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Advancing Nurses

Contribution Through a

Clinical Career Pathway

What’s to be covered

Background to the development of a clinical nursing career pathway in Hospital Authority (HA)

The development journey

Current situation

Looking into the future

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Hospital Authority

Established in 1990

Now Managing 41 Public Hospitals

49 Specialist Out-Patient Dept

74 Out-Patient Department

16 Chinese Medicine Clinic

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Hospital Authority Cluster Hospitals Map

4

HA’s Performance in 2011/12

No. of Hospital Beds (as of end March 2012) 27,054

In-Patient

Services

No. of Discharges & Deaths 1,004,326

No. of Patient Days 7,217,755

Bed Occupancy Rate 83%

Ambulatory

Diagnostic &

Therapeutic

Services

Day Patient: Discharges & Deaths 496,640

A&E Services - No. of Attendance 2,241,176

No. of Specialist Out-patient

attendances 6,731,155

No. of General Out-patient

attendances 5,316,486

Rehabilitation

& Outreach

Services

No. of Home Visits by Community

Nurses 838,896

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Nursing Manpower (As at 31 Oct 2013)

Others 17,970 (27.0%)

Medical 5,734 (8.6%)

Nursing 22,446 (33.7%)

Allied Health 6,578 (9.9%) Mgt Admin

2,180 (3.3%)

Supporting (Care-Related)

11,761 (17.6%)

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Back in 1993

Was it an obvious answer?

What’s the HA context?

How can it be built on existing developments?

Why a clinical nursing career pathway?

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HA was established to improve the MANAGEMENT of public hospitals in Hong Kong

New Management Initiatives – new structure focusing on management

An emphasis on efficiency as oppose to effectiveness

The Context

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Chief Nursing Officer (CNO)

Senior Nursing Officer (SNO)

Senior Nursing Officer (Education) [SNO(E)]

Nursing Officer (NO)

Nursing Officer (Education) NO(E)

Registered Nurse (RN)

Enrolled Nurse (EN)

General Manager (Nursing) [GM(N)]

Departmental Operations Manager (DOM)

School Principal (SP)

Ward Manager (WM)

Nurse Specialist (NS) - 1993

Pre HA HA New Positions

Structural Changes Needed

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Issues

Management oriented structure

No clear clinical career option

Lack of focused clinical development

Lack of clear direction for profession

and career development

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From Nursing Officer to

Advanced Practice Nurse

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Critical Timeline

1993 2000 2003 2010 2006 2008 2011-13

•Nurse Specialist

•Health Care Assistant

•Joint Liaison Group

• Introduction of Nurse Clinic

•Advanced Practice Nurse pilot

• Introduction of Primary Nursing Model

Consolidation of Nurses

Career Progression Model

and Implementation of

Nurse Consultant

Report of Advanced

Practice Nurse pilot

•Nurses Career Progression Model & Retention Strategy

•Nurse Consultant pilot

Nurse Consultant

Pilot Report

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Characteristics of a Profession Four Criteria

(Encyclopedia of Sociology, NY: Macmillan, 1992. p1554)

Esoteric knowledge

Autonomy on the job

Authority over clients

Altruistic

Underlying these four characteristics is a fifth: the

public must recognize the occupation as a profession.

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Building the Career Structure

Guiding Principles

a) Focus emphasis on direct patient care;

b) Conceptual and system change;

c) Professional participation in the review;

d) Accountability follows authority; and

e) Remuneration follows quality patient-centred care.

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New Nursing Career Structure and

Progression Model in HA

The new clinical structure has 3 functional

groups of nurses:

Registered Nurse (RN)

Advanced Practice Nurse (APN)

Nurse Consultant (NC)

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Objectives of the New Career Structure

to provide better role delineation of

nurses;

to strengthen the clinical focus and

accountability of nursing practice; and

to enable nursing specialization in line

with health care developments.

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Nursing Professional Development –

Clinical Nursing Model – Building

an Enabling Environment

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Primary Nursing

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Primary nursing is a system of delivering care in which each patient is assigned to the care of a primary nurse. This nurse, in collaboration with the patient, family and other members of the health care team assesses, plans, implements and evaluates the patient’s nursing care from admission to discharge.

Primary Nursing

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Advantages of Primary Nursing Approach

Includes:

A better organization of nursing care delivery;

Enhance autonomy in nursing practice; and

Increase professional accountability

Primary Nursing Care Practice Model

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Four Elements for Primary Nursing

Decision making

Work allocation and/or patient assignments

Communications with health care team members

Management

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Nurse Clinics developed in 2000

Nurse Clinic

A&E Nurse Clinic

Cardiology Nurse Clinic

Clinical Oncology Nurse Clinic

Continence Nurse Clinic

Endocrinology Nurse Clinic

Enterostomal & Wound Nurse Clinic

Geriatric Nurse Clinic

Gynaecology Nurse Clinic

Haematology Nurse Clinic

Medical Nurse Clinic

Midwife Clinic

Neurology Nurse Clinic

Obstetric Nurse Clinic

Nurse Clinic

O&T Nurse Clinic

Paediatric Nurse Clinic

Palliative Nurse Clinic

Primary Health Care (Hypertension)

Primary Healthcare Nurse Clinic (Community Care)

Psychiatric Nurse Clinic

Renal Nurse Clinic

Respiratory Nurse Clinic

Rheumatology Nurse Clinc

Special Medical Nurse Clinic

Surgical Nurse Clinic( Breast Care)

Wound Nurse Clinic

No. of Nurse Clinics : 151 (as at 31 July 2013)

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From Novice to Expert

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Nurses Career Progression Model

Career

Nurse Consultant Department Operations Manager

Advanced Practice

Nurse

Ward/

Unit Manager

Registered Nurse (Specialty Nurse)

Registered Nurse (Pre-Specialty)

Registered Nurse (Beginner)

Clinical Management

Tier 3

Tier 2

Tier 1

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Career Progression

Specialty Nurse

1) Specialty Qualification 2) Experience 3) Performance

3rd

Registered Nurse (Pre-Specialty)

1) Generic Competency 2) Specific Competency 3) Experience 4) Performance

2nd

Registered Nurse (Beginner)

1st 1) Preceptorship 2) Performance

Nurse Consultant

1) Clinical Managerial Leadership Expertise

2) Experience 3) Performance

5th

Advanced Practice Nurse

1) Sub-Specialty/Mgt Qualification 2) Higher Academic Qualification 3) Experience 4) Performance

4th

Milestones

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The Path to the New Career Structure

Commence discussion with staff in 2000

HA Board meeting on 28 February 2008

HA Human Resources Committee meeting on 15 April 2008

Revised Strategies & Package presented at AOM on 17 April 2008 for decision

Package endorsed by HA Board in May 2008

Implementation commenced in June 2008

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2008 Strategies for Retention of Nurses

Pilot Nurse Consultant posts – subsequently reported in 2010

Restructure the management related allowance (MRA) of the Department Operations Manager to differentiate increased responsibilities and management duties

Move the pay package of APN (W&UM) in line with the existing Ward Managers (WM) – 170+ converted and increased by 36 WMs

Increase the number of APNs (>450) in clinical units to enhance supervisory support and senior coverage

Increase the number of APNs to take on emerging roles through the establishment of more nurse-led clinics – more nurse clinics established

Flexible contract structure - implemented with success

Offer 6-years contract with contract gratuity at the end of each 3 years

Offer of conversion to permanent employment for eligible contract full-time RNs after 3 years of full time service.

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Nurse Consultant in HA

Scope of NC Practice

Consultation service

Ensure Care

Standard

Nurse Consultant

Direct care and

management of

complex and high

risk cases

Strategic plan

Enhance clinical

patient care, monitor

standard & outcomes

of care

Community care

development &

networking

Care delivery model/ care

pathway/ guidelines

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Roles of Nurse Consultant and Scope of Practice

Continuous Quality Improvement (5.0%) Quality control of service standard, protocol development and implementation

Research (3.6%) Promote and implement evidence-based practice

Education (8.7%) Staff supervision, in-service education, community education

Service Development (35.0%) Development of care delivery model, facilitating intra- and inter-disciplinary and cluster service collaboration, initiating new service projects, and strengthening hospital-community interface % = observed time spent in each role

Expert Practice (47.7%) Expert clinician / consultant, complex patient care & patient risk identification / stratification, care coordination

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Contributions of Nurse Consultants NCs have made major contributions as identified by

triangulation of the qualitative and quantitative data in the

study:

Achieve significant reductions in hospital admission (p<.001), A&E visit

(p<.001) and length of hospital stay (p<.001) between patients who were

under NC care and those who were not.

Achieve significant improvements in specialty-specific indicators (such

as improved urea level, improved HbA1c level, and decreased number of

dressing changes in the respective renal, wound/ stoma specialty) (p<.05)

between patients who were under NC care and those who were not.

Facilitate patients’ earlier and timely access to specialty care.

Innovate practice to improve/ reform existing procedures/ care

processes.

Strengthen cross-specialty collaboration to improve service delivery.

Secure continuous quality improvement and care standardization.

Enhance patient satisfaction and empowerment.

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Professional Development

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A Model of Building Specialty

Qualification in HA

Core Clinical Competencies (Web-based)

Basic Life

Support

Wound Mgt

Patient Edu-

cation

Patient Safety & Infection Control

Occupa-tional Safety And

Health

Legal And

Ethical Issues

Communi- cation Skills

Pain Mgt

Multi-disciplinary Collabora-

tion

Advanced specialty Competencies (option)

Focused Nursing Assess-

ment

Advanced Cardiac

Life Support

Patient Empower

ment Rehabili-tation

Thera-peutic

Communi-cation

Discharge Planning & Service

Co-ordination

Evidence Based

Practice

Specialty certification

Post-basic Certificate in

Specialty Nursing e.g.

Emergency nursing,

Intensive care,

Paediatrics, etc.

Nursing Assess-

ment

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Specialty Nursing Certificate Courses conducted by HA

Course Title

1. Advanced Medical Nursing

2. Advanced Surgical Nursing

3. Anaesthetic and Recovery Nursing

4. Cardiac Care Nursing

5. Cardiac Surgical Nursing

6. Community Nursing

7. Community Psychiatric Nursing

8. Continence Nursing

9. Diabetes Nursing

10. Emergency Nursing

11. Gerontological Nursing

12. Haematological & Bone Marrow

Transplant Nursing

13. Intensive Care Nursing

Course Title

14. Neonatal Intensive Care Nursing

15. Paediatric Intensive Care Nursing

16. Peri-operative Nursing

17. Primary Health Care Nursing

18. Psychiatric Rehabilitation Nursing

19. Rehabilitation Nursing

20. Renal Nursing

21. Respiratory Nursing

22. Rheumatology Nursing

23. Substance Abuse Nursing

24. Breast Care

25. Orthopaedics & Traumatology

Nursing

26. Advanced Paediatric Nursing

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Training Framework for Advanced Practice Nurses (APN)

People Management Leadership skill

Team work

Motivation

Communication skills

Performance Management & SDR

Supervisory skills development for first-line leaders

Service Management Managing difficult complaints

Conflict Management

Quality and risk management

Service development

Change management

Advanced Nursing Practice including ACLS 34

Nurse Consultant Development

Navigating Change Enabling Change Managing Change

Corporate essentials in

Spearheading Services

The Next of Nursing

Management

Research: You & I

Bringing change

through Project

Management

Presenting to

Audience’s wants

Writing to Readers’

Wants

Influencing for

success

1st - 2nd month 5th - 6th month 3rd - 4th month

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A Clear Direction for Education, Training and Development

Coordination between service and

education

Clinical practice

Learning culture

Continuing education

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The Complete Picture

Practice

Environment

Education &

Continuing

Development

Role and Role

Development

Policy

&

Structure

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Critical Timeline

1993 2000 2003 2010 2006 2008 2011-13

•Nurse Specialist

•Health Care Assistant

•Joint Liaison Group

• Introduction of Nurse Clinic

•Advanced Practice Nurse pilot

• Introduction of Primary Nursing Model

Consolidation of Nurses

Career Progression Model

and Implementation of

Nurse Consultant

Report of Advanced

Practice Nurse pilot

•Nurses Career Progression Model & Retention Strategy

•Nurse Consultant pilot

Nurse Consultant

Pilot Report

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What’s the future?

Current Issues Opportunities for Nursing

Ageing population

Primary Health Care

Non-communicable Diseases

Hospital accreditation

Health Care Financing & Insurance

Health system pressure - waiting list and waiting time

Professional advancement - Academy

Tertiary education for nurses

Prevention/early prevention; health maintenance

Enhancing care in the community

Independent practice

Enhanced scope of practice and credentialing

Refine and redefine of health professional boundaries – service needs and pressure from patients

Relevancy of nursing education and practice – basic and post basic

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Reflections

Be prepare and think ahead

Be opportunistic

Be patience and never lose sight of the

patient

There is always a way out

Don’t lose the big picture

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(William Jennings Bryan)

Destiny is not a matter of chance.

It is a matter of choice!

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References

Chan, E (2006) Evaluation of Advanced Practice Nurse Pilot

Scheme, Hospital Authority Head Office, 2006

Lee, D; Chan, C; Chair, SY; & Chan, D (2010) A report on Study on

the review of clinical nursing career structure, CUHK, 2010

Lee DTF, Choi KC, Chan CWH, Chair SY, Chan D, Fung SYK, Chan

ELS (2013) The impact on patient health and service outcomes of

introducing nurse consultants: a historically matched controlled

study. BMC Health Services Research 2013; 13(1): 431. doi:

10.1186/1472-6963-13-431

Hospital Authority (2008), Career Structure and Retention Strategies

for Nurses, Hospital Authority AOM paper No. 540, 2008

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