Nurse Practitioner - Like services in Residential Aged Care Services - Evaluation Report
5. Nurse Practitioner Orientation
5.1 Introduction to the need for orientation
To ensure that the design of the services across the trial sites would be robust and comparable, it was considered essential that all of the participating Nurse Practitioner Candidates shared a similar understanding of the preferred role in aged care; that they all demonstrated a core set of requirements assessed in similar ways; and that they all practiced to protocols and standing orders developed collaboratively with local general practitioners, pharmacists, radiography groups and pathology groups prior to the commencement of the trial services.The Joanna Briggs Institute Research and Development team delivered a three-day self-directed orientation program that also involved a six week worksite project for each candidate to establish liaison with local general practitioners, pharmacists, medical imaging groups and pathology groups. This included seeking practical training from these collaborating health professionals and verification of meeting the core requirements of the project.
The orientation program included six specific subject areas, which are summarised below. Each day concluded with open discussion of the day’s learning activities. It was important for the candidates to gain a good understanding of the nature and purpose of the trial, so that they could act as advocates in their jurisdictions, and work effectively with their project managers. On the final day, the site project managers were brought to Adelaide to participate in presentations by the candidates on their learning experience, ongoing self directed learning plans, and to participate in a question and answer style forum to ensure any questions or concerns they may have had were raised and responded to.
This orientation program consisted of:
Introduction to the orientation program
This session outlined the structure and expectations of the nurse practitioner/candidates learning experiences and outcomes as well as giving an overview of the national evaluation project.
Introduction to Evidence Based Practice
This overviewed the principals of evidence based practice and required the candidates to reach an agreement on common guidelines for common project related interventions
Evidence Based Clinical Guidelines
This module outlined the difference between traditional methods, and EB methods, and lead to discussion of issues that may impact on the implementation of guidelines in the trial.
Introduction to the emerging role of the nurse practitioner, nationally and internationally
This considered the role of the nurse practitioner in the US, the UK, and Australia. The legislation and endorsement processes were reviewed and the place of the Nurse practitioner within the health care system explored.
Pharmacology
This consisted of a self-directed program on pharmacological issues in aged care, requiring the Nurse Practitioner to meet a number of objectives. Library resources were made available to assist with this module. It was subsequently completed during the following 4-6 week self-directed learning phase by the candidates.
The Identification of Skill and Knowledge Deficits and Development of an Individual Learning Plan
In this component of the orientation, the candidates were required to produce a detailed description of diagnostic, referral and treatment activities they anticipated engaging in. They were also required to identify specific learning needs that would need to be met to engage in these activities safely and effectively. These learning plans formed the basis of the candidate’s learning activity on return to their respective sites over a 6 to 8 week period following the orientation. Candidates were encouraged to maintain the learning plan and continue to expand it over the duration of the trial as evidence of ongoing learning (although this was not a specific requirement of the evaluation).
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5.2 The Orientation training materials
The candidates were provided with a learning resource package included readings and self directed learning modules (Appendix I).5.3 Identifying knowledge/skill deficits and learning needs
Given the variation in knowledge and skills within the group, each candidate was required to identify the knowledge and skills needed to carry out the core nurse practitioner-like role. The purpose of this was to assist all Nurse Practitioner Candidates in the trial to deliver a common core of interventions to generate valid evidence for future policy and practice development. Given current priorities in Australian health and aged care policy, the core interventions related to the minimisation of preventable disease and the management of chronic illnesses and conditions. Potential interventions were those that enable safe & sustainable initiation of practices such as:- Coordination of a winter flu strategy within the facilities eg initiating fluvax (following agreed protocols / standing orders);
- Identification & treatment of symptomatic urinary tract infections including the ordering of investigations and the prescribing of antibiotics according to identified sensitivity (following agreed protocols / standing orders);
- Wound Management including ordering investigations and prescribing treatment / medications (following agreed protocols / standing orders);
- 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) (following agreed protocols / standing orders);
- Ordering medical imaging for suspected fractures (following agreed protocols / standing orders);
- Prescribing complementary therapies & managing their therapeutic benefits;
- Evaluating and adjusting existing medication regimes for chronic diseases (in consultation with the general practitioner and pharmacist) including alteration of dosage, rewriting medication charts (following agreed protocols / standing orders);
- Referring to specialists - eg speech pathology, ophthalmology, dental, palliative care, wound specialists;
- Managing physical restraint authorisation;
- Prescribing and administering anti-psychotics in emergency situations (following agreed protocols / standing orders); and
- Initiating increases in dosages of medication (eg prednisolone for asthmatics in clinical case of increasing shortness of breath) (following agreed protocols / standing orders).
Candidates were asked to consider the knowledge and skills needed to engage in the above core activities and to develop a learning plan to address any knowledge or skill deficits identified. The learning plan required candidates to:
- identify specific activities (for example, listening to the chest or prescribing a named medication);
- state the knowledge and skills needed to effectively carry out the activity;
- set learning objectives; and
- identify an appropriate "trainer" accessible on their own work site.
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Table 1 Learning plan format
Intervention/ Diagnostic Activities (eg: Auscultation: Path Tests) | Knowledge Needed | Knowledge Objective(s) | Skills Needed | Skill Objective(s) | Nominated Trainer | Verification of Achievement of Objectives by Trainer |
 | | | | | | |
5.4 The self-directed learning process
Based on the learning plan developed in the core program, each participant accessed a range of health professionals to acquire specified knowledge and skills over a period of six weeks. Completion of this learning plan was verified, by signature, by all health professionals who assisted the participant.Individual self directed learning programs included components that addressed areas of clinical practice and knowledge such as:
- Physical examination;
- Diagnostic reasoning (including the evaluation of signs and symptoms; the ordering of diagnostic tests; and the interpretation of the results 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)
