1. Guideline development,re- licensing, continuing education and the nursing profession Dr.Cordula Wagner NIVEL www.nivel.nl

2. Content presentation (re-) licensing continuing education definition guidelines quality of nursing guidelines accreditation nursing guidelines discussion ENQual workshop II

3. Nurses in The Netherlands 424.418 work as nursing professionals –329.000 education level 1 – 5 –137.000 no specific education –77.037 work in hospitals –118.297 work in long term care –142.130 work in home health care organisations 135.000 registered nurses –84% female

4. Task differentiation Nurses –Specialised nurse –Nurse specialist Physician assistent (PA) Nurse practitioner (NP) Advanced nurse pratitioner (ANP)

5. Educational levels and Licensing RN (level 5) – 4 years higher education RN (level 4) – 4 years in hospital Carer (personal care) (level 3) – 3 years Carer (level 3) – 3 years Caring help (level 2) – 1 year Home help (level 1) – couple of month

6. Re-licensing All nurses are registered in a specific register Registration gives title protection Still working on criteria for re-licensing

7. Continuing education Continuing education is not obliged for nursing professionals In most hospitals nursing professionals are stimulated to follow further education In nursing homes and home health care carers and helpers have less opportunity to follow further education

8. Definition Evidence based guidelines systematically developed recommendations to help social workers, nurses, physicians and patients with decisions about suitable care in specific situations (www.agreecollaboration.org ) ENQual workshop II

9. Guidelines Survey 800 guidelines and protocols –A few national guidelines –A lot of local guidelines –Most guidelines for the cronically ill Difference between guidelines (what?) and protocols (How?) ENQual workshop II

10. Guideline development General practitioners - 70 national standards; developed by specialised organisation Medical specialists - 50 national guidelines; developed by specialised organisation Nursing profession - 800 guidelines and protocols; developed by individual health care organisations, - compliance 50% ENQual workshop II

11. Examples guidelines 19952000 Restricted medical actions42%72% Patient routing38%57% Critical moments40%50% ENQual workshop II

12. Poor quality aim of the guideline described 57 % clarity in sequence of decisions39 % clarity in dealing with patients preferences 8 % actual recommendations69 % recommendations for several users14 % situations whereby deviation is allowed 3 % relation to other guidelines indicated13 % ENQual workshop II

13. Poor quality procedure for actualizing 8 % evaluation of achievement of aims 1 % criteria for testing compliance 1 % mentioning who can answer questions 66 % estimated health costs/gain 0,4 % Conclusion: 1) guidelines do not comply with criteria 2) need for authority to judge and improve guidelines ENQual workshop II

14. Platform Quality of nursing care 1999 feasibility study to investigate the agreement within the profession for a Quality Platform that would authorize guidelines about 65 nursing organizations; 51 are a member of the umbrella organization AVVV (Dutch Association of Nurses and Careworkers) 2000 - Platform on the Quality of nursing care founded Platform consists of representatives of various nursing organizations budget for 3 years ENQual workshop II

15. Aim of the Platform the development of quality criteria for accreditation; accreditation of evidence based guidelines for the nursing profession; to stimulate quality improvement of guidelines; development of a comprehensive quality policy for the nursing profession. ENQual workshop II

16. Accreditation of nursing guidelines Quality criteria based on the AGREE instrument Independent testing committee of 5 experts -> positive/negative advice Q-Platform decides about Quality Label -> National guideline First guidelines were not good enough to get the Quality Label Discussion: criteria to difficult to reach ENQual workshop II

17. Conclusion Quality of local guidelines is poor -> develop new guideline the step-wise approach works, but asks for specific knowledge -> not feasible in every health care organization A central specialized organization What to do with the great amount of local guidelines? Legal consequences! ENQual workshop II

18. Questions Do nurses in your country have national or local guidelines? Do they have evidence based guidelines? Is there a difference between guidelines and protocols Do you have quality criteria for guidelines? Do you have a quality label? Are nurses obliged to follow further education? What are the criteria for re-licensing? ENQual workshop II