The purpose of this assignment is to compare and contrast the current literature related to advanced nursing practice. And to relate this literature to my practice and the role of the palliative care nurse across clinical settings.
In my current role as a pain nurse specialist, I am involved in the care and management of patients with intrathecal (IT) catheters mainly for patients with intractable cancer pain. Patients who have been tried and failed on escalating doses of various opiates, and continue to have unsatisfactory pain management with intolerable side effects are often referred to our service for consideration for an intrathecal catheter. Intrathecal catheters have been used for many years now in effort to target the specific pain pathways within the spinal cord, as the medication is delivered directly into the Central nervous system, only small doses are required, and therefore patients experience less side effects, with improved pain control (Myers, J. Chan, V., Jarvis, V., Walker-Dilks, C., 2010).
The majority of these patients are approaching the end stages of their disease process, therefore we work quite closely with the hospital Palliative care service when the patient in an inpatient. However post discharge we visit the patients weekly in their own homes, this often involves working at an advanced nursing level, working autonomously, assessing the patient and titrating medication via their IT pump, with some direction from the doctor at Auckland hospital. However this role also involves providing the patient and their family with an element of palliative care also, they often require additional emotional support at this stage.
In 2002 the World health organization (WHO) defined palliative care as
” An approach that improves the quality of life of patients and their families facing he problems associated with life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”
Advanced nursing practice refers to nurses working at an expanded level of practice within a specialized area. Advanced practice is generally defined as the integration of practical knowledge, clinical experience, theoretical knowledge and research base, education, and may involve organization leadership (ANA, 1995). The term advanced practice has been given to various roles within nursing, such as Clinical nurse specialists (CNS), nurse practitioners (NP’s) and other specialized roles within nursing, such as the anaesthetic nurse (Davies, Hughes, 1995).
The literature related to advanced nursing practice and palliative care was reviewed using online databases, such as Medline, Ovid, Pubmed and the Cumulative index for nursing and allied health literature (CINAHL). Key words used in the search, were ‘advanced practice nursing’, ‘Clinical nurse specialist’, ‘nurse practitioner’, ‘palliative care’ and ‘nurse prescribing”.
After reviewing the literature, three articles were selected, and will be summarized below.
In 2004 Aigner et al did a comparative study of nursing resident outcomes between care provided by NP/Physicians, compared to Physicians only. The study was based in Texas, USA. The main objective of the study was to determine how the standard of care for nursing homes residents compares when provided by either NP/Physician, or physician only.
Eight nursing homes were evaluated, and two hundred and three residents were randomly blinded. Chi-squared tests were used for comparison for the data analysis.
Four outcomes were selected to assess the quality of the care provided by the two groups, they were, patients charts were retrospectively reviewed and the following outcome assessed-
Number of presentations to the emergency department (ED), the cost of the visit, and the diagnosis.
Number of hospital admissions in general, and the cost of being admitted to hospital.
The number of acute visits and diagnoses for that visit.
The completion of progress notes, patient histories and assessments.
Also the average number of medications used by each subject and the number of telephone calls and / or beeps relayed to the nurse practitioner, was collated. Comparisons were also made between the two groups regarding, diagnosis made during acute visits compared to during hospital admissions, and the comparison between the cost of recurrent admissions versus hospitalization (Aigner, M., Drew, S., Phipps, J., 2004).
The results overall did not show a significant difference of care provided by either the NP/physician group compared to the physician only group. No decrease was found in the amount of ED presentations and the costs were approximately the same. There was however a significant difference in the amount of acute visits made by the NP/Physician group , which was likely related to an increase presence of the NP in the nursing homes (P
If a similar study was to be conducted again, it would interesting to explore patient satisfaction between the two groups, and the satisfaction of the other staff working within each clinical area. And also to look more into cost effectiveness.
Macmillian nursing was first introduced to the UK in 1975, and today there are over 2000 Macmillan nurses. The role of the Macmillan nurse is a specialist palliative care nursing role that involves expert clinical skills, consultation, education, teaching and leadership (Corner et al, 2002).
In 2007 Ryan -Woolley, McHugh, G. and Lucker, K. conducted a study in Manchester, looking at Macmillan nurses view on nurse prescribing in cancer and palliative care medicine. It looked at the perceived motivators of why specialist nurses felt nurse prescribing would benefit them and their patient groups, and also explored the potential barriers to training for the implementation of this extended role.
A national postal survey was sent out to 2225 Macmillan nurses throughout the UK, 70% response rate was achieved (1575), 11% of Macmillan nurses who responded were already trained as extended formulary independent nurse prescribers. Half of the nurses (88 of 168) were able to prescribe from the extended drug formulary. The mean age was 43.9 years (SD 7.3), with a range 26-63 years. The majority of the nurses that responded were either working as palliative care clinical nurse specialists (CNS) (772, 49.0%) or tumour site specific CNS (413, 26.2%). Others were either working as different types of CNS in the community (83, 5.3%), oncology (61, 3.9%) and chemotherapy (19, 1.2%) or as a lead cancer nurse (45, 2.9%) (Ryan-Woolley et al, 2007).
Extended formulary independent nurse prescribing (EFINP) was initiated in the UK in 2002, to allow patients to get improved access to medicines and also make the best use of nurses clinical skills and experience. This differs from independent nurse prescribing, as independent nurse prescribers may need to assess and diagnose and treat patients (Ryan-Wooley et al, 2007). 21% or nurses who completed his survey had completed the EFINP course., some had completed other relevant courses that enabled them to be independent prescribers, and 2% were in the process of completing the EFINP course (Ryan-Wooley et al, 2007).
In the surveys the overall agreement was that nurse prescribing improved patients care by enabling them to receive their medication in a timely fashion. One quarter of the prescribers felt there were issues around training, and that the medical mentoring was not adequate. Some felt that the training provided was not specific enough for cancer and palliative care nursing. Out of 88 of the nurses who were already prescribing, 44 were community based, 28 were hospital based, and the other 15 were based in both the hospital and community. The majority of the nurses had been prescribing regularly throughout the past month. The qualifications of Macmillan nurses were mixed with around half having a first degree (57%) but only a minority (244 of 1504, 16.2%) having a Masters degree.
Some of the barriers for nurse prescribing that were identified in the survey were;
Having a supportive organization and team
Having medical support
Multi-disciplinary team (MDT) support
Supported practice and training once practicing
Access to GP computer systems (Ryan-Wooley et al, 2007).
In 2012 Steiner, K., Carey, N, Courtney, M., did a study on the profile and practice of nurses who prescribe pain medication throughout the United Kingdom (UK). They looked at the nurse backgrounds, experience, work setting and prescribing practice. 214 nurses throughout the UK that were on the Association for nurse prescribing (ANP) website were sent a questionnaire. All participants were qualified as nurse independent /supplementary prescribers (NIP/NSP). The questionnaire included fixed choice and open-ended questions. The questionnaire had four sections;
Section 1 covered demographic information (age, job title, area of practice, geographical area, type of services provided, how many nurse prescribers the service had, and what future provisions they had in place for nurse prescribers within that clinical area.
Section 2 looked at prescribing qualifications, levels of experience and the area they practiced in.
Section 3 focused on nurse prescribing within pain management, including the type of medications prescribed and the number of pain medications that would be prescribed during a typical week.
Section 4 asked the nurses about the level of training they had received to become a nurse prescriber, and if they were satisfied with the training program that they had undergone, and if they had any unfulfilled training needs. It also asked them what there preferred training method was.
Out of the 214 nurses that responded, 35% were in primary health care and nurse practitioners, 11.7% were pain or palliative care nurses and 10% in emergency care. The nurses worked across a variety of settings, both primary, secondary and tertiary care.
43.1% prescribed pain medications up to 5 times per week, and 42.6% prescribed between 6-20 times per week, and remainder prescribed upto 50 times per week. The main category nurses prescribed medication for was patients in acute pain post surgery (40.6%), 12% prescribed for patients with cancer or advanced illness (palliative care), 12.1% prescribed for chronic pain. A further 33.6% prescribed for patients with a overlap of different pains. The main types of medication prescribed were as follows-
Paracetamol and Non steroidal anti inflammatories (95.3%)
Other medications to treat side effects, such as antiemetic’s, were also prescribed by the nurses. The nurses who worked within a pain service or palliative care service were significantly more likely to prescribe opiates than the other participates (p The lack of training at an appropriate level (n=9)
The lack of support for role development (n=1).
The preferred learning methods of the nurses surveyed were:
Formal study days (62.6%)
Prescribing forum (57.5%)
Work-based learning 45.3%) (Stenner et al, 2012).
Despite the relatively low sample size, this study clearly identifies that nurses working in a wide variety of settings throughout the UK are prescribing pain medications. It also identifies that nurses in pain specialist or palliative care roles are more likely to have post graduate education in pain management, and also more likely to prescribe strong opioids. Training and development issues were highlighted.
By 2051, it has been predicted that there will be over 1.14 million people aged 65 years and over in New Zealand (NZ statistics, 2000), by 2051 there is likely to be about half as many older people than children (NZ Stats, 2000). In the last decade, the number of people being diagnosed with cancer has increased by 24% (Ministry of health 2001). Therefore there will need to be sufficient palliative care services to meet the needs of an increasing number of people with cancer. Introducing more NP’s into specialist palliative care services would possible be a good way of managing the increased workload predicted. More NP’s in the community and residential care facilities may also take the strain off tertiary centre’s, by preventing hospital admissions.
To assist with the predicted increase having NP or CNS that can prescribe will help ease the burden. The Acute pain service nurse specialists at Auckland city hospital are currently in the process of applying for expanded practice roles, to allow nurses with the correct post graduated training (according to NZ nursing council framework) to prescribe a limited number of medications, working alongside a designated prescriber. In 2013 the NZ nursing council put together a consultation document for expanded/extended nurse prescribing, it stated “that the reason for this consultation is to improve patient care by enabling registered nurses to make prescribing decisions so patients receive more accessible, timely and convenient healthcare. The role of the Nursing Council is to ensure public safety in reaching that goal.
The reasons for extending nurse prescribing are to:
• improve patient care without compromising patient safety;
• make it easier for patients to obtain the medicines they need;
• increase patient choice in accessing medicines; and
• make better use of the skills of health professionals” (NZ Nursing council, 2013).
In order for nurses to obtain expanded practice roles, professional development and recognition programs (PDRPs) are being introduced, so nurses have a framework to work to (Kai Tiaki, 2009).
As discussed in both articles 2 and 3 there are likely to be some implications to the introduction of this new role, such as financial/time restraints, lack of medical support, standardization of training and on going education needed to remain up to date on current practice (Ryan-Wooley at el, 2007, Stenner at el, 2012).
However with the continued shortage of doctors and the continued increase for healthcare, especially within the older population, expanding the role of the nurse is a necessary initiative, which is likely to improve patient outcomes (World health organization, 2006).
Introducing expanded nurse roles and designated prescribing into palliative care services within New Zealand, especially in primary and residential home settings, may be a good way of managing the predicted increased need for more palliative care services in the future, secondary to the rise in the older population and the number of people being diagnosed with cancer. As mentioned in the above articles it will provide patients with a more effective service that they can access easily, decrease the burden on doctors, provide a more cost effective service, and likely a more holistic approach to patients (Aigner, M et al, 2004). Also more nurses may be inclined to train for the role as the expectation and education required is less than what is required to be an NP.
In relation to my role as a pain nurse specialist and caring for palliative patients with intrathecal catheters, I believe the implementation of expanded practice nursing with designated prescribing and or a Nurse Practitioner role would without a doubt improve patient outcomes. Pain is the most concerning aspect for patients (and their family) facing the end stages of their life, and currently cancer pain is under-treated in nearly 50% of patients (Joshi, M., Chambers, W., 2010). At diagnosis 20-50% of cancer patients present with pain and 70 % of patients with advanced disease will require large doses of strong opiates for pain management (Joshi, M., Chambers, W., 2010).
These patients will often end up being admitted into hospital for pain management, and management of associated side effects, and the quality of there life is often very impaired due to the side effects of opiates (drowsiness, nausea, pruritis etc ). According to recent figures from Auckland hospital, the cost of an inpatient bed is over $4000 a day. When patients have intrathecal catheters inserted for their pain management, they require significantly less opiate, and therefore side effects are less. With good pain control and minimal side effects these patients can often return to there homes and have a better quality of life, and not require recurrent hospital admissions for poor pain control, which therefore saves thousands of dollars to the health service.
However due to the possible dangerous complications related to Intrathecal analgesia (infection, catheter migration, overdose) (Sjoberg, L., et al, 1991), specialized nursing management is required in the community (Myers et al, 2009). If there were more specialized Nurse practitioners or CNS with delegated prescribing rights, in the primary care setting, patients could be discharged from hospital sooner and medications titrated and symptoms treated within the patients home, without requiring a Doctor to make changes to prescriptions and therefore providing the patient with more effective and timely treatment.
Aside from pain and symptom management, having the advanced knowledge and skills to provide the necessary psychosocial, emotional and spiritual support to both patients and their family is also very important in this patient group (O’Connor, M., Lee, S., Aranda, S., 2012). Often time listening and counseling these patients can be more important than the medications (Meier, D,.Beresford, L., 2006)
According to WHO, 56 million people die throughout the world each year, 60% of these people would benefit from palliative care. With the amount of older people in New Zealand predicted to increase so rapidly in the next 50 years, the need for more advanced practice nurses within this specialty is obvious. A comprehensive framework is required to allow nurses to have a sound professional development plan and providing good clinical support and continued opportunities for learning is necessary. Primary health care settings have been highlighted as an area were NP and CNS are in shortage and likely investment in training nurses with the necessary advanced skills to manage palliative patients in the community will be a cost effective investment in future years by keeping patients out of tertiary care, and likely improve patient and family satisfaction by providing a more holistic approach to the end stages of life.
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