The Perception of other Healthcare Professional with Clinical Nurse Specialist

Twenty-first century realities affecting healthcare are dramatically and radically changing the landscape for nursing practice. Much of the intensive and comprehensive professional and role development for the entire field of nursing grew out of the focused action of nursing leaders during the 20th century. A clinical nurse is certainly one involved in clinical practice with knowledge, experience and understanding of providing nursing care. Leadership implies authority in the broadest sense of the word, is nonhierarchical and not confined to a specific set of skills, attributes or traits. One can deduce, then, that clinical nursing leadership reflects all of the complexity of the culture, the organization, the practice setting and situational variables of each clinical nurse. Nursing is a profession within the health care sector focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality. Nurses may be differentiated from other health care providers by their approach to patient care, training, and scope of practice. Nurses practice in a wide diversity of practice areas with a different scope of practice and level of prescriber authority in each. Many nurses provide care within the ordering scope of physicians, and this traditional role has come to shape the historic public image of nurses as care providers. However, nurses are permitted by most jurisdictions to practice independently in a variety of settings depending on training level. In the postwar period, nurse education has undergone a process of diversification towards advanced and specialized credentials, and many of the traditional regulations and provider roles are changing.

The shortage of primary care physicians who care for adults (in internal medicine and family medicine) is projected to reach 35,000 to 44,000 by 2025. The worlds population is growing, many people got sick and diseases nowadays continue to evolve and that number is virtually certain to increase, as will that populations ongoing health care needs. But theres a solution to the looming gap in primary care services: nurse-managed clinic staffed by advanced practice nurses.

Review of Related Literature Nurse-led clinics were first established in the United Kingdom and the United States in the 1980s in the primary care setting to improve continuity of care after patient discharge while attempting to contain costs. The differentiation between a nurse-led clinic and other forms of clinics such as physician clinics or hospital clinics lies in the fact that nurse-led clinics are run independently by nurses and that their focus is more holistic, preventive and educative rather than therapeutic or medicinal. The major interventions in such clinics are assessment, evaluation and monitoring of patients health status, as well as health counseling and education prior to therapy, diagnosis and case management. By providing psychosocial support, promoting secondary prevention strategies and a holistic approach to patients

needs, nurse-led clinics may represent one way of tackling the problem of the rising number of older and chronically ill patients and address issues of consumer satisfaction with their care. A nurse-led clinic (also known as a nurse-managed or a nurse-run clinic) can be difficult to define because each can vary in the service provided. Clinics are generally run by a qualified and registered nurse and have developed in a variety of specialism in recent years. They are found in hospital or community settings where patients are seen by a nurse as opposed to another health care professional such as a doctor. The patient will visit via an appointment system, although drop-in nurse-led/nurse-run clinics do exist, running at specified times. The nurse has his or her own patient case load and the ability to admit and discharge from the clinic. The level of professional autonomy will vary both within countries and across the world but is generally high and many clinics offer what may be termed advanced practice. This may include detailed physical assessment, clinical history taking, monitoring of ongoing conditions, managing medicines such as nurse prescribing if legislation and professional development allows this health promotion, education, and psychological support. Importantly, clinics can assist in providing a high quality service while using health care resources efficiently and can offer a continuity of patient care. The aim of all nurse-led/nurse-run clinics must be to provide a measurably effective service. Audit and evaluation are an important part of a developing service.

Scope of Nursing Practice ARTICLE VI Nursing Practice Section 28. Scope of Nursing. - A person shall be deemed to be practicing nursing within the meaning of this Act when he/she singly or in collaboration with another, initiates and performs nursing services to individuals, families and communities in any health care setting. It includes, but not limited to, nursing care during conception, labor, delivery, infancy, childhood, toddler, preschool, school age, adolescence, adulthood, and old age. As independent practitioners, nurses are primarily responsible for the promotion of health and prevention of illness. A members of the health team, nurses shall collaborate with other health care providers for the curative, preventive, and rehabilitative aspects of care, restoration of health, alleviation of suffering, and when recovery is not possible, towards a peaceful death. It shall be the duty of the nurse to: (a) Provide nursing care through the utilization of the nursing process. Nursing care includes, but not limited to, traditional and innovative approaches, therapeutic use of self, executing health care techniques and procedures, essential primary health care, comfort measures, health teachings, and administration of written prescription for treatment, therapies, oral topical and parenteral medications, internal examination during labor in the absence of antenatal bleeding and delivery. In case of suturing of perineal laceration, special training shall be provided according to protocol established;

(b) establish linkages with community resources and coordination with the health team; (c) Provide health education to individuals, families and communities; (d) Teach, guide and supervise students in nursing education programs including the administration of nursing services in varied settings such as hospitals and clinics; undertake consultation services; engage in such activities that require the utilization of knowledge and decision-making skills of a registered nurse; and (e) Undertake nursing and health human resource development training and research, which shall include, but not limited to, the development of advance nursing practice; Provided, That this section shall not apply to nursing students who perform nursing functions under the direct supervision of a qualified faculty: Provided, further, That in the practice of nursing in all settings, the nurse is duty-bound to observe the Code of Ethics for nurses and uphold the standards of safe nursing practice. The nurse is required to maintain competence by continual learning through continuing professional education to be provided by the accredited professional organization or any recognized professional nursing organization: Provided, finally, that the program and activity for the continuing professional education shall be submitted to and approved by the Board.

Elsewhere, a CNS is defined as a Registered Nurse (RN) who, through both practice and masterate level education, has become an expert in a clinical area of nursing (Sparacino, 2005). The American Nurses Association (1996) defines the CNS as an, "expert clinician and client advocate in a particular specialty or subspecialty of nursing practice" (p. 3). In the literature there appear to be commonalities about what constitutes 'expert'. The qualities most often referred to are: expert delivery of care; facilitating change and quality improvements; education of self (postgraduate) and in the workplace to colleagues and patients; active involvement in research; functioning as a leader; and cultural and ethical fluency (Borbasi, 1999; Castledine, 1999; National Nursing Organizations New Zealand, 2005). The most important quality is considered to be the delivery of expert care (Benner, 1984; Patterson, 1987). More recently it appears that emphasis is shifting from the delivery of care to the multitude of roles the expert is additionally expected to fulfill, such as leader, researcher, teacher, change agent, policy writer and professional spokesperson (Castledine; National Nursing Organizations New Zealand). Hamric et al. (2005) describe several competencies integral to the CNS role. These include clinical practice, coaching and guidance, consultation, research, leadership, collaboration and ethical decision making. There is emphasis on the direct patient care component of the definition, as clinical practice, skills, knowledge and clinical wisdom are said to be the core of CNS practice (Sparacino, 2005). A clinical nurse specialist (CNS) is an advanced practice registered nurse, with graduate preparation (earned master's or doctorate) from a program that prepares CNSs. According to the APRN Consensus Model for Regulation (2008), "The CNS has a unique APRN role to integrate care across the continuum and through three spheres of influence: patient, nurse, system. The three spheres are overlapping and

interrelated but each sphere possesses a distinctive focus. In each of the spheres of influence, the primary goal of the CNS is continuous improvement of patient outcomes and nursing care. Key elements of CNS practice are to create environments through mentoring and (p. 8) system changes that empower nurses to develop caring, evidence-based practices to alleviate patient distress, facilitate ethical decision-making, and respond to diversity. The CNS is responsible and accountable for diagnosis and treatment of health/illness states, disease management, health promotion, and prevention of illness and risk behaviors among individuals, families, groups, and communities." (p. 9). CNSs are clinical experts in a specialized area of nursing practice and in the delivery of evidence-based nursing interventions.

CNSs work with other nurses to advance their nursing practices, improve outcomes, and provide clinical expertise to effect system-wide changes to improve programs of care. CNSs work in specialties that are defined by one of the following categories:

Population (e.g. pediatrics, geriatrics, womens health) Setting (e.g. critical care, emergency department, long-term care) Disease or Medical Subspecialty (e.g. diabetes, oncology, palliative) Type of Care (e.g. psychiatric, rehabilitation) Type of Problem (e.g. pain, wounds, palliative)

There are three domains of CNS practice, known as the three spheres of influence (NACNS 2004):

Patient Nursing personnel System (healthcare system)

The three spheres are overlapping and interrelated, but each sphere possesses a distinctive focus. In each of the spheres of influence, the primary goal of the CNS is continuous improvement of patient outcomes and nursing care. Core competencies Within the three spheres of CNS practice, Sparacino (2005) identified seven core competencies: 1. Direct clinical practice includes expertise in advanced assessment, implementing nursing care, and evaluating outcomes.

2. Expert coaching and guidance encompasses modeling clinical expertise while helping nurses integrate new evidence into practice. It also means providing education or teaching skills to patients and family. 3. Collaboration focuses on multidisciplinary team building. 4. Consultation involves reviewing alternative approaches and implementing planned change. 5. Research involves interpreting and using research, evaluating practice, and collaborating in research. 6. Clinical and professional leadership involves responsibility for innovation and change in the patient care system. 7. Ethical decision-making involves influence in negotiating moral dilemmas, allocating resources, directing patient care and access to care. Although these core competencies have been described in the literature they are not validated through a review process that is objective and decisive. They are the opinion of some within the profession. A set of core competencies has now been described and validated through a consensus process (2008) that clearly defines the spheres of influence, the synergy model and the competencies as defined by Sparacino (2005). These core competencies are now expected to be used in all educational programs and will be revised in the coming years in order to be maintained as current and reflective of practice. Competencies include the ability to: Conduct advanced assessments and develop intervention strategies within a patient-centered framework for individuals, communities and populations Facilitate problem solving in complex clinical situations Anticipate, explain and manage the wide range of patient and population responses to actual or potential health problems Utilize both qualitative and quantitative data to guide clinical practice and decision-making Initiate and promote change in clinical care based on current literature and best practice Incorporate the determinants of health and the complex interaction of sociological, psychological and physiological processes in the context of the patients lived experience Advocate for individuals, families, groups, and communities in relation to health care Assist in developing evidence-informed clinical practice guidelines (CPG), care plans, quality indicators, and cost effective programs or protocols to deliver nursing care Demonstrate knowledge of evidence-informed practice related to the area of specialization

 Identify gaps in knowledge related to area of clinical practice Provide leadership for collaborative, evidence-informed care that improves patient and population outcomes Clinical expertise in a specialty is the hallmark of CNS practice (NAGNS, 2004). In addition to clinical expertise in providing care to a specific population, GNSs influence patient outcomes through implementation, integration, and translation of evidence-based practice (EBP) into daily operational activities. As more healthcare systems, government agencies, and third-party payers focus on EBP and patient/client outcomes, the clinical and operational expertise of the CNS are significantly important. Evidence based practice (EBP) is a term that has saturated the nursing literature in the past decade. Understanding the concept of EBP is an essential part of professional nursing practice in general and advanced nursing practice in particular. The clinical nurse specialist (CNS) is most often the individual called upon to provide leadership in translating research findings into evidence-based, patient-centered, and cost-effective care. The CNS plays a vital role in fostering EBP across clinical settings in many ways. These activities include the following: generating ideas for projects, evaluating EBP research proposals, overseeing EBP study design and execution and recommending process improvements, ensuring application of research results to practice, staying abreast of newly published studies, developing new evidence-based standards and protocols, sponsoring EBP educational sessions, and publishing newsletters (Marshall, 2006). This difference stems from the day-to-day activities and the advanced practice training and education of the CNS. Clinical nurse specialists are prepared at the graduate level in core content areas of research, ethics, health policy, health promotion, organization and financing of healthcare, human diversity, and social issues.

HEALTH CARE DELIVERY SYSTEM in the PHILIPPINES The Philippine health care system has rapidly evolved with many challenges through time. Health service delivery was devolved to the Local Government Units (LGUs) in 1991, and for many reasons, it has not completely surmounted the fragmentation issue. Health human resource struggles with the problems of underemployment, scarcity and skewed distribution. There is a strong involvement of the private sector comprising 50% of the health system but regulatory functions of the government have yet to be fully maximized. Health facilities in the Philippines include government hospitals, private hospitals and primary health care facilities. Hospitals are classified based on ownership as public or private hospitals. In the Philippines, around 40 percent of hospitals are public (Department of Health, 2009). Out of 721 public hospitals, 70 are managed by the DOH while the remaining hospitals are managed by LGUs and other national government gencies (Department of Health, 2009). Both public and private hospitals can also be classified by the service capability (see DOH AO 2005-0029). A new classification and licensing system will soon be adopted to respond to the capacity gaps of existing health facilities in all levels. At present, Level-1 hospitals account for almost 56 percent of the total number of hospitals (Department of Health, 2009; Lavado, 2010) which have very limited capacity, comparable only to infirmaries.

Significance Nurses affect so many aspects of health care in addition to direct clinical carequality measurement and improvement, case management, data collection for clinical trials, insurance coverage review, health and insurance hot lines, patient education classes, and many others. In many of these roles, we hold certification or additional training. Philippines is known to have lots of nurse professional, most of them works abroad while others who stayed in the country if not unemployed are working as volunteers nor a trainee in a hospital setting, while others who has work doesnt receive enough compensation. But despite of the number of nurses there is still shortage of nurses in a hospital, thus affecting the care given to the patients most especially in a government facility. Also, nurses roles changes over time, which include nurse led clinics. Nurse led clinics have been successful in other countries, thus here in the Philippines discussion is still on a rise. But thus nurse led clinic be an answer to a high numbers of unemployed nurses in the Philippines? Or thus the nurse led clinic be able to exemplified the health care delivery system in the country? Will the patients benefits on this kind of practice? What will the other heath care professional think of this? In this study, it aims to explore the perception of other health care team with regards to nurse led clinic, this include doctors, midwifes as well the registered nurses. Result of this study will serve also as a baseline for future research on this topic must especially if the nurse led clinic will be pursue in our country.

Scope and limitation This study only focus on the perception of the health care professional on the nurse led clinic.

Data Gathering Open ended questions will be formulated based on the topic on nurse led clinic. The interview will last for 10-15 minutes. Note taking will be done and if allowed by the respondents it will also be recorded.

The term nurse led clinic emerged predominately within the nursing literature in the 1980s. Although historically, nurses had been running clinics of some sort before this time, there was a clear growth in a large variety of nursing disciplines of this form of healthcare provision. In addition, the clinics have coincided with an expansion of practice, which has encroached into areas normally reserved for medicine. This has included detailed physiological assessment, together with the manipulation and prescribing of medication. The rise of the nurse led clinic has notably accelerated in the 1990s.

Definition A clinic where the nurse has his or her own patient case load. This involves an increase in the autonomy of the nursing role, with the ability to admit and discharge patients from the clinic, or to refer on to other more appropriate healthcare colleagues. This power to refer to others is often highly variable between clinics, but can include referrals to professionals allied to medicine, such as dietician, physiotherapists, and social work teams, through to medical teams or consultants. An educative role explaining the illness to the patient and carers. This includes the significance of symptoms, differentiating between those of concern that require further treatment or adjustment of medication and those that may be from alternative causes. The issues of health education and promotion fall into this category. Psychological support this does not appear in all of the literature focusing on nurse led clinics, but listening to the patients concerns, fears and perceived improvements in health is clearly an important role. Monitoring the patients condition this is an area which has developed rapidly in recent years. This involves the skills of history taking and physical assessment, considering the significance of assessment and ordering further investigations. This will also involve referring on to more appropriate colleagues or initiating treatments. The emergence of Patient Group Directions (PGDs) and nurse prescribing has meant that manipulating medications is an increasing role of the nurse-led clinic.

The aim of the nurse led clinic is to monitor the condition and to maintain the patient in their optimal state of health/ increasingly, this has meant a move towards empowering the patient to identify the signs of deterioration themselves, and to take appropriate action. Such action may include the use of more easily accessible specialist advice through the nurse-led clinic, a drop in service, or via a telephone helpline. It is pointless altering the hierarchical power boundaries

between patient and service providers, if there is no readily accessible service to respond promptly to what the patient discovers.

This issue of empowerment is an important component of the nurse-led clinic. In evaluating the worth of the service, it has to be considered whether the aim is to redistribute work amongst healthcare professionals, and make accessibility to those services easier for the patient, or whether there is an aim to enable the patient to deal more effectively themselves with a variety of healthcare problems. The measurement of such empowerment needs to be off set against the frequency with which the patient comes into contact with the clinic. Such frequent contact could be seen as the factor which prevents deterioration, as opposed to an increased patient awareness of their own condition and the significance of symptoms.

Many nurse-led clinics are found either in General Practice in the community, or in the outpatients department of the hospital setting (Hatchett, 2000). In the latter, the nurse tens to be specialized within one area. These can be in a large variety of quite specific but varied areas. This can include back pain management (Wallis 2000), peritoneal dialysis (Denning 2000), and intermittent claudication (Binnie et al. 1999)., leg ulcer management (Vowden 1997), intractavle childhood constipation (Muir and Burnett 1999) and pre admission clinics (Alderman 1997). The majority of this literature exploring nurse-led clinics tends to be found within the popular nursing press and often extends to only a few pages. Such papers tend to be highly positive regarding the clinics, but are generally descriptive and lack the deeper analysis, which provides insight into how and why the clinic has formed. Two important issues are how the nurse demonstrate, maintains and further develops competence in often expanding areas of practice and how the worth of the clinic is demonstrated. Professional competence is a recurring theme within the text, because of its link to both public protection and to ensuring the clinic is a valued contribution to managing healthcare, and not a second rate service emerging due to over worked medical colleagues.