Advanced Nurse Practitioners (ANP's)

The development of ANP's was first recommended by the Commission on Nursing in 1999. The Commission based on the knowledge available, consultations across the nursing practice, educational and regulatory family and International Research was satisfied that a need existed for the development of the Clinical Carer Pathway, Staff Nurse to CNS to ANP.

6.25, 6.26 Report of The Commission on Nursing

Seventeen years later it is regrettable that only 12 ANP posts exist in HSE and some of those will be lost through retirement in the short term with little or no obvious development of ANP posts ongoing. Indeed, there is evidence of a number of ANP posts having been developed to the point of approval only for the HSE to withdraw the funding.

In examining the current distribution of ANP's the following evidence emerges:

There are no ANP's in

• Sligo / Leitrim Mental Health Services
• Cavan / Monaghan Mental Health Services
• Louth / Meath Mental Health Services
• Longford/ Westmeath Mental Health Services
• Clare Mental Health Services
• Wicklow Mental Health Services
• Wexford – Waterford Mental Health Services
• Carlow Kilkenny South Tipperary Mental Health Services
• Kerry Mental Health Services
• South Lee Cork Mental Health Services
• North Dublin Mental Health Services
• West Dublin Mental Health Services
• Kildare

(The only Dublin Service with ANP's are Area 2 and Central Mental Hospital Dundrum)

In 2010 the Health Committee of the OCED's Directorate for Employment, Labour and Social Affairs published a paper.:

“Nurses in Advanced Roles: a Description and Evaluation of experiences in 12 Developed Countries” which make a number of points, we want to highlight:

• Many Countries are seeking to improve health care delivery by reviewing the roles of health professionals, including nurses. Developing new and more advanced roles for nurses could improve access to care in the face of a limited or diminishing supply of doctors.

• Evaluations show that using advanced practice nurses can improve access to services and reduce waiting times. Advanced Nurse Practitioners are able to deliver the same quality of care as doctors for a range of patients, including those with minor illnesses and those requiring routine follow-up. Most evaluations find a high patient satisfaction rate, mainly because nurses tend to spend more time with patients, and provide information and counselling.

• OECD countries are at different stages in implementing more advanced roles for nurses. Some countries (e.g. the United States, Canada and the United Kingdom) have been using advance practice nurses for a long time, initially in the primary care sector, but most recently also hospitals.

In most countries, one of the main reasons for developing more advanced roles for nurses is to improve access to care in a context of a limited supply of doctors. Another reason for the development of APN roles is to promote higher quality of care , for instance by creating new posts to provide more intensive follow-up and counselling for patients with chronic illness in primary care or the creation of advance nursing posts in hospitals to oversee quality improvement initiatives. In some countries, the development of ANPs is also seen as a way to contain costs. By delegating certain tasks from more expensive doctors to less expensive “intermediate level” advanced nurses, it may be possible to deliver the same (or more) services at a lower cost. Also, by improving quality of care, it may be possible to reduce health spending in the longer term by avoiding complications and unnecessary hospitalisations.

In addition, the development of more advanced roles for nurses is often seen as a way to increase the attractiveness of the nursing profession and retention rates by enhancing career prospects .

• The number of nurses in advanced practice roles still represents a small proportion of all nurses even in those countries that have the longest experience in using them. In the United States, NP's and CNS's represented respectively 6.5% and 2.5% of the total number of registered nurses in 2008. In Canada, they accounted for a much smaller share, NP's only representing 0.6% and CNS's 0.9% of all registered nurses in 2008, although their numbers have increased in recent years.

• In general, the available evaluations show that the use of advanced practice nurses can improve access to services and reduce waiting times for the set of services they provide. There is also a large body of evidence showing that advanced practice nurses are able to deliver the same quality of care as doctors for a range of services transferred to them (e.g. Routine follow up of patients with chronic conditions, first contact for people with minor illness), provided that they have received proper education and training. Most evaluations find a high patient satisfaction rate with services provided by advanced practice nurses, and in many cases a higher satisfaction rate than for similar services provided by doctors. This seems to be due mainly to the fact that advanced practice nurses tent to spend more time with each patient, providing them with more education and counselling. Fewer studies have tried to measure the impact of APN activities on health outcomes, but those that have tried to do so have not found any negative impact on patient outcomes following the transfer of certain tasks from doctors to nurses.

• A number of factors may either act as a barrier or facilitator to the development of advanced roles for nurses. This study has focussed on four factors: 1) the professional interests of doctors and nurses (and their influence on reform processes); 2) the organisation of care and funding mechanisms; 3) the impact of legislation and regulation of health professional activities on the development of new roles; and 4) the capacity of the education and training system to provide nurses with higher skills.

• In most countries covered under this study, the opposition of the medical profession has been identified as one of the main barriers to the development of more advanced nursing roles.

• A majority of countries covered in this study also mentioned the importance of ensuring that the education and training system provides sufficient opportunities to train nurses with more advanced skills as a key success factor. A lack of skilled nursing staff may make it difficult to fill new APN posts. In the United States, governments at the federal and state levels have recently increased funding to support new education and training programmes for all nurses including advanced practice nurses, in response to concerns that the education system was not producing enough nurses at the level required to perform advanced practice. In Canada and Ireland, the funding of new Master's level programmes and the growing ability of universities to enrol more students in these programmes have contributed greatly to the growing number of advanced practice nurses in recent years.

• In all countries where nurses now assume more advanced roles, governments have had to facilitate and support the process to overcome all of these barriers: by providing the necessary leadership to get the process started and to involve all relevant parties and mobilise their support (or at least minimise their opposition); by adapting the legislative and regulatory framework to allow nurses to perform new roles; by providing proper financial incentives for primary care groups and hospitals to create APN posts; and by helping to finance new education and training programmes to prepare nurses to fill theses more advanced positions.

• The development and implementation of advanced practice nursing roles should be evaluated in terms of their impact on patient care and costs. Many countries have tested new “models” of health service delivery involving new roles for nurse through local pilot projects. However, in many cases, pilot projects that have demonstrated positive results in terms of patient care and costs have not been pursued and extended more broadly, because of lack of sustainable funding. These represent missed opportunities to achieve efficiency gains in health service delivery.

• More generally, there will be a need to take a broader approach to evaluating new models of health service delivery. The movement towards greater teamwork and group practices increases the importance of looking beyond the impact of only one specific team member. Evaluation studies need to expand their scope from “simply” comparing how advanced practice nurses do certain tasks compared with doctors, to looking more broadly at the overall organisation of services. Identifying those factors or sophisticated statistical methods to control for different factors. Some evaluations in certain countries have already moved in this direction.

Conclusion

1. The Irish Department of Health obviously contributed to the work of the OECD in putting the above Paper together. In this regard it is interesting to note the reference to Ireland and the ‘growing number of ANPs in recent years'. I can only assume this is referring to another part of the Health Service other than Mental Health or indeed ID. If this Paper was being written today, 6 years later, it would clearly reflect the reducing numbers of ANPs from a very low base in Mental Health.

2. Left to their own volition the HSE and indeed the Department of Health will never meet the challenge and will never facilitate appropriate numbers of ANPs in Mental Health. If we assume a figure of only 4000 Mental Health Nurses in the HSE and 12 ANPs then the proportion of ANPs represents only 0.003% of the Psychiatric/Mental Health Nursing Population which is a tiny proportion of the ANPs recorded in the Nursing population.
   The above study records Canada at 0.6% of Nurses employed as ANPs as much smaller when compared to the U.S. When one looks at the current Irish experience it is clear that in Mental Health in Ireland our proportion of ANP is less than 2% of the Canadian proportion. This truly reflects the failure of the Irish Services to implement this Recommendation of the Commission on Nursing. When the real figure for actual Psychiatric Nursing Posts is used the percentage is even worse.

3. The OECD reflects the international view that ‘the development of ANP roles for nurses is often seen as a way to increase the attractiveness of the nursing profession and retention rates by enhancing career prospects'.
   This is a point we have continuously asserted.

4. The achievements of our ANPs has been very well highlighted. We have listened to Ministers extoll on the virtues of the ANP in Mental Health. The work of Gordon Lynch in the past in Kildare CAMHS and the current work of Colman Noctor in CAMHS, St. Patricks Hospital are but two which have been publicly recognised. However, I could equally name each of the other ANPs in similar vein.

5. The OECD study describes in very clear terms both the value of the ANP to the Health Service and the impediments to their greater establishment. It is time the Irish Mental Health Services embraced the opportunities presented by the quality of Irelands system of nursing education. However, this will not happen without a strong organisational impetus from the Department of Health and HSE.

6. Management must commit in a demonstrably meaningful way to increasing the numbers of ANPs in every area of the Health Service.

End.