final- the perception of other healthcare professional with clinical nurse specialist

7/27/2019 Final- The Perception of Other Healthcare Professional With Clinical Nurse Specialist

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The Perception of other Healthcare Professional with Clinical Nurse Specialist

Twenty-first century realities affecting healthcare are dramatically and radically changing the

landscape for nursing practice. Much of the intensive and comprehensive professional and role

development for the entire field of nursing grew out of the focused action of nursing leaders

during the 20th century. A clinical nurse is certainly one involved in clinical practice with

knowledge, experience and understanding of providing nursing care. Leadership implies

authority in the broadest sense of the word, is nonhierarchical and not confined to a specific set

of skills, attributes or traits. One can deduce, then, that clinical nursing leadership reflects all of

the complexity of the culture, the organization, the practice setting and situational variables of

each clinical nurse.

Nursing is a profession within the health care sector focused on the care of individuals, families,

and communities so they may attain, maintain, or recover optimal health and quality. Nurses

may be differentiated from otherhealth care providers by theirapproach to patient care, training,

and scope of practice. Nurses practice in a wide diversity of practice areas with a different

scope of practice and level ofprescriber authority in each. Many nurses provide care within the

ordering scope ofphysicians, and this traditional role has come to shape the historic public

image of nurses as care providers. However, nurses are permitted by most jurisdictions to

practice independently in a variety of settings depending on training level. In the postwar period,

nurse education has undergone a process of diversification towards advanced and specialized

credentials, and many of the traditional regulations and provider roles are changing.

The shortage of primary care physicians who care for adults (in internal medicine and family

medicine) is projected to reach 35,000 to 44,000 by 2025. The worlds population is growing,

many people got sick and diseases nowadays continue to evolve and that number is virtually

certain to increase, as will that populations ongoing health care needs. But theres a solution to

the looming gap in primary care services: nurse-managed clinic staffed by advanced practice

nurses.

Review of Related Literature

Nurse-led clinics were first established in the United Kingdom and the United States in the 1980s in the

primary care setting to improve continuity of care after patient discharge while attempting to containcosts. The differentiation between a nurse-led clinic and other forms of clinics such as physician clinics

or hospital clinics lies in the fact that nurse-led clinics are run independently by nurses and that their

focus is more holistic, preventive and educative rather than therapeutic or medicinal. The major

interventions in such clinics are assessment, evaluation and monitoring of patients health status, as well

as health counseling and education prior to therapy, diagnosis and case management. By providing

psychosocial support, promoting secondary prevention strategies and a holistic approach to patients
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needs, nurse-led clinics may represent one way of tackling the problem of the rising number of older

and chronically ill patients and address issues of consumer satisfaction with their care.

A nurse-led clinic (also known as a nurse-managed or a nurse-run clinic) can be difficult to

define because each can vary in the service provided. Clinics are generally run by a qualified

and registered nurse and have developed in a variety of specialism in recent years. They arefound in hospital or community settings where patients are seen by a nurse as opposed to

another health care professional such as a doctor. The patient will visit via an appointment

system, although drop-in nurse-led/nurse-run clinics do exist, running at specified times.

The nurse has his or her own patient case load and the ability to admit and discharge from the

clinic. The level of professional autonomy will vary both within countries and across the world

but is generally high and many clinics offer what may be termed advanced practice. This may

include detailed physical assessment, clinical history taking, monitoring of ongoing conditions,

managing medicines such as nurse prescribing if legislation and professional development

allows this health promotion, education, and psychological support.

Importantly, clinics can assist in providing a high quality service while using health care

resources efficiently and can offer a continuity of patient care. The aim of all nurse-led/nurse-run

clinics must be to provide a measurably effective service. Audit and evaluation are an important

part of a developing service.

Scope of Nursing Practice

ARTICLE VI

Nursing Practice

Section 28. Scope of Nursing. - A person shall be deemed to be practicing nursing within the meaning of

this Act when he/she singly or in collaboration with another, initiates and performs nursing services to

individuals, families and communities in any health care setting. It includes, but not limited to, nursing

care during conception, labor, delivery, infancy, childhood, toddler, preschool, school age, adolescence,

adulthood, and old age. As independent practitioners, nurses are primarily responsible for the

promotion of health and prevention of illness. A members of the health team, nurses shall collaborate

with other health care providers for the curative, preventive, and rehabilitative aspects of care,

restoration of health, alleviation of suffering, and when recovery is not possible, towards a peaceful

death. It shall be the duty of the nurse to:

(a) Provide nursing care through the utilization of the nursing process. Nursing care includes, but not

limited to, traditional and innovative approaches, therapeutic use of self, executing health care

techniques and procedures, essential primary health care, comfort measures, health teachings, and

administration of written prescription for treatment, therapies, oral topical and parenteral medications,

internal examination during labor in the absence of antenatal bleeding and delivery. In case of suturing

of perineal laceration, special training shall be provided according to protocol established;


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(b) establish linkages with community resources and coordination with the health team;

(c) Provide health education to individuals, families and communities;

(d) Teach, guide and supervise students in nursing education programs including the administration of

nursing services in varied settings such as hospitals and clinics; undertake consultation services; engage

in such activities that require the utilization of knowledge and decision-making skills of a registered

nurse; and

(e) Undertake nursing and health human resource development training and research, which shall

include, but not limited to, the development of advance nursing practice;

Provided, That this section shall not apply to nursing students who perform nursing functions under the

direct supervision of a qualified faculty: Provided, further, That in the practice of nursing in all settings,

the nurse is duty-bound to observe the Code of Ethics for nurses and uphold the standards of safe

nursing practice. The nurse is required to maintain competence by continual learning through

continuing professional education to be provided by the accredited professional organization or anyrecognized professional nursing organization: Provided, finally, that the program and activity for the

continuing professional education shall be submitted to and approved by the Board.

Elsewhere, a CNS is defined as a Registered Nurse (RN) who, through both practice and masterate level

education, has become an expert in a clinical area of nursing (Sparacino, 2005). The American Nurses

Association (1996) defines the CNS as an, "expert clinician and client advocate in a particular specialty or

subspecialty of nursing practice" (p. 3). In the literature there appear to be commonalities about what

constitutes 'expert'. The qualities most often referred to are: expert delivery of care; facilitating change

and quality improvements; education of self (postgraduate) and in the workplace to colleagues and

patients; active involvement in research; functioning as a leader; and cultural and ethical fluency

(Borbasi, 1999; Castledine, 1999; National Nursing Organizations New Zealand, 2005). The most

important quality is considered to be the delivery of expert care (Benner, 1984; Patterson, 1987). More

recently it appears that emphasis is shifting from the delivery of care to the multitude of roles the expert

is additionally expected to fulfill, such as leader, researcher, teacher, change agent, policy writer and

professional spokesperson (Castledine; National Nursing Organizations New Zealand).

Hamric et al. (2005) describe several competencies integral to the CNS role. These include clinical

practice, coaching and guidance, consultation, research, leadership, collaboration and ethical decision

making. There is emphasis on the direct patient care component of the definition, as clinical practice,skills, knowledge and clinical wisdom are said to be the core of CNS practice (Sparacino, 2005).

A clinical nurse specialist (CNS) is an advanced practice registered nurse, with graduate preparation

(earned master's or doctorate) from a program that prepares CNSs. According to the APRN Consensus

Model for Regulation (2008), "The CNS has a unique APRN role to integrate care across the continuum

and through three spheres of influence: patient, nurse, system. The three spheres are overlapping and
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interrelated but each sphere possesses a distinctive focus. In each of the spheres of influence, the

primary goal of the CNS is continuous improvement of patient outcomes and nursing care. Key elements

of CNS practice are to create environments through mentoring and (p. 8) system changes that empower

nurses to develop caring, evidence-based practices to alleviate patient distress, facilitate ethical

decision-making, and respond to diversity. The CNS is responsible and accountable for diagnosis and

treatment of health/illness states, disease management, health promotion, and prevention of illness

and risk behaviors among individuals, families, groups, and communities." (p. 9). CNSs are clinical

experts in a specialized area of nursing practice and in the delivery ofevidence-based

nursing interventions.

CNSs work with other nurses to advance their nursing practices, improve outcomes, and provide clinical

expertise to effect system-wide changes to improve programs of care. CNSs work in specialties that are

defined by one of the following categories:

Population(e.g. pediatrics, geriatrics, womens health)

Setting (e.g. critical care, emergency department, long-term care)

Disease or Medical Subspecialty (e.g. diabetes, oncology, palliative)

Type of Care (e.g. psychiatric, rehabilitation)

Type of Problem (e.g. pain, wounds, palliative)

There are three domains of CNS practice, known as the three spheres of influence (NACNS 2004):

Patient

Nursing personnel

System (healthcare system)

The three spheres are overlapping and interrelated, but each sphere possesses a distinctive focus. In

each of the spheres of influence, the primary goal of the CNS is continuous improvement of patient

outcomes and nursing care.

Core competencies

Within the three spheres of CNS practice, Sparacino (2005) identified seven core competencies:

1. Direct clinical practice includes expertise in advanced assessment, implementing nursing care,

and evaluating outcomes.
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2. Expert coaching and guidance encompasses modeling clinical expertise while helping nurses

integrate new evidence into practice. It also means providing education or teaching skills to

patients and family.

3. Collaboration focuses on multidisciplinary team building.

4. Consultation involves reviewing alternative approaches and implementing planned change.

5. Research involves interpreting and using research, evaluating practice, and collaborating in

research.

6. Clinical and professional leadership involves responsibility for innovation and change in the

patient care system.

7. Ethical decision-making involves influence in negotiating moral dilemmas, allocating resources,

directing patient care and access to care.

Although these core competencies have been described in the literature they are not validated through

a review process that is objective and decisive. They are the opinion of some within the profession. A set

of core competencies has now been described and validated through a consensus process (2008) that

clearly defines the spheres of influence, the synergy model and the competencies as defined by

Sparacino (2005). These core competencies are now expected to be used in all educational programs

and will be revised in the coming years in order to be maintained as current and reflective of practice.

Competencies include the ability to:

Conduct advanced assessments and develop intervention strategies within a patient-centered

framework for individuals, communities and populations

Facilitate problem solving in complex clinical situations

Anticipate, explain and manage the wide range of patient and population responses to actual or

potential health problems

Utilize both qualitative and quantitative data to guide clinical practice and decision-making

Initiate and promote change in clinical care based on current literature and best practice

Incorporate the determinants of health and the complex interaction of sociological, psychological and

physiological processes in the context of the patients lived experience

Advocate for individuals, families, groups, and communities in relation to health care

Assist in developing evidence-informed clinical practice guidelines (CPG), care plans, quality indicators,

and cost effective programs or protocols to deliver nursing care

Demonstrate knowledge of evidence-informed practice related to the area of specialization


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Identify gaps in knowledge related to area of clinical practice

Provide leadership for collaborative, evidence-informed care that improves patient and population

outcomes

Clinical expertise in a specialty is the hallmark of CNS practice (NAGNS, 2004). In addition to clinical

expertise in providing care to a specific population, GNSs influence patient outcomes through

implementation, integration, and translation of evidence-based practice (EBP) into daily operational

activities. As more healthcare systems, government agencies, and third-party payers focus on EBP and

patient/client outcomes, the clinical and operational expertise of the CNS are significantly important.

Evidence based practice (EBP) is a term that has saturated the nursing literature in the past decade.

Understanding the concept of EBP is an essential part of professional nursing practice in general and

advanced nursing practice in particular. The clinical nurse specialist (CNS) is most often the individual

called upon to provide leadership in translating research findings into evidence-based, patient-centered,

and cost-effective care. The CNS plays a vital role in fostering EBP across clinical settings in many ways.

These activities include the following: generating ideas for projects, evaluating EBP research proposals,

overseeing EBP study design and execution and recommending process improvements, ensuring

application of research results to practice, staying abreast of newly published studies, developing new

evidence-based standards and protocols, sponsoring EBP educational sessions, and publishing

newsletters (Marshall, 2006). This difference stems from the day-to-day activities and the advanced

practice training and education of the CNS. Clinical nurse specialists are prepared at the graduate level

in core content areas of research, ethics, health policy, health promotion, organization and financing of

healthcare, human diversity, and social issues.

HEALTH CARE DELIVERY SYSTEM in the PHILIPPINES

The Philippine health care system has rapidly evolved with many challenges through time. Health service

delivery was devolved to the Local Government Units (LGUs) in 1991, and for many reasons, it has not

completely surmounted the fragmentation issue. Health human resource struggles with the problems of

underemployment, scarcity and skewed distribution. There is a strong involvement of the private sector

comprising 50% of the health system but regulatory functions of the government have yet to be fully

maximized.

Health facilities in the Philippines include government hospitals, private hospitals and primary health

care facilities. Hospitals are classified based on ownership as public or private hospitals. In the

Philippines, around 40 percent of hospitals are public (Department of Health, 2009). Out of 721 public

hospitals, 70 are managed by the DOH while the remaining hospitals are managed by LGUs and other

national government gencies (Department of Health, 2009). Both public and private hospitals can also

be classified by the service capability (see DOH AO 2005-0029). A new classification and licensing system

will soon be adopted to respond to the capacity gaps of existing health facilities in all levels. At present,

Level-1 hospitals account for almost 56 percent of the total number of hospitals (Department of Health,

2009; Lavado, 2010) which have very limited capacity, comparable only to infirmaries.


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Significance

Nurses affect so many aspects of health care in addition to direct clinical carequality

measurement and improvement, case management, data collection for clinical trials, insurance

coverage review, health and insurance hot lines, patient education classes, and many others. In

many of these roles, we hold certification or additional training.

Philippines is known to have lots of nurse professional, most of them works abroad while

others who stayed in the country if not unemployed are working as volunteers nor a trainee in a

hospital setting, while others who has work doesnt receive enough compensation. But despite

of the number of nurses there is still shortage of nurses in a hospital, thus affecting the care

given to the patients most especially in a government facility. Also, nurses roles changes over

time, which include nurse led clinics.Nurse led clinics have been successful in other countries,

thus here in the Philippines discussion is still on a rise. But thus nurse led clinic be an answer to

a high numbers of unemployed nurses in the Philippines? Or thus the nurse led clinic be able to

exemplified the health care delivery system in the country? Will the patients benefits on this kind

of practice? What will the other heath care professional think of this? In this study, it aims to

explore the perception of other health care team with regards to nurse led clinic, this include

doctors, midwifes as well the registered nurses. Result of this study will serve also as a baseline

for future research on this topic must especially if the nurse led clinic will be pursue in our

country.

Scope and limitation

This study only focus on the perception of the health care professional on the nurse led clinic.

Data Gathering

Open ended questions will be formulated based on the topic on nurse led clinic. The interview

will last for 10-15 minutes. Note taking will be done and if allowed by the respondents it will also

be recorded.


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The term nurse led clinic emerged predominately within the nursing literature in the 1980s.

Although historically, nurses had been running clinics of some sort before this time, there was a

clear growth in a large variety of nursing disciplines of this form of healthcare provision. In

addition, the clinics have coincided with an expansion of practice, which has encroached into

areas normally reserved for medicine. This has included detailed physiological assessment,

together with the manipulation and prescribing of medication. The rise of the nurse led clinic has

notably accelerated in the 1990s.

Definition

A clinic where the nurse has his or her own patient case load. This involves an increase in the

autonomy of the nursing role, with the ability to admit and discharge patients from the clinic, or

to refer on to other more appropriate healthcare colleagues. This power to refer to others is

often highly variable between clinics, but can include referrals to professionals allied to

medicine, such as dietician, physiotherapists, and social work teams, through to medical teams

or consultants.

An educative role explaining the illness to the patient and carers. This includes the

significance of symptoms, differentiating between those of concern that require further treatment

or adjustment of medication and those that may be from alternative causes. The issues of

health education and promotion fall into this category.

Psychological support this does not appear in all of the literature focusing on nurse led

clinics, but listening to the patients concerns, fears and perceived improvements in health is

clearly an important role.

Monitoring the patients condition this is an area which has developed rapidly in recent

years. This involves the skills of history taking and physical assessment, considering the

significance of assessment and ordering further investigations. This will also involve referring on

to more appropriate colleagues or initiating treatments. The emergence of Patient Group

Directions (PGDs) and nurse prescribing has meant that manipulating medications is an

increasing role of the nurse-led clinic.

The aim of the nurse led clinic is to monitor the condition and to maintain the patient in their

optimal state of health/ increasingly, this has meant a move towards empowering the patient to

identify the signs of deterioration themselves, and to take appropriate action. Such action may

include the use of more easily accessible specialist advice through the nurse-led clinic, a drop

in service, or via a telephone helpline. It is pointless altering the hierarchical power boundaries


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between patient and service providers, if there is no readily accessible service to respond

promptly to what the patient discovers.

This issue of empowerment is an important component of the nurse-led clinic. In evaluating the

worth of the service, it has to be considered whether the aim is to redistribute work amongst

healthcare professionals, and make accessibility to those services easier for the patient, or

whether there is an aim to enable the patient to deal more effectively themselves with a variety

of healthcare problems. The measurement of such empowerment needs to be off set against

the frequency with which the patient comes into contact with the clinic. Such frequent contact

could be seen as the factor which prevents deterioration, as opposed to an increased patient

awareness of their own condition and the significance of symptoms.

Many nurse-led clinics are found either in General Practice in the community, or in the

outpatients department of the hospital setting (Hatchett, 2000). In the latter, the nurse tens to be

specialized within one area. These can be in a large variety of quite specific but varied areas.

This can include back pain management (Wallis 2000), peritoneal dialysis (Denning 2000), and

intermittent claudication (Binnie et al. 1999)., leg ulcer management (Vowden 1997), intractavle

childhood constipation (Muir and Burnett 1999) and pre admission clinics (Alderman 1997). The

majority of this literature exploring nurse-led clinics tends to be found within the popular nursing

press and often extends to only a few pages. Such papers tend to be highly positive regarding

the clinics, but are generally descriptive and lack the deeper analysis, which provides insight

into how and why the clinic has formed. Two important issues are how the nurse demonstrate,

maintains and further develops competence in often expanding areas of practice and how the

worth of the clinic is demonstrated. Professional competence is a recurring theme within the

text, because of its link to both public protection and to ensuring the clinic is a valued

contribution to managing healthcare, and not a second rate service emerging due to over

worked medical colleagues.

final- the perception of other healthcare professional with clinical nurse specialist

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