Role of the Advanced Practice Nurse in

Polyclinic Chronic Diseases

Management: From Concept to Practice
APN Elizabeth Ho Moon Liang
MN (Singapore), BSc Nur (Australia)

 Healthcare Transformation: Primary Care Focus. Nursing Symposium.

11 May 2008. “Role of APN in Polyclinic Chronic Disease Management:
From Concept to Practice.”

TRENDS Seminar. 30 Jan 2008. “APN internship Program in XXX –

Preparation for Nurse-led Clinics.”

1st Sigma Theta Tau Conference. 13 Jul 2007. “Role of APN in Chronic
Disease Management in Community Setting.”

NHGP 1st Nursing Conference. Nov 2004. “The Role of APN in

Community Nursing: The Need and Challenges Ahead.”
 Top 10 Causes of Death in Singapore

30%

25%

20%

15%

10%

5%

0%
Cancer Ischaemic Heart Disease
Pneumonia Cerebrovascular Disease
Accidents, Poisoning and Violence Other Heart Diseases
Diabetes Mellitus Chronic Obstructive Pulmonary Disease
Urinary Tract Infections Nephritis, Nephrotic Syndrome & Nephrosis
Chronic Disease Management

What is Singapore Current Care Model for

Chronic Disease Management?

• Care Complexity
• Team Concept
• Integration of Care
• Right Siting
• IT Leverage

Are we prepared for

Tomorrow’s Health Challenges?
Issue of Sustainability
 Chronic Disease Management
Year 2030: +10%

Year 2012: 1st Batch of Baby

Bloomers hit over 65 years

Year 2007: 8.7%

(Singapore Department of Statistic, 2005 from MCYS 2006,

http://www.mcys.gov.sg/successful_ageing/report/CAI_report.pdf)
 Chronic Disease Management

Year 2007: 8.7% Increase by Year 2030: 18.7%

399,010 2 times 796,000

1 Elderly: 1 Elderly:
9.8 Working People 3.5 Working People
(Goh, 1997 and Chan, 2001)
Chronic Disease Management
Emphasis on
Cancer Screening
Singapore's Coexisting of
Age Profile several
illnesses in an
individual

Complexity
Changing
of the
family
healthcare
structures
structure
Political concerns on
increasing health
expenditure
Chronic Disease Management

Emphasis on Cancer Management

•Ministry’s aim for cancer management is to reduce

premature deaths
from all cancers by 10% 124 deaths per 100,000
population in 1997 to 112 deaths per 100,000 in
2010

•Emphasis on Women’s Health to prevent breast cancer

(commonest cancer) among women and cervical cancer
(fourth commonest)

(Singapore Ministry of Health, State of Health Report, 2001)

Chronic Disease Management
Cognitive:
Beliefs, Values, Perceptions etc.

Emotions:
Social: Anger, denial,
Social roles, frustration, etc.
family etc.
Spiritual

Financial
Personality
Type

Healthcare Diseases’
Access Burden
 Evolving HCP-Patient Relationship
The Goal of CDM is NOT Cure but
Maintenance of Pleasurable and Independent
Living
TRADITIONAL CARE COLLABORATIVE CARE
 Principal care giver:  Principal care giver:
Doctors. Patients themselves.

 Professionals are experts.  Professionals are experts

about disease.
 Patients are passive. Patients are experts of
their lives.
 Shared responsibility.

(Bodenheimer, Lorig, Holman and Grumbach, 2002. JAMA, 288(19), p.2469 - 2475)
 Patient
Empowerment

Partnership Behaviour Change

Family Nursing
The Need…

Est. no. of patients per month

Hypertension – 3,372
Hyperlipidemia – 1,306
Diabetes – 3,336

1 Dr see an average of
51 patients per day!!
Concept of Advanced Practice Nurse

Medicine

Nursing
Definition of APN
Definition
An advanced level of nursing practice that
maximizes the use of in-depth nursing
knowledge and skill in meeting the health needs
of client (individuals, families, groups, populations
or entire communities).

It also means extending the boundaries of the

usual nursing scope of practice and contributing to
nursing knowledge and the development and
advancement of the profession.
Canadian Nurses Association (2002)
 Excellence in direct clinical
practice is the first and
foremost characteristic of
advanced nursing practice

(Hamric, Spross, & Hanson, 2000 cited in Hamric and Hanson 2003)
Studies on Nurse-Led Clinics

Murchie, Campbell, Ritchie, Simpson & Thain, 2003

Secondary prevention clinics for coronary heart disease: four
year follow up of a randomised controlled trial in primary
care between the usual general practitioner practice (control
group) and the nurse-led secondary prevention clinics
(intervention group).

Conclusions:
•improved medical and lifestyle components
•significantly fewer total deaths
•fewer coronary events.
BMJ (2003) 326: 84-87
 Studies on Nurse-Led Clinics (cont’)
Denver, Barnard, Woolfson & Earle, 2003
A randomised controlled study, comparing the effectiveness
of a nurse-led hypertension clinic with conventional community
care in general practice in the management of uncontrolled
hypertension in patients with Type 2 diabetes

Conclusions:
•A target systolic BP less than 140mmHg is more readily
achieved (threefold greater than conventional care).

•Treatment regimens in nurse led groups were more likely to be

adjusted six times more compared with those in conventional
care.
Diabetes Care (2003) 26(8): 2256-
Potential Benefits on Nurse-Led Clinics

•Allow longer doctor consultation time on

complicated cases discharged from hospital specialist
outpatient clinics or even holding family conferences

•Able to provide patient value added services, with

the ability to furnish medications

•Reduce patient waiting time at different service

stations
 Development of Nursing Education

1992 - commencement of 3-year Diploma Nursing Course at

Nanyang Polytechnic, School of Health Sciences

1993 – commencement of Advanced Diploma in Nursing at

Nanyang Polytechnic, School of Health Sciences

1994 - introduction of 2 year local part-time Bachelor of

Health Science (Nursing) Course by Australian Universities

2002 – introduction of Master of Nursing at National

University of Singapore (NUS), Graduate Medicine Faculty
Becoming an APN

Master of Nursing Programme

Division of Graduate Medical Studies

Eligibility Requirements
• Bachelor’s degree in nursing
• Advanced Diploma in Nursing or its equivalent
• Minimum 2 years post-Advanced Diploma
experience in specialty area
• Registration with Singapore Nursing Board.
• Minimum TOEFL score of 580/ IETLS score of 6
Core Modules
• Foundations of Advanced Practice Nursing
Advanced Health Assessment
Advanced Practice Nursing I
(cardiovascular, respiratory and renal disorders)
Advanced Practice Nursing II
(endocrine, oncology, gastroenterology
,neuroscience disorders)
Advanced Clinical Skills
Applied Pharmacology
• Health Care Policy, Economics and Finance
• Therapeutic Communication & Patient Education
• Research Project
• Evidence-Based Practice
• Clinical Research Methodology
• Applied Biostatistics
• Evaluation of Clinical Care
 Becoming an APN
After graduation

Obtain APN Provisional License

from Singapore Nursing Board

APN Certification APN Role Development

Requirements:
• Minimum 1040 clinical hours
• Fulfilled needed competencies
• 12 Case Studies
• Involve in Research & QI
Projects
• Involve in Teaching
• Demonstrate Clinical
Leadership
• Develop clinical competencies
criteria
• Develop clinical protocols
• Initiate APN Clinic
• Evaluate APN Practice
• Support others: APNs/ Interns
• Involve in APN & Nursing
professional development
APN Clinical Consult Emphasis

15% 15%

70%
Acute Problems
Chronic Disease Management
Health Promotion and Disease Prevention
 20 Common Chief Complaints

• Cough • Headache
• Sore Throat • Joint Pain
• Breathlessness • Backache
• Chest Pain/ Discomfort • Eye-related problems
• Giddiness • Skin Rash
• Numbness • Dysuria
• Dyspepsia • Insomnia
• Abdominal Pain • Fatigue
• Constipation • Loss of Appetite
• Diarrhea • Loss of Weight
 Acute and Primary Care Differences

Health History Presentation

Problems seen early, Problems usually seen late,
Ill defined Better defined

Diagnostic Certainty
A great deal of High degree of
diagnostic uncertainty diagnostic certainty

Focus of APN
Focus on Person Focus on Disease

Care Continuity
Continuity Sustained Minimal Continuity
 APN Internship Training Focus

 Relevant history  Recognize & manage

 Appropriate PE significantly ill patient
 Develop working Dx  Recognize serious
 Critical use of Inx illness inherent in
common presentations
APN Internship Training Focus (cont’)
CORE KNOWLEDGE (cont’)
 Manage Chronic Diseases competently
(Hypertension, Hyperlipidemia and DM)
 Manage common problems competently
(URTI, Knee pain, Eczema, Headache & GE)
 Furnish medications safely and
cost-effectively
 Health promotion and prevention strategies
 Prioritization and proper documentation
Expected Skills for APN
PROFESSIONAL
 Mentoring and Teaching
 Research and Evidenced-based practice
Enabler
 Patient relationship
 Self development
 Challenges in Clinical Work

"Many Many Patients who Diagnose

Chief Complaints" Patient

• Listen • Be patient yet firm

• Problems prioritization • Explain by comparing and
• Encourage self-monitoring
• Take a broad perspective contrasting
• Don't go against resistance
Challenges in Clinical Work

"Peekaboo" Patients "Blank" Patients

…..

• Be sensitive, alert and • Be really patient and gentle

inquisitive • Give a range of "symptom"
• Probe deeper gently description choices
• Don't cause alarm and • Go through systemically
anxiety!! review of systems
Challenges in Clinical Work

"People people" Incidence & Probability

Good PE skills
XXX APN Internship Program

(4 to 8 wks)

SNB APN Certification Interview

(16 to 20 wks)

(14 to 24 wks)
5th Phase
Confirmatory
4th Phase Stage
(12 to 16 wks)
Collaborative
3rd Phase
Stage
Enabling
(6 to 10 wks) 2nd Phase
Stage
1st Phase Preparation
Observation Stage
Period
Nursing Profession Component
XXX APN Internship Program

Clinical Component

1st Phase: OBSERVATION PERIOD

Aim: Observe clinical decision-making processes and be
exposed to a variety of signs and symptoms

2nd Phase: PREPARATION STAGE

Aim: Preceptor critically assesses and observes the nurse
intern on health assessment skills, clinical decision-making
process and management of every patient case.
XXX APN Internship Program

Clinical Component (cont’)

3rd Phase: ENABLING STAGE

Aim: Toggle cases with Preceptors. See consults
independently. Summarize case, report findings and give
sound clinical decisions suggestions to the Preceptor
before closing each consultation session.

4th Phase: COLLABORATIVE STAGE

Aim: Jointly work together with the Preceptor to solve
patient management issues. Intern expected to develop a
sense of accountability and responsibility for his/ her own
advanced professional judgment and actions .
XXX APN Internship Program

Clinical Component (cont’)

5th Phase: CONFIRMATORY STAGE

Aim: Expected to manage consults independently.
Expected to place patient’s safety in utmost priority. Nurse
intern should consult Preceptor when unsure. All cases
need to be signed off by Preceptor.

Competency check at 6-month, 12-month and 18-month

period. (DM, Hypertension, Hyperlipidemia, CVA, IHD,
Asthma/ COPD and Heart Failure)
XXX APN Internship Program

Nursing Profession Component

Aim: Under the guidance of Director of Nursing and

Assistant Director of Nursing.

 Expected to be pro-active and responsible in

updating, discussing and evaluating his/ her progress
in internship.

 Expected to integrate the new role into the current

system
From Concept to Practice

Case 1: Nurse-led Clinic Model

Mr Ong, 64 year-old. Has diabetes, hypertension

and hyperlipidemia. Has microabluminuria. He
had mitral valve proplapse diagnosed at age 50.
No more cardiology follow up.

Last doctor’s consult, BP: 150/ 96mmHg. Dr

added Enalapril 5mg every morning.
2 weeks TCU to do blood test and 4 weeks to see
Nurse.
From Concept to Practice (cont’)
Care Management
 Check blood pressure
 Check blood results to ACE inhibitor
 Check side effects of ACE inhibitor
 Self management support

APN Management
 Trouble-shoot abnormal BP >130/80mmHg
 Trouble-shoot abnormal blood results
 Reconsider ACE inhibitor management
 Assess progression of MVP
 Trouble-shoot any other acute problems
 From Concept to Practice

Case 2: APN Collaboration

Mr Ong, 64 year-old. Has diabetes, hypertension

and hyperlipidemia.
On Mixtard insulin. ESRF on dialysis.
HbA1C% all along around 7%.
This consult HbA1C% is 8.5%. RBS: 27.0mmol/L

Mr Ong sees Nurse before Doctor’s consult.

From Concept to Practice (cont’)

Care Management
 Check meds/ insulin compliance
 Check diet/ exercise and SBGM
 Self Management Support

APN Management

 Establish safety in hyperglycemia state

 Consider sepsis possibility
 Consider other causes that rises glucose
 Consider hypoglycemia with Inc insulin
 Prescribe SBGM schedule
 APN Clinic Development in XX Polyclinic

APN Enhanced Patient Empowerment Program (AEPEP)

Started in October 2007, Friday Morning
Cases:
• Stable Chronics with other complications or Co-morbidities
-- e.g. 3rd degree heart block with pacemaker, Renal impairment,
Myasthenia Gravis, etc.
2) Unstable Chronics
-- Those that newly started on medications e.g. ACE inhibitors,
statins, OHGAs

Difficult Control Clinic (DCC)

• Started also around October 2007, Friday Afternoon
• Chronic Cases with difficult control
• Collaborates with Family Physician in management
APN Role Definition
Challenges in APN Role

Sound Clinical
"People people" Decision Making skills

Commitment to
Nursing Profession
 Long Long Journey…

How wide the scope? How narrow the scope?

How much to pump in?

(Money, Time & Manpower)

What extent of impact or difference?

Can we take our time?

References
Ang, B.C. (2002). The quest for nursing excellence. Singapore Medical Journal,
43 (10), 493-495.
Bodenheimer, Lorig, Holman and Grumbach (2002). Patient self-management of
chronic disease in primary care. JAMA, 288(19), 2469 – 2475.

Canadian Nurses Association, (2002). Advanced nursing practice – a national

framework (1st ed.). Ottawa: Canadian Nurses Association. Retrieved
November, 23, 2004, from
http://www.cna-nurses.ca/pdfs/anp_national_framework_e.pdf

Chan, A. (2001). Singapore's Changing Age Structure and the Policy Implications
for Financial Security, Employment, Living Arrangements and Health Care.
Asian MetaCentre Research Paper, Oct (3) from
http://www.populationasia.org/Publications/RP/AMCRP3.pdf on 02 April 2008.

Denver, E.A., Barnard, M., Woolfson, R.G. and Earle, K.A. (2003). Management
of uncontrolled hypertension in a nurse-led clinic compared with conventional
care for patients with type 2 diabetes. Diabetes Care, 26 (8), 2256-2260.
Goh, L.G. (1997). Future Health Issues and Delivery Needs of the Elderly.
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http://www.sma.org.sg/smj/3810/articles/3810ia4.htm on 02 April 2008.

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Ministry of Health Singapore. (2004). Health Facts Singapore 2004 – population

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http://www.moh.gov.sg/corp/publications/statistics/population.do

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http://www.moh.gov.sg/corp/publications/statistics/principal.do

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Murchie, P., Campbell, N.C., Ritchie, L.D., Simpson, J.A. and Thain, J. (2003).
Secondary prevention clinics for coronary heart disease: four year follow up of a
randomized controlled trial in primary care. British Medical Journal, 326, 84-87.
National University of Singapore. (2003). Master of Nursing. Retrieved
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Sharples, L.D., Edmunds, J., Bilton, D., Hollingworth, W. Caine, N., Keogan, M. et
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