Nurse Practitioner - Like services in Residential Aged Care Services - Evaluation Report
Executive Summary
Introduction
Aged Care Nurse Practitioner roles are well established in many overseas jurisdictions and there is evidence from these jurisdictions to suggest that the introduction of such roles increases service-users satisfaction, improves outcomes (timely access, assessment and client interventions), reduces the prescription of pharmaceuticals, decreases readmission to acute care and reduces costs. The Australian Government Department of Health and Ageing announced funding to pilot Aged Care Nurse Practitioner services to examine the introduction of the aged care nurse practitioner role in the Australian context. 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; and to conduct an external evaluation across all sites. Subsequently, seven nurse practitioner candidates on six sites were funded to participate in the trial which commenced in August 2005 and received initial funding for a period of eleven months. In May 2006, additional funding was secured – until June 2007 – to enable further data to be collected. This Report presents the findings of the external evaluation conducted by the JBI Research Unit from inception to June 2007. Site-specific reports were also submitted to the Australian Government Department of Health and Ageing by each site.The Trial
The national trial sought to establish and evaluate each of the seven pilot nurse practitioner-like services.The term "nurse practitioner-like services" was adopted 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 and members of multidisciplinary teams associated with aged care to inform the Australian Government Department of Health and Ageing, the Aged Care Sector, the nursing and medical professions and legislative and regulatory bodies.
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Results
Resident demographics/health
- Over two thirds of residents who participated in the trial were female, and aged 80 or over.
- Over 20% were born outside Australia, and over 10% spoke a language other than English as their first language.
- On average, residents had about six co-morbidities and were currently taking eight medications.
- Data on residents' admissions to hospitals/emergency departments was scarcely reported during a six months reporting period.
Practitioner interventions
- A total of 3146 visits were entered into the study from 510 residents. Both the number of residents recruited to the project and the number of visits entered into the study varied significantly between the seven sites.
- The mean number of visits to the Nurse Practitioner Candidates (NPCs) per resident was 6.2 0.3; most residents had 1-4 visits.
- Symptom management was cited most frequently as the main problem being addressed during visits to the NPC.
- NPCs categorised the intervention conducted during the visit according to 12 core interventions. Implementing treatments/medications for acute conditions was the most commonly cited core intervention.
- The total time spent per visit averaged 50 0.7 minutes across all sites and ranged from a mean of 25.3 minutes (site 5) to 87.6 minutes (site 8). However, the total time spent per visit decreased at most sites between 2006 and 2007.
- NPCs initiated almost half of the visits, and registered nurses initiated almost 20%.
- NPCs made a referral to a specialist in just over 13 of every 100 visits. Referrals to GPs made up half of all referrals. The rate of referral was similar between 2006 and 2007.
- NPCs ordered a diagnostic test in 7 of every 100 visits. Pathology screening tests made up more than half of these diagnostics. Practitioners tended to order less tests in 2007 compared to 2006.
- NPCs prescribed medications at the rate of 29.5 prescriptions per 100 visits. This tended to increase in 2007 compared to 2006.
- NPCs ordered consumables at the rate of 9.7 consumables per 100 visits. This tended to decrease in 2007 compared to 2006.
- The study recorded 67 cases where a NPC's hypothetical prescribing pattern (date, time, drug, dose, dosage, route of administration) was compared directly to a medical officer's actual prescribing pattern. In all but one case the NPC's hypothetical prescription was written before, or at the same time as, the medical officer. On average, the NPC's prescription was written some 11 hours before the medical officer.
Evaluation of service
- NPC collaborators (eg general practitioners, registered nurses, allied health professionals, care staff) were highly supportive of the practitioner and her role in the site.
- The health of a sample of residents at each of the seven sites was measured using the SF-12 questionnaire and compared to a group of residents in a nearby control site. In general, the health of the residents was good. The following independent variables were included in multiple regression analysis to determine if they were significantly related to resident health: age, gender, treatment (NPC or control), number of times service used in last 6 months, quality of life, length of stay, general satisfaction and site. The only significant predictors of resident health were quality of life and general satisfaction. This indicates that a resident's health was not related to whether they were receiving care at a NPC or control facility.
- The satisfaction of a sample of residents at each of the seven sites was measured using the general satisfaction questionnaire and compared to a group of residents in a nearby control site. In general, residents were more satisfied with their care than less satisfied. The following independent variables were included in multiple regression analysis to determine if they were significantly related to resident health: age, gender, treatment (NPC or control), number of times service used in last 6 months, quality of life, length of stay, resident health (SF-12 score) and site. The only significant predictors of resident satisfaction were resident health, length of stay and site. This indicates that a resident's satisfaction was not related to whether they were receiving care at a NPC or control facility.
- Analysis of focus group discussions of residents and their families led to two syntheses: (i) the NPCs had led to improved health care for residents, and (ii) residents and their families had grown to accept the residents during trial as they became more familiar with NPCs.
- Analysis of focus group discussions of staff working with the NPCs (general practitioners, nurses, allied health professionals etc) led to another two syntheses: (iii) an acceptance of the role of the NPC and the importance of collaboration between multidisciplinary staff, and (iv) improved health care provision to residents through avoidance of unnecessary resource use and greater satisfaction and confidence of both residents and staff of Aged Care Facilities.
- A large number of factors (described fully in the report) imposed considerable limitations on the trial and, as a result, no high quality evidence of the effectiveness of the role was identified.
- Given the limitations of the trial, it is not possible to make definitive recommendations for policy and service delivery, other than to strongly recommend the initiation of a large, multi-site, well designed comparative study of the effects of defined interventions delivered by licensed nurse practitioners with the ability to prescribe and order diagnostic tests on a range of well defined outcomes
- Notwithstanding these limitations – and in no way dismissing them – the trial results suggest that a nurse practitioner-like role in aged care is generally acceptable to residents, their families, medical practitioners and other members of the health care team.
Conclusions
Overall, the role of Aged Care Nurse Practitioner candidates was viewed positively by residents, their families and key stake holders; and sites consistently reported that nurse practitioner candidates played an important role in educating, encouraging and supporting staff and in liaising with other stakeholders such as general practitioners, allied health professionals and pharmacists. The trial was complicated by the variability across sites related to jurisdictional variation in practice patterns and the regulation of practice and the findings are tentative and equivocal and should be treated with caution. There is no evidence that the introduction of a nurse-practitioner-like service compromises the quality of care or health outcomes in residents and some evidence to suggest that it improves health status. In line with the international evidence, the nurse practitioner candidates prescribed and ordered diagnostics appropriately and tended to do so less frequently than medical practitioners. Given the relative success of this trial in organisational and service delivery terms on the one hand; and the lack of evidence in relation to effectiveness, a larger, multi-site randomised clinical trial involving licensed Aged Care Nurse Practitioners who are able to prescribe is clearly warranted.Top of page
Barriers identified in the trial
Further investigation should consider the limitations and findings of the present trial and, specifically, address the following issues identified in this trial:- The Aged Care Nurse Practitioner role needs to be well defined as a generic role in aged care rather than a person-specific role.
- The need for National Clinical Practice Guidelines for the Aged Care Nurse Practitioner, rather than State/Territory specific guidelines. This could be achieved by the establishment of a national group of nurse practitioners, geriatricians, general practitioners, pharmacists, radiologists and pathologists to develop and endorse national clinical practice guidelines for the Aged Care Nurse Practitioner.
- The need for a national curriculum (including clinical education) for Aged Care Nurse Practitioners to minimise variability in the preparation of Aged Care Nurse Practitioners across Australian Higher Education institutions.
- The lack of continuity between States and Territories in terms of licensure and regulation of nurse practitioners prevents simple movement of practitioners between jurisdictions. Additionally, the very low numbers of currently registered Aged Care Nurse Practitioners is a significant barrier to the advancement of the role in the short term.
- The requirement for access to "best practice" resources and ongoing professional development in aged care for all practicing Aged Care Nurse Practitioners.
- The need to recognise and promote the clinical leadership potential of Aged Care Nurse Practitioners in the aged care sector.
- The need to conduct a well designed, large scale, multi-site, national study to establish the relationship between the delivery of services by licensed Aged Care Nurse Practitioners on specified outcomes and costs, compared to services of other providers of such services.
- The need for debate and endorsement of national policy on the role of the Aged Care Nurse Practitioner, developed jointly with older people, nurses, GPs, Pharmacists, Pathologists and Radiologists.
- The issue of access to Medicare Provider status for Aged Care Nurse Practitioners.
- The need to develop and endorse a national formulary for Aged Care Nurse Practitioners
- Aged Care Nurse Practitioners' ability to prescribe medications as part of the PBS.
- The need to identify a preferred model of service delivery.
- The need to identify strategies to overcome current knowledge deficits of the health professions and the general Australian population about the role of the Aged Care Nurse Practitioner.
Recommendations
The study findings show high levels of acceptance of the trial's nurse practitioner-like service by service users and other health professionals and high levels of resident satisfaction. However, findings related to the cost effectiveness of the role are equivocal and suggest a need for further rigorous, large scale, multi-factorial investigation.Recommendation 1
The barriers to implementation identified in the trial be considered by the Australian and state and territory governments and the aged care sector.Recommendation 2
The introduction of a nurse practitioner role in aged care be further investigated at a national level.Top of page
