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| Peter Boswarva is a Clinical Nurse Consultant HIV Disease, St Vincent's Hospital, Sydney. |
The health maintenance of individuals with HIV disease at St. Vincent's Hospital, Sydney is increasingly being managed in the ambulatory care setting. Based upon successful nurse practitioner clinics in North America, particularly in San Francisco and New York, the concept of an Australian nurse practitioner in HIV disease was developed in an attempt to cope with an increasing case load. The Pilot Course for Nurse Practitioners In HIV Disease was conducted at St. Vincent's Hospital, Sydney from July 1989 to June 1990. The aim of the course was to prepare registered nurses to provide primary health care to individuals with HIV disease. The emphasis of the course was on teaching and counselling roles and assessement, screening, and decision making skills. At completion of the course, students should have acquired the knowledge, clinical skills, and professional attitudes that would allow them to:
The course objectives were substantially met.
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The majority of people with advancing HIV disease experience a gradual decline in health over several years, punctuated by repeated, acute, debilitating infections. The introduction of antiviral therapy and prophylaxis against significant opportunistic diseases, has decreased the incidence and severity of the acute infections and has extended life expectancy. Patients are ideally managed on a health maintenance programme, with frequent health status assessment, and health maintenance counselling. Several researchers evaluating these types of programmes run by nurse practitioners as primary health care providers in Canada and the U.S.A., show that patient outcomes are equivalent to clinics run by other health professionals (Feldman, Ventura and Crosby, 1987; Wolbert, Rogers, Keyes, Marte and Smothers, 1989).
The concept of an Australian nurse practitioner, based upon successful nurse practitioner roles in North America, particularly in San Francisco and New York, was accepted by the hospital administration at St Vincent's Hospital and a pilot course was developed specifically for the management of HIV patients. Funding for the course was given by the AIDS Bureau of the NSW Department of Health.
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The purpose of the pilot course was to prepare registered nurses to provide primary health care to people with HIV disease whose needs may lie at any point along a health-illness continuum. The focus was on the teaching and counselling roles, and the assessment, screening and decision making skills used in the ambulatory care setting. The programme attempted to integrate theoretical knowledge with the development of advanced clinical skills to enable the students to develop an understanding of the multiple needs of people with HIV disease and their carers and relatives.
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The role of the nurse practitioner has two components:
Ambulatory care provision and primary care provision (Figure 1). The ambulatory care role encompasses the traditional, out-patient clinic nursing role of diagnostic testing, on-going medical treatments, counselling and teaching. As a primary care provider, the nurse practitioner expands the traditional role of the nurse by using enhanced physical examination and history taking skills, independently managing cases within specific protocols and client recruitment and assessment for clinical trials and follow-up evaluation.
Figure 1.
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At the completion of the course, the students will have acquired the knowledge, clinical skills and professional attitudes that will enable them to:
At the completion of the course the students will be able to competently:
Successful completion of the Pilot Course enabled the graduate to practice as a Nurse Practitioner in HIV Disease in the Ambulatory Care Service at St. Vincent's Hospital, Sydney.
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Six protocols detail the scope of nurse practitioner responsibility (Appendix 1).
The first three refer to screening activity or the first visit of a patient and delineate history taking, physical examination and appropriate laboratory data required. Their objectives are:
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The Pilot Course was an inservice course of two, 25 week semesters and included:-
The theoretical component of the course was grouped into three units:
| Unit 1. |
Foundation Studies in Primary Health Care:-
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| Unit 2. |
Professional and Philosophical Issues:-
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| Unit 3. |
Physiopsychosocial Needs. This Unit was designed around needs that loosely follow the NADA categories in the first taxonomy of nursing diagnoses. The needs are:
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Each of the fourteen sub-units contains anatomy and physiology, pathophysiology and diagnostic investigations relevant to the systems involved in the need; appropriate nursing diagnoses and interventions; and associated services or skills provided by other health professionals.
Teaching techniques included: Didactic lectures, group discussion, student orientated study (SOS), films, role play and worksheets.
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Students were assigned to physician preceptors in HIV/AIDS clinics, initially as observers, then becoming more involved with patient assessment and management as knowledge, skills and acceptance developed. Students rotated through specialist clinics as observers, viz. neurology, ocular immunology and dermatology (Appendix II), and worked in the treatment clinic (day hospital).
Students attended the weekly AIDS Unit case conference, and presented at least one case per week during the second semester.
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Each student was seconded to five of the following clinical areas, dependent upon preference and previous experience, for one week:
In addition students attended the San Francisco General Hospital (AIDS Nurse Practitioner Clinic) and the VIth International Conference on AIDS, San Francisco.
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A three-member interview panel selected the four most suitable applicants of the eleven interviewed, using experience, personal qualities and professionalism as selection criteria. The panel consisted of nursing representatives from nursing administration and the outpatients department, and the course coordinator. Each of the four participants was, or was eligible to be classified as, a Clinical Nurse Specialist - AIDS. Two had a background of ambulatory care, one a background of inpatient, acute care and the other of community screening.
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The course commenced on July 3, 1989 with most lectures being given by on-campus personnel. One notable exception was Ms Barbara Brodie, a Family Nurse Practitioner working in AIDS at San Francisco General Hospital. Ms Brodie contributed 160 hours to the programme in both theoretical and clinical areas.
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Evaluation Methods: All participants were given one questionnaire aimed at evaluating the content, organisation and implementation of the course, including clinical placements, secondments and case presentation studies. Due to the intimacy of the course, anonymous evaluation was impossible, although participants clearly put time and thought into the questionnaire as shown by their discriminatory use of the grading system and by their detailed comments.
Most of the evaluation questions required the participants to use a 6-point scale, which was defined as follows: '1 represents the lowest scale, i.e., non-relevant topic, poorly presented material or non-motivating, and 6 represents the highest scale, i.e., highly relevant, well presented material, meaningful'.
Theoretical Component: Each presenter and topic was evaluated with regard to presentation, relevance of topic, individual work required, and interest generated.
Clinical Component: Clinical secondments, outpatient clinics and preceptorships were evaluated with regard to clinical exposure, helpfulness of the staff and exposure to information.
In the assessment of the achievement of objectives, different definitions of the six-point scale were used, as explained below.
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Participants assessed the achievement of objectives on a six-point scale. No achievement at all was graded as 0, little achievement as 1, adequate achievement as 2, good achievement as 3, very good achievement as 4 and full achievement as 5.
Participants generally assessed the attainment of objectives as very good achievement, the scores ranging between an average of 4 and 4.25 for the first three objectives and good achievement (score of 3) for the fourth objective.
Achievement of Specific Objectives
Achievement of specific objectives ranged between means related to very good achievement and full achievement.
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Several clinically orientated teaching strategies such as case conferences, long and short case histories and case presentations, a data base form and the VIth International Conference on AIDS were assessed for their value as learning tools. Scores ranged between means of 5 and 5.75 (maximum score 6).
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The course objectives are, I believe, appropriate for nurses in a primary health care role, and have been substantially achieved by the graduates.
The course evaluation has identified several areas of the curriculum in need of minor revision, and this should he attended to before subsequent courses are conducted.
An evaluation of the service provided by the nurse practitioners, in terms of patient satisfaction and well-being is planned for the near future.
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Screening or Initial Visit: History
| Definition: | Process protocol for areas to be addressed in history taking of the adult patient with actual or suspected HIV disease. |
| Objective: | To collect subjective data which, together with Protocols 2 and 3 will form a data base from which to assess HIV related problems. |
Data Base:
Chief Complaints
History of Present Illness
| Past Medical History | HIV status and Ab seroconversion history T4 count and chronological profile Transfusions - when, where Previous STD- what/when/where Intestinal parasites /when/ type/ treatment Hepatitis /serostatus History of HSV, shingles Past opportunistic infections/neoplasms Chronic Illness/Major surgery |
| Risk Factors: | Sexual orientation /years active/number of partners High risk activities /Intravenous drug use Known HIV exposure |
| Personal Profile: | Alcohol/tobacco /recreational drugs Sleep/rest/diet |
Present Medication:
Allergies:
Previous Geographical Residence/Travel over past 15 years:
| Review of Systems: | Potentially HIV Related Anomalies |
| General | Fatigue, fever,night sweats, weight loss, anorexia |
| Skin | HSV, shingles, tinea, rashes, suspicious lesions |
| Lymphatics | Adenopathy |
| Head | Headache |
| Eyes | Sight changes, photophobia |
| Nose | Nosebleed, purulent discharge |
| Mouth | Thrush, soreness, alteration in taste |
| Throat/Neck | Difficulty /painful in swallowing, neck pain, stiffness |
| Respiratory | Cough, sputum, SOB at rest/on exertion |
| CIT | Diarrhoea, bloating, gas, nausea/vomiting |
| GU/Rectal | Ulcers, painful defaecation, discharge |
| Neurological | Memory changes, limb weakness/ numbness, painful feet, problems with concentration, walking, handwriting, buttock/ leg wasting |
Screening or Initial Visit: Physical Examination
| Definition: | Process protocol for the physical examination of the adult patient with actual or suspected HIV disease. |
| Objective: | To collect objective data which, together with Protocols 1. and 3 will form a data base from which to assess HIV related problems. |
Data Base:
Vital Signs
| Physical Examination | Potentially HIV Related Anomalies |
| Skin | Seborrhoeic dermatitis, Kaposi's sarcoma, shingles (including old scarring), folliculitis, molluscum |
| Lymphatics | Lympadenopathy, lymphoedema |
| Eyes | Cotton wool exudate, haemorrhage |
| Mouth | Candida, hairy leukoplakia, palatal/buccal lesions,ulcers, cold sores, angular stomatitis |
| Nose | Purulent discharge |
| Neck | Rigidity |
| Lungs | Dry cough with deep inspiration, Rapid, shallow breathing pattern at rest |
| Abdomen | Hepatomegaly, splenomegaly,masses, tenderness |
| GU/Rectal | Lesions, condylomata, ulcers, discharge |
| Neurological | Poor short term memory, focal findings consistent with CNS space occupying lesion, peripheral neuropathy |
Screening or Initial Visit: Laboratory Data
| Definition: | Protocol for the laboratory screening of adult patients with actual or suspected HIV disease. |
| Objective: | To collect objective data which, together with Protocols 1 and 2 will form a data base from which to assess HIV related problems. |
Data Base:
| Laboratory Evaluation | Potentially HIV Related Anomalies |
| Haematology | Decreased WCC, RBC, Hb, platelets, lymphocytes |
| Biochemistry | Increased LDH, Alk Phos., transaminaises, CK Increased ß2
Microglobulin Increased Neopterin |
| Serology | RPR/TPHA +ve HBsAg/cAb +ve CMV Ab +ve Toxoplasma Ab +ve Cryptococcal Ag +ve |
| Immunology | HIV +ve CD4 <400 T4/TB <1 |
Additional Data for System Specific Involvement
| System | Clinical Evaluation |
| Pulmonary | CXR, sputum culture, ±Induced sputum, ABG/Capillary BG |
| GIT (diarrhoea) | Stool - AIDS work-up |
| GU: | Urinalysis, MSU |
| Cutaneous | HSV and HZV raicroscopy and culture (Pathfinder Kit) |
| Fevers | Stool - AIDS work-up, blood culture (MAIS), CXR, induced sputum; High fever - blood culture (ordinary) |
| Haemopoietic | B12, folate, blood culture (MAIS) |
Further Evaluation on Screening or Initial Visit, or for Change in Status of Known Patient
| Definition: | Process protocol for the referral of adult patients with actual or suspected HIV disease. |
| Objective: | To define the circumstances under which consultation with, or referral to a physician or other health care personnel is appropriate. |
| Consultant | Circumstance |
| Physician | Whenever a "potentially HIV related anomaly", as listed in Protocols 1 - 3, is newly discovered. |
| Dietitian | Presence of anorexia, weight loss, diarrhoea. |
| Physiotherapist | Neuromuscular dysfunction limiting mobility. |
| Occupational | Therapist Neurological deficit restricting ADL'S. |
| Social Worker | Psychosocial, financial and housing problems. |
| Ankali Counsellor | Upon the patient's request after the service has been explained |
Health Care Plan
| Definition: | Protocol for the diagnosis and treatment of adult patients with HIV disease. |
| Objective: | To assess the current status of the disease process and initiate appropriate care. |
| Diagnosis: | Consistent with subjective findings per Protocol 1, objective findings per Protocols 2 and 3, physician consultation and assessment of current status of the patient. |
| Treatment: | Referral or consultation as per Protocol 4. |
Counselling regarding risk factors, diet, healthy lifestyle, etc., as indicated.
Orientation to Clinic during initial visit.
Intervention within a timely interval consistent with the need for stabilisation of acute disease.
Follow-up and Ongoing Care
| Definition: | Protocol for the ongoing assessment of adult patients with HIV disease. |
| Objective: | To maintain comfort and maximal functioning level of the patient. |
Data Base:
Plan:
| Diagnosis: | Consistent with the findings as per Protocols 1 - 3, physician consultation, and assessment of current status of the patient. |
| Treatment: |
Referral or consultation as per Protocol 4. Nursing and psychosocial intervention as indicated to improve comfort, function, and prevent or minimise decrease in comfort and function. Ongoing assessment to diagnose and rule out newly occurring disease processes based on symptom, physical exam and laboratory value changes. Referral to specialty care as indicated. Counselling regarding risk factors, diet, etc., as per Protocol 5. |
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Clinical Component
| First Semester Clinical Placement | Second Semester Clinical Placement |
|---|---|
| 1. Weekly case presentations of different patients comprehensively examined by each student. | 1. Weekly case presentations of different patients comprehensively examined by each student. |
| 2. Attendance and participation at two HIV clinics per week with physician preceptor. | 2. Attendance and participation at two HIV clinics per week with physician preceptor. |
| 3. Attendance and participation at one HIV neuropathy clinic per month with physician preceptor. | 3. Attendance and participation at one HIV neuropathy clinic per month with physician preceptor. |
| 4. Attendance at one HIV ophthalmology clinic per month. | 4. Conduction of drug trial clinics, including selection, assessment and follow-up of patients. |
| 5. Attendance at two dermatology clinics per month. | 5. Attendance and participation at the treatment clinic. |
| 6. Attendance at one HIV Unit clinical round per week. | 6. Attendance at one HIV Unit clinical round per week. |
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