Nurse Practitioner - Like services in Residential Aged Care Services - Evaluation Report
1. Introduction
Internationally, nurse practitioners (NPs) have been employed in acute care services for at least the last 60 years, contributing to health care provision and related services across a range of specialties. As nursing education and training has developed, the notions of what a nurse practitioner is, and what they do, have been defined and refined to meet the changing needs and contexts of patient care and the varied settings in which care is delivered.
By the 1990s the potential for the NP role in the Australian health care setting had gained credence through consultation, discussion and debate on how the role could be applied. A number of significant trends (such as the changing demographics of the population, changing workforce demographics, shifts in emphasis from acute to community/primary health care and rising consumer expectations) necessitated a move in this direction. Not the least of these trends is the need to deliver suitable health services to a number of sectors in the community.
The NP role has been mainly introduced into the acute care sector, with rapid expansion of the role across acute care specialities, particularly those associated with outpatient, clinic or specialist nursing care elements such as emergency, diabetes and respiratory. However, in Australia and New Zealand the NP role is still evolving (ACT Health, 2002; Gardner et al., 2004). The development of the role is influenced by differing health care agendas but with an emphasis on the potential benefits that NPs can provide in the delivery of health care services (ACT Health, 2005).
1.1 International Perspectives
The international literature suggests that establishment of the nurse practitioner role facilitates a more diverse health service with greater flexibility and increased access to health care, and increased satisfaction and flexibility in health care delivery. Although the role itself has developed across a range of settings, with specific criteria for practice, therapeutic medication management; referral to other health professionals; and ordering certain diagnostic tests and procedures are the defining characteristics of the role that differentiate it from other advanced nursing practice roles.In the UK, the NP role was developed to address the lack of appropriately qualified and experienced medical staff; client dissatisfaction with quality of care, including consultation time and choice of available treatments; and poor access to primary health care (Reveley, 2001; United Kindom Assembly, 2002). In the US there has been a focus on developing a nursing career path, and the development of strategies to better meet client health needs (Walsh, 1999). Overall, research has identified positive benefits from the NP role especially in terms of client outcomes and consumer satisfaction (Kinnersley et al., 2000; MacLellan, 2002; Rhee & Dermyer, 1995; Sakr et al., 1999).
1.2 Nurse Practitioners in Aged Care
Aged care NP roles are well established in the United States and the United Kingdom and there is robust evidence that suggests that the introduction of such roles increases service-users' satisfaction, improves outcomes (timely access, assessment and client interventions), reduces the prescription of pharmaceuticals and decreases readmission to acute care. Furthermore, aged care NPs have been found to be 20% less costly, with nurse practitioners' performance comparable or superior.As part of its commitment to improving services for older people, the Australian Government Department of Health and Ageing called for expressions of interest in 2004 from approved providers of residential aged care services to pilot the introduction of nurse practitioners in this sector.
The raison d'etre for exploring the formalised establishment and evaluation of the NP role in aged care in Australia was to establish what the potential benefits might be for residents in relation to safety, quality, satisfaction, clinical care and outcomes. Over a period of almost fourteen months, a number of Approved Providers responded to the call for expressions of interest.
In April 2005 the JBI Research Unit was contracted to work with interested Approved Providers and ACT Health to assist them to develop proposals within a framework that would facilitate a national evaluation. All of the Approved Providers submitted proposals in July 2005 based on the core framework for implementation and evaluation developed by the JBI Research Unit team. The JBI Research Unit focused on methods that sought to:
- standardise implementation of the NP role,
- promote collaborative models of practice with other health professions providing care to residents,
- promote evidence based practice through development of guidelines based on international evidence independent,
- standardised data collection,
- promote more robust evaluation through the use of control sites and validated instruments for health, wellbeing and satisfaction of residents with the model.
1.2.1 Aims, significance and benefits of the aged care nurse practitioner trial
This national trial sought to establish and evaluate each of the seven pilot nurse practitioner-like services. The term "nurse practitioner-like services" has been used to accommodate the delivery of nurse practitioner services by registered nurses working toward establishing their eligibility for licensure/registration as a nurse practitioner. The trial involved the establishment of nurse practitioner-like roles and broadly evaluating these roles. The evaluation component focused on the implementation process and on the views of older people, the community, provider agencies, the health care workforce (in the aged care sector the NPC or NPs work with a variety of health care workers and professionals (eg: dieticians, nutritionists, therapists, social workers etc) not just the medical and nursing profession) to inform the Australian Government Department of Health and Ageing, the aged care sector, the nursing and medical professions and legislative and regulatory bodies.All of the nurse practitioner-like services were provided by experienced registered nurses with specialist knowledge, skills and competencies in gerontological nursing. During the course of the evaluation some candidates completed the requirements for registration as a nurse practitioner and were recognised by their State licensing bodies. However, this did not impact significantly on the evaluation as Federal Government requirements for prescribing have not been changed to facilitate full use of the skills, knowledge and abilities gerontological NPs would otherwise be able to use. In addition to their previous experience in gerontological nursing, all nurse practitioner candidates were assessed to ensure competence before undertaking a range of activities normally associated with extended practices sufficient to deliver services to:
- enhance the health care of aged care residents by monitoring/managing their chronic conditions,
- provide early health care assessment, detection and prompt treatment of symptoms/conditions that would ordinarily lead to an acute medical episode and possible admission/readmission to the acute care sector,
- provide timely initiation of treatment eg directly ordering diagnostic investigations, commencing medications (oral antibiotics),
- provide enhanced communication, coordination and monitoring of that care to other health care providers, the client and/or their carers,
- as a consequence of early detection and intervention, reduce hospital admissions (to Casualty or as an in-patient; both in frequency and length of hospital stay); and
- reduce complications related to less than prompt commencement of treatment/s
