The Development Of Nurse Led Clinic Nursing Essay

Healthcare services and setting had evolved as early as 1980s, the changes occurred are to meet the high demand of care required and also to improve the standard of practice. However, shortage of nurses has always been the issue happening world-widely, as the turnover rate of nurses is high and hospitals had difficulties in recruiting nurses. Therefore many countries are promoting nursing as a profession through developing and enhancing the nurse’s role (Hunt, 2009). Nursing profession is a rewarding and challenging career, as the career pathways are developing, and this allows nurses to move towards the specialty that they are interested in. Through these act, it also increases their job satisfactory as their nursing roles are being enhanced. The different routes of pathways that nurses can choose are management role, educator role, clinician or advanced practitioners. Besides having an exciting and challenging experience, advanced practitioner nurses are also required to be professionally knowledgeable, obtaining higher level of decision-making skills and clinically competent for extended practices (Denisco & Barker, 2013). This essay will discuss the development of the role of advance practice nurse (APN) in Singapore, the influence of advance practice nurse on nursing in Singapore, the contemporary nurses’ role in relation to advance practice nurse, the current and potential impact of advance practice nurse on the healthcare system in Singapore, the politics of advance practice nurse in nursing practice as well as the different perspectives of advance practice nurse had on healthcare and health.

In the United States, the entry level set for APN is the completion of a Master program. If a nurse wants to practice as an APN in states, certification is required to recognize that the individual has met certain predetermined qualification. Such qualifications include graduation from an accredited or approved program, acceptable performance on a qualifying examination, and completion of a given amount of work experience (Fulbright, n.d.) Similarly in Singapore, we had National University School that conducts a two years Master of Nursing program that comprises of 80 modular credits (MC), which has the same weightage as doctoral degrees in other healthcare profession. Nurses are required to complete and pass the 19 modules (Nus, 2009). Before graduation, registered nurses are require to

undergo one-year of internship in the acute hospital, where they are required to perform history taking from patients and manage patient illness competently with the supervision of the medical team. They have been assigned to their mentor whom is a medical physician to guide them, topping up with them at least three years of experience in that specialise field, to have a fuller understanding of patients’ condition and situation (Snb, 2012). Upon completion of internship, they need to go for an interview conducted by the panel of experts which includes two specialist consultants and the chief of nursing officer. Only after passing all these, can they be legally certified as APN. APN practising licenses are being renewed annually as the requirement set from Singapore Nursing Board, a licence beyond nursing licence.

Fifth cohort of APNs is already seen graduated from master’s program in 2010 since the introduction in 2003, adding on more disciplines for APNs to be specialised in, by the year 2013. Due to the great demands needed, Ministry of Health has targeted 200 APNs to be in place by 2014, though there are already 78 certified APNs and 15 APNs undergoing training as of February 2012 in Singapore (Boyle & Heale, 2012). Acting as a bridge between nurses and other healthcare professionals, including doctors, APNs helps to narrow the gap towards the vision set for Singapore’s healthcare delivery, by practicing in multi-disciplinary sectors (Singhealth Group, 2012). The delivery of the healthcare system has been changing rapidly, therefore the way of delivery care to patients also changes. Traditionally, when an individual fall sick, they would seek treatment from the physician. However, when an individual becomes unwell presently, they can see an APN in the clinic for treatment first rather than a physician. Seeing an APN for consultation is more cost effective than a physician’s, however not all patients can accept the reality that nurses are as efficient as physicians. And if patient’s condition deteriorate and became complicated, referral to the physician at the right time could save queuing and waiting time for patients, there after reducing the long consultation queues and sharing physicians’ burden (Kleinpell, 2009).

There are both intrinsic and extrinsic factors leading to rising costs of healthcare, therefore the need of having APN are important. With better health care service and awareness in today’s world, population expanded, resulting in longer lifespan, and therefore more senior citizens exist. According to Smeltzer, Bare, Hinkle & Cheever (2010), "In 2003, the 35.9 million adults who were older than 65 years of age constituted 12.4% of the US population. By the year 2030, 20% of the US population is expected to be older than 65 years of age." Judging at the population, the presence of high demand for health care exists, the ability to meet those high demands and decrease the health care cost is of utmost essential. The extrinsic factors that lead to rising costs of healthcare are the availability of new medical technology as well as the availability of advanced manufactured drugs. Advanced Practitioners can help to manage chronic stable-conditioned patients, as well as follow-up on patient care upon discharge in the primary setting, hence reducing healthcare costs. The role expansion of APN is believed to benefits the patients, nurses and their non- nursing colleagues, enhancing the image of nursing profession, hence is definitely more than the job scope of a registered nurse (Kleinpell, 2009; Milstead, 2013).

Nurse Practitioner in the United States plays the role of the primary care providers who practice in hospital and community settings. According to their practice specialty, they are expected to provide nursing and medical services to individuals, families and groups. In addition, they also diagnose and managed acute episodic and chronic illnesses, played an important role in emphasizing health promotion as well as disease prevention to the public. The other services that the nurse practitioner can provide are ordering and conducting investigation, interpreting abnormal laboratory results, as well as prescribing medications. The major part of nurse practitioners are teaching and counselling individuals, families, and group. Besides practicing autonomously and in collaboration with healthcare professionals, APNs also diagnose, treat, and manage patient’s health problems (Lundy & Janes, 2009). The nurse practitioners also serve as healthcare researchers, interdisciplinary consultants, and patient advocates, reducing the chance of chronic diseases from developing. In Singapore, scope of practice for APN is a combined role of both nurse practitioner and clinical nurse specialist. The APN are required to practice their specialty in the clinical areas, which includes planning and managing patients in collaboration, as well as consulting with other healthcare professionals. APN needs to document their assessment, diagnosis, management and monitors the patient’s treatment as well as follow-up care accordingly. They also exercise their competent clinical judgment to detect changes in patient’s condition and prevent complications in the clinical setting, refer patient and accept referrals from other health care professional to maintain continuity of care. Using communication, counselling, advocacy and interpersonal skills appropriately to initiate, develop, and discharge therapeutic relationship with the patient in the process of treating them, they demonstrate clinical leadership in the delivery of efficient advanced practice to the nurses in the clinical setting (Tan Tock Seng Hospital, 2013).

Demand of primary care for the ageing population had increased and the supply of physicians is a constrained, posing an increment to the healthcare costs, therefore the response to meet these needs shifted from physicians to nurses. The expanded roles of nurses, advanced practice nurse has brought positive outcomes to the healthcare industry. The availability of APN had helps to relieve the problems of not having enough primary care physicians in certain countries. Nurses are given the autonomy and empowerment in patients care, therefore we can change the traditional paternalistic practice approached to holistic care approached. However, physicians also played an important role in providing quality care to patients as their expert knowledge on medicine are valuables in providing treatment (Kleinpell, 2009).

Advanced Practitioners are highly recognized and accepted by the public in the US, as there are evidence showing that the APNs are actively delivering the safety and effectiveness of primary care, preventive services and chronic diseases in the country. Besides all these, APNs were also seen working intensively with the political system. According to Barker (2009), "a new group that holds great potential for nurse interaction is the Congressional Nursing Caucus in the U.S. House of Representatives, begun in 2003 by Representatives Lois Capps." Educations, briefings and meetings were held regularly by APNs, discussion pertaining to society issues was kept abreast, bringing to the attention of policy makers if situation arises. The development of nurses’ role had strongly protruded the professional image of nurses, using this benefit to attract more people to join nursing profession and able to retent nurses through the nursing development role. Nurses expanded role also takeover some role of the physician, likewise nurses also can operate anticoagulant clinic that used to be led by physicians only (Butts & Rich, 2011). Through this, the results of introducing nurse led clinic had eventually fulfilled the hospital "Patients Charter Standard" with regard to shorter waiting time, improved consultation period, and patient can have better understanding on their treatment. The nurse-led clinic are also situated in rural areas to meet to the public needs, through this, it also improve the care of the patient in rural area, by making healthcare accessible. Therefore the patients in the rural area can compliance to treatment and there is a continuity of care after they are discharge from the main hospital. The care rendered also meets the standard of care required from the APN, in the situation if there is any doubt in providing treatment to the patient, the APN can use videoconference and telehealth to communicate with other allied health and medical team ( Mcmurray & Clendon, 2011). Similarly in Singapore, APNs are given the autonomy and empowerment in clinical setting, they are able to collaborate care independently with the knowledge they had with the medical team during ward round, like provide consultation, history taking, physical examination, order investigations and treatments, which also improved patient outcomes (Tan, 2012). The APN are also being recognized and respected from other healthcare professionals, they have nurse-led clinic in the hospital setting and are given the rights to admit patient, and make appropriate referral to other allied health stuff in the hospital. Being used to be the leader of the hospital where they practice, APNs are able to influence clinical practice and care to their junior nurses with the enhanced role and knowledge gained, therefore improving patient outcome and the skills of the junior nurses in the ward. The presence of APN also improves the quality indicators through the therapeutic relationship that they established with the patient. Therefore it resulted in greater patient independence, promotion of health, patient’s adjustment to illness, increases patient satisfactory and it also reduces patient revisiting the emergency department, and it also reduced healthcare cost (Chew & Yee, 2013).

However, there are barriers to the development of nurse-led clinic and the role of Advanced Practitioner Nurse as there are doctors whom are unwilling to give up their role, such as decision-making and towards the training or even the recruitment of these nurses. There are also many new roles of nurses during the period of development, therefore at times where training and assessment may not be properly evaluated, are likely to increases the risks of professional isolation and result in reducing the overall success that was made in the past (Hamric, Spross & Hanson, 2008).

Nurses are essential in a healthcare setting, without them, physicians feel handicap, communication with patient and patients’ relatives would be lacking, resulting in patient not well taken care of in the hospital settings (MOH, 2011). The most basic nursing requires a nurse to fulfil two years of study as well as attachment to a public hospital, not to mention degrees and bachelors in nursing, which requires longer period of time to obtain (Rosdahl & Kowalski, 2008). Upon graduation, a nurse needs to register with SNB for practising certificate, and thereafter renew with SNB annually. This is to prevent illegal and uncertified nursing practice taking place in Singapore, protecting the citizens under the law (Nurses and midwives act, 2012). All these makes nursing a profession (Brooks & Dunn, 2009). However, the white paper had recently labelled nursing as low-skilled, putting all those upgrading trainings and nursing policies down the drain. This article has certainly spark disagreement once it’s published, resulting in newspaper reporting on that fateful article and many people speaking up for nurses (Yeong, 2013). Doctors, whom are considered highly-skilled profession, needs to take physician’s pledge and follow the code of medical ethics (Singapore medical council, 2012; American medical association, 2013). Nurses, whom are stated as "lowly-skilled" profession, happens to possess nurses’ pledge as well as code of ethics and a set of professional conduct to guide nursing practice (Singapore Nursing Board, 2013; Singapore Nursing Board, n.d.). So, is human life that worthless, to have a lowly skilled professionals, handling critically ill patient? Not to mention empathizing and dealing with difficult relatives as well as patients that requires knowledge and experience. Classifying nursing as a low skilled profession is perhaps, one of the ignorant matter that have surfaced so far, for nurses touch people’s heart and contributing to the health of public in many ways.

In conclusion, the role of the APNs is still evolving, and they are practicing in a wide variety of settings. Only by showing support to our leaders by providing more efficiency care to our patients, nursing association or government promoting positive nurses’ image to the public, can the effort of nurses be recognised in enhancing quality care to the patients. The role and development of the Advanced Practitioners will continue to be monitor and the outcomes of practice will be evaluated for the effectiveness of APN. There is still a need to develop the roles of APN in Singapore as this is newly introduced in only 2003, the public still need to have more ideas on the role of APN so that they can meet the future patients and services need in the future.