1. Providing Treatment, Restoring Hope Redesigning Nurses Work Thomasine D. Guberski, PhD, CRNP Associate Professor University of Maryland School of Nursing Track 1 Meeting September 24, 2007

2. Slide 2 Scope of the Problem  Increasing number of patients  Number of medical officers Range is 4.1 (Tanzania) to 26.9 (Nigeria) MO per 100 000  Number of nurses Range is 11.3 (Zambia) to 108 (Kenya) per 100 000 World Bank, 2004

3. Slide 3 Current Care Paradigm General Care Patients in Stable Condition  Providers Nurses and CO’s General Care Patients in Unstable Condition  Providers Nurses and CO’s Patients on ART in Unstable Condition  Providers MO’s and CO’s Patients on ART in Stable Condition  Providers MO’s and CO’s

4. Slide 4 Breaking the paradigm  How do we effectively shift to new care paradigm, without losing quality of care? Break the paradigm that ART care must be given only by MO and CO Implementation of the team model for HIV care Formally increase patient care responsibilities for nurses  The redesign of nursing roles and responsibilities to more effectively care for patients with HIV/AIDS requires a different level of authority, responsibility and accountability

5. Slide 5 Current Initiatives  Strengthen community nursing care for all HIV+ patients  Nurses assume primary responsibility for patient triage in all settings  Follow stable patients on ARV therapy in a variety of settings  Train community health workers to assess symptoms  Facilitate transition from episodic to continuity care  Develop, implement and evaluate the nursing roles and responsibilities in the treatment plan for their institution.  Design, implement and evaluate clinic structure and flow for continuity care.

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7. Slide 7 Current Initiatives  Establish nurse-run clinics in which the nurses will provide care to patients across the spectrum of HIV: diagnose and manage common opportunistic infections assess and manage common signs and symptoms in HIV infected patients provide community nursing for enrolled patients refer patients for and provide palliative care follow patients on ARV therapy recognize appropriate referral parameters refer patients to the MO/CO as appropriate

8. Slide 8 Successes and Challenges  Breaking the paradigm that only MO/CO can enroll patients  Improvements in patient flow  Nurse run refill clinics  Triage in home-based care  Nurse run clinics in Rwanda  Nurse run clinics in Mombasa  Nurse practice acts  Sustainability

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10. Slide 10 Viral Suppression Rates on Therapy Two nurse run clinics Rwanda

11. Slide 11 Percentage of Patients with a Documented OIs at ART Start (Uganda & Kenya) Total 545 Patients with Documented OI Number of OI/patient None one 2 or more

12. Slide 12 Shifting the paradigm  How do we effectively shift to new care paradigm, without losing quality of care?

13. Slide 13 How to Make Paradigm Shift a Reality  Include nurses in all phases of planning and implementation  Shift responsibility for stable ART patient care to nurses  Increase MO responsibility for unstable general care patients  Implement nurse triage in all settings  Improve recognition of potential OI’s by all nurses  Community nurse referral required for all unscheduled, non-emergency visits  Increase education and responsibility of community health workers  Implement paradigm shifting protocols across all settings

14. Slide 14 Breaking the Provider Paradigm General Care Patients in Stable Condition  Providers Nurses and CO’s General Care Patients in Unstable Condition  Providers MO’s and CO’s Patients on ART in Unstable Condition  Providers MO’s and CO’s Patients on ART in Stable Condition  Providers Nurses and CO’s

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16. Slide 16 Senior level nurse educators Thomasine D. Guberski, PhD, CRNP Associate Professor, UM School of Nursing Yvelline Auguste, MS, FNP Haiti Amy Bositis, MS, CRM Zambia Cara Endyke-Doran, MSN, MPH, Zambia Yvonne Henley, AS, RN Tanzania Alphonse Kajiranga, RN Rwanda Nike Kehinde, RN, RM, Nigeria Beatrice Kiama, RN Kenya Marik Moen, MSN, MPH, Rwanda Barbara Smith, PhD, RN, FAAN Professor and Associate Dean for Research UM School Of Nursing