University of the east Ramon Magsaysay - MMCI Graduate school

CHAPTER I

Introduction Who doesnt remember running to the school nurses office with a nosebleed or ear ache? But how many among us have gone to a nurse-managed clinic for our adult health care? In this era of experimentation in health delivery, the nurse-led clinic is part of the conversation about how best to medically serve us, particularly the poor and uninsured populations. 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

University of the east Ramon Magsaysay - MMCI Graduate school

number is virtually certain to increase, as will that populations ongoing health care needs. Graduate nurses are now facing massive unemployment and underemployment. Statistics of unemployed Filipino nurses hit 150,000 in 2008. Newly licensed nurses would volunteer to work in the hospitals to get the needed experience and training. The Philippine Nurses Association (PNA) claims that volunteer nurses are being exploited by requiring volunteers to pay a fee at the same time availing of the volunteers professional services. But theres a solution to the looming gap in primary care services: nurse-managed clinic staffed by advanced practice nurses. Other countries have already been implementing having a nurse led clinics, but here in the Philippines it may be sound a new to most nurses. Will theses program be a solution to the shortage of medical doctor or lessen the unemployment rate of most nurses? What do nurses thinks about it? Will they think that it would be beneficial for them. This study aims to know the perception of registered nurses on nurse-led clinic. Patient access to care is a significant problem expected to markedly increase over the next twenty years due to physician shortages and a population explosion of newly insured patients with progressive and chronic illness. Research shows that nurse-led clinics may be a potential solution to access if barriers to implementation can be identified and overcome. Although many studies have examined practice outcomes of nurse-led clinics, there is a lack of current knowledge about differences for nurse practitioners (NPs) who run or wish to run a nurse-led clinic versus those who do not and if there are specific barriers or benchmarks toward success.

University of the east Ramon Magsaysay - MMCI Graduate school

Significance of the Study Nurses affect so many aspects of health care in addition to direct clinical care quality 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? In this study, it aims to explore the perception of registered nurses on nurse-led clinic and how far they know about it. For future researchers, the beginning effort laid out in this study is hoped to inspire future researchers, whether in nursing or in other fields of service. 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.

University of the east Ramon Magsaysay - MMCI Graduate school

Scope and Limitation The main focus of this study is to know the perception of registered nurses on nurse-led clinic. The respondents will be randomly chosen in selected institution/hospitals in Metro Manila and other registered nurses who is currently unemployed or working on a different field. Their will no estimated number of respondents not unless the researcher will reach the point of saturation. The respondents must be a registered nurse, working as a nurse, working on other fields or unemployed, and registered nurses who are willing to participate in an interview.

CHAPTER II

Review of Related Literature 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. 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

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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 nurseled/nurse-run clinics must be to provide a measurably effective service. Audit and evaluation are an important part of a developing service.

University of the east Ramon Magsaysay - MMCI Graduate school

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. 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.

University of the east Ramon Magsaysay - MMCI Graduate school

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), intractable 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 demonstrates, 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.

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

University of the east Ramon Magsaysay - MMCI Graduate school

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.

Nurses in the Philippines Nursing is the nations largest health care profession, with 2.6 million registered nurses (RNs), and many more needed in the future. Nurses are the largest single component of any hospital staff, the primary provider of hospital patient care and they deliver most of the nations nursing home care. Nurses work in a variety of other settings. Nursing has become the preferred course of a growing number of college enrollees. The CHEDs Policy, Planning, Research and Information Office sees almost half a million or 497,000 students taking the nursing course in the school year 2008-2009 (manilatimes.com). While many countries in the world are experiencing nursing shortage, the Philippines appear to have an oversupply of nurses. The Officer-in-Charge of the Professional Regulation

University of the east Ramon Magsaysay - MMCI Graduate school

Commission (PRC), Commissioner Ruth R. Padilla, revealed that the country has an oversupply of 400,000 licensed nurses and that the hospitals can only accommodate 60,000 nursing positions (Jaymalin, 2008). Padilla also pointed out that the country yearly produces 100,000 licensed nurses; however, no additional positions are created in the government and private hospitals nationwide. Graduate nurses are now facing massive unemployment and underemployment. Statistics of unemployed Filipino nurses hit a whooping 150,000 (estimated count) in 2008. More graduates were added since then. Although many of the unemployed nurses passed the board examination, one of the key pains of nursing recruiters in the country is the lack of nurses experience and training in actual and hospital work. The sad news is, there are reported cases that some new nurses are even sacrificing and more than willing to pay the local hospital just to allow them to have work experience in their resume. This is becoming a trend and some folks are reported to be benefiting from it (www.filipinonurses.com). Registered nurses volunteer for many reasons. A volunteer experience can bring physical and spiritual renewal to their personal and professional lives (Vali 2009).They may volunteer for many of the same reasons as anyone else, to meet new people, to gain new skills, to feel part of a group and to help people. The Philippine Nurses Association through its National President Leah Paquiz

has disclosed that the oversupply of nurses is fast becoming the countrys problem
(Melencio 2008). Some newly licensed nurses would volunteer to work in the hospitals if only to get the needed experience and training. There are varying reports about the repercussions of nurses volunteers work. The PNA claims that volunteer nurses are being exploited (Balagtas 2008) by requiring volunteers to pay a fee at the same time availing of the volunteers professional services. On the other hand, the Department of

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Health (DOH) is defending the training-for-free scheme in government hospitals, saying that the fees are cancelled by hospitals for specialized training courses for nurse trainees.

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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;

University of the east Ramon Magsaysay - MMCI Graduate school

(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.

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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.

University of the east Ramon Magsaysay - MMCI Graduate school

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.

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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.

University of the east Ramon Magsaysay - MMCI Graduate school

Competencies include the ability to: Conduct advanced assessments and develop intervention strategies within a patientcentered 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 decisionmaking 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

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The Role of Nurse Practitioner-Led Clinics 1. Provide comprehensive family health care services through an inter-professional team of nurse practitioners, registered nurses, a range of other health care

University of the east Ramon Magsaysay - MMCI Graduate school

professionals, and collaborating family physicians, each working to their full scope of practice; 2. Provide system navigation and care coordination across the health care system such as acute care, long-term care, public health, mental health, addictions, and community programs and services; 3. Emphasize health promotion, illness prevention, early detection/diagnosis; 4. Promote the development of new, comprehensive, chronic disease

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management and self-care programs, as well as strengthen linkages with existing programs (e.g. the Ontario Diabetes Strategy) as well as the integrated cancer screening programs; 5. Provide patient-centered care where the patient is a key member of the team and uses information and support to make informed decisions on how to manage his/her self-care needs; 6. Create linkages with other health care organizations at the community level in order to meet the needs of the specific community; 7. Use information technology as the backbone of system integration, linking patient records across different health care settings giving providers timely access to test results and other important data; and 8. Evolve through continuous quality improvement processes, evidence-based practice and flexibility for innovation and responsiveness to local community and provider concerns.

University of the east Ramon Magsaysay - MMCI Graduate school

Perception Perception is the ability to interpret the environment. Through the senses as defined by Kozier, Erb, Berman and Snyder (2004). Furthermore, Hirnle (2003) look at perception as a highly individual cognitive process, hat allows each person to experience the environment uniquely. Hence, perception has something to do with how an individual views things around.

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CHAPTER III METHODOLOGY

Research Design The study will utilize a qualitative, non-experimental design. It is an exploratory study aim to determine the perception of registered nurses on nurseled clinic. Exploratory research is a flexible research design that provides an opportunity that examines all aspects of the problem is needed. Qualitative, since it will focus on the perception of registered nurses and thus subjective data will be collected.

The Sample The target participants will be thirty respondents. Ten of them will be registered nurses who works as a nurse in any institution/hospital in Metro Manila, other ten

University of the east Ramon Magsaysay - MMCI Graduate school

respondents will be the unemployed registered nurses and the last 10 respondents will be registered nurses working in different fields. But the number of respondents may still be subjective to change, if the researched will reach the point of saturation. The selection of the respondents will be based on their knowledge and experience on the topic under investigation. Their ability to express their views likewise considered.

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Study Setting The study will be conducted in the institution were in the respondents are employed, for those who are working and for unemployed nurses, basically in their home setting.

Data Gathering The inductive descriptive method of investigation was employed in the conduct of the study. Respondents were contracted either by telephone calls, personal approach or written letters informing them about the scope of the study. Interview will be mainly utilized in data gathering of the study. A brief biographical data well be extracted from the respondents before the start of the actual interview. Guide questions will be posted by the researcher to the respondents and they will be encouraged to express their views as freely as possible with use of examples, reflections, descriptions and clarifications on the subject matter. The length of interview per respondents will vary from 20-30 minutes.