Nurse Practitioner - Like services in Residential Aged Care Services - Evaluation Report
4. Designing and establishing the trial
The national project involved six, self-nominated trial sites across different jurisdictions and with differing clientele and service plans. Each site varied in its understanding and application of the trial intervention. To achieve a degree of uniformity across sites, the Joanna Briggs Institute provided initial cross-site support to the National Aged Care Nurse Practitioner Trial. This support consisted of:
- Providing initial input on trial design and evaluation for trial sites in Western Australia; South Australia; the Australian Capital Territory and New South Wales, and assisting with protocol development [Component 1];
- Providing baseline orientation to the nurse practitioner candidates located in Western Australia; South Australia; Australian Capital Territory and New South Wales [Component 2];
- Assisting with the development of agreed Practice Guidelines in all sites [Component 3];
- Designing and testing a Minimum Data Set for use in these, and future, trials [Component 4]; and
- Conducting an external evaluation of the trials in Western Australia; South Australia; Australian Capital Territory and New South Wales [Component 5].
The Aged Care Nurse Practitioner Trial aimed to establish and evaluate pilot nurse practitioner-like services across four Australian jurisdictions. The potential impact of these trials on aged care policy and the improvement of resident outcomes merited a rigorous approach to trial objectives and design; consistency between sites in terms of the development and use of guidelines and protocols; consistency between sites in terms of ordering investigations, prescribing to a limited formulary and to a medical "standing order"; and consistency between sites in terms of collection of process, outcome and cost data. While these guiding principals framed the design of the evaluation, the varied jurisdictions and legal requirements, including the lack of prescribing rights, and varied state licensing and practice requirements meant it was not possible to achieve the level of consistency between sites as would be desirable. However, this evaluation does illustrate that standardisation is currently possible and practicable for core elements of the NP role and how data collection can be managed, particularly in the event that future trials may be considered.
It was therefore essential that the trial focused on the piloting of identifiable Nurse Practitioner-like Services provided by experienced gerontological nurses who were all subjected to a common orientation and assessment to demonstrate competence in a number of identified extended practices sufficient to deliver services. The alternative, to establish trials that vary according to the interests of the Nurse Practitioner Candidates and the varying approaches of both nursing regulatory bodies and higher education providers of nurse practitioner programs would not have provided the degree of consistency between sites that enabled standardisation of practice and of data collection. Further work at the polocy level may achieve greater gains for residential care by working within the Nurses Acts of all jurisdictions that permit nurses to initiate extended role functions if they can demonstrate competence and if they are complying with a standing order authorised by a medical practitioner. The broad aim of all of the sites was to establish and deliver, in collaboration with general practitioners, pharmacists, radiography groups and pathology groups, services that:
- enhanced the health care of residents by managing chronic conditions
- provided early detection and prompt treatment of underlying symptoms that would ordinarily lead to an acute medical episode
- provided improved coordination of prevention, detection and treatment of illness through an increase in the capacity of the nurse to initiate actions eg directly ordering investigations
- reduced hospital admissions (to Casualty or as an in-patient; both in frequency and length of hospital stay) as a consequence of early detection and intervention
- improved outcomes without increased costs for treatment regimes (eg wound care).
JBI provided a template which incorporated consistent structures for all sites, but enabled sites to accommodate variations in legislative requirements, as well as for the committees advising the project to give input while ensuring local variation was not incongruent with the national evaluation.
To assist sites in completing their proposals, staff of the JBI Research Unit worked with the project managers to guide and inform proposal development. A meeting in Adelaide for project leaders from the participating sites was also held early in the project to talk though the draft proposals and ensure that all sites had an opportunity to discuss and raise questions around their site’s needs, and to review the process for the national evaluation component.
Each site completed the templates to specification, including budgetary requirements and individually submitted them to the Department of Health and Ageing. The proposals (with budgets) were delivered on time to the Department of Health and Ageing. Subsequently, the proposals were accepted by the Department.
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