Transforming Healthcare Services - An approach towards Independent Nursing Practitioners

This report analyzes the strengths and weaknesses of Independent Nursing Practice (INP) model and explores opportunities for collaboration with other healthcare professionals. It also discusses the barriers and challenges towards the implementation of change.

Running head: Transforming Healthcare Services
Transforming Healthcare Services
-An approach towards Independent Nursing Practitioners
Name of the Student
Name of the University
Author Note

1Transforming Healthcare Services
Abstract:
Advanced nursing practice (APN) comprises of roles like nursing midwifery, clinical
nurse specialist, nurse anesthetist and nurse practitioners. Independent Nursing Practice (INP)
is a form of nursing practitioner profession, in which the nurses can work independently, but
with collaboration, with other healthcare professionals like general physicians,
pharmacologists, social care workers and other professionals from a multidisciplinary
healthcare team. The INP is required to be highly mobile, and deliver care in various setups
ranging from patient’s homes to various healthcare and daycare facilities. The profession
faces different challenges in its implementation, and the aim of this report is to analyze the
strengths and weaknesses of the model, and explore the opportunities for collaboration with
other healthcare professionals, keeping in mind that through effective collaborations, the
model can be further improved. The barriers and challenges towards the implementation of
change are also discussed in the report. The strengths of the model include flexibility of
practice, does not require physician supervision, can allow the nurses to act as teachers and
counselors for the patients. However several healthcare organizations do not have sufficient
trust on the competencies of independent nursing practice that can merit its utilization,
independent of general physicians. Provision for support is offered by Nursing and
Midwifery board though endorsements for advanced clinical nursing practice. Other strengths
include the ability of the practice being conducted in different settings, which increases
accessibility to healthcare services and increase the range of healthcare setups supported by
healthcare organizations. INP can also be effective model for the care of elderly patients,
considering how the practice can address the needs identified through the social determinants
of health. INP also fosters the development of active collaboration within a multidisciplinary
healthcare team and develops a culture where the quality of care can be constantly developed.

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The strategies of improvement in the existing model can be implemented at two levels:
patient experience and strategic cultural alignment. The steps can be divided into four stages:
complex care, development of partnership network and value based care and incorporating
strategic enablers like branding of services, technology, facility planning, etc. However, the
different factors that affect services should also be considered. Strengths and weaknesses of
service can also be measured through the value of services, calculated by the equation device
by UK healthcare. INP also allows access to quality care in a coordinated and patient centric
manner, it fosters health promotion through health education and training, and it also
improves affordability of healthcare services, as well as improves the overall health
infrastructure. Collaboration of care can also be developed through leadership and
commitment, attributed in nursing profession, apart from fostering health literacy and
improving access to affordable and high quality care. Different barriers to the practice
includes the providence of adequate time, and time lost in the regular travelling, the cost of
care as well as resistance from general physicians in acknowledging INP as a credible
healthcare option. However an effective collaboration such barriers can be overcome, and
ensure that the nursing profession flourishes further.

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Contents
ABSTRACT:..............................................................................................................................1
Introduction:...............................................................................................................................4
Description of the current service:.............................................................................................4
Patient Demographics:...............................................................................................................5
Factors Influencing Consumer Care Provision or Access..........................................................5
Current Model of Care:..............................................................................................................8
Strengths and Weaknesses of Health Service:.........................................................................13
Proposed NP Model:................................................................................................................14
Conclusion:..............................................................................................................................15
Recommendations:...................................................................................................................16
References:...............................................................................................................................18

4Transforming Healthcare Services
Introduction:
Advanced Practice Registered Nursing (APRN) comprises of four roles which are
nurse mid-wife, clinical nurse specialist, nurse anaesthetist and nurse practitioner. Nursing
practitioners are registered nurses with an accredited graduate degree and specialization
certifications reflecting the area of expertise (Nursing.upenn.edu, 2018). Independent Nursing
Practice allows the nurses to carryout work independent of other healthcare professionals,
and also allows collaboration whenever required. This means that the nursing practitioners
can practice and prescribe medications independently (Rigolosi & Salmond, 2014).The
Independent nursing practice model comprises of models that are small business or private
and are very mobile, which means that the nurses often have to travel to client’s locations.
This model combines the functions of a small business ownership and a professional practice,
which raises are significant challenge in respect to the combination of responsibilities
associated with each of these functions (Hamric et al., 2013).
In the current context, the Independent Nursing Practice model will be critically
analysed and evaluated to identify the strengths and weaknesses in the model. Opportunities
for collaboration with other professionals in order to support the service model shall also be
discussed, which can allow improvement in the model. Furthermore, the different barriers
and challenges for improvement will also be analysed which can help nib the development of
improvement strategies for the model.
The setup for the independent practice is setup in an aged residential care centre (Blue
Care) which houses about 100 residents of ages 70 to 100 years.
Description of the current service:

5Transforming Healthcare Services
Independent Nursing Practice involves the providence of differential services
depending upon the local demand as well as the scope of the nursing practitioner, showing a
lot of flexibility in practice. This entails the independent practice to be conducted at different
service environments. Independent NP can provide non acute care in a home setup (MacPhee
& Borram, 2012). The types of care provided can include: regular monitoring of blood
glucose, blood pressure, and blood clotting; regular health checkups; care for wound;
treatment for upper respiratory system, continence care, assessing the medication provided,
assessment for falls and also provide referral for other services.
Patient Demographics:
In the present scenario, the selected population comprises of elderly patients.
Factors Influencing Consumer Care Provision or Access
Independent NP enables the nursing practice to be conducted without the
supervision of a physician. This helps the nurses to gain independence and autonomy as they
are able to provide medical care without management or oversight of the physician (Antohe
et al., 2016). A ‘full practice’ status of an NP is a provision that enables independent
assessment, diagnosis, interpretation of diagnostic tests, and prescription of medicines
(Moran et al., 2016). Licensed Independent Nurse Practitioners can conduct their practice in
different setups like: ambulatory, acute, long term care and also function as primary or
speciality care providers. They can assess, diagnose, treat and manage both chronic
conditions as well as acute episodic conditions. Therefore the practitioners need to be adept
with health promotion and disease prevention. They can also order, conduct, supervise as
well as interpret laboratory and diagnostic results, provide prescriptions for pharmacological
substances and non-pharmacological therapies. Moreover, the independent nurses can also be
involved in teaching and counselling of the patients. Hain and Fleck (2014) however pointed

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out that many professional healthcare organizations do not support independent nursing
practice as they believe that physicians have better competency in medical care compared to
Nursing Practitioners due to their rigorous training, and hence NP are incapable of providing
care within the same quality and safety parameters as physicians (Hain & Fleck, 2014).
According to the Australian Department of Health, endorsement from Nursing and
Midwifery Board of Australia is required to work as a nurse practitioner. The endorsement
can be received on the merit of several factors like a general registration as a registered nurse
with no restriction on practice; advanced practice in clinical leadership in the area of
expertise in the last 5 years and complemented with research, education and management;
showing competence in the competency standards set by the Nursing and Midwifery Board
of Australia, and completion of the required qualification as mandated by Nursing and
Midwifery Board of Australia. Such factors can ensure the development of competency,
expertise and knowledge of the nurses to independently conduct their practice
(nursingmidwiferyboard.gov.au, 2018).
The practitioners can work with individuals, families or communities in different
care settings like hospitals, community health settings and private practice. However, there
isn’t any limit on where an independent nursing practitioner can work, and currently in
Australia Nursing Practitioners are involved in speciality areas like: aged care, emergency,
drug and alcohol, private practice, surgical, medical, women’s health, rural and remote setup,
mental healthcare facilities, communities, chronic and complex care centre as well as
paediatric units (Nursing.upenn.edu, 2018). This also increases accessibility to healthcare
services, as well as increase the range of care settings that can be supported by healthcare
organizations.

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In each of such settings, the consumer population needs, social determinants of health
and primary healthcare principles can differ. In an aged care centre, the NP needs to deal with
elderly patients. The health needs of the elderly population are underlined by the higher
prevalence of chronic conditions, physical disabilities, mental health conditions, and
related co-morbidities. Shrivastava et al. (2013) suggested that the health needs of the
elderly patients cannot be viewed in isolation. This is because of different inter-related factors
that can be attributed to the various health problems seen among them. Several determinants
of health that affects the well being of the elderly has been identified by different authors, and
includes: social factors (isolation of the patients, due to their children moving out in search
for occupation), mistreatment of the elderly, lack of awareness about the risk factors, dietary
and nutritional needs, psycho-emotional factors (like mental stress and isolation), financial
factors (reduction of income after retirement thereby challenging the access to basic needs
like proper nutrition, shelter and clothing), factors attributed to healthcare systems (healthcare
insurance for elderly and government care facilities) and physical determinants. These factors
can significantly affect the medical problems of the elderly, and also have an impact on the
quality of life experienced by them (Song et al., 2013; Braz et al., 2012). INP can ensure
provision of care that spans across several of these social determinants, providing a multi-
dimensional care for the patient.
Shrivastava et al. (2013) proposed that prevention and control of health issues among
the elderly populace requires a multidimensional approach that requires an active
collaboration of different sectors like healthcare, social welfare, urban/rural development
and legal, which can be a significant challenge considering the diverse range of professional
skills required to maintain communication with them. Also, a lack of comprehensive policy
that addresses the determinants of health is a weakness of this service. A community or a
home based care program for the elderly patient’s needs to begin with the development of a

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comprehensive policy that can include the other determinants of health apart from the
medical aspects. A strong sense of commitment and social action is needed for the proper
implementation of the care model at the basic level. Improving the knowledge of the elderly
about health and risk factors is an important measure, as pointed out by Song et al.
(2013).Other measures include social measures that involves creating a culture where care of
the elderly is also participated by their children; involving regulatory strategies that enables
members of society to care for their aged parents developing health insurance policies for the
elderly to cover their healthcare needs; developing pension schemes; development of elder
friendly houses and roads; promoting primary prevention strategies like healthy lifestyle;
providence of education, information and communication for the elderly, middle aged
(individuals who will move on towards elderly age group in the near future) and the youth
(acting as caregiver for the elderly) about issues related to hygiene, physical exercise,
nutrition, avoiding alcohol and tobacco, accident prevention and developing awareness about
the early signs of geriatric problems (Song et al., 2013). Training of medical professionals to
understand the specialized needs of the elderly, provision of medical aids, setting up
gerontology units, ensuring proper communication with the patients can also be implemented
in the primary care policies for effective care (Shrivastava et al., 2013).
Current Model of Care:
Different strategies have been identified that can improve the healthcare service for
the elderly. These strategies have been embodied in different care plans globally, which shall
be discussed next.
The UK Healthcare Strategic Plan (2015-2020) aims the development of Patient
Centered Care, and considers two aspects of improvement: Patient Experience and
Strategic cultural alignment. The plan necessitates the involvement of patient experience

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governance models and strong clinical and administrative leadership. This also requires
engagement of medical staff in the process of change, and creates strong cultural alignment
(Spurgeon et al., 2015). The plan has 4 stages: stage 1 aims growth in complex care, stage 2
aims to improve partnership network, stage 3 aims to develop value based care and
payment and stage 4: incorporates strategic enablers (like a service line operating model,
technology, strategy implementation, facility planning and marketing/branding). Different
services can be identified that can directly affect a patient’s experience like: inpatient
hospitalization and rehab services, skilled nursing facility, outpatient rehabilitation, home
care, wellness program, pharmacy support, physicians clinic, diagnostic laboratory, urgent
care and ambulatory services. Other factors can influence the services that the patient directly
interacts with, and includes: applied analytics, care management team, health management
interventions, integrated care, telehealth, informatics and risk stratification, patient
engagement and seamless technology (ukhealthcare.uky.edu, 2018).

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Figure 1: Alignment of services to ensure patient centered care; source:
(ukhealthcare.uky.edu, 2018).
Figure 2: Strengthening of partnership networks; source: (ukhealthcare.uky.edu, 2018).
Figure 3: Calculating value of care as a factor of quality, service, access to care and cost;
source: (ukhealthcare.uky.edu, 2018).
Figure 1 and 2 above shows how services can be strategically aligned to the needs of
the patient, and help to support other services in order to strengthen and improve care through
the development of partnership networks. Figure 3 shows how the value of a service model;
can be analysed from individual components like the sum quality of care, service, and
accessibility to it over the cost of care (ukhealthcare.uky.edu, 2018).
The partnership HealthPlan of California suggests that community based approaches
can be developed through an improved access to primary care, improve access to alcohol and

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drug treatment, developing comprehensive care plan for elderly, supporting the recruitment
of providers and commitment to the development of health information exchange and clinical
data repository. The plan identifies partnership of 4 pillars (providers, employees, public
resources, and community partners) on which a health of individuals can be promoted
(Partnershiphp.org, 2018).
Central Health strategic plan incorporates four aspects in the improvement of
healthcare model: 1. Improving healthcare through the access of high quality, patient
centric coordinated clinical service. 2. Health Promotion through the alignment of health
education policies to foster the ability of patients to improve their own health conditions as
well as that of their families. 3. Improving health coverage through affordable healthcare
products and enrolment to healthcare services that can improve accessibility to care. 4.
Developing health infrastructure by ensuring necessary services being in place and
accessible by the patient. INP allows all such factors to be considered in the service.
The various aspects identified above can be utilised in the designing of a strategic plan that
can improve the healthcare service model of independent nursing practice (centralhealth.net,
2018).
 Keeping the patient’s experience central to the service
 Help in the development of complex care
 Develop partnership network
 Develop value based care
 Using strategic enablers
 Health education
 Improving accessibility to care
 Implementation of health promotion and wellness programs

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In the nursing practice, such aspects can be addressed through the development of
competencies and skills of the nurse to provide complex and specialized care, which can be
catered as per the individual need of each patient. Independent NP can also help to improve
accessibility to other healthcare services through referrals and partnerships. Within a home
care setting, this can be a very useful strategy as it can ensure the providence of care in the
residential setup, and done at the comfort of the patient. Collaboration of care practitioners
can also ensure a continuum of uninterrupted care spanning across social support, speciality
care, medication management, home health care, care facilities and primary care. The unique
specialization of independent nurses allows the providence of care within all these domains.
Such viability can be attributed to the adaptability of Independent NP
(Onlinenursing.simmons.edu, 2018; nursingmidwiferyboard.gov.au, 2018).
High quality of healthcare can also be maintained through the improvement of health
of the members in aged care center, improving the member experience of care, and also
minimizing the cost of maintenance of care. The quality of care can also be improved by
addressing the social determinants of health that affects the health of the individuals (Adler et
al., 2016). Involving community based programs, and social care workers can help to reduce
a sense of isolation experienced by the patients. Furthermore, developing a community and
society where the elderly are taken care of by their children or are supported by care workers
to ensure the elderly resident’s health needs are properly addressed can be useful methods.
The independent nurse can also work in collaboration of other care professionals, sharing
health information of the patient, and also ensuring a smooth transition of service, without
causing any interruptions to care. Involvement of psychological and medical support can help
to identify any early signs of geriatric health problems (health.vic.gov.au, 2018).

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Regular visits from Nursing Practitioners to assess the health and well being of the
residents in the aged care can allow regular monitoring of the health condition of the patients
and also enable early treatment or intervention in case of any significant health risk. Regular
visits can also improve patient satisfaction (Forsgärde et al., 2016). Risk assessment can also
be suggested to be carried out in the care facility that can help to maintain a safe environment
for the residents, and also identify any hazards in the environment. The elderly patients and
their families can be educated by the nurses, which can help to develop an understanding of
age related problems and co-morbidities and empower the patients and their families to
actively participate in the maintenance of well being of the elderly people (Castro ET. Al.,
2016).
Strengths and Weaknesses of Health Service:
Collaborative care can be understood as the integrated application of skills,
knowledge, attitudes and values that allows working across professions with other healthcare
workers, patients, and their families, as well as communities as an when necessary to improve
health outcomes. Collaborative care therefore should be able to place the needs of the patient
at the centre of collaborative care, maintain commitment to leadership to enable an inter-
professional and interpersonal collaboration, foster an equal opportunity that values
contributions from each practitioner in the collaborative team, and maintain an effective
communication between team members (Valentine et al., 2015). A collaborative approach
helps to integrate different specialities like mental and behavioural health, public health,
physical therapy and nutrition. Nursing practitioners however is the only profession in this
collaboration who has an understanding of the roles of the other professionals in the team.
This emphasizes their crucial role in the collaborative care, as they are able to assess clinical.
Emotional and social conditions of the patient comprehensively, and utilise available
resources to develop a patient cantered plan. Moreover, the adaptability, commitment to

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goals, empathy and communication skills possessed by the nurses can account for strong
leadership and team playing abilities (nursingworld.org, 2018).
Aged healthcare faces a number of challenges that are applicable to health of
individuals and it requires cross-sector solutions. The challenges include funding issues,
shortage of workforce, usage of technologies and population health planning. Aged care
service also helps to reduce unnecessary hospitalizations, and thus reduce load on the local
health services, which emphasizes the necessity of collaboration of aged care service with
healthcare services. Furthermore, collaboration can ensure the providence of accessible,
affordable and quality care for the elderly which can be delivered through sustainable and
viable aged care service providers (like residential care for the aged) (Hospitalhealth.com.au,
2018).
Proposed NP Model:
Collaboration of service in an aged care facility can be developed over 6 domains:
social support, speciality care, primary care, care facility and home health. The social support
can be provided through the provision of health literacy, housing, durable devices, meals and
transportation facilities for the elderly who cannot afford it. Health literacy can help to
improve understanding of health conditions and its risk factors and facilitate proper health
seeking behaviour by the mental health patients (Bonabi et al., 2016). This shows how health
literacy can encourage patient to seek medical help on time. Provision of housing, durable
equipments (like prosthetics and aids), meals and transportation for elderly who are not able
to afford the same can ensure that their financial instability is not adversely affecting their
health condition. Speciality care can be provided through the collaboration of specialists in
surgery, cardiology, oncology, nephrology, dialysis, pain management and transplant
services. This can provide support to elderly patient suffering from long term or acute

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conditions which requires specialist interventions. Home health support can be provided
through the providence of medical supplies, home nursing services, sub-acute rehab and
home therapies. This can be achieved through specialised nursing services that can offer
medical prescription services, as well as rehabilitation or home care services. Moreover,
services that are a part of care facilities like long term care, palliative care, primary care and
medication can also be provided through independent nursing practices and allied health
services. (Shrivastava et al., 2013)
Services in residential care facility can also be improved through the usage of
information technology to support clinical staff and improve the flow of information and
work process in the care facility. Information technology can be utilized to improve
productivity and help in the integration of patient records, foster safe and effective work
practice, and also enable proper communication of clinical information across different
healthcare domains. Technology can also ensure accuracy and consistency of information
flow as the patients move between different care facilities. Thus, such aspects can results in
the reduction of time needed by the clinicians and increase productivity (Sydney.edu.au,
2018).
Conclusion:
The collaborative process can help in the involvement of multidisciplinary team as
well as the patient and their families, with the nurses at the centre of the communication
process. Since the nurse is equipped to understand and analyse the roles of each member of
the collaboration, they are able to effectively communicate vital information between the
team, and furthermore the skills of nurse pertaining to effective communication, and research
based practice can further help to collaborate the efforts of the multi disciplinary team
(Altman et al., 2018).

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Recommendations:
Different barriers exist in the nursing practice model and can span through different
levels: individual, professional, organizational as well as time, cost and system related factors
(Fitzgerald et al., 2017; Hain & Fleck, 2014).
Individual barriers include: selection of the ‘right’ person with the required
specialization in the right place; challenge to attract experienced NP in aged care service;
challenge communicating with different healthcare professionals, patients and their families;
competitive salaries offered by public sectors; challenges in covering leave for the nursing
practitioner and allotting necessary time needed for professional development and payment of
study fee for nursing practitioner service. Communication can be a key skill in overcoming
many of these challenges (Arnold & Boggs, 2015). These problems can also be overcome by
the demonstration of competency by the NP and their autonomy; exhibiting nursing career
development through the role of nursing practitioner; employing NP with excellent clinical
skills and interpersonal strengths; involving human resources management that can manage
nurses on leave and enable skill development; assisting the NP to integrate clinical
competency with critical thinking and management skills.
Professional barriers include: resistance from medical professionals towards NP;
involvement of different healthcare professionals from different disciplines for the care of
elderly; shortage of time to build a meaningful patient-nurse relationship and develop
awareness of NP’s roles; and difficulty in finding mentors for NP (McCarter et al., 2016).
These challenges can be overcome through specific strategies which can include: developing
credible relation between the nurse and other healthcare professionals; creating a trusting
relation; developing meaningful and effective communication; involving an advocate or
strategic leader; involving strong mentorship and developing relations with the community.

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Organizational barriers can include poor administrative support; structural changes in
organization affecting the role of NP; cultural shift experienced by the RN and managers;
shortage of time to develop proper clinical governance strategy (Elliott et al., 2016).
However, such challenges can be mitigated through the setup of strong governance system;
maintaining clarity in the role of NP and defining the scope of support clearly; involving NP
with organizational experience; ensuring access to clinical governance procedures and
protocols; and providence of organizational resources for the NP (Hain & Fleck, 2014).
Time related barriers can include the shortage of time to meet corporate demands,
mismatch between time based funding and the philosophy of holistic care; time needed to
learn the organizational processes; time lost in travelling and longer time needed for the
treatment or management of complex conditions or co-morbidities.
Cost barriers can include challenges in the coverage of the initial setup as well as
ongoing service for NP; availability of sustainable resources to secure income; loss of income
due to travelling; covering information technology costs; and lack of support system or
referral process. Such challenges can be reduced through the utilization of organizational
resources to cover expenses; and using technology and infrastructure efficiently (Hain &
Fleck, 2014; McInnes et al., 2015; Health.gov.au 2018).

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