Illuminating the Path: Becoming a Respiratory Nurse Practitioner John Serginson NP Respiratory Caboolture Hospital RN BN MCN MNPS GD Nur Sc (crit care). Rhona MacDonald NP Respiratory Lung Health Unit Ipswich P&CHS RGN, MNPS. 1

Outline Reflections on our different journeys from CNC to NP. Themes, observations & lessons A few of us talked about this topic last year & how the journey to being an NP brings hard earned lessons but the path is largely invisible to those who haven’t walked it and so that may put off potential candidates.

2008 Planning model of care , DON $ 2010  Appointed to NP role 1990 – 1998 CCU / ICU RN/CNC/ Edu 2006 MCN. QH NP scholarships 2007 Scholarship  QUT 2008 Planning model of care , DON $ 2010  Appointed to NP role 2010 Resp NP project Caboolture H 2010 Practice Scope approved. 2009 UQ MNPS. DON Exec Dir →$ 2000 TPCH Thoracic CNC Dynamic practice, clinical leadership, professional efficacy. Critical success factors Vision: unmet needs: Pts & health service. “NP shaped hole” Supportive mentors: find & develop Supportive executive: $ & professional Clinical & professional credibility

Potholes NP in role: Clinical training Academic study support, funding, scope, access, autonomy, integration & outcomes. Potholes Limited referrals Confidence > competence Clinicians don’t share vision Lenient mentor NP Candidature Recurrent funding Model development Clinical training Shared clear vision Service shaping Academic study Limited autonomy: NP works as CNC No NP role Physicians write & control model Exec doesn’t $ support vision Unable to complete clinical training Role developed to meet physicians’ needs: Scope limited by physicians’ (NP does what they did as a CNC). Conceptual model for service developed separate to Executive / DON. Model based around skill set / interest of candidate vs service needs . ↓ NPC expertise in clinical leadership to recruit executive support, strategically develop and implement the model. Unclear need, model, skills or knowledge No clinical support Study without candidature. Pre NP candidature

Evolution of Clinical Reasoning CNC Strategies developed with pts , Communicate → specialists in team to discuss findings / suggest changes. Focused on resp. issues, symptom impacts & support needs. Diagnosis & Mx plan clear → Assess, educate, support, behaviour Patients are undifferentiated. → Assess (Hx, PE, tests) → Diagnose / clarify Dx NP Resp. focus & other issues found: address or refer each. Develop MX plan. Communicate →physicians / GPs outside team: evidence to support recommendations. Follow your process, keep open mind, consider DDx but avoid early fixation. Tests: when to & when not to, risk vs benefit, cost verses utility, false positive & false negatives & confounders.

Primary & Community Health Service (Ipswich) Employed as a CNC within Lung Health Service Completed NP course in June 2010 Employed as NP from February 2011 How to add value to our existing service? How to change from CNC to NP? How are the staff in our service going to respond?

Service looked at: ED presentations with asthma N= 605 in 12 months No formal follow up for patients who presented Some presenting to ED several times Strain on ED & the hospital Ipswich general has 341 beds (soon to be 431) Significant numbers in rural locations (could benefit from home visits but too far to travel).

Resp NP Patients Rapid access asthma clinic Rural clinics Smoking cessation clinics Patients referred from no formal diagnosis (request & interpret investigations). Patients referred from physician teams for action plans Commencing appropriate medications Problem solving with lung health team

Rapid access Asthma clinic: Weekly clinic: 14 patients per week. referrals from ED, GP or wards also phone or write to all ED visits in month. SB nurse practitioner Investigations ordered (spiro, CXR, bloods as needed) Medications ordered or adjusted Action plans completed IF NP can gain control (NP patient only) If issues: S/B specialist for further investigations & follow up

Rural clinic 3 rural hospitals in district 1 clinic / month at each Generally more severe patients Referrals from main hospital, GP, rural hosp. May not have definite diagnosis (patients need work up) Clinic done with exercise physiologist: modified exercise programs can be done up.

Value Add by NP within service

How to change CNC to NP 2-3 yrs of hard work Think holistically Work autonomously Take your team with you Good communication with all

Hurdles & stress PBS versus LAM (QH List of approved medicines) No provider number for state (Qld Health) funded NPs Unable to refer out from Qld Health Poor understanding of the NP role

End of day stress relief.

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