Nurse Practitioner in Critical Care

INTRODUCTION AND BACKGROUND In India, reshaping health systems in all dimensions of health has been recognized as an important need in the National Health Policy, 2015 (NHP, 2015 draft document). It emphasizes human resource development in WKHDUHDVRIHGXFDWLRQDQGWUDLQLQJDORQJVLGHUHJXODWLRQDQGOHJLVODWLRQ7 KHJRYHUQPHQWUHFRJQL]HVVLJQL¿FDQW expansion in tertiary care services both in public and private health sectors. In building their capacity, it is highly VLJQL¿FDQWWKDWWKHKHDOWKFDUHSURIHVVLRQDOVUHTXLUHDGYDQFHGHGXFDWLR QDOSUHSDUDWLRQLQVSHFLDOWDQGVXSHU specialty services. To support specialized and superspecialized healthcare services, specialist nurses with advanced preparation are essential. Developing training programs and curriculum in the area of tertiary care is recognized as the need of the hour. Nurse practitioners (NPs) will be able to meet this demand provided they are well trained and empowered to practice. With establishment of new cadres in the center and state level, master level prepared NPs will be able to provide cost effective, competent, safe and quality driven specialized nursing care to patients in a variety of critical care settings in tertiary care centres. Nurse practitioners have been prepared and functioning in USA since 1960s, UK since 1980s, Australia since 1990s and Netherlands since 2010. Nurse practitioners in critical care / acute care, oncology, emergency care, neurology, cardiovascular care, anesthesia and other specialties can be prepared to function in tertiary care settings. Rigorous educational preparation will enable them to collaboratively diagnose and treat patients with critical illnesses both for prevention and promotion of health. A curricular structure / framework is proposed by INC towards preparation of Nurse Practitioner in Critical Care (NPCC) at Masters Level. The special feature of this program is that it is a clinical residency program emphasizing a strong clinical component with 15% of theoretical instruction and 85% of practicum. Competency based training is the major approach and NP education is based on competencies adapted from International Council of Nurses (ICN, 2005), and NONPF competencies (2012). Every course is based on achievement of competencies. Critical Care Nurse Practitioner Program is intended to prepare registered BSc Nurses to provide advanced nursing care to patients who are critically ill. The nursing care is focused on stabilizing patients’ condition, minimizing acute complications and maximizing restoration of health. These NPs are required to practice in critical care units of tertiary care centers. The program consists of various courses of study that are based on VWURQJVFLHQWL¿FIRXQGDWLRQVLQFOXGLQJHYLGHQFHGEDVHGSUDFWLFHDQGWKHPD QDJHPHQWRIFRPSOH[KHDOWKVVWHPV These are built upon the theoretical and practice competencies of BSc trained nurses. On completion of the program and registration with respective state council they are permitted to independently administer drugs and order diagnostic tests, procedures, medical equipment and therapies as per institutional protocols. The NPs in CC when exercising this authority, they are accountable for the competencies in a) Patient selection/admission into ICU and discharge E 3 UREOHPLGHQWL¿FDWLRQWKURXJKDSSURSUL DWHDVVHVVPHQW c) Selection/administration of medication or devices or therapies d) Patients’ education for use of therapeutics e) Knowledge of interactions of therapeutics, if any 2 f) Evaluation of outcomes and g) Recognition and management of complications and untoward reactions. 7KH13LQFULWLFDOFDUHLVSUHSDUHGDQGTXDOL¿HGWRDVVXPHUHVSRQVLELOLWDQ GDFFRXQWDELOLWIRUWKHFDUHRI critically ill patients under his/ her care. 7KHVDLGSRVWJUDGXDWHGHJUHHZLOOEHUHJLVWHUHGDVDQDGGLWLRQDOTXDOL¿FDW LRQEWKH6WDWH1XUVLQJ&RXQFLO Philosophy Indian Nursing Council believes that there is a great need to establish a postgraduate program titled Nurse Practitioner in Critical Care to meet the challenges and demands of tertiary health care services in India which is UHÀHFWHGLQWKH1DWLRQDO+HDOWK3ROLF1+3GUDIWGRFXPHQWLQRUGHUWRSURYLGH TXDOLWFDUHWRFULWLFDOO ill patients and families. INC believes that postgraduates from a residency program focused on strong clinical component and competency based training must be able to demonstrate clinical competence based on sound theoretical and evidence based knowledge. The teaching learning approach should focus on adult learning principles, competency based education, collaborative learning, clinical experience with medical and nursing preceptors, experiential learning and self-directed learning. Education providers/preceptors/mentors must update their current knowledge and practices. Medical faculty are invited to participate as preceptors in the training. INC also believes that a variety of educational strategies can be used in the clinical settings to address the GH¿FLWRITXDOL¿HGFULWLFDOFDUHQXUVLQJIDFXOW,WLVKRSHGWRIDFLOLWDWHGHYH ORSLQJSROLFLHVWRZDUGVUHJLVWUDWLRQ licensure and create cadre positions for appropriate placement of these postgraduate critical care NPs to function in critical care units of tertiary care centers. An educational framework for the NP curriculum is proposed (See Figure 1). 3 II. PROGRAM DESCRIPTION II. Program Description The NP program is a Nursing residency program with a main focus on Competency based training. The duration is of two years with the curriculum consisting of theo ry that includes core courses, advanced practice courses and clinical courses besides clinical practicum which is a major component (Refer Curricular framework). III. AIM The critical care NP program prepares registered BSc nurses for advanced practice roles as clinical experts, managers, educators and consultants leading to M.Sc degree in critical care NP IV. OBJECTIVES On completion of the program, the NP will be able to 1. assume responsibility and accountability to provide competen t care to critically ill patients and appropriate family care in tertiary care centres 4 2. demonstrate clinical competence / expertise in providing cri tical care which includes diagnostic reasoning, complex monitoring and therapies 3. apply theoretical, patho-physiological and pharmacological p rinciples and evidence base in implementing therapies / interventions in critical care 4. identify the critical conditions using differential diagnosi s and carry out treatment/interventions to stabilize and restore patient’s health and minimize or manage complicatio ns independently or collaboratively as a part of critical care team 5. collaborate with other health care professionals in the crit ical care team, across the continuum of critical care V. MINIMUM REQUIREMENTS TO START THE NP CRITICAL CARE PROGRAM The institution must accept the accountability for the NP program and its students and offer the program FRQJUXHQWZLWKWKH,1&VWDQGDUGV,WPXVWIXO¿OOWKHIROORZLQJUHTXLUHPHQWV ( VVHQWLDOLW&HUWL¿FDWH a. If any institution opting to start NP program already has BSc (N) or MSc (N) program recognized by ,1&LWZLOOEHH[HPSWHGIURP12&1R2EMHFWLRQ&HUWL¿FDWH(VVHQWLDOLW&HU WL¿FDWHIRU13LQFULWLFDO care post graduate residency program from State Government b. If the institution is having any University education program of training nurses and doctors or if they have DNB program, NOC will not be required to start NP program 2. Hospital The hospital should be a parent tertiary care centre, with a minimum of 200 beds. It can have a medical college or nursing college 3. ICU Beds The hospital should have a minimum of 4 ICUs namely medical ICU, surgical ICU, cardio/cardiothoracic ICU and Emergency care unit with a minimum of 5 beds each and total of 20 beds. ,&8VWDI¿QJ D (YHU,&8VKRXOGKDYHDFKDUJHQXUVHZLWK%6FRU06FTXDOL¿FDWLRQ b. The nurse patient ratio should be 1:1 for every shift for ventilated patients c. For the rest of ICU beds the nurse patient ratio should be 1:2 for every shift d. Provision of additional 45% staff towards leave reserve e. Doctor patient ratio can be 1:5 ) DFXOW6WDIIUHVRXUFHV D &OLQLFDODUHD)XOOWLPHTXDOL¿HG*10ZLWKHDUVRIH[SHULHQFHLQFULWLFDOF 5 DUHQXUVLQJRU%6FZLWK years experience in critical care nursing or MSc(Specialty-Medical Surgical Nursing/Pediatric Nursing/ Obsetrics & Gynaecology Nursing) with one year critical care nursing experience (One faculty for every 10 students) b. Teaching faculty: Professor/Associate professor- 1(Teaching experience- 5 years post PG), Assistant professor- 1 (Teaching experience- 3 years post BSc) F 7KHDERYHIDFXOWVKDOOSHUIRUPGXDOUROHRUDVHQLRUQXUVHZLWK06FTXDOL¿ FDWLRQHPSORHGLQWKHWHUWLDU hospital. d. Guest lecturers: for pharmacology Preceptor student ratio -Nursing 1:10, Medical 1:10 3 KVLFDODQGOHDUQLQJUHVRXUFHVDWKRVSLWDOFROOHJH a. One classroom/conference room at the clinical area b. Skill lab for simulated learning (hospital/college) c. Library and computer facilities with access to online journals d. E-Learning facilities /LVWRIHTXLSPHQWIRU,&8HQFORVHG$SSHQGL[ 6 WXGHQW5HFUXLWPHQW$GPLVVLRQ5HTXLUHPHQWV a. Applicants must possess a registered B.Sc nurse with a minimum of one year clinical experience, preferably in any critical care setting prior to enrollment. b. Must have undergone the BSC in an institution recognized by the Indian Nursing Council. c. Must have scored not less than 55% aggregate marks in the BSc program d. Selection must be based on the merit of an entrance examination and interview held by the competent authority Number of candidates: 1 candidate for 4-5 ICU beds, Salary: 1 . In-service candidates will get regular salary 2. Salary for the other candidates as per the salary structure of the hospital where the course is conducted Eligibility for appearing for the examination Attendance: Theory, practical and Clinical – 100% VI. EXAMINATION REGULATION &ODVVL¿FDWLRQRIUHVXOWV Pass: 50% pass in theory and Clinical Practicum 6 Second Division: 50-59% First Division: 60-74% Distinction: 75% and above For declaring the rank, aggregate of two years marks will be considered If a candidate fails in theory or practical, he/she has to reappear for the paper in which he/she has failed. Maximum number of attempts = 2, Maximum period to complete the program = 4 years Practicum: 6hours of examination per student Maximum number of students per day = 5 students Examination should be held in clinical area only Examined by one internal and one external examiner The examiner should be MSc faculty teaching the NP program with minimum two years of experience. Dissertation 6 XEPLVVLRQRIWKHUHVHDUFKSURSRVDO%PRQWKVLQ¿UVWHDU 6XEPLVVLRQRIWKHGLVVHUWDWLRQ¿QDOPRQWKVEHIRUHFRPSOHWLRQRIVHFRQGHDU Research guides: Main guide – Nursing faculty (3years experience) teaching NP program, Co guide: Medical preceptor Guide student ratio- 1:5 There should be a separate research committee in the college/hospital to guide and oversee the progress of the research (minimum of 5 members with principal or CNO-MScN) Ethical clearance should be obtained by the hospital ethics committee 9,, $VVHVVPHQW)RUPDWLYHDQG6XPPDWLYH ‡ 6 HPLQDU ‡ : ULWWHQDVVLJQPHQWV7HUPSDSHUV ‡ &DVH&OLQLFDOSUHVHQWDWLRQ ‡ 1 XUVLQJSURFHVVUHSRUW&DUHVWXGUHSRUW ‡ &OLQLFDOSHUIRUPDQFHHYDOXDWLRQ ‡ /RJERRN&RPSHWHQFOLVWDQGFOLQLFDOUHTXLUHPHQWVFRXQWHUVLJQHGEWKHPHGLF DOQXUVLQJIDFXOWSUHFHSWRU ‡ 2 EMHFWLYH6WUXFWXUHG&OLQLFDO([DPLQDWLRQ26&( 263( ‡ 7 HVWSDSHUV ‡ ) LQDOH[DPLQDWLRQ