THE ROLES OF THE Nurse Practitioner and Clinical Nurse Specialist in Community Dawn Busby, RN(EP), MN Family Nurse Practitioner Klinic Community Health Centre Michelle Todoruk-Orchard, RN, MN, ET, CDE Clinical Nurse Specialist WRHA Home Care Program

THE ROLE OF A FAMILY NURSE PRACTITIONER IN COMMUNITY The Strong Model of Advanced Practice Direct Comprehensive Care Education Support of Systems Publication and Professional Leadership Research Direct Comprehensive Care This component of the strong model comprises approximately 80% of overall practice of an NP… The Focus is mainly on direct clinical practice that includes assessment and diagnosis of health and illness concerns, minor procedures, such as mole removal or endometrial biopsy, interpretation of lab & diagnositic reports, and patient education and counselling. The NP also determines the need for health Promotion, as well as primary and secondary strategies to support health needs. My clinical practice roster includes infants, children, adolescents and adults throughout the lifespan in various stages of health and disease. Education, Support of Systems, Publication and Professional Leadership, and Research together comprise approximately 20% of overall practice of an NP. Education – clinical preceptorship & mentoring of nurse practitioner graduate students, nursing peers, medical students and residents, as well as community groups. Support of Systems – provided leadership and expertise in the development of clinical procedures to support nursing staff employed by Klinic to provide service to clients who are in need of: cervical cancer screening, STI treatment and testing, immunizations, and emergency contraception. Publication and professional leadership – examples include participation in the Nurse Practitioner Association of Manitoba, and the WRHA Advanced Practice Leadership Committee. Provides leadership to promote analysis of key issues to influence practice and policy. Explains & promotes the rule to clients, peers, and public. Research – It is a great Challenge to remain current with the literature relating to the breadth of primary care, and to keep up to the rapid pace of research dissemination. An NP critically analyzes research literature and applies this to practice through the utilization of best practice and incorporating evidence-based practice into direct patient care.

THE ROLE OF A CLINICAL NURSE SPECIALIST IN COMMUNITY The Strong Model of Advanced Practice Education Support of Systems Publication and Professional Leadership Research Direct Comprehensive Care Comprehensive Care (20%) The CNS provides direct comprehensive care and consultation to nurses in the community in specific, well defined clinical areas Wound Care Continence Care Diabetes Education The CNS develops and delivers comprehensive education to multi-disciplinary staff related to evidence informed care and practice changes Wound care Therapeutic Stockings Continence Management Diabetes Care Support of Systems Based on the needs of the client population as assessed through direct comprehensive care and feedback/ interactions with staff, the CNS will develop evidence informed programs or systems to support programs Best Practice Teams Continence Therapeutic Stocking Program Publication and Professional Leadership The CNS disseminates and shares programs developed through evidence informed practice: Present at National and International Conferences National Home Care Summit Canadian Association of Wound Care National Health Care Leadership Conference World Union of Wound Healing Societies Publish articles related to area of expertise Wound Care and Therapeutic Stockings The CNS is part of the Leadership Team that sets strategic direction for the Home Care Program Member of the Continuing Care Program Management Team (CCPMT) Co-Chair of the Home Care Practice Team Member of Quality Improvement Committee- lead for practice based quality inititiatives The CNS plays a key role in Regional Initiatives Co-Chair Regional Wound Care Strategic Planning Committee 7 years Co-Chair Therapeutic Stocking Committee 3 years Member, WRHA APN Committee 3 years Research The CNS is involved in: Introduction of evidence informed practice (Research Utilization) Development of Practice Change Framework (Knowledge Translation and Transfer) Participation in Research (Canadian Bandaging Trial- 10 site RCT comparing short and long stretch compression bandages)

Mr. Smith 82 year old male in assisted living PMHx Alzheimer's Dementia Congestive Heart Failure Diabetes Venous Insufficiency with Stasis Ulcer This case example will demonstrate both the differences in the NP/CNS roles as well as the overlap that can occur in a practice environment. Dawn Mr. Smith is an 82 year old male client of the Nurse Practitioner. He lives in an assisted living environment for clients with Alzheimer’s Dementia and receives his health care via home visiting from the NP as Mr. Smith is unable to get to appointments due to mobility issues, and he has no family available to assist him. The assisted living team support him by providing his regular medications, meal service, recreation and housekeeping services. In addition to Alzheimer's Dementia, Mr. Smith has been diagnosed with Congestive Heart Failure, Diabetes, and Venous Insufficiency with stasis ulcers and he is currently receiving homecare support. His CHF and Diabetes are stable and well controlled. Mr. Smith has developed venous stasis ulcers and despite the current management, he develops a cellulitis. He is started on antibiotics for the infection and the CNS/Wound care team are consulted for their expertise in the best practice guidelines to manage Mr. Smith’s ulceration. Michelle The CNS for Home Care will make a home visit or arrange for a WCBPT member to visit to provide assessment and direction regarding care and management of the VLU including: Performing a comprehensive lower leg assessment Providing client and primary nurse with education regarding VLUs Performing or arranging for ABPI or toe pressures as indicated to determine arterial involvement/ degree of compression that can be applied Arranging for minor sharp debridement by a WCBPT member if required Providing wound care treatment orders and recommending type and degree of compression required for healing Arrange follow-up by CNS or WCBPT on an ongoing basis until wound is healed. Once wound is healed, work with NP to facilitate moving client to graduated compression stockings In addition if the client requires further teaching regarding Diabetes management, the CNS will provide this and/or arrange for a visit from a Diabetes Best Practice Team member (ie. Home Care Dietitian).

The Overlap of scopes of practice of the NP/CNS is well demonstrated by this model developed by Denise Bryant-Lukosius, D. (2003).