The idea of Advanced Nursing Practice (ANP) is reported to have commenced in the USA in the early parts of the 20th century (Mantzoukas, 2006) and its development has been well recorded in the literature (Ketefian, Redman, Hanucharurnkul, Masterson & Neves, 2001; Furlong & Smith, 2005). But lack of clear definitions for the concept, its scope of practice and standards has resulted in a great diversity in practice (Woods, 1999; Pearson & Peels, 2002; Daly and Carnwell, 2003). Furlong and Smith (2005) identifies that several attempts have been made to conceptualise advanced nursing practice. This has resulted in some consensus on the core concepts that underpin ANP such as clinical autonomy, professional and clinical leadership, research capabilities, application of theory and research to practice and graduate level education requirement (Ketefian et al., 2001; Furlong & Smith, 2005; Mantzoukas, 2006). Knowledge level, skill level and population of response model developed by Calkin (1984) and ‘from novice to expert’ model by Benner (1984) are some of the models that were developed but none of these analysed contextual influences on advanced nursing practice.
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Manley (1997) developed a conceptual framework that describes four integrated sub roles (expert practitioner, educator, researcher and consultant); necessary skills and processes as well as contextual prerequisites for the advanced nurse practitioner to achieve outcomes strove for. This framework was developed from a model by Hamric (1989) and shares similarities in the four sub roles, some skills and processes. However, the framework by Manley (1997) establishes a relationship between the ANP role, its context and its outcomes, giving it an advantage over the models of Calkin, Benner and Hamric. It is worth stating, at this point, that the term ANP is not for a single role but for different advanced nursing roles such as nurse practitioners, certified nurse midwives, nurse anaesthetists and clinical nurse specialists (Ketefian et al., 2001)
I have worked for one year as a general nurse (Nursing Officer rank) after completing my four-year nursing training in Ghana. My responsibilities include ensuring adequate nutrition and elimination, administering medication and reporting on patient’s response, allocating task based on skill of staff, supervising staff and students in the ward, and participating in ward rounds (GHS, 2005). Henry (2007) states that Ghanaian nurses have automatic promotion after every five years of service until they reach the rank of Principal Nursing Officer. It seems that this is changing. My experience is that, recently, higher education certificate as well as evidence of continuous professional and personal development is a requirement for certain roles in the nursing profession. Moreover, research, leadership and application of theory to practice are some of the advanced nursing skills that are not well developed in my current role. I have, therefore, enrolled in the MSc. Advanced Nursing course to develop these skills to advance my nursing practice.
It appears that the four advanced nursing roles described by Ketefian et al. (2001) are present in Ghana, although the term ANP is not used. East and Arudo (2009) identifies that due to shortage of health personnel, nurses in sub-Saharan Africa perform certain roles and tasks that would be classified, in other countries, as advanced practice. Ghanaian nurses in these roles have some degree of clinical autonomy, especially in the district hospitals, but not necessarily a graduate level education. Instead, a post-basic diploma is required for some of them (nurse anaesthetist and clinical nurse specialist roles). Until recently, post-basic diploma was the qualification for medical assistants (similar to nurse practitioner role). Thus, ANP roles in Ghana developed as a result of shortage of health personnel and the health needs of the population. However, the roles are different from those in the UK and USA in areas such as research, professional and clinical leadership, academic qualification, and clinical autonomy.
Therefore, with the ANP conceptual framework of Manley (1997) as the focus, I hope to achieve the following objectives in advancing my practice:
Develop a teaching package to slow progression of chronic kidney disease (CKD) among patients with diabetes
Advance myself as a nurse educator and the other sub roles identified by Manley (1997)
Develop leadership and effective change management skills
Contribute to the professional development of my colleagues.
The Project: Introduction and Rationale for Selection
In advancing my nursing practice, my focus for this project is to develop a teaching package to slow progression of chronic kidney disease among patients with diabetes. Other patients at risk of developing kidney failure, including those with hypertension would also benefit from this project. The package would, also, be used among patients with stages 1 – 4 chronic kidney disease.
In the final year of my nursing training, I had to submit a ‘care study’ to the Nursing and Midwifery Council of Ghana. The patient I worked with had been diagnosed with type II diabetes. The care study required that I participate in the active management of the patient and present a report on that, as well as a literature review on the condition. I reflect on the entire process now and I realise that complications of diabetes were just mentioned to the patient, with no adequate information on how they can be prevented.
This project is, therefore, anticipated to create awareness of chronic kidney disease as a major complication among patients with diabetes in Ghana and how to delay its progression, if not avoid it. My primary focus would be to develop a strategy that would reach out to all patients, including those with low literacy skills. This would advance the nursing care and health education given to such patients, thereby, delaying the need for dialysis (Thomas et al., 2008).
Literature Review
WHO (2002:11) defines chronic conditions as “health problems that require ongoing management over a period of years or decades” and has labelled them as the biggest challenge faced by the health sector in the 21st century. While the economic cost of managing chronic diseases is high, Suhrcke, Fahey & McKee (2008) identify some strong economic arguments that may be made in support of the need for societies to invest in their (chronic diseases) management. They identify some primary benefits such as improved health (in terms of patient’s quantity and quality of life in years), long-term cost savings from complications avoided and workplace productivity experienced by patients and their employers. Nevertheless, preventing their occurrence is central in the general management of chronic conditions (Nolte & McKee, 2008) and this is a responsibility for all, including governments, private sectors, healthcare systems and individuals (Novotny, 2008).
Chronic Kidney Disease (CKD) is becoming a global pandemic (Mahon, 2006; Chen, Scott, Mattern, Mohini & Nissenson, 2006; Clements & Ashurst, 2006). The disease causes gradual decline in kidney function (Silvestri, 2002). It has been categorised into 5 stages according to the glomerular filtration rates (Johnson & Usherwood, 2005) and the progression through these stages is influenced by several processes, mostly lifestyle-related (Riegersperger & Sunder-Plassmann, 2007). Management of stage 5 (end stage) is either by dialysis or kidney transplant (Johnson & Usherwood, 2005, Chen et al., 2006). Patients with CKD stages 4 and 5 experience other complications such as anaemia and metabolic acidosis that must, also, be managed efficiently (Silvestri, 2002; Murphy, Jenkins, McCann Sedgewick, 2008). This, in addition to dialysis, accounts for the reported higher costs of managing CKD (Gonzalez-Perez, Vale, Stearns, Wordsworth, 2005; Kaitelidou, Ziroyanis, Maniadakis, Liaropoulos, 2005).
Presently, more than 23,000 adults in the UK undergo dialysis treatment as a result of kidney failure and this number is expected to increase yearly (World Kidney Day, 2009). Korle-Bu Teaching Hospital (Ghana) recorded 558 cases of CKD between January 2006 and July 2008 in the country (All Africa, 2009) and this may represent less than 30% of the total disease burden as the hospital serves a few regions in the country.
Several studies have identified diabetes mellitus and hypertension as the major causes of CKD (Clements & Ashurst, 2006; Rosenberg, Kalda, KasiuleviÄius & Lember, 2008; Marchant, 2008; Stropp, 2008; Thomas, Bryar, Mankanjuola, 2008; Ulrich, 2009). Amoah, Owusu and Adjei (2002) report of little, but outdated, statistics on the prevalence of diabetes in Ghana. Another report is on the assumption that diabetes is uncommon in Ghana (ibid.). However, it appears that my clinical experience at KATH alone suggests otherwise to the latter. Amoah et al. (2002), again, report that data on diabetes in Ghana is unreliable and this is confirmed by incongruent data observed in the literature. For example, Abubakari and Bhopal (2008) report that prevalence of diabetes in Ghanaian adults (25years and above) was 6.3% in 1998 while the Ministry of Health, Ghana (2001 cited by Aikins, 2004) estimates diabetes in 4% of Ghanaians between 15 to 70 years. Notwithstanding, Aikins (2004) reports of increase in the prevalence rates of chronic illnesses in the country, and diabetes is no exception.
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Primary care management delays nephropathy and other complications of diabetes (Thomas et al., 2008). They add that there could be a lot of potential savings if the need for dialysis can be delayed, even if for a short period for a few patients. Since prevention reduces healthcare costs (Booth, Gordon, Carlson & Hamilton, 2000), Ghana, not being a rich country (CIA, 2008) stands to benefit from such an approach. Chen et al. (2006), also, identify that delaying the progression of CKD improves clinical outcomes and moderates costs. Strategies to delay progression include good glycaemic control, blood pressure control, smoking cessation and other lifestyle modification (Nicholls, 2005; Clements & Ashurst, 2006; Rosenberg et al., 2008). Patients’ knowledge on these factors may lead to a change in behaviour which, in turn, would yield positive outcomes in the management of their conditions.
Health education is one of such strategies to achieve positive outcomes and prevent complications, especially if the method used is appropriate for the age group as well as their cultural background (Funnell et al., 2008). It is often used interchangeably with ‘health promotion’ in the nursing literature and criticisms have been made on that (Whitehead……). The argument has been that health promotion has shifted from preventing specific diseases or detecting risk groups towards health and well being of whole populations (Naidoo & Will, 2000). Hitherto, health education remains central to health promotion (Whitehead, 2), and, because of the dominance of the medical model, health promotion is mostly equated to prevention of disease, through primary, secondary or tertiary prevention in clinical settings (Naidoo & Wills, 2000).
Secondary and tertiary prevention interventions prevent complications such as chronic nephropathy development in patients with diabetes and health education is one of such interventions (Rosenberg et al., 2008; Naidoo & Wills, 2008). Diabetes is, predominantly, self-managed (Collins et al., 1994; Funnell & Anderson, 2002), making education very necessary as it empowers the patients to take charge of their health behaviour and other factors that influence their health status (Piper, 2009). Whitehead (1) adds that health education focuses on lifestyle-related and behavioural change processes, making it an integral part of comprehensive diabetes care (type II education).
The above implies that when patients with diabetes receive health education, it enhances their ability to collaborate with the effective management of the disease and, consequently, avoid its complications. However, very little knowledge on CKD as well as misunderstandings of illness and treatment has been reported (Jain, 2008; Holström & Rosenqvist, 2005). Patients may not appreciate the role that lifestyle modification, in addition to pharmacological interventions, can play in effective management of diabetes. Since diabetes, usually, do not present any physical symptoms, patients tend to distance themselves from it and, as a result, ignore the education being provided because they do not feel ill (Holström & Rosenqvist, 2005). Complexity of self-management of diabetes may also be a major contributor to the reported misunderstandings (Szromba, 2009). The primary concern then becomes who should educate these patients and what strategies should be used to achieve positive outcomes?
Making time to educate patients and their families on everything that they need to know is seldom easy because of the busy schedules of nurses in the ward (Rankin & Stallings, 2001). Yet, Hamric (1989) and Manley (1997) have documented the integration of health education into the roles of advanced nurse practitioners and Rankin & Stallings (2001) have attested to this. Advanced nurse practitioners are able to draw on their knowledge and skills related to higher education as well as their expertise from practice to achieve positive outcomes in the clinical settings (Manley, 1997). Szromba (2009) suggests that alternative methods to the traditional lecture method of health education should be utilized to enhance self-care. Babcock and Miller (1994) suggest that discussion, demonstration, modelling, group activities and role playing are other teaching strategies that the health educator can employ. However, they add that consideration should be given to the strategy that best fits the objectives, content, the clients, the health educator and the reality of the learning situation. This underscores the importance of client needs assessment in health education.
Literacy skills of the clients should, also, be taken into consideration during health education. This project is to be implemented in Ghana and WHO (2009) estimates an adult illiteracy rate of about 35% of the total population. The use of written materials may be a difficulty in such settings, especially as the literates may not understand the jargons used in health very well. Therefore, the health educator should ensure that materials are simplified so readers do not have difficulties in understanding the content. Rankin & Stallings (2001) suggest that health educators should, therefore, focus information on the core of knowledge and skills that clients need to survive and cope with problems, teach the smallest amount possible, make points vivid, present information sequentially and allow patients to restate and demonstrate what has been learnt. They also suggest the strategic use of educational media such as flipcharts, photographs, drawings and videotapes to enhance understanding.
Aims and Anticipated Outcome
The primary focus of this project is to develop a teaching strategy to slow the progression of chronic kidney disease among patients with diabetes in Ghana. Consideration would be given to strategies that would reach out to and promote understanding among patients with low literacy skills. It is anticipated that when patients have enough information on their disease condition, they would collaborate with the healthcare team in the management of the condition.
I hope to enhance my knowledge on the management of chronic kidney disease and my role as a nurse educator. This experience would, also, be transferred to my colleagues in Ghana and lead to general improvement in the management of chronic kidney disease in the hospital.
This collaboration would, therefore, reduce complications of the disease and enhance patients’ quality of life. As has been identified by Thomas et al. (2008), when complications such as kidney failure and the need for dialysis is delayed for a short period among few patients, a lot of financial savings is made. Therefore, in addition to providing quality care for patients and enhancing their quality of life, this project would reduce the cost of managing complications of diabetes and chronic kidney disease in Ghana.
The Professional and Organizational Context
Komfo Anokye Teaching Hospital (KATH) is the second largest teaching hospital in Ghana, training many doctors, nurses and other paramedics in the Ashanti Region of Ghana. It is an autonomous service delivery agent under the Ministry of Health of Ghana (MOH, 2009a). In addition to training many of the health personnel in the Ashanti Region at KATH, many people within and outside the Ashanti Region seek healthcare there. As a result, provision of quality healthcare has always been the focus. An organisation that recognises the need for change, weighs costs and benefits, and plans for the change when the benefits outweigh the costs is ready for a change (Dalton & Gottlieb, 2003). KATH is, therefore, ready for change because some of its employees are sent overseas or to other parts of the country, whenever there is the need for a new skill or knowledge to be gained, to bring about a positive change within the institution. This may be a factor that would facilitate my agenda to implement some changes within the institution upon my return to Ghana.
However, Ghana, as a country is underdeveloped (CIA, 2008). Therefore, financial support, many a time, becomes a difficulty. Another challenge may be the fewer nursing staff. The Ministry of Health (2009b) estimates that there was a nurse-to-population ratio of 1:2024 in Ashanti Region and 1:1451 for the entire country in year 2007 while the WHO estimates that there are 9 nurses/midwives per 10,000 of the Ghanaian population (WHO, 2009xxxxx).
Nevertheless, the desire to provide quality patient care and reduce healthcare costs, and dedication from the health personnel are factors that would supersede the anticipated obstacles to the implementation of this project.
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