or terminal; • Frequent presentations to acute care;
• Frequent inpatient palliative care admissions; • Refractory symptoms;
• Client/caregiver/family distress; • Psychosocial/spiritual issues; • Challenging family dynamics; • Request for death at home;
• Facilitation of end-of-life care, choices and decision-making; • Anticipated loss and grief issues; and
• Opportunities to educate and support other staff.
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Acceptance of referrals is determined by the NPC’s: • Scope of practice;
• Clinical expertise;
• Employing health service’s requirements; • Current workload; and
• Academic work commitments. Clients may be referred via:
• The employing health service; • The NPM;
• A palliative care physician; • An acute health service; • A community health service; • A GP;
• A residential aged care facility; or • A client and/or caregiver/family. Clients will exit the care of the NPC when:
• All symptoms are controlled;
• The client’s condition is stable and/or deteriorating as expected; • The client has been transferred out of the region;
• The client requests it; or • The client dies.
Clinical internship
The NPC requires a minimum of six months (full time) supervised clinical practice but this can be extended to accommodate part-time positions (as in Gippsland). Supervised clinical practice is aligned with and complements the requirements of the Master of Nurse Practitioner.
Specialist clinical placements and supervision
Under the Specialist Palliative Care Consultancy Service Plan, the GRPCC has allocated funds to pay for specialist clinical supervision and clinical placements.
A palliative care consultant, nominated by the NPC’s employing health service, undertakes most of the clinical supervision while the NPM provides over-arching professional and clinical support that is both formal and informal. Supervision is developed and applied to clinical training through agreement between the NPC, the clinical supervisor and the NPM, and is tailored to the NPC’s day-to-day clinical practice.
As far as possible, clinical supervision is standardised across NPCs and sub-regions, ensuring similar levels of:
• primary and secondary consultation;!
• collaboration in MDT meetings and video/case conferencing; • opportunities for education, training and clinical placements;
17 • clinical experiences in facilities, tertiary and other, outside the region; and
• exposure to related specialties, e.g. radiology and pathology.
Ideally a senior pharmacist supervises the clinical therapeutics component. If this is not possible, the NPC develops a relationship with a local pharmacist.
Other specialists, such as GPs, medical consultants, social workers and counsellors, provide additional support and supervision depending on the identified learning needs of the NPC. See Appendix 7 for Clinical Supervision Agreement
Nurse Practitioner Mentor
The role of the NPM is to:
• provide clinical leadership and expert advice to NPCs;
• model the way for Gippsland’s PC NPCs and inspire a shared vision; and to • be a trusted advisor and mentor.
These objectives are achieved, in part, through: • clinical supervision (regular and as required);
• structured support and guidance in areas such as clinical leadership, therapeutic communication and professional development;
• the structured Program and addressing individual training needs;
• providing clinical advice via telephone or in person on the assessment, care planning and management of complex clients;
• promoting and communicating information about the role and services of the NPCs; • modelling expert skills and culturally safe nursing practice;
• demonstrating skilled mentoring/coaching and teaching;
• demonstrating and encouraging initiative, flexibility, creativity and resilience; and • promoting teamwork.
See Appendix 6 for the NPM’s Key Objectives, Duties and Responsibilities. See Appendix 8 for Mentorship Meetings: Agenda
Professional internship
The NPM and clinical supervisor oversee the NPC’s professional internship. The professional internship includes:
• development of leadership and management skills, including communication and relationship building;
• research, analytical and presentation skills; and
• development of the portfolio required for endorsement20.
5 Reporting
The NPC is required to prepare and submit a number of documents throughout the Program including:
• Statement of Intent; • Personal Learning Plan; • Candidacy Program Report; • Case Studies during the Program;
• Case Studies presented to an expert panel towards the end of the Program; and • Log Book.
The NPC’s employer is required to prepare and submit to the GRPCC twice per year:
• A Candidacy Clinical Mentor Report, demonstrating the progress of the NPC towards endorsement; and
• A Nurse Practitioner Candidate Activity Report.
See Appendix 10 for the Candidacy Clinical Mentor Report.
See Appendix 9 for the Nurse Practitioner Candidate Activity Report.
The GRPCC undertakes an annual Service Satisification Survey of the Palliative Care Nurse Practitioner Program in May each year. The Survey investigates the delivery of the sub-regional pallative care specialist service.
The Candidacy Clinical Mentor Report, Service Satisfaction Survey and Candidate Activity Report inform the GRPCC Annual Report to the Department of Health.
Statement of Intent
In consultation with their employing health organisation, clinical mentors and supervisors, the NPC prepares a Statement of Intent (Statement). The purpose of the Statement is to ensure that all professional development, clinical preparation and training requirements are met before application for endorsement as a NP.
The Statement details:
• the NPC’s commitment to fulfilling all the objectives of the Program;
• the responsibilities of the employing organisation, clinical supervisors and mentor/s in providing adequate supervision and opportunities for learning;
• the objectives of formal supportive structures; and
• the responsibility of the NPC to seek endorsement within a reasonable time of completing of the Program.
Personal Learning Plan
In consultation with the NPM and clinical supervisors, the NPC formulates a Personal Learning Plan (PLP). The PLP supports advanced practice and includes:
• supervised activities encompassing the holistic dimensions of palliative care: physical, psychosocial, cultural and spiritual;
19 • the names and roles of allied health mentors who provide coaching and education in
the holistic dimensions of palliative care;
• clinical placements in palliative care, sub-acute and community settings; • self-directed learning activities; and
• timelines and milestones.
Candidacy Program Report
The NPC submits a Candidacy Program Report (Report) to the NPM and Steering Committee at six monthly intervals. The Report demonstrates the NPC’s progress towards endorsement. It assists evaluation of the NPC’s learning outcomes and identification of areas for further
learning. The Report also flags barriers to development of the NPC’s role and provides opportunities to address them.
Case Studies during the Program
The NPC develops and presents case studies during the Program to the clinical supervisor and/or the NPM. They occur within timeframes agreed to by the NPC, NPM and clinical supervisor.
The case studies reflect the NPC’s growing clinical capacity as well as the aims of the Program and the PLP.
The NPC prepares at least three case studies. They reflect the intended scope of practice and extended practice, and include evidenced-based approaches, interventions and
recommendations, literature reviews and reflective practice.
This process is intended to be supportive, with the clinical supervisor and NPM giving constructive feedback and advice.
Case Study presentations to expert panel
The GRPCC requires the NPC, towards the end of the candidature, to present two case studies to an expert panel. These case studies draw together the NPC’s learnings from the Program and include all the elements of the NMBA’s Nurse practitioner standards for practice while focusing on clinical leadership and professional efficacy and effectiveness. They
demonstrate the NPC’s readiness to submit their portfolio for endorsement to the NMBA. This process is also intended to be supportive. It provides an opportunity for celebration of the NPC’s achievements and showcasing of the individual’s role and its impact21. It also promotes consistency of practice in the NPCs supported by the GRPCC.
The expert panel will consist of members from a range of areas. In addition to assessing the NPC against the Nurse practitioner standards for practice, the panel will take a broad
perspective of the NPC’s role and its innovation, flexibility and complementarity22 to the NPC’s employing health service.
21Begbie, J. and Wheelhouse, A. The Nurse Practitioner Panel: A Crucial Step In The Endorsement Process? Retrieved 2 May 2014 from http://www.slideshare.net/informaoz/jo-begbie-and-alyson-wheelhouse-southern-health
Logbook
The NPC maintains a logbook of activities undertaken during the Program such as: • reading of relevant articles;
• documentation of clinical discussions;
• clinical supervision and mentorship activities; • peer reviews; and
• other professional meetings and clinical presentations.
The logbook provides documented evidence of skill and knowledge acquisition, clinical outcomes and the variety of clinical and professional experiences gained through the Program. NPCs funded by the Victorian Nurse Practitioner Program NPC Support Package23 are required to submit two six-monthly logbooks to the Department of Health.
See Figure 5 for Timeline of reporting requirements
23Department of Health. Nursing in Victoria NP Candidate Support Packages Retrieved 31 March 2014 from
Timeline
Figure 5. Timeline of reporting requirements
Date By whom To whom Action
Beginning of Program NPC • Employer!
• GRPCC! • Steering Committee! • Clinical supervisor/s! • NPM! Statement of Intent Beginning of Program (evolving) NPC • Employer! • GRPCC! • Steering Committee! • Clinical supervisor/s! • NPM!
Personal Learning Plan
6 monthly NPC • NPM
• Steering Committee!
Candidacy Program Report
At least 3 units NPC • NPM • Steering Committee! Case Studies 6 monthly NPC • NPM! • Steering Committee! • Department of Health24! Logbooks
End of Program NPC • Expert panel Two Case Studies
1 June, 1 December Employer • GRPCC Candidacy Clinical Mentor Report
1 June, 1 December Employer • GRPCC Nurse Practitioner Candidate Activity Report
May GRPCC • Employers Service Satisfaction Survey of the PC NP Program
Program Logic
A program-logic links the components of the Program and demonstrates how they flow through to the goals of NP endorsement and excellent palliative care in Gippsland.
Figure 6. Program logic
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Appendices
Appendix 1.
References
Australian Commission on Safety and Quality in Health Care Safety and Quality
Improvement Guide Standard 1: Governance for Safety and Quality in Health Service Organisations (October 2012) Sydney
Begbie, J. and Wheelhouse, A. The Nurse Practitioner Panel: A Crucial Step In The Endorsement Process? Retrieved May 2014 from
http://www.slideshare.net/informaoz/jo-begbie-and-alyson-wheelhouse-southern-health
Centre for Palliative Care. Victorian Palliative Care Nurse Practitioner Collaborative (2014) What is a Nurse Practitioner Retrieved March 2014 from
http://centreforpallcare.org/index.php/education/vpcnpc/
Cooper,D. (2011) Implementation of Aged & Palliative Care Nurse Practitioner Role Melbourne Citymission
Department of Health. Nursing in Victoria NP Candidate Support Packages Retrieved March 2014 from
http://www.health.vic.gov.au/nursing/furthering/practitioner/np-candidates
Department of Health. State Government of Victoria Local Government Area Profiles, Gippsland Region 2012
http://www.dpcd.vic.gov.au/home/publications-and-research/urban-and-regional-research/census-2011/victoria-in-future-2012/VIF-2012-One-page-Profiles
Retrieved September 2013
Department of Health, State Government of Victoria Strengthening palliative care: Policy and strategic directions 2011 – 2015
Department of Health, State Government of Victoria Strengthening palliative care: Policy and strategic directions 2011 – 2015 Implementation strategy
Department of Human Services (2009) Victorian clinical governance policy framework. A guidebook. Statewide Quality Branch, Rural and Regional Health and Aged Care Services, Victorian Government
Department of Planning and Community Development, State Government of Victoria Victoria in Future 2012 Data Tables
Government of Western Australia, Department of Health, Nursing and Midwifery Office 2012 Nurse Practitioner Candidacy Program Implementing nurse practitioner candidacy opportunities across WA Health
Lyth, GM. (2000) Clinical supervision: a concept analysis Journal of Advanced Nursing 31 (3): 722 - 729
Mills, J., Francis, K., Bonner, A. (2005) Mentoring, clinical supervision and preceptoring: clarifying definitions for Australian rural nurses. A review of the literature. Rural and Remote Health Journal 5:410 Retrieved January 2014 from
Nursing and Midwifery Board of Australia (2013) Explanatory note and FAQ on title
protection Retrieved March 2014 from http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/FAQ.aspx
Nursing and Midwifery Board of Australia Nursing and Midwifery Board Newsletter March 2014 Retrieved March 2014 from
http://www.nursingmidwiferyboard.gov.au/News/Newsletters/March-2014.aspx
Nursing and Midwifery Board of Australia (2013) Nursing and Midwifery Endorsement nurse practitioners Registration Standard Retrieved March 2014 from
http://www.nursingmidwiferyboard.gov.au/Registration-Standards.aspx
Nursing and Midwifery Board of Australia (2014) Nurse practitioner standards for practice Retrieved March 2014 from
http://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Codes-Guidelines/nurse-practitioner-standards-of-practice.aspx
25
Appendix 2.
Abbreviations
AH Allied Health
CHS Community Health Service
CPG Clinical Practice Group
Framework Framework for the Palliative Care Nurse Practitioner Candidacy Program
GP General Practitioner
GRPCC Gippsland Regional Palliative Care Consortium
MDT Multidisciplinary Team
NMBA Nursing and Midwifery Board of Australia
NP Nurse Practitioner
NPM Nurse Practitioner Mentor
PC NPC Palliative Care Nurse Practitioner Candidate
PLP Personal Learning Plan
Program Palliative Care Nurse Practitioner Candidacy Program
RACF Residential Aged Care Facility
Report Candidacy Program Report
SIG Special Interest Group
Statement Statement of Intent
Appendix 3.
Definitions
25Term Definition Australian Health
Practitioner Regulation Agency (AHPRA)
The organisation responsible for the implementation of the National Registration and Accreditation Scheme across Australia.
Australian Nursing and Midwifery Accreditation Council
The independent accrediting authority for nursing and midwifery under AHPRA. It sets standards for accreditation and accredits nursing and midwifery courses and providers.
Clinical governance The system by which the governing body, managers, clinicians and staff share responsibility and accountability for the quality of care,
continuously improving, minimizing risks, and fostering an environment
of excellence in care for clients, caregivers and families26.
Clinical Supervision Clinical supervision offers a formal opportunity for a developing practitioner to share clinical, organisational, developmental and emotional experiences with an experienced clinician in a secure environment.
Clinical supervisor and supervisee are both active roles. Clinical supervision:
• involves observation, evaluation, feedback, facilitation of
supervisee self-assessment, and acquisition of knowledge and skills by instruction, modelling, and mutual problem solving;
• builds on the recognition of the strengths and talents of the
supervisee; and
• encourages self-efficacy27.
Competence (or competency)
The ability of an individual to do a job properly. A set of defined behaviours combined with knowledge and skills.
Competency Standards (Nurse Practitioner)
There are three generic standards that define the parameters of NP clinical practice. These standards are defined by nine competencies, each with specific performance indicators.
Standard 1: Dynamic practice that incorporates application of high
level knowledge and skills in extended practice across stable, unpredictable and complex situations.
Standard 2: Professional efficacy whereby practice is structured in a
nursing model and enhanced by autonomy and accountability.
Standard 3: Clinical leadership that influences and progresses clinical
care, policy and collaboration through all levels of the health service.
Credentialing The process of verifying the qualifications, background and professional standing of a health professional for the purpose of forming a view about their competence and suitability to perform a specific role within a specific organisation.
Endorsement Refers to a category that a Registered Nurse (RN) may apply to the NMBA to have noted on their registration. Therefore a NP is an RN with an endorsement to practice as a NP.
Internship and Clinical Placement
Supervised clinical practice undertaken, often as part of an academic course, to enhance and refine knowledge, skills and professional attributes required for safe and effective practice.
25Nurse Practitioner Candidacy Program Implementing nurse practitioner candidacy opportunities across WA Health 26Victorian clinical governance policy framework. A guidebook.
27
Mentor/mentoring An experienced, skilled and trustworthy person who is willing and able to provide guidance and to share their knowledge, expertise and experience on career, technical, professional and cultural issues. The process is one-to-one, reciprocal and confidential. Nothing is reported except by mutual consent.
Nursing and Midwifery Board of Australia (NMBA)
The Board is responsible for:
• registering nursing and midwifery practitioners and students;
• developing standards, codes and guidelines for the nursing and
midwifery profession;
• handlings notifications, complaints, investigations and disciplinary
hearings;
• assessing overseas trained practitioners who wish to practice in
Australia; and
• approving accreditation standards and accredited courses of
study.
Standard A criterion, which is established by consensus, agreed upon and approved by a recognised body that provides for common guidelines and professional characteristics.
Title Protection The title “Nurse Practitioner” is legislated under section 95 of the Health Practitioner Regulation National Law (2009). Only a registered nurse who has successfully completed and approved NP master’s level course of study and met the requirements of endorsement stipulated by the NMBA is legally permitted to use this title.
Appendix 4. Palliative Care Nurse Practitioner Candidacy Program Steering
Committee - Objectives
• To oversee, advise, guide and support the NPC Program to meet the Nurse practitioner standards for practice (Nursing and Midwifery Board of Australia); • To oversee, advise, guide and support the progress of NPCs in the areas of clinical
practice, research, education and leadership, both within their specific settings and in palliative care practice in general, to the achievement of endorsement; • To review the NPC Program’s progress against key milestones;
• To recommend and/or facilitate opportunities for training and mentorship;
• To confirm that appropriate structures for clinical supervision and mentorship are in place;
• To oversee, advise, guide and support current and newly endorsed NPs in optimising their roles;
• To make recommendations for developing the capacity of the NP and NPC roles to improve and/or complement access to health services for clients, carers and families while enhancing diversity and flexibility;
• To make recommendations regarding the drug formulary for NPs in community-based practice and any additional drugs required by specific client groups; • To advise the NPC Program of the barriers and enablers to implementation of the
NP role and strategies for managing same; • To advocate for the NPC Program;
• To advise the NPC Program about strategies for collaborating with key stakeholders; and
• To advise and guide the NPC Program in developing a communication and marketing strategy for informing and educating stakeholders and the broader community of the program’s progress and achievements.
Appendix 5.
Risk Management Matrix
Risks are listed, categorised and described. The consequence of each risk is rated high, medium or low. The probability of each risk is rated as unlikely, possible or likely. The overall risk score is derived from the two ratings, consequence plus probability (C+P):
Description Impact Consequence Probability Score (C+P)
Strategy
Clinical
incidents Client safety at risk. High Possible High Incidents management system of employer is followed; incidents, adverse events & near misses are reported to the
NPM to enable support, analysis, learning & improvement.
Complaints Program’s reputation &
credibility at risk.
High Possible High Complaints management system of employer is followed;
complaints are reported to the NPM to enable support, analysis, learning & improvement.
NPC operates outside scope of practice
Client safety at risk; Program’s reputation & credibility at risk.
High Possible High Ensure position description is current; performance
management system of employer is followed; performance is reported to the NPM to enable support, analysis, learning & improvement.
NPC is not achieving milestones
NPC is demoralised; the palliative care needs of clients & sub-region are not met; NPC is not endorsed.
High Possible HIgh Performance management system of employer is followed;
the NPM works with the NPC to enable support, analysis of the issues, learning & improvement; the employer provides an alternate avenue of support if the NPC’s relationship with the NPM is implicated.
NPC does not complete Program
NPC is not endorsed; sub-regional palliative care needs are not met; Program’s reputation & credibility at risk.
High Possible HIgh Detect and address issues early through maintenance of
regular monitoring and reporting; consider flexibility in accommodating any personal or academic issues through the course of the Program.
NPC leaves soon after completing Program
The sub-region does not have an NP; the
employer and GRPCC are at risk of losing the benefit of their
investment.
High Possible High As far as possible, when recruiting, seek the aspiring NPC’s
assurance of remaining in the region; acknowledge the benefit to the sub-region of the NPC during the Program; ensure succession planning.
Lack of GP and/or medical specialist engagement
Lack of referrals; barriers to appropriate care of clients.
High Likely Very
high
NPC to enlist the assistance of the NPM and/or supervising palliative care physician for individual cases; focus initial energies on receptive GPs and medical specialists; promote and market the PC NP Program.
Appendix 6.
NPM - Key objectives, duties and responsibilities
Key Result Area Key Performance Indicator
1. Clinical Supervision of PCNPCs in the
region 1.1 Participates in fortnightly MDT meetings by teleconference when required as part of the supervision process
1.2 Progress clinical practice of the NPCs through reflection, and provision of guidance and professional
support as required.
1.3 Provide regular face to face structured clinical supervision sessions including completing mandated
documentation, as required by individual PCNPC
1.4 Provide feedback and advice to the Manager on progress of NPCs
2. Develop a PCNPC pathway for endorsement
2.1 Provide advice on the individual training needs of Gippsland’s PCNPCs
2.2 Develop a structured program for progression of the PCNPC journey in the rural context
2.3 Provide advice and support to NPCs in developing their portfolios for endorsement
3. Deliver a secondary consultation
service to Gippsland 3.1 Provide clinical advice via telephone or in person on the assessment, care planning and management of complex clients as triaged by the NPCs
4. Provide clinical leadership 4.1 Participate in and provide expert clinical advice to the Clinical Practice Group
4.2 Develop evidence based guidelines and policies in conjunction with the Clinical Practice Group
4.3 Develop, implement, monitor and evaluate risk management plans
4.4 Actively promote and communicate information in respect of the role and services PCNPs provide
4.5 Initiate, contribute and encourage research and quality improvement activities
4.6 Provide professional leadership, strategic direction, expert advice and support for clinicians and GRPCC
Management
4.7 Work with GRPCC Manager to identify and prioritise support for nursing development in the region
5. Provide education and clinical
teaching 5.1 5.2 Role model expert skills and culturally safe nursing practice Demonstrate skilled mentoring/coaching and teaching
5.3 Under direction, act as a nursing resource providing expert advice and education to nursing staff and
other health care professionals within scope of practice
5.4 Identifies and supports staff education and professional development
6. Work collaboratively and effectively to lead change
6.1 Demonstrate and encourage initiative, flexibility, creativity and resilience in an environment of change
6.2 Promote teamwork and seek opportunities to support others in achieving goals
6.3 Develop relationships with visiting palliative medicine specialist by attending visits in a mentoring capacity
with NPC where practical
6.4 Develop and maintain relationships with key stakeholders of the Consortium
7. Demonstrates a commitment to professional development, quality, continuous improvement,
occupational health & safety and risk management.
7.1 Undertakes professional development in accordance with registration requirements.
7.2 Takes responsibility for own health & safety and that of others who may be affected by workplace
Appendix 7.
Clinical Supervision Agreement
Name of Clinical Supervisor: __________________________________________________________
It is agreed that Clinical Supervision sessions be held: ______________________(e.g. Monthly) on: _________________________________ at: _____________________________________________ for: __________________________________________________________________________________ It is agreed that the Clinical Supervisee will prepare cases / items for discussion or other information relevant for Clinical Supervision prior to each session.
A review date is set for: _______________________________________________________________
1. Goals of Clinical Supervision (Clinical Supervisee):
_______________________________________________________________________________________________ _______________________________________________________________________________________________ ____________________________________________________________________
2. Expectations of Clinical Supervision (Clinical Supervisor):
_______________________________________________________________________________________________ _______________________________________________________________________________________________ ____________________________________________________________________
We, the undersigned, agree to undertake Clinical Supervision within the framework provided by the Gippsland Region Palliative Care Consortium.
Both Supervisor and Supervisee retain a copy.
Signed: ____________________________________________________ Clinical Supervisor ___________________________________ Date ___________________________________ Signed: ____________________________________________________ Clinical Supervisee ___________________________________ Date
Appendix 8.
Mentorship Meetings: Agenda
Mentor: ____________________________________________________ Mentee: ____________________________________________________ 1. Managing self - how is everything going?
• Opportunities for reflective practice; what is manageable/achievable?
2. Clinical Supervision - brief case reviews, clinical narratives
• Briefly record clinical activities (don’t have to be complex) that you think demonstrate
advanced practice.
3. Clinical Leadership: as per Standard 3 Nurse Practitioner Competency Standards ANMC
“Clinical leadership that influences and progresses clinical care, policy and collaboration through all levels of health care.”
3.1 Engages in and leads clinical collaboration that optimises outcomes for patients/clients/ communities
Examples:
• Reflect on ways in which you may have added value to direct or indirect clinical activities
and any other clinical interaction/encounter with residents, carers, family, clinical staff or other relevant stakeholders
• Build capacity to discern the differences between clinical practice and clinical leadership
• Develop an understanding of clinical governance
• Opportunities to identify examples of clinical leadership that address residents’/clients’
therapeutic needs
• How do we form effective clinical partnerships?
• Discuss leadership attributes that may emerge from over time when working/interacting with
other clinicians
• Develop skills to articulate the value and legitimacy of the NP role within the clinical context
and the extended health system.
3.2 Engages in and leads informed critique and influences systems of health care
Examples:
• Opportunities to discuss changing trends in health care, changes in government policy and
their impact on the health of individuals
• Increasing understanding of your role and influence on health care
• Increasing understanding the relationship of your role with the nursing profession’s codes of
conduct and ethics and with regulatory bodies.
4. Any other items relevant to the mentorship meetings/activities
Name of Clinical Supervisee: __________________________________________________________ Insert Health Service name
Appendix 9. Nurse Practitioner Candidate Activity Report
Please complete the following questions. Dot points are acceptable.
1. Describe what strategies or actions you have taken to build relationships with local GPs, nurses and allied health professionals to improve palliative care outcomes.
2. Are you providing a triage and referral service for complex patients in your sub-region. How many patients have been referred to you in the last six months?
3. Are you undertaking clinical assessments in an advanced role?
4. How many multi-disciplinary meetings have you participated in the last six months?
5. Do you provide advice about advance care planning to clients, carers and the palliative care team?
6. What education have you provided to health professionals in the last six months?
Appendix 10.
Nurse Practitioner Candidacy Clinical Mentor Report
See Attachment
