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Nurse Practitioner Practice in Thailand

Somchit Hanucharurnkul * August 2007

Primary care plays an increasingly important role in various countries including Thailand. This is consistent with the philosophy of economic sufficiency as proposed by His Majesty King Bhumibol Adulyadej of Thailand. Primary care can be expected to lower the costs of care, improve health through access to more appropriate services and reduce the inequities in the populations health (Starfield, Shi and Macinkio, 2005) With the initiation of health care reform and a universal health care coverage system implemented in 2002, the need for nurse practitioners (NPs) to work at primary care units was evidenced. The Institute of Research and Community Health Development has set the policy to create three levels of primary care. The first level is the community medical center, which is responsible for 15,000-20,000 people. Health care personnel at this level are composed of one physician, one dentist, one pharmacist, 3 nurses and 6 other health care personnel. The second level is the community health center which is responsible for 5,000-10,000 people. The third level is the health post/district that is responsible for less than 5,000 people. There will be no physician, no dentist, and no pharmacist at the second and the third level of primary care but there will be two and one nurses, respectively at these two levels. Therefore, all together, 15,000 nurses were estimated to be needed. Thus many schools of nursing established the four months post basic nursing program to prepare general nurse practitioners to work in the community as primary care providers. The

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National Health Security Office and Thailand Nursing and Midwifery Council (TNMC) have signed the mutual agreement to educate 1,000 general nurse practitioners each year for seven years. These training programs are post basic and last for four months. At present the TNMC has certified 4,100 general nurse practitioners and more continue to be prepared. It is expected that by the year 2013, sufficient NPs will have been educated in the short-term programs and the four-month program will be terminated. At the same time many schools of nursing are offering community health nurse practitioner (CHNP) programs at the masters level. All together there are about 250 CHNP graduates each year. The NP was not really a new role for the community health nurse in Thailand since one of the first post-basic NP programs was initiated in the 1970s. It is clear that many of the elements in the scope of primary care have long been aspects of community health nursing practice. Since the original NP model grew out of professional nursing and public health or community health nursing, it was decided to name this NP role as a Community Health Nurse Practitioner (CHNP) so that the community element would not be lost. This community health nurse practitioner will be certified as an advanced practice nurse by TNMC. Type of nurse practioner, their preparation, qualification and practice are summarized in Table 1

Table 1 Type of NP General NP

Type of NP, preparations, qualifications and practice Preparations Qualifications Practice Take health history and perform physical examination. Interpret simple laboratory findings. Assess and prescribe medication for acute common health problems according to established protocol. Manage stable chronic illness such as stroke, hypertension, diabetes, ect. Provide emergency care and make referrals. Take health history and perform physical examination of the new born, including prescribe simple laboratory investigation. Assess and prescribe intervention according to the established protocol while waiting for the physician. Teach parents and relatives related to newborn care including answer questions and concern of parents. Assess, screen and refer abnormal findings to eye physician specialist. Prescribe treatment for minor common eye problems according to established protocol. Promotion for healthy eye and prevention of blindness at all age groups.

Certified Primary 4 months Post Medical Care by Basic nursing TNMC education with at least 2 years of clinical experiences

Neonatal NP

4 months Post Basic nursing Education with at least 1 year of clinical experience with newborn

Not certify by TNMC Practice under physicians authorization in selected hospitals

Eye NP.

4 months Post Basic Nursing Education with at least 1 year of clinical experience with patients with eye problems

Not certify by TNMC Practice under physician authorization in selected hospitals

Type of NP Community Health NP.

Preparations 2 years

Qualifications Master of Nursing Science in Community Health Nurse practitioner

Practice Establish partnership with the community and all sectors to improve health and conditions of living of the people in the

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At least 3 years of experience in Community Health Certified as Advanced Practice Nurse by TNMC community. Perform advanced health assessments of individuals, families and communities. Diagnose and prescribe medication and intervention for common health problems according to the established protocol. Management of chronic illness / conditions including dying patients at home. Initiate and co-ordinate health promotion and risk reduction with individuals, families and communities. Make referrals of patients to other health care providers when appropriate.

The practice of the CHNP is in primary care and outpatient settings. Even though the law/regulation in Thailand permits CHNPs to assess and evaluate common symptoms of acute illness, prescribe and manage medications according to established protocol, the critical tools for primary care NPs are advanced patient history taking and physical assessment according to Anderson (2005). Effective communication skills and the capacity to establish relationships with patients enhance the NPs ability to obtain a comprehensive history. Particular attention must be paid to personal health habits, stressors, genetics, and health risk factors to identify appropriate health promotion, prevention of illness, and early detection of disease. Much of the primary care NP practice involves the diagnosis and management of acute, self-limiting, minor illness and stable chronic health problems. Primary care practice requires the capability to recognize signs and symptoms of complex and unstable health problems requiring medical or other interprofessional consultation. It also requires recognition of emergency situations and initiation of effective emergency care. In addition, CHNPs in Thailand need to establish and sustain

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partnership with the patients, family and the community; they also need to plan and implement various programs to improve the health and living conditions of people as a whole. Since health is related to almost everything in peoples lives, and people in the community can attain healthful life styles, the CHNPs need to become knowledgeable and skilled in empowering the people to be self-reliant and selfcaring. Mobilizing community resources for health and community development is a skill that the CHNP brings to the primary care setting and is essential in establishing a successful clinical practice.

References Anderson, A.R. (2005). The primary care nurse practitioner. In A.B. Hamric, J.A. Spross & C.M.Hanson (Eds.) Advanced nursing practice: An integrative approach (pp 447-474) Philadelphia: W.B. Saunders. Starfield, B. Shi, L.& Macinkio, J. (2005). Contribution of Primary care to health system and health. The Milbank Quarterly. 83(3): 457-502.