Better health and ageing for all Australians

Nurse Practitioner - Like services in Residential Aged Care Services - Evaluation Report

2. The National Aged Care Nurse Practitioner Trial

Up to Working in aged care

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2.1 Overall trial design

The trial was designed to apply a common methodology across each of six sites so that a common minimum data set could be utilised. In accordance with previous research it was decided to use an approach that encompassed both qualitative and quantitative approaches to capture the complexity and scope of the NP role.

2.1.1 Trial sites

Seven nurse practitioner candidates, providing six nurse practitioner-like services, participated in the aged care nurse practitioner trial based on six trial sites:
  1. Baptist Community Services, Newcastle, New South Wales (service sited at the Warabrook Centre for Aged Care);
  2. Hall and Prior Aged Care, Albany, Western Australia (service sited at Clarence Estate Residential Health and Aged Care);
  3. Hall and Prior Aged Care, Perth, Western Australia (service sited at Kensington Park and McDougall Park Aged Care Home);
  4. Barossa Village Incorporated, South Australia (service sited at Barossa Village Residency);
  5. Resthaven, South Australia (service sited at Resthaven, Paradise, extended to include Leabrook and the 15 community Extended Aged Care in the Home (EACH) packages from late 2006);
  6. Australian Capital Territory, Canberra. There were two sites within the ACT. One position was in the public sector within the Aged Care and Rehabilitation Service and worked across the acute, community and residential aged care sectors; and one position was within the private residential aged care sector Uniting Care Ageing at Mirinjani Retirement Village.

2.2 Methods and procedures

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2.2.1 Trial stages

The first phase of the trial consisted of five stages:
      Stage 1: Education, training and assessment of the Nurse Practitioner Candidates
      Stage 2: Development of agreed clinical guidelines/protocols
      Stage 3: Establishment of Nurse Practitioner-like Services
      Stage 4: Evaluation of Nurse Practitioner candidate Services
      Stage 5: Development of Report to the Australian Government
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2.2.2 Stage 1: Education, training and assessment of nurse practitioner candidates

All NPCs were experienced registered nurses who had extensive experience, knowledge and skills related to gerontological nursing and the aged care sector. Of the seven participating NPC, three had almost completed the educational and clinical requirements for the award of a Masters degree related to licensure as a Nurse Practitioner at their respective universities to enable licensure/registration as a nurse practitioner (two in the ACT, and one in South Australia).

Two NPCs completed the requirements for licensure/registration as actual NPs (ACT (public sector) and Barossa) during the trial. There was therefore wide variation in the knowledge and skills of the candidates.

An education and training program was designed to identify and address the knowledge and skills needed for the achievement of maximum health and independence of the clients referred to the NPC. The NPCs at an advanced stage in their tertiary NP studies were not required to undertake the additional education and training program. However, their respective universities were required to declare/state that this level of competency had been achieved.

At the beginning of the aged care NP trial all NPCs were provided with an orientation package (Appendix I) and attended a four day orientation program at the Joanna Briggs Institute in Adelaide.

An individual educational learning plan was developed for each of the NPCs to address the core competencies that were required within the educational and training program. Those NPCs who had not yet commenced tertiary studies subsequently accessed a range of health professionals over an intensive six week period to acquire the specified knowledge and skills. Completion of the individualised learning plans required verification, by signature, by all health care professionals who assisted the NPC, and this verification included an indication that the candidate had demonstrated competency in each of the specified learning tasks.

The individual training program, while tailored to the learning needs of each individual, included standardised modules that addressed:
  • Physical examination of the aged care client;
  • Diagnostic reasoning (including the evaluation of signs and symptoms; and the ordering and interpretation of diagnostic tests),
  • The pharmacology (including indications, contraindications, pharmaco-kinetics, prescribing etc) of specified medications,
  • The management of specified medical conditions, and
  • The case management of older people (including referrals to other health professionals)
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2.2.3 Stage 2: Development of agreed clinical guidelines/protocols

In Stage 2 of the project an interdisciplinary steering committee was established at each site consisting of at least: a senior nurse, a medical practitioner, a pharmacist, a radiologist, and a pathologist. This group was responsible for assisting in developing guidelines, policies and protocols that set parameters for safe practice in relation to the specific areas of the NPC’s extended practice. Parameters for safe practice were to be actioned through the development of guidelines (eg prescribing guidelines, diagnostic services guidelines, referral to medical specialist guidelines). An example of parameters that were established through guidelines is prescribing from a limited list, with capacity to review and adjust dosage and frequency of medications.

The ACT utilised the clinical practice guidelines that were developed during the Aged Care Nurse Practitioner Pilot Project for each of their NP/NPCs. In terms of diagnostic investigations and medications, each NPC discussed this with the client’s appropriate medical officer who wrote the script or diagnostic test (and was therefore legally responsible for follow-up). The NPC monitored the client’s progress and provided communication to the multi-disciplinary team that included the medical officer. Each NP/NPC was supported by a clinical support team which met on a fortnightly basis to provide both clinical and professional education and support.

Extension of the current role being undertaken by nurses to that of a nurse practitioner-like role also required supportive and developmental processes. These included:-
  • developing and trialing guidelines for prescribing;
  • developing and trialing guidelines for initiating diagnostic tests and investigations;
  • developing and trialing guidelines for referring to other health care professionals;
  • involvement in admission and discharge of residents to/from the local hospital.
All sites developed site-specific guidelines/protocols (Appendix II-VI). Again the ACT utilised the clinical practice guidelines that were developed during the Aged Care Nurse Practitioner Pilot Project. The level of collaboration on guideline/protocol development increased over the duration of the project, with sharing and localisation of resources occurring between jurisdictions.
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2.2.4 Stage 3: Establishment of Nurse Practitioner-like Services

Ethical approval and support for the national aged care nurse practitioner trial was obtained through the Royal Adelaide Hospital Research Ethics Committee for the trial as a whole, and, specifically, for sites that did not have access to an ethics committee constituted according to national requirements in Australia.

The nurse practitioner-like services on each site were developed through a consultative process with residents, families, care staff and other health care professionals. The model of practice across sites incorporated holistic care directed by a specialist NPC who liaised with, and directed care for, residents who were acutely or chronically ill, linking care with GPs and other health care professionals.

The model enabled safe, sustainable and timely initiation of practices such as:
  • Coordination of a winter flu strategy within the facility eg initiating fluvax;
  • Identification and treatment of symptomatic urinary tract infections including the ordering of investigations and the prescribing of antibiotics according to identified sensitivity;
  • Wound Management including ordering investigations and prescribing treatment / medications;
  • Managing other infections including ordering tests and prescribing medications (eg diarrhoea, upper respiratory tract infections);
  • Prescribing and administering treatments/medications for acute conditions (eg antiemetics, anti-diarrhoea, aperients, medicated creams);
  • Ordering medical imaging eg for suspected fractures;
  • Prescribing complementary therapies & managing their therapeutic benefits;
  • Evaluating and adjusting existing medication regimes (in consultation) including alteration of dosage, rewriting medication charts;
  • Referring to specialists - eg PGAT, Speech pathology, ophthalmology, dental, palliative care, wound specialists;
  • Managing physical restraint authorisation;
  • Prescribing and administering anti-psychotics in emergency situations (after development of protocols / standing orders);
  • Initiating increases in dosages of medication (eg prednisolone for asthmatics in clinical case of increasing shortness of breath); and
  • Other as identified by the project team.
Expected outcomes were reductions in impact and cost of acute medical conditions and improvement in general health conditions and monitoring and management of chronic conditions.
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2.2.5 Stage 4: Evaluation of nurse practitioner services (concurrent with stage 3)

The evaluation strategy included the development of a minimum data set that was designed to apply a common methodology across the seven trial locations. This allowed the simultaneous exploration of issues relevant to each of the individual sites, as well as the collection and analysis of activity data. In addition a series of five discrete Sub Projects were conducted.

2.2.5.1 Activity analysis/Minimum Data Set (MDS)

A modification of the Minimum Data Set created for the NSW Nurse Practitioner Trials and the Victorian Nurse Practitioner project (Phase 1 and Phase 2 evaluations) was used to collect activity data. The MDS was designed to serve two purposes. Firstly, to standardise data collection related to the functions and extent of the role; and secondly to provide a comparison point for future evaluations to the NSW and Victorian Nurse Practitioner trials that essentially collected similar data.

The database for the NSW and Vic studies was originally designed as a Microsoft Access Database with two components. The front end incorporated the forms for data collection while the data was stored in a separate location. In initial trials within the Victorian project team, this was problematic as it required that both the components be installed to the local hard drive in prescribed folders, and would not allow installation to a more secure location such as a server. This meant that the data collected could not be securely protected by regular backing up.

The core fields of these previous minimum data sets were maintained, additional fields added according to the specific needs of this national evaluation and the MDS was redesigned as an online database maintained by the Joanna Briggs Institute. The new program enabled sites to enter data; improved the stability of the tool; allowed installation to a server where secure, 24 hour access could be established for legitimate users; allowed reports to be more easily run; and improved the merging of data so that analysis could be conducted more readily (Appendix VII).

Each NPC was trained in the use of the MDS via a teleconference call or an onsite visit prior to the commencement of data collection. During the data collection phase the project team were available Monday to Friday to answer queries and solve problems related to the MDS and other aspects of the evaluation.
There were five sub projects relating to the data collection: (i) Resident/Consumer Focus Group, (ii) Stakeholder Focus Group, (iii) Comparative Survey, (iv) Collaborator Questionnaire and (v) Economic Evaluation.

2.2.5.1.1 Sub Project 1: Resident/Consumer Focus Group
In this Sub Project, consumer views on nurse practitioner-like services were elicited through focus group discussions conducted by site project staff (Appendix VIII).

Residents/consumers views on the following were canvassed:
    • quality of the service provided by the NPC including the consumer’s experience, choice and values;
    • the ongoing feasibility of the NPC role;
    • access to the Nurse Practitioner-like service;
    • appropriateness of the Nurse Practitioner-like service provided;
    • outcomes, including consumer experience, symptom relief, complications, consumer satisfaction, educational value and unexpected outcomes; and
    • scope for improving and broadening current practice of the NPC.
Residents/Consumers were accessed via the relevant facilities and times and locations were advertised for several weeks prior to the date of the focus group. In the ACT, information sessions were held and letters and posters were distributed to all residents in the facility to discuss the national aged care nurse practitioner trial and the data that was required to be collected. This provided an opportunity for residents to ask questions.

Verbatim transcripts of the focus groups were subjected to thematic analysis utilising the JBI-NOTARI software. JBI-NOTARI is designed to assist qualitative researchers to integrate coding with qualitative linking, shaping and modelling. This is a commonly used approach to data analysis in qualitative research.
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2.2.5.1.2 Sub Project 2: Stakeholder Focus Group
In this Sub Project, key-stakeholder views on Nurse Practitioner like-services were elicited through focus group discussion conducted by site project staff using a focus group guide (Appendix IX). Key-stakeholders included general practitioners, nurses, administrators, pharmacists, and other allied health professionals.

Key stakeholder views on the following were sought regarding:
    • quality of the service provided by the NPC;
    • feasibility of the NPC role;
    • access to the Nurse Practitioner-like service;
    • appropriateness of the Nurse Practitioner-like service provided;
    • collaborative practice including the identification of professional roles and boundaries, participation in case conferencing, referrals to and from other health care workers, initiation of care plans and health professional experience;
    • outcomes including impact on other services;
    • scope for improving and broadening current practice of the NPC; and
    • the sustainability and the cost-effectiveness of the NP model of practice.
As both sets of focus groups were conducted by staff from the facilities, support and training materials were developed and provided to each site. Telephone support was also provided to sites on an as needed basis by JBI Research Unit staff familiar with the conduct and analysis of focus groups.
2.2.5.1.3 Sub Project 3: Comparative Survey
The comparative Sub Project was designed to allow a direct comparison between the individual Nurse Practitioner-like service trials under evaluation and organisations that provided similar aged care services. In the early stages of the evaluation members of the research team met with members of staff of individual trial sites to identify potential comparable organisations to approach to be included as comparisons in the evaluation process.

Questionnaire packages were distributed to each trial site and a comparator group in sealed envelopes. These contained the following:
  • the General Satisfaction Questionnaire, the SF-12, and a short demographic questionnaire (Appendix X);
  • a stamped self-addressed envelope;
  • instructions on how to complete the questionnaires; and
  • a justification for the study.
This approach assured anonymity of respondents, minimised costs to the participant, and kept the required time commitment to a minimum. The primary objective was to elicit the level of resident health and satisfaction with the service provided by the NPC and compare this with a comparable aged care facility where no Nurse Practitioner-like service existed.

The 12 Item Short Form Health Survey (SF-12®) has been widely used internationally, and is a derivative of the SF-36®, both of which have been extensively published and reported in health care literature, including evaluations of reliability and validity. The SF-12® scoring algorithms involve weighted item responses, and has the added benefit of improving efficiency and lowering cost for both profiles and summary scales where the objective is to monitor overall physical and mental health outcomes. As with the GSQ, a number of changes were made to descriptors used in the SF-12® as not all the activities were appropriate for older adults in residential care settings. The discussion on the wording of descriptor terms used in the SF-12® concluded with a series of changes being made to the form prior to its full implementation across all sites. This process, as with the GSQ was begun prior to the 3 day orientation in Adelaide, at a round table meeting of site project coordinators, and which continued with site project managers over a period of time.

The General Satisfaction Questionnaire (GSQ) is a tool used commonly to assess client satisfaction with a given service using a questionnaire and 4 point Likert type scale. This was re-formatted and the qualitative component was removed. This generated a numeric value to determine client satisfaction. The client satisfaction score ranges from 27, which indicates the lowest level of satisfaction, to 108, which indicates the highest level of satisfaction with the service. A number of the items were reverse scored allowing for the calculation of a global satisfaction score derived by summing each of the 27 items.
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2.2.5.1.4 Sub Project 4: Collaborator Questionnaire
The various nursing, medical and allied health care professionals who participated in interdisciplinary collaborative care with the NPCs were asked to complete a structured postal questionnaire. This included information about the evolving collaborative relationships between the roles and functions of the nursing and medical/allied health professions, their different foci and any overlap of activities (Appendix XI). The purpose of Sub Project 4 was to establish the level of collaboration experienced by those who worked with the individual NPCs.
2.2.5.1.5 Sub Project 5: Economic Evaluation
One of the main purposes of a project such as this is to evaluate the cost-effectiveness of the NP model vis-á-vis the current model with its pre-existing services delivered by medical officers and nurses (with a more limited role in delivery of these services). This study included a simple cost-benefit analysis of the NP model, which, under our assumptions, was consistent with a ‘cost effectiveness’ analysis. Using budget information contained in the individual project reports, in combination with data extracted from an Economic Evaluation questionnaire (Appendix XII), conclusions were drawn about the overall cost-effectiveness of the Nurse Practitioner model.

2.2.6 Stage 5: Development of Report to the Australian Government

The first interim report was submitted to the Commonwealth Department of Health and Ageing was submitted in June 2006.

This document represents the final report, and includes an examination of the NP role from the commencement of the project (June 2005) until the end of data collection (April 2007).
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