National_Evaluation_NP_Like_Services_in_Aged_Care

NURSE PRACTITIONER-LIKE SERVICES IN RESIDENTIAL AGED CARE SERVICES

EVALUATION REPORT

NATIONAL EVALUATION OF NURSE PRACTITIONER-LIKE SERVICES IN

RESIDENTIAL AGED CARE SERVICES

FINAL REPORT

PREPARED BY THE JOANNA BRIGGS INSTITUTE

DECEMBER 2007

© Commonwealth of Australia 2007

ISBN: 1-74186-541-7 Online ISBN: 1-74186-542-5

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Disclaimer As an independent consultancy report this document does not necessarily reflect the views of the Commonwealth Government.

National Aged Care Nurse Practitioner Trial: Final Report, vol. 1 — Evaluation Report Page i

Contents List of tables...................................................................................................v

Executive Summary.....................................................................................vii Acronyms .....................................................................................................xii 1 Introduction ..............................................................................................1

1.1 International Perspectives....................................................................1

1.2 Nurse Practitioners in Aged Care ........................................................2

1.2.1 Aims, significance and benefits of the aged care nurse practitioner trial ...........................................................................2

2 The National Aged Care Nurse Practitioner Trial ..................................4

2.1 Overall trial design ...............................................................................4

2.1.1 Trial sites.......................................................................................4

2.2 Methods and procedures .....................................................................4

2.2.1 Trial stages....................................................................................4

2.2.2 Stage 1: Education, training and assessment of nurse practitioner candidates ...............................................................5

2.2.3 Stage 2: Development of agreed clinical guidelines/protocols....................................................................6

2.2.4 Stage 3: Establishment of Nurse Practitioner-like Services...........6

2.2.5 Stage 4: Evaluation of nurse practitioner services (concurrent with stage 3) ............................................................7

2.2.6 Stage 5: Development of Report to the Australian Government..............................................................................11

3 The Trial Sites.........................................................................................12

3.1 Warrabrook, NSW..............................................................................12

3.1.1 The locality ..................................................................................12

3.1.2 The facilities ................................................................................12

3.1.3 The nurse practitioner candidate.................................................12

3.2 Australian Capital Territory ................................................................12

3.2.1 The locality ..................................................................................13

3.2.2 The Canberra Hospital and Calvary Healthcare. .........................13

3.2.3 Mirinjani Retirement Village.........................................................13

3.2.4 Nurse Practitioner/Nurse Practitioner Candidates.......................14

3.2.5 Aged Care Clinical Practice Guidelines.......................................14

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3.3 Barossa Village, SA ...........................................................................15

3.3.1 The locality ..................................................................................15

3.3.2 The facility ...................................................................................15


3.4 Resthaven, Paradise, SA...................................................................15

3.4.1 The locality ..................................................................................15

3.4.2 The facilities ................................................................................16


3.5 Clarence Estate Residential Health and Aged Care ..........................16

3.5.1 The locality ..................................................................................16

3.5.2 The facility ...................................................................................16


3.6 Kensington Park and McDougall Park Aged Care Home, Perth, WA ...................................................................................................17

3.6.1 The locality ..................................................................................17

3.6.2 The facilities ................................................................................17


4 Designing and establishing the trial .....................................................19

5 Nurse Practitioner Orientation ..............................................................21

5.1 Introduction to the need for orientation ..............................................21

5.2 The Orientation training materials......................................................22

5.3 Identifying knowledge/skill deficits and learning needs......................22

5.4 The self-directed learning process.....................................................24

6 Developing Practice Guidelines............................................................25

6.1 Practice Guidelines and Standing orders/practice protocols..............25

6.2 Purpose of practice guidelines and protocols in the trial ....................25

6.3 The guideline and protocol development process:.............................25

6.3.1 Warrabrook .................................................................................26

6.3.2 ACT.............................................................................................26

6.3.3 Resthaven ...................................................................................26

6.3.4 Barossa .......................................................................................26

6.3.5 Clarence Estate, Albany and Kensington Park, Perth .................27

6.3.6 Discussion...................................................................................27

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7 Developing the Minimum Data Set........................................................29

8 Piloting of the Instruments ....................................................................32

9 Integrated trial results: Evaluation .......................................................34

9.1 Collaborator survey............................................................................34

9.2 Resident health and satisfaction ........................................................44

9.2.1 Analysis of questionnaire data ....................................................46

9.2.2 Demographics .............................................................................46

9.2.3 Short form health survey SF-12 ..................................................48

9.2.4 General satisfaction survey .........................................................53

9.3 Qualitative analysis ............................................................................60

9.3.1 Methods ......................................................................................60

9.3.2 Findings.......................................................................................61

9.3.3 Stakeholder focus groups............................................................64

9.3.4 Discussion...................................................................................68

9.3.5 Conclusion ..................................................................................71

10 Discussion, Conclusion and Recommendations ................................72

10.1 Role of the nurse practitioner in aged care.......................................74

10.2 The clinical leadership potential of Aged Care Nurse Practitioners in the Aged Care Sector ..............................................76

10.3 The impact of Aged Care Nurse Practitioners on resident outcomes..........................................................................................76

10.4 The acceptability of the Aged Care Nurse Practitioner role..............76

10.5 Strategies for the development of appropriate national clinical practice protocols and guidelines .....................................................77

10.6 Strategies for the development of a national Aged Care Nurse Practitioners Formulary ....................................................................77

10.7 Costs associated with prescribing and ordering diagnostics ............78

10.7.1 Prescribing ................................................................................78

10.7.2 Ordering diagnostic tests...........................................................78

10.8 Costs associated with the nurse practitioner ....................................78

10.9 Barriers, enablers and other issues that impact on the introduction and sustainability of a nurse practitioner role................82

10.9.1 Jurisdictional differences in policy and regulation......................82

10.9.2 Medicare Funding......................................................................82

10.9.3 Pharmacetical Benefit Scheme Funding ...................................83

10.9.4 Knowledge and attitudes towards new roles .............................83

10.9.5 Workforce issues.......................................................................84

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10.10 Potential national service delivery models for Aged Care Nurse Practitioner services.........................................................................84

10.10.1 Primary Health Care Based ......................................................84

10.10.2 Health service based as part of Geriatric Services ...................85

10.10.3 Australian Government Department of Health and Ageing-Based...........................................................................85

10.10.4 Regionally based as part of a consortium of providers .............86

10.10.5 Facility based as part of nurse-staffing .....................................86

10.10.6 Independent contractor status ..................................................87

10.11 Conclusions......................................................................................88

10.11.1 Barriers identified in the trial .....................................................88

10.12 Recommendations ...........................................................................89

11 References..............................................................................................90

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List of tables Table 1 Learning plan format ................................................................................ 23

Table 2 Guidelines used by different sites in the nurse practitioner-like service national evaluation ................................................................................... 27

Table 3 The survey form sent to collaborators. Respondents were asked to assess their agreement with the following statements, on a scale from 1 (Disagree completely), 2 (Disagree somewhat), 3 (Agree somewhat) and 4 (Agree completely) ................................................................................ 34

Table 4 Summary of the professions of the 62 collaborators included in the evaluation. Allied health, enrolled nurses, general practitioners, managers/administrators, pastoral, personal care assistants and registered nurses are presented. Profession was not recorded in four cases ........................................................................................................ 35

Table 5 Summary of 62 collaborator surveys (all NPC sites, except NPC 8). The mode is in bold. ........................................................................................ 36

Table 6 Summary of responses to question 3 in the Collaborator survey “I support the concept of NPCs”, grouped according to profession. ............ 37

Table 7 Summary of responses to question 4 in the Collaborator survey “I believe that NPCs will enhance health care service provision”, grouped according to profession. ........................................................................... 37

Table 8 Summary of responses to question 5 in the Collaborator survey “I believe that NPC models will be sustainable in the long term”, grouped according to profession. ........................................................................... 38

Table 9 Responses to the question “Please identify the strengths, if any, of this Nurse Practitioner model”......................................................................... 38

Table 10 Responses to the question “Please identify the weaknesses, if any, of this Nurse Practitioner candidate model”.................................................. 41

Table 11 Responses to the question “Please identify any improvements that could be made to this Nurse Practitioner model” ............................................... 43

Table 12 Responses to the question “Please provide any further comments on this Nurse Practitioner model not covered by earlier questions” .............. 44

Table 13 Summary of the total number of health and satisfaction questionnaires returned from NPC and control sites ........................................................ 45

Table 14 Demographic summary of residents from control and NPC facilities included in the assessment of health and satisfaction ............................. 47

Table 15 Summary of responses to amount spent by residents in the last six months at control sites and nurse practitioner candidate sites. Mode response is formatted in bold ................................................................... 48

Table 16 Summary of the number of responses to the Short Form Health Survey (SF-12), questions 1,8,9,10,11,12 for both control (GP) and nurse practitioner candidate (NPC) sites. Data are the number of responses, the mode response is presented in bold................................................... 48

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Table 17 Summary of Short Form Health Survey (SF-12), questions 2 and 3 for both control (GP) and nurse practitioner candidate (NPC) sites. Data are the number of responses, the mode response is presented in bold......... 49

Table 18 Summary of Short Form Health Survey (SF-12), questions 4,5,6,7 for both control (GP) and nurse practitioner candidate (NPC) sites. Data are the number of responses, the mode response is presented in bold......... 50

Table 19 Summary statistics for total SF-12 score for control and nurse practitioner candidate sites. Data (mean, sample size (n), standard error (SE) and range (minimum, maximum) are presented for each of the NPC sites and overall for all sites............................................................. 51

Table 20 Summary of coefficients of multiple regression using the total SF-12 score as dependent variable. The coefficients, standard errors, t values, probabilities and 95% confidence intervals of the coefficients are presented. Significant predictors are formatted in bold ............................ 53

Table 21 Summary of the 27 items in the general satisfaction survey .................... 54

Table 22 General satisfaction questionnaire (questions 1-21) responses of 80 residents from a control (GP) RACFs and 104 residents from the NPC sites. Mode is in bold................................................................................ 55

Table 23 General satisfaction questionnaire (questions 22-27) responses of 80 residents from a control (GP) RACFs and 104 residents from the NPC sites. Mode is in bold. Answers were framed “In terms of the treatment provided to you by the (GP/NPC) service” ............................................... 56

Table 24 Summary statistics for total general satisfaction score for control and nurse practitioner candidate sites. Data (mean, sample size (n), standard error (SE) and range (minimum, maximum) are presented for each of the NPC sites and overall for all sites .......................................... 57

Table 25 Summary of coefficients of multiple regression using the total general satisfaction score, raised to the fourth power, as dependent variable. The coefficients, standard errors, t values, probabilities and 95% confidence intervals of the coefficients are presented. Significant predictors are formatted in bold................................................................ 58

Table 26 Tabular display of Synthesis 1 from focus group interviews of residents and/or relatives......................................................................................... 62

Table 27 Tabular display of Synthesis 2 from focus group interviews of residents and/or relatives......................................................................................... 64

Table 28 Tabular display of Synthesis 3 from focus group interviews of stakeholders ............................................................................................. 65

Table 29 Tabular display of Synthesis 4 from focus group interviews of stakeholders ............................................................................................. 67

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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.

Results

Resident demographics/health

• Over two thirds of residents who participated in the trial were female, and aged 80 or over.

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• 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.

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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

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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.

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

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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.

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Acronyms

ACT Australian Capital Territory

ANOVA Analysis of variance

CPG Clinical practice guideline

DHA Department of Health and Ageing

EN Enrolled nurse

GP General practitioner

GSQ General satisfaction questionnaire

INPRAC Implementing the Nurse Practitioner Role in residential aged care

JBI Joanna Briggs Institute

JBI-NOTARI Joanna Briggs Institute Narrative Opinion and Text Review Instrument

MDS Minimum data set

n Sample size

NP Nurse practitioner

NPC Nurse practitioner candidate

NSW New South Wales

OT Occupational therapist

PCA Personal care assistant

PBS Pharmaceutical Benefits Scheme

RACF Residential aged care facility

RN Registered nurse

SA South Australia

SF-12 12-item short form health questionnaire

UK United Kingdom

USA United States of America

WA Western Australia

National Aged Care Nurse Practitioner Trial: Final Report, vol. 1 — Evaluation Report Page 1

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.

The national trial 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 study from inception to June 2007.

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


2 The National Aged Care Nurse Practitioner Trial

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

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

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)


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.

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.

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.

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.

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).


3 The Trial Sites It should be noted that this background is derived from information available from the sites and represents the intent of the sites, but not necessarily actual practice.

3.1 Warrabrook, NSW

3.1.1 The locality This trial site is located in the Hunter region of New South Wales. There are 37 General Practitioners who service Warabrook Centre for Aged Care. There is also access to three pharmacies that service the facility via communication of resident needs through care staff and residents. There are no onsite Allied Health professionals but access can be arranged through appropriate referral processes. Examples of regular Allied Health Professionals who service Warabrook include Mental Health for Older Persons Team, Podiatrist, Speech Pathologist and Pathology Services.

3.1.2 The facilities The Warabrook Centre for Aged Care is a 151 bed facility with a client mix that includes 51 High Care and 100 Low Care Residents including 2 respite places. Residents have complex health care needs, and chronic illnesses which compound their care requirements. The facility is operated by a church-related, charitable, not-for-profit organisation. Throughout this report, the Warabrook Centre for Aged Care will also be identified as RACF 6.

3.1.3 The nurse practitioner candidate The NPC had completed 75% of a masters degree linked to licensure as a nurse practitioner in New South Wales when the trial commenced and has since completed. The Nurse Practitioner-like service included the use of agreed protocols and standing orders by the NPC to initiate diagnostic investigations and referral to other health professionals. Throughout this report, the NPC from Warabrook Centre for Aged Care will also be identified as NP 6.

3.2 Australian Capital Territory The ACT had been previously undertaking research into the potential of the role of the aged care nurse practitioner. Thus, the national ‘Aged Care Nurse Practitioner Trial’ was deemed a ‘nested’ project for ACT Health, ie, the ACT provided data and information to JBI who were undertaking the evaluation component on behalf of the Australian Government. During this period, ACT Health continued to research the role of the nurse practitioner in aged care with ‘Implementing the Nurse Practitioner Role in Aged Care (INPRAC)’ project which is a jointly funded initiative between the


Australian Government (Department of Health and Ageing, Quality Outcomes Branch) and ACT Health to implement the NP role in Aged Care. The project resulted from negotiations between representatives of ACT Health and the Department of Health and Ageing to extend the parameters of the 2004-05 Aged Care Nurse Practitioner Pilot Project.

3.2.1 The locality The ACT and surrounding regions has a population of over 500,000 people and provides a wide range of health care services. The primary and community care system is a fundamental part of the ACT health care system. This sector provides a range of care including aged care, drug and alcohol, dental and indigenous health services, community-based allied health services, mental health services, alcohol and drug services, home and community care support services, health promotion services and community nursing. General Practitioners play an integral role with about 85 per cent of people seeing a GP each year (ACT Government 2002). In any given year there are about 65,000 separations from public hospitals (ACT Health 2004-5). All these services play a vital role in preventing and reducing the need for hospital admissions, maintaining the wellbeing of the community outside of the hospital setting and supporting consumers following discharge from hospital (ACT Government 2002). There are currently twenty-eight residential aged care facilities (includes both low and high level) in the ACT.

3.2.2 The Canberra Hospital and Calvary Healthcare. The Canberra Hospital is a major national tertiary hospital that provides a full range of medical, surgical and obstetric services as well as the provision of complex services such as major cardiac surgery and intensive care services. Calvary Public Hospital also provides a comprehensive range of surgical, medical and obstetric services and is a major centre for elective surgery. Services at both acute hospitals are moving towards clinical streaming, increasing the emphasis on a client centred health system. Clinical streaming builds upon a networking of services to focus on the provision of services across the care continuum. Streamed services operate under one management model and provide services such as health promotion, early intervention, community and outpatient services through to acute care services. Areas that are already established as service networks include ACT pathology, cancer services and aged care and rehabilitation (ACT Government 2003-2004). Throughout this report, the Canberra Hospital and Calavary Healthcare will also be referred to as RACF 8.

3.2.3 Mirinjani Retirement Village Uniting Care Ageing has provided the clinical placement for the NPC through the Implementing the Nurse Practitioner Role in Aged Care (INPRAC) project. Uniting Care Ageing is a not for profit organisation. The Uniting Church in Australia Property Trust (NSW) has been providing quality aged care services for over 40 years and has a long-term commitment to continue to meet the growing needs of the community. The Church’s aged care services group,


UnitingCare Ageing NSW/ACT, is one of the largest aged and community care providers in Australia, operating some 92 residential aged care facilities containing 5771 places, 72 community care services providing for over 4000 clients and 3000 self care units located at 80 different sites. The total annual turnover of these operations is in excess of $300 million. UnitingCare Ageing NSW/ACT employs in excess of 5000 staff to support these operations. Throughout this report, the Mirinjani Retirement Village will also be referred to as RACF 7.

3.2.4 Nurse Practitioner/Nurse Practitioner Candidates Within the national Aged Care Nurse Practitioner trial and the INPRAC project there were two NPCs. One position was placed with ACT Health (public sector) within the Aged Care and Rehabilitation Service. Although this position was physically located at the Canberra Hospital, the role worked across the acute (The Canberra Hospital and Calvary Healthcare), the community and the residential aged care sectors. Throughout this report, this NPC will also be identified as NP 8. The other NPC position was placed with the private residential sector with the organisation of Uniting Care Ageing at Mirinjani Retirement Village, Weston Creek, ACT. Throughout this report, this NPC will also be identified as NP 7. At the beginning of the national aged care NP trial, the two NPC were finalising the requirements for the Master of Nurse Practitioner degree at the University of Canberra. Both had completed the required lectures and clinical viva, however needed to complete a thesis that would fulfil the final component. Both candidates successfully completed all requirements and are continuing in NP positions following the completion of this trial.

3.2.5 Aged Care Clinical Practice Guidelines Aged Care Clinical Practice Guidelines were developed by the NPCs during the ACNPPP and have been reviewed and updated during the INPRAC project. During these clinical placements the NPCs enhanced the clinical practice guidelines that were developed as part of the Aged Care Nurse Practitioner Pilot Project, 2004-2005. These included the scope of practice, diagnostic investigations and medication formulary for the Aged Care NP. (Appendix III). Clinical Practice Guidelines are regulated in the ACT. Before the NP is able to enact and practice within the full scope of the role, such as prescribing, ordering diagnostic tests and referring to other health care professions, written endorsement of the multidisciplinary stakeholders who have been involved in the development/adaptation of the guidelines including the medication formulary is required. Additionally, formal agreement and signed approval is required from the CEO and General Manager of the health service in which the NP is employed. Therefore, after assessment of the client/resident any initiation of medication or diagnostic tests (those activities normally associated with the extension of the NP role) was conducted in consultation with the appropriate medical officer.


3.3 Barossa Village, SA

3.3.1 The locality The facility is located in the Barossa Valley, South Australia.

3.3.2 The facility The Barossa Village Residency is an 80 bed facility with a client mix that includes 49 high care beds and 24 low care beds, and seven unfunded beds being used for rehabilitation services and other care. Residents at Barossa Village Residency have complex health care needs and chronic illnesses that compound their care requirements. The facility is operated by a community managed, charitable, not-for-profit organisation that provides a wide range of other services to the ageing population including, 54 Community Aged Care Packages, 5 Extended Care at Home Packages some of whom have already been seen by the Nurse Practitioner (though not as part of this trial), 7 Extended Care at Home (Dementia) packages and approximately 200 people in small groupings of retirement cottages across the region. It enables socially isolated residents of the region to attend congregate programmes at a Nuriootpa based Community Centre and works collaboratively with many other service providers within the region to achieve the best range of options for care possible within funding availability. Throughout this report, the Barossa Village Residency will also be identified as RACF 11.

3.3.3 The nurse practitioner candidate The NPC had completed a masters degree linked to licensure as a NP in South Australia when the trial commenced and has since been licensed as a NP by the Nurses Board of South Australia as the first Aged Care Nurse Practitioner in South Australia. The NP has previously operated as a Clinical Nurse and deputy Residential Services Manager at Barossa Village for a number of years and has shown a great passion for this quality service for the better health treatment of residents and clients. The NP service included the use of agreed protocols and standing orders by the NP to initiate medications, diagnostic investigations and referral to other health professionals. Throughout this report, this NPC will also be identified as NP 11.

3.4 Resthaven, Paradise, SA

3.4.1 The locality The Resthaven nurse practitioner-like service is in North East Adelaide. Pharmacy services are provided by a local pharmacy and allied health services from Resthaven are been used. GP involvement for the project has concentrated on the two primary GPs who have the majority of the residential facility resident numbers. The outer northern suburbs of Adelaide are identified areas of GP shortage. During phase 2 of the national evaluation, a further site was added to the candidate’s jurisdiction – Resthaven Leabrook is


situated on the corner of Kensington and Glynburn Roads in Adelaide’s Eastern suburbs.

3.4.2 The facilities The Resthaven Paradise site has 40 high care and 87 low care residents. The service is operated by a church-related, charitable, not-for-profit organisation. The Resthaven Leabrook site has 40 high care and 71 low care beds, including a 14 place low dependency secure dementia care unit and two low dependency respite care places. Throughout this report, this facility will also be identified as RACF 10.

3.4.3 The nurse practitioner candidate The NPC had no previous education or training in the NP role when the trial commenced. The Nurse Practitioner-like service introduced included the use of agreed protocols and standing orders by the NPC to initiate medications, diagnostic investigations and referral to other health professionals. Throughout this report, this NPC will also be identified as NP 10.

3.5 Clarence Estate Residential Health and Aged Care

3.5.1 The locality The facility is located in Albany, a regional centre in the south-west of Western Australia which serves a population of 31900 thousand people. Albany is a retirement destination for many Western Australians, and the proportion of its population aged 65+ is greater than 18%, compared with the state average of 11%. It is expected that Albany’s aged will comprise 30% of the population by 2012. Residents at Clarence Estate have the right and opportunity to allocate a pharmacy or pharmacist of their choice. There are approximately eight pharmacies in Albany. The facility uses an artromick system. As with the choice of pharmacist, residents also nominate a General Practitioner of their choice. They have approximately 33 General Practitioners to choose from and usually nominate the General Practitioner who had cared for them in the community. Clarence Estate has an on-site physiotherapist and occupational therapist. A podiatrist visits six-weekly. Clarence Estate also has a dietitian and social worker, who are based centrally. Clarence Estate’s residents can be referred to any private allied health worker they wish to see in the community.

3.5.2 The facility Clarence Estate Residential Health is an 86 bed facility with a client mix that includes 36 high care beds; 18 dementia-specific standard high care beds; 16 extra services high care beds; and 16 extra services low care beds. Residents have complex health care needs, and chronic illnesses which


compound their care requirements. The facility is operated by a private, for-profit organisation. Throughout this report, this facility will also be identified as RACF 5.

3.5.3 The nurse practitioner candidate The NPC had no previous education or training in the NP role when the trial commenced. The Nurse Practitioner-like service introduced included the use of agreed protocols by the NPC to make recommendations to participating medical practitioners regarding the ordering of medications, diagnostic investigations and referral to other health professionals. Because of restrictions to the use of standing orders in Western Australia, it was not possible to use standing orders on this site and, thus, the nurse practitioner-like service was mediated through medical practitioners.

3.6 Kensington Park and McDougall Park Aged Care Home, Perth, WA

3.6.1 The locality Both of these facilities are located in Perth, Western Australia and together serve around 10% of the total population of Perth which is 1, 292 297. Access to pharmacy and allied health services is good and GP services are in the vicinity. A doctor service gap is evident after hours and on the weekends. While a locum service is operating it does mean that the resident often has to wait some time before the locum can visit the resident.

3.6.2 The facilities Kensington Park Aged Care Home is a 60 bed high care facility. All residents admitted to this facility have dementia and it is essentially a dementia specific facility. Additionally, residents have complex health care needs, and chronic illnesses which compound their care requirements. McDougall Park Aged Care Home is a 52 bed high care facility. The client mix includes residents with complex care health needs, chronic diseases including dementia which compound their care. Residents at Kensington Park and McDougall Park homes are offered the services of the organisation’s allocated pharmacy services. The Artromick system is used. Residents have a choice to nominate their own general practitioner however it is more likely that the resident uses the services of a general practitioner nominated by the facility, ie a general practitioner who has already agreed to take on another client. Both facilities use an on site Physiotherapist, Occupational Therapist, Podiatrist and the organisation employs a Dietician and Social Worker. Both facilities are operated by a private, for profit organisation. Throughout this report, these facilities will also be collectively identified as RACF 4.


3.6.3 The nurse practitioner candidate The NPC had no previous education or training in the NP role when the trial commenced. The Nurse Practitioner-like service introduced included the use of agreed protocols by the NPC to make recommendations to participating medical practitioners regarding the ordering of medications, diagnostic investigations and referral to other health professionals. Because of restrictions to the use of standing orders in Western Australia, it was not possible to use standing orders on this site and, thus, the nurse practitioner-like service was mediated through medical practitioners. Throughout this report, this NPC will also be identified as NP 4.


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: 1. 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];

2. Providing baseline orientation to the nurse practitioner candidates located in Western Australia; South Australia; Australian Capital Territory and New South Wales [Component 2];

3. Assisting with the development of agreed Practice Guidelines in all sites [Component 3];

4. Designing and testing a Minimum Data Set for use in these, and future, trials [Component 4]; and

5. Conducting an external evaluation of the trials in Western Australia; South Australia; Australian Capital Territory and New South Wales [Component 5].

This chapter discusses the first component of the support provided by JBI. Subsequent chapters address the other four components to JBI’s involvement in the project. 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).

The Joanna Briggs Institute Research and Development team worked across the trial sites to develop proposals for all sites that were based on a common core program. The proposals consisted of two sections, one (Part A) for the sites to complete a series of fields related to the specific persons involved in, or advising on the project, and a second section (Part B) that detailed the scope and process of the national evaluation. Staff of the JBI Research Unit worked with the nominated project managers in each site to assist with the completion of Part A. 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.


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).

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);



• 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).

Expected outcomes were reduction in impact & cost of acute medical conditions and improved general health condition and management of chronic conditions. 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. This learning plan was formatted in table form (Table 1) and included space for the nominated “trainer” to verify that the candidate had achieved the objective. 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)


6 Developing Practice Guidelines

6.1 Practice Guidelines and Standing orders/practice protocols

Although some variation between trial sites was expected (and legitimate), a common process of guideline/`protocol development was considered to be essential.

6.2 Purpose of practice guidelines and protocols in the trial The development and use of evidence-based guidelines served to:

• minimise practice variability between trial sites; • enable key stakeholder involvement in the evolution of the aged care nurse

practitioner role; and • establish an evidence based framework for the development of national

consistency in designing and delivering nurse practitioner services in aged care.

Practice protocols – that is, clear practice parameters – were identified as an important component of a trial such as these, where none of the service providers (nurse practitioner candidates) were licensed as nurse practitioners.

6.3 The guideline and protocol development process: Concurrent with Stage 2, the Joanna Briggs Institute Research and Development team developed brief summaries of appraised evidence for all of the identified nurse practitioner interventions and forwarded these to the clinical advisory panels on each site (that included - but was not limited to - local general practitioners, pharmacists, radiography groups and pathology groups.) A member of the Joanna Briggs Institute Research and Development team was made available to attend an initial Protocol Development Group meeting on trial sites to facilitate the protocol and standing order development process and present the evidence to support it. The topics for guideline development were discussed with the candidates during the 3 day orientation program, based on the agreed core interventions for the national evaluation. Summaries were sourced from international sources and a series of summaries were identified for each core intervention, following appraisal for rigour of methodological development, recency of update/publication, and how evidence was managed and incorporated, one summary was chosen for each core intervention. It was expected that sites would, on receiving the summaries, contextualise them to meet local legislative and clinical imperatives and contexts and then develop guidelines and associated protocols. This process generated a healthy level of discussion and debate between the sites and JBI, which stimulated the sharing of resources between sites, and lead to cooperative development of guidelines, saving time and resources across participating sites involved in guideline development.


6.3.1 Warrabrook Eleven guidelines/protocols were developed by this site (Appendix II):

• Upper Respiratory Tract Infections; • Urinary Tract Infections; • Pain; • Eye Conditions; • Hip Fractures; • Ear Conditions; • Bronchitis, Nursing Home Acquired Pneumonia and Influenza; • Diarrhoea; • Dermatologic manifestations; • Constipation; and • Delirium.

6.3.2 ACT Six comprehensive clinical guidelines and a comprehensive medication formulary were developed by this site (Appendix III):

• Comprehensive Geriatric Assessment; • Cognition; • Pain Management; • Continence; • Mobility and Falls; and • Infections.

6.3.3 Resthaven Nine guidelines/protocols were developed by this site (Appendix IV):

• Vaccination; • Urinary Tract Symptoms; • Constipation; • Falls and Injury Prevention; • Medication management; • Diabetes mellitus; • Acute Pain; • Eye/ Visual Symptoms; and • Diarrhoea.

6.3.4 Barossa Eight guidelines/protocols were developed by this site (Appendix V):

• Vaccination; • Urinary Tract Symptoms;


• Restraint; • Falls; • Diabetes Mellitus; • Dehydration; • Conjunctivitis; and • Acute Pain.

6.3.5 Clarence Estate, Albany and Kensington Park, Perth Ten guidelines/protocols were developed by these sites (Appendix VII) :

• Constipation • Bacteremia • Diarrhoea • Oral candidiasis • Respiratory – pneumonia • Skin infections • Genito-urinary – urinary tract infection • Venous leg ulcers • Uro-genital – vulvo-vaginal candidiasis • Pain and medication management/review.

6.3.6 Discussion Some sites shared resources and all sites developed guidelines for pain management (Table 2). All guidelines were subjected to content analysis in Phase 2 of the trial (see section 2.12 of volume 2). Table 2 Guidelines used by different sites in the nurse practitioner-like service national evaluation Topic NSW SA WA ACT Pain Urinary tract infection

Constipation

Diarrhoea

Fall prevention

Atopic dermatitis Cellulitis Conjunctivitis Fungal infection Medication review Pneumonia

Scabies Anaphylaxis


Topic NSW SA WA ACT Bacteremia Bacterial skin infection Balanitis Blepharitis Candidiasis Ceruminosis Chronic wounds Cognition Common cold Continence COPD Dehydration Delirium Dermatophyte infect Dermatophyte skin infection Diabetes mellitus Dry eyes Dry skin Ear infection Eyes Faecal impaction Hip fracture Infected wounds Infections Inflammatory/seborrheic dermatoses Influenza Oral thrush Pharyngitis Pruritis vulvae Restraint Seborrheic dermatitis Sinusitis Skin infection Subcutaneous drug reaction Vaccination Vaginal thrush Venous leg ulcers Wound management


7 Developing the Minimum Data Set The Minimum Data Sets created for the NSW Nurse Practitioner Trials and used in the Phase 1 and Phase 2 evaluations of the Victorian Nurse Practitioner project were evaluated for capacity to collect activity and cost data pertinent to the specific requirements of a broader, national evaluation. The NSW dataset was created using Microsoft Access with two components to generate a series of databases that were loaded on the individual machines of the trialists. Assistants who were educated in the process of data entry supported the trialists in data entry; however, a number of problems and short falls were identified in the design and dissemination of these databases to trial sites. 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 software that the data collection utilised was platform specific, and had to be implemented across computers with varied specifications and abilities.

• The Microsoft Access database was set up on a site by site basis, there was no capacity for researchers to extract data, or view the progress of data entry for completeness or quality control purposes.

• To extract or view data, the participating sites were required to know how to export the data from MS Access, and burn it to CD ROM for postage to the researchers.

• There were time delays and security issues in the transfer of CD ROMs of data to the researchers from participating sites.

• As the data was kept on local machines, it was unclear what the implications of that would be for this national evaluation where the raw data is actually owned by the Commonwealth Department of Health and Ageing, not by JBI, or the participating sites.

It was identified that a number of limitations discovered during previous trials would impede some preferred characteristics of data collection for this national evaluation, namely:

• The ability to collect data continuously • The ability to observe and evaluate the data being collected for

completeness across all sites • The capacity to give sites real time feedback on specific items of

data entry, and regular summaries of their sites total databank state of completeness

• The flexibility for multiple persons to input data for a facility without needing access to multiple copies of licensed software with the associated costs


• The flexibility for project staff to conduct data entry with 24/7 access regardless of locality by providing a web based interface

• The capacity for JBI project staff to conduct upgrades in real time response to the needs of project sites

• The capacity for JBI project staff to extract data on an as needed basis, without impinging on project sites time and resources.

• The flexibility to update or edit entered data without resulting in duplication of data fields or exports.

The MDS was initially created to serve two purposes: to standardise data collection related to the functions and extent of the role; and to provide a comparison point to the NSW and Victorian Nurse Practitioner trials which essentially collected similar data. Due to the limitations identified in the coding and delivery of the MDS, and its capacity to share data between the sites and the coordinating body, it was decided to produce a separate build for this evaluation. The role, elements and features of the proposed MDS were discussed at the 3 day orientation in Adelaide. This included tabling of a document outlining the fields proposed in the new build for review and discussion by the candidates of these fields, and their implementation. Once the orientation was completed, the field specification map was used to develop a technical specification with BMD developers. The technical specification formed the basis of subsequent development, including the mapping of the relationships between the elements in the MDS, and how the data would be entered and extracted for coding and analysis. The planning of the MDS was based in part on what type of data would be required for the analysis, and what the optimal format of that data would be for extraction to Microsoft Excel and SPSS (Statistical Package for Social Sciences). The second focus of the planning phase was to ensure that the MDS would promote a standardised approach to data entry while also enabling sites to add context specific data. This was achieved by building in to the MDS mandated text using a series of drop down menus for interventions, tests, medications and referrals. Sites were able to add to these lists as required, and provide detailed descriptions of care interventions in open text fields linked to specific interventions. The development of the MDS included an online system of help files and resources, which the candidates and/or their managers have access to download and print out. The MDS also was designed to include an automated problem/bug reporting system so that users could submit a report to the development team as soon as it occurred. Each site was given individual log on codes for the reporting of any problems in the MDS to ensure that sites could be responded to appropriately if they logged a request in the bug reporting system. Global changes to the MDS were communicated to all sites. Due to the acknowledged complexity of the evaluation, particularly the role of local legal and clinical variation, the MDS which consists primarily of pre-defined fields was also designed to enable individual users to add specific content for pre-defined areas where variation was considered likely. On launch of the MDS, each site was either visited, or contacted via telephone to discuss the implementation of the MDS, the data collection process and to orientate the candidates to the required data fields.


During the data collection phase the project team remain available during working hours to answer queries and solve problems related to data entry in, or orientation to the MDS and other aspects of the evaluation. The inbuilt IT support systems and structures were available 24 hours a day for reporting of technical bugs that may occur during the data collection phase. Sites were able to use these systems to notify JBI of progress or problems with data collection, and JBI was able to make changes to data entry fields as the trial progressed to ensure completeness of data capture, and to accommodate new directions subsequent to completion of stage one of the trial. These changes included:

• The ability to add a short ‘review’ or ‘follow-up’ visit to a resident, of lesser duration and complexity than a typical visit.

• The ability to add multiple hospital or ER visits or readmissions • Addition of options to ‘visit initiated by’ data field • Addition of one option to the core intervention list

Any changes to the MDS were communicated to all site NP’s and related project staff. To provide further assistance to sites, a step-by-step, illustrated help file was created and loaded on to the MDS access page. From here it could be viewed, or downloaded and printed. A copy of the help file accompanies this report. An illustration of the schema for the data relationships accompanies this report, as does an illustration of the functional relationships between the fields in the MDS web portal.


8 Piloting of the Instruments The piloting of the MDS commenced at the 3 day orientation. At this time, an outline of the specification was discussed with all candidates, and their input sought on the categories of data, the structure of the database, and their views on functions to promote the utility of the database. This discussion fed directly in to the development process. There was ongoing discussion with the sites leading up to and following the release of the MDS. Where problems were identified that related to how the MDS functioned from the users perspective, a developmental approach was taken, with the IT team working directly in response to site feedback to continue development and create changes to the data input side of the MDS. This ongoing, informal approach was accompanied by a group analysis and feedback session with all the sites via teleconference. At this teleconference, changes that had been made were reviewed, and the items and methods of data entry were discussed. From this meeting, a new list of suggestions for further development of the MDS was generated, and circulated to all sites for discussion and confirmation. Following confirmation from all sites, a range of changes to the MDS were forwarded to the IT development team for implementation. The MDS has proved to be a robust, flexible and easy to use method of data collection for all involved. Other key instruments in this trial related to the evaluation of resident satisfaction, wellbeing, the comparator sites, and the collaborator questionnaire. Resident satisfaction was assessed using The General Satisfaction Questionnaire. The General Satisfaction Questionnaire (GSQ) is a tool used commonly to assess client satisfaction with a given service using a 4 point Likert type scale. This was re-formatted for the target audience of older adults in residential settings and the qualitative component was removed as the focus groups were specifically tailored to capture the qualitative data relevant to this national evaluation. The GSQ generates a numeric value to determine client satisfaction. The client satisfaction score ranges from 80, which indicates the highest level of satisfaction with the service, to 20 which indicates the lowest level of satisfaction. The revisions of this tool were primarily related to the semantics of making questions meaningful for older adults rather than changing the meaning, direction, or intent of any of the questions, thus the changes made following feedback from the participating sites were implemented in the version used in the evaluation without compromising the validity of the instrument. 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. Similarly, the focus group discussion schedules, demographic data collection tools, economic evaluation questionnaire, and collaborator questionnaire were subject to review and feedback by the sites prior to implementation. A further benefit of using this set of tools for data collection was that they had been used in previous iterations of trials to evaluate nurse practitioner related services, satisfaction with services and general health perceptions. The applicability of these instruments to the objectives of this national evaluation were clear, and had been subject to testing and evaluation in the previous trials. Hence the piloting and development of the instruments used in this national evaluation can be said to have been ongoing from the time of the Victorian and New South Wales trials, with minor amendments to meet the particular characteristics of the constituency represented in this trial.


9 Integrated trial results: Evaluation

9.1 Collaborator survey Survey forms were sent to professional and other staff that had been involved in active collaboration with the nurse practitioner candidate. The 14 quantitative questions are listed below, questions 15-18 involved free text (Table 3). Sixty two surveys were filled out by collaborators as part of the national evaluation. Table 3 The survey form sent to collaborators. Respondents were asked to assess their agreement with the following statements, on a scale from 1 (Disagree completely), 2 (Disagree somewhat), 3 (Agree somewhat) and 4 (Agree completely) # Question

Prior to being involved in the NPC project:

1 I was aware of the NPC concept

2 I supported the concept of introducing NPCs

Currently

3 I support the concept of NPCs

4 I believe that NPCs will enhance health care service provision

5 I believe that NPC models will be sustainable in the long term

I feel that the NPC I have been collaborating with:

6 Is qualified to an appropriate level

7 Conducts themselves in a competent and professional manner

8 Provides a high level of service

9 Adequately addresses the concerns of the clients

10 Shows a high level of clinical initiative

11 Works actively with collaborators (including myself and others)

12 I have experienced the following level of collaboration

13 I have developed a good working relationship (yes/no)

14 Based on my experience with this NPC model I would recommend clients see a NPC


GPs and RNs make up the bulk of the collaborators surveyed, and are responsible for 21% and 31% of the total number of collaborators surveyed (Table 4). Two of the sites received surveys from eight collaborators, while one site had fifteen. Table 4 Summary of the professions of the 62 collaborators included in the evaluation. Allied health, enrolled nurses, general practitioners, managers/administrators, pastoral, personal care assistants and registered nurses are presented. Profession was not recorded in four cases Profession NPC

4 NPC

5 NPC

6 NPC

7 NPC 10

NPC 11

Grand Total

%

Allied 1 0 1 1 3 0 6 9.7 EN 0 2 2 3 1 0 8 12.9 GP 1 0 2 0 5 5 13 21.0 Manager 3 0 2 0 2 0 7 11.3 Pastoral 0 0 0 0 0 1 1 1.6 PCA 0 0 1 3 0 0 4 6.5 RN 3 5 3 2 4 2 19 30.6 unknown 3 1 0 0 0 0 4 6.5 Grand Total 11 8 11 9 15 8 62 100.0 The collaborators were extremely supportive of the NPCs. Most collaborators agreed completely with all of the statements on the collaborator survey (Table 5). Interestingly, the first two statements, concerning awareness of, and support for, the NPC concept prior to involvement in the project, showed the least level of acceptance. However, following involvement in the project, the level of complete support for the concept increased from 65% (ie 40/62) to 82% (51/62). Tellingly, only one of the 62 collaborators disagreed at all with the concept of the NPC. Questions four and five, in particular, which relate to the sustainability of the NPC model in the long term, were the only other questions which attracted any real difference of opinion between collaborators. Only two of the collaborators (3%) would not recommend their patients see a NPC, and all collaborators experienced positive (either medium or high) collaboration levels with the NPC. None of the collaborators stated that they had not developed a good working relationship with the NPC.

Table 5 Summary of 62 collaborator surveys (all NPC sites, except NPC 8). The mode is in bold. Disagree

completely Disagree

somewhat Agree

somewhat Agree

completely n/a u/known

Qn Prior to being involved in the NPC project:

1 I was aware of the NPC concept 9 3 14 35 0 1

2 I supported the concept of introducing NPCs 1 7 13 40 1 0

Currently

3 I support the concept of NPCs 0 1 8 51 1 1

4 I believe that NPCs will enhance health care service provision 0 1 9 51 1 0

5 I believe that NPC models will be sustainable in the longterm

0 3 13 45 1 0

I feel that the NPC I have been collaborating with:

6 Is qualified to an appropriate level 0 0 3 54 2 3

7 Conducts themselves in a competent and professionalmanner

0 0 1 60 1 0

8 Provides a high level of service 0 0 1 60 1 0

9 Adequately addresses the concerns of the clients 0 0 1 60 1 0

10 Shows a high level of clinical initiative 0 0 2 59 1 0

11 Works actively with collaborators (including myself andothers)

0 0 2 59 1 0

14 Based on my experience with this NPC model I wouldrecommend clients see a NPC

1 1 6 51 0 3

Very low Low Medium High n/a

12 I have experienced the following level of collaboration 0 0 8 53 0 1

No Yes

13 I have developed a good working relationship 0 55 0 7


Responses to the three questions (3, 4, 5) that attracted the minor differences of opinion between collaborators are listed for each profession in Table 6, Table 7 and Table 8. Table 6 illustrates that GPs make up more than three-quarters of the collaborators who either only partially agree or disagree with the concept of nurse practitioners. Similarly, Table 7 illustrates that GPs make up the vast number (7 of 10) collaborators who either only partially agree or disagree with the concept that nurse practitioner candidates will enhance health care service provision. However there are similar numbers of GPs and nurses (combining RNs and ENs) who express some reservations about the sustainability of the NPC role. Table 6 Summary of responses to question 3 in the Collaborator survey “I support the concept of NPCs”, grouped according to profession. Q3 I support the concept of NPCs Profession Disagree

completely Disagree

somewhat Agree

somewhat Agree

completely n/a u/known Grand

Total Allied 0 0 1 5 0 0 6 EN 0 0 0 8 0 0 8 GP 0 1 6 5 1 0 13 Manager 0 0 0 7 0 0 7 Pastoral 0 0 0 1 0 0 1 PCA 0 0 0 4 0 0 4 RN 0 0 1 17 0 1 19 unknown 0 0 0 4 0 0 4 Grand Total

0 1 8 51 1 1 62

Table 7 Summary of responses to question 4 in the Collaborator survey “I believe that NPCs will enhance health care service provision”, grouped according to profession. Q4 I believe that NPCs will enhance health care service provision Profession Disagree

completely Disagree

somewhat Agree

somewhat Agree



0 1 9 51 1 0 62


Table 8 Summary of responses to question 5 in the Collaborator survey “I believe that NPC models will be sustainable in the long term”, grouped according to profession Q5 I believe that NPCs will be sustainable in the long term Profession Disagree

completely Disagree

somewhat Agree

somewhat Agree



0 3 13 45 1 0 62

All free text responses to the four open ended collaborator survey questions, sorted according profession, are included in Table 9, Table 10, Table 11 and Table 12. Some of the recurrent points made by collaborators about the strengths of the NPC model include (Table 9):

• Timeliness and immediacy of care provision (availability, accessibility), especially when NPCs are on site;

• Praise for the current nurse practitioner candidates, their knowledge and abilities, and their role in improving resident outcomes;

• Improved communication between care providers and between residents/family and the RACF;

• Nurse practitioner candidates as advisers to other nurses, personal care assistants and allied health.

Table 9 Responses to the question “Please identify the strengths, if any, of this Nurse Practitioner model” Job2 q15 Allied Clearer therapeutic action when NPC is involved. More timely action taken

than waiting for RN staff to act Allied Enhanced communication between all parties Allied Enhanced knowledge and liaison skills Allied First point of contact; high level of expertise; excellent liaison between GP

and other staff Allied Good interpersonal skills; sound knowledge; refers on to allied health for

intervention appropriately (ie in timely manner) EN Better wound management, better pain management; on the spot advice EN Expert knowledge EN Having an experienced nurse help and support nursing staff to make

medical based decisions


Job2 q15 EN More knowledge, less need to call MOs about small issues EN Needs to work with staff as they know the residents and have developed a

relationship with them and know the residents/relative's wishes EN Someone to talk to with concern of a residents when they are unwell and

no doctor available til later in the day EN Very knowledgeable and can share information/knowledge easily GP Allows nurse involvement GP Complex issues would need to be referred on GP Especially noted help in recognition of pain, pain management and family

meetings and family involvement GP Good communicator GP Has more time to do detailed assessments. Time spent establishing

protocols and procedures with the visiting GP on a regular basis. GP In specific situations, eg nursing homes GP Initiation of treatments GP More immediate and appropriate care GP Nurse is more accessible to the clients than a busy GP. Nurse can be eyes

and ears of doctor whilst nurse is competent to act alone. Best care is achieved by a doctor and nurse working together - teamwork

GP Present nurse practitioner candidate is outstanding - I doubt most following nurse practitioners will be to this standard

GP She can triage patients before contacting GP; much quicker than GP; areas of competence which GP does not have (eg wound care)

GP This nurse practitioner candidate has an excellent knowledge base, and relates well to residents, staff and GPs; maintaining good communication.

Manager Accessing good medical intervention through follow up of issues identified Manager Available for advanced clinical assessment and initiation of treatment in a

timely manner Manager Early assessment; more comprehensive assessment as more time, easier

relationship with care staff; better liaison with GPs as speaks same clinical language

Manager Expediency of commencing intervention; more patient contact; more approachable than GP; capacity to triage cases

Manager Holistic care of residents; has helped with team work amongst our allied health professionals.

Manager Residents have access to quicker treatment for any clinical issues that arise - often a delay waiting for doctor's visit; knowledge level of NPCC is a great asset to all staff and therefore to the facility.

Manager This model is able to give support and implement individual care needs that monitor a resident's care to ensure that quality care is given. This role will play a significant part for quality care as the work force in aged care is reliant on support carer workers and declining numbers of registered nurses.

PCA I can always ask a question and never feel stupid; extra knowledge PCA Our NPC has extremely good communication skills, explaining her

reasoning for certain things. She is approachable, competent and confident

PCA Support for resident and staff RN Confirms the need to involve clients' GP. Ability for NPC to discuss issues

with GP. RN Diagnoses problems effectively - deals with them promptly and efficiently;

liaises well with GPs RN Easy access; availability for residents when required; able to give

diagnoses


Job2 q15 RN Enables access to clinical expertise, support and guidance, easier than

contacting doctors. Continuity of care. RN Excellent clinical skills; good communication skills RN Excellent rapport with residents colleagues, doctors. Very good clinical,

interpretive skills. Able to use initiative within parameters of study. RN Finding information; educating staff RN Good communicator and passionate about her job RN Great communication skills with doctors, residents and staff. Good clinical

and assessment skills. When contacted by staff to discuss a problem related to health of one resident tries to visit ASAP or spends time discussing problem and tries to find a solution to benefit resident

RN Skills and openness of NPC; good communication with nursing staff RN Support and leadership; client/resident have better care; families like the

concert RN The specific nurse practitioner candidate I work with has fantastic clinical

skills. She is very approachable for both staff and clients. RN Time RN Timely assessment and treatment for patients; improved communication

between the surgery and RACF; gives staff a point of clinical contact within RACF; increased patient satisfaction

unknown Families have given me positive feedback re the NPC role unknown On site, allows triage of patients unknown On site; do not have to wait for locum or GP to arrive

About half of the collaborators identified their perceptions of the weaknesses of the NPC model (Table 10). Although several participants stated that they felt there were no weaknesses with the current model, some of the recurrent themes expressed here include:

• The lack of prescribing rights, and the need for expansion of pharmacological role;

• Potential for resistance to the role by other nursing, allied and medical staff

• A lack of availability when NPCs visit other sites.


Table 10 Responses to the question “Please identify the weaknesses, if any, of this Nurse Practitioner candidate model” Job2 q16 Allied Clear legal boundaries Allied Development of case conference (formal) activities Allied None witnessed Allied Not enough NPCs - need more. Need more GP education Allied Pharmacology could be expanded Allied Some resistance to the model at higher management level. This results in

NPC feeling unsupported. Some resistance at RN level - possibly more education and collaboration needed at beginning of project

EN I have not had any weaknesses since we started with a nurse practitioner candidate

EN None witnessed EN Not being on site full time EN Sometimes takes too long to get back to see resident due to big workload GP Does not have prescribing rights GP Effectiveness depends on the quality of the NPC and requires

sustainability GP Lack of ability to prescribe; lack of ability to order tests GP More available GP Need more GP No 24 hour cover GP Nurse must be a good communicator and be able to develop a good

working relationship with treating doctors and the nursing home staff GP Nurse practitioners are ideal in areas of need, ie deficit of GPs which is

not the case in this area GP Role merged with that of DON. Better care but did it make a financial

difference is debatable Manager Acceptance by other nursing staff who are clinically threatened/challenged

by model Manager As a trial it means that when trial is over and model altered this facility

will notice the loss of NPC from being 5 days/week to whatever the new model is.

Manager Much of the value of the program was immediate on-site access to the NPC - when off site, staff tended to just phone GP or send resident to hospital

Manager Not always available due to other commitments Manager The regulatory framework in WA has prevented the NPC from prescribing

and ordering tests. Manager Unable to prescribe medications PCA They have too much work. Need to be based here more. PCA Unable to write scripts RN Availability - due to being too thinly RN Communication with all staff RN Greater level of responsibility/ability such as prescribing rights, ordering

pathology tests and radiography is required to improve the efficiency of the NPC role.

RN Inability to prescribe some medication (ie antibiotics etc). RN Lack of clearly defined role/scope of practice RN Model is quite restrictive for client needs RN Needs to work in ACT only, there is enough (more than enough) work to

do here. RN Nil


Job2 q16 RN Nil RN Nil RN Not accepted by all visiting doctors. Not available on 'out of hours' shifts.

Available visiting hours have been cut since project first started. RN NPC needs to keep RNs informed of what she is doing or intends to do RN The time constraints/availability; the ability at times to follow through on

interventions implemented; Lack of prescribing rights RN Unable to write prescription unknown Limitations of models due to nursing board restrictions unknown None

Responses to the question seeking suggested improvements to the model were similar in nature to the comments listed previously as weaknesses of the model. The main themes mentioned (Table 11) included the need for:

• Prescribing rights,

• More NPCs,

• Better integration with other nursing, medical and allied health staff were all consistently mentioned.

Additionally, some participants raised concerns about how the role would be filled on a permanent basis. The final question, seeking any additional comments, received the least number of comments from collaborators. Nevertheless this question yielded several interesting comments (Table 12). Many of the comments also reflected those that have been previously mentioned. Some comments included:

• Praise for the current nurse practitioner candidates, their knowledge and abilities, and their role in improving resident outcomes;

• The need for clarification and further development of the role in RACFs.


Table 11 Responses to the question “Please identify any improvements that could be made to this Nurse Practitioner model” Job2 q17 Allied NPC may need to work over a couple of facilities. Provision of clinics

would be helpful for high and low care residents Allied Pharmacology could be expanded EN Having a NPC on site full time EN More abilities and cooperation from doctors EN More time in one facility to give more back up. Less time away. EN Nil EN Very important in workplace; on the spot advice GP Better suited to other nursing care settings, probably more rural GP Continued support by aged care GP Grant prescribing rights GP More time per week in one facility might allow improvement of

weaknesses previously identified GP None GP Strengthening of the framework with which she works. Define where the

buck stops. GP Two nurse practitioner candidate GP Use only in areas of need Manager A collaborative role in discharge planning from hospital still warranted Manager Acceptance by colleagues as it is a new role. Education on the role to

other registered nurses. Manager Initial introduction slower, more encompassing of all staff (eg AIN's/RNs)

to introduce them to model Manager Nil Manager Prescribing rights PCA Being able to write scripts PCA If they could order drugs for the residents PCA More NPCs; encourage PCAs to study more as this role offers aan

improved career path RN 24 hr on call service; prescribing rights RN Available funds to enable model to be available on all shifts RN Being able to write scripts RN Covers up to four facilities and community packages RN Greater level of support. Better mentoring program. Increased GP

support for the practitioner candidate. RN Greater scope of practice (currently hampered by number of GPs she can

act on behalf of). RN nil RN Nil RN Nil RN Nurse practitioner candidates should be available in a permanent basis in

all residential care. Their availability and accountability is important for the resident especially when they could not see a GP in an instant

RN The model needs to be expanded further. How many NPCs will there be? Are numbers going to be restricted?

unknown Greater scope with lab requests etc unknown This role is a definite improvement to the nursing home - NPC has

different outlook


Table 12 Responses to the question “Please provide any further comments on this Nurse Practitioner model not covered by earlier questions” Job2 q18 Allied This model has provided positive health outcomes for residents and

positive education outcomes for staff EN ____ has been a pleasure to work with and has taught me some

valuable issues and information EN Has made a great improvement to resident care with a NPC on the

premises instead of waiting days for MO to visit EN Very pleasant person who is helpful with suggestions when resident

unwell GP Education of staff and maintenance of RN skills need to be continued GP I believe the nurse/doctor communication should be somewhere defined

in the role of a NPC, somewhat in the same mould as the consultant and his registrar. I am very excited by these developments in care delivery which I believe can go some way to break down the tyranny of distance which I believe is an Australian problem (ie large distances, small populations)

GP We were lucky we had a good nurse to start off with. The standard of care was high initially, I think was really working hard to make it succeed.

Manager An excellent model and one that the health profession must embrace given changing health and ageing population

Manager Nil Manager Role accepted and accessed by residents Manager This will greatly benefit the care of the aged person, especially with

dementia. PCA I am very pleased with our NPC. It is a great benefit to staff and

residents to have her at . Not only do our residents get reviewed faster, as a care supervisor I have learnt a great deal from her.

RN Excellent initiative, we need more RN Must evolve a collaborative and partnership role RN Should prove to be an essential part of aged care in the future RN The NPC is not handling any problems that a RN/DON would not handle

in another nursing home that does not have a NPC

9.2 Resident health and satisfaction A large part of the evaluation of the NPC in RACF addressed (1) assessment of resident health and satisfaction with care in the facilities where the NPC was practising – the NPC site, and (2) comparison with residents located in a nearby, similar RACF – the control site where residents could only access a GP. Consenting residents were asked to fill out, or were assisted to fill out, a questionnaire in three parts: (i) demographic data including age (years), gender, location, service used (NPC or GP), number of times that the service had been used in the past six months, a self assessed quality of life on a scale of 1 (lowest) to 10 (highest),


length of stay (weeks), and estimates of expenses (prescriptions, non-prescription medications, other health products, out of pocket fees) paid in the last six months. (ii) the 12 item Short Form Health Survey (SF-12), comprising 12 questions assessing the resident’s health, particularly in the last 4 weeks. Six of the questions (questions 1, 8, 9, 10, 11, 12) use a 5-point Likert scale, two questions (2, 3) use a 3-point Likert scale, and four questions (4, 5, 6, 7) are yes/no answers. For the analysis of this data, the responses were coded differently according to the number of options on the Likert scale, with poor health scoring lowest and better health scoring highest. For example 5-point scales were scored from 1 (poor health) to 5 (excellent health). Yes/no scales were scored as 1 (poor health) and 2(better health). In this way, the highest possible total score for the survey was 44, comprised of (6 × 5 =30) + (2 × 3 = 6) + (4 × 2 = 8). The lowest possible score was 12 (6 × 1 =6) + (2 × 1 = 2) + (4 × 1 = 4). (iii) the General Satisfaction Questionnaire, comprising 27 questions related to the resident’s satisfaction with their health care. The first 20 questions are 4-point Likert-scale, question 21 uses a visual analog scale (from “worst service imaginable” to “best service imaginable”) and questions 22-27 are 4-point Likert responses. The Likert scale questions were scored from 1 (lowest satisfaction) to 4 (highest satisfaction); the visual analog scale was converted to a four point scale by breaking it down into four equal sections. This questionnaire therefore yielded a maximum total score of 108 (27 × 4 = 108) and a minimum of 27 (27 × 1 = 27). A total of 187 questionnaires were collected from the NPC and control sites (107 and 80 questionnaires, respectively). Equal numbers (20) of questionnaires from both control and NPC sites were targeted; this was achieved to varying degrees of success. Three sites (RACF 4, 6, 10) achieved high, equal numbers of questionnaires, one site had a lower but equal number of questionnaires completed (RACF 11) and one site (RACF 8) had unequal numbers. As in the previous evaluation, data was collected from only one control site in WA and from only one of the two nurse practitioner candidate sites in the ACT. Table 13 Summary of the total number of health and satisfaction questionnaires returned from NPC and control sites NPC ID Control site NPC site Grand Total 4 20 20 40 5 0 20 20 6 18 18 36 8 14 21 35 10 17 17 34 11 11 11 22 Grand Total 80 107 187


9.2.1 Analysis of questionnaire data The analysis of data from questionnaires, particularly those which incorporate Likert-scales, is contentious. Likert-scale data is ordinal in that there is a clear progression in the options presented; for example, a respondent can choose between ‘Very dissatisfied’, ‘Dissatisfied’, ‘Satisfied’ and ‘Very satisfied’. It is not readily apparent that a participant choosing ‘Very satisfied’ is twice as satisfied as one that has selected ‘Dissatisfied’; hence the requirements of interval scale data and parametric analysis have not been met. In theory, ordinal data is therefore analysed using non-parametric techniques. However, in practice it is quite common to find parametric statistical methods applied to Likert-scale data. This may be because there are no non-parametric equivalents to some of the more ubiquitous analytical tools (eg multiple regression analysis, bivariate logistic regression) used in multivariate analysis. In our view, the practice of using parametric approaches to Likert-scale data is tolerable when (a) the dependent variable being examined (in this case the total SF-12 score and the total GS score) are total scores, which allow for far greater variation than is possible if the responses to a single question are examined, (b) sample size is relatively large and (c) other assumptions for using parametric statistics (eg normality, homogeneity of variances) are met. This is the approach that we have taken to the analysis of this dataset. Interpretation of the results will be made with the caveat of acknowledging the analytical difficulties posed by the dataset. Other variables (eg age, gender, length of stay) will be analysed using parametric statistics unless its assumptions are not supported, in which case non-parametric alternatives will be used. All data analysis was conducted using Stata software (v9, Statacorp LP).

9.2.2 Demographics Overall, the demographic characteristics of residents from control and nurse practitioner candidate sites were very similar (Table 14). There was no difference in the gender ratio between sites (Pearson Chi-square, χ2=0.65, P=0.42) and no difference in age (Wilcoxon rank-sum test, z=-0.78, P=0.43). Similarly, there was no difference in the number of times that the service was used in the last six months (5.5 ± 0.5 versus 6.9 ± 0.6, Wilcoxon rank-sum test, z=-1.41, P=0.16), no difference in the self assessed quality of life score (out of ten) (6.9 ± 0.3 versus 7.0 ± 0.2, Wilcoxon rank-sum test, z=0.135, P=0.89), and no difference between the length of stay in weeks (148.3 ± 19 versus 145.6 ± 15, Wilcoxon rank-sum test, z=-0.46, P=0.65).


Table 14 Demographic summary of residents from control and NPC facilities included in the assessment of health and satisfaction Variable Control NPC Number 80 107 Gender Women 58 (73%) 71 (66%)

Men 22 (28%) 35 (33%) Unknown 0 (0%) 1 (1%) Age Mean (yrs) 82.6 83.6 SE 1.0 0.8 Min 49 48 Max 97 99 Number of times service used

Mean 5.5 6.9

Quality of life Mean score /10

6.9 7.0

Length of stay Mean (weeks)

148.3 145.6

Additionally, as part of the demographic data, residents were asked to provide an estimate of the amount that they had paid for a range of items in the last six months. The items included any prescriptions, non-prescription medications, other health-related products and any out-of-pocket fees above Medicare rebates. The responses are summarised in Table 15. The data show that the majority of residents for which data was available had spent more than $150 on prescriptions, and lesser amounts on non-prescription medications, other products and out-of-pocket fees. Unfortunately, a large proportion of residents were unable to respond to these questions. In some cases the RACF was able to provide the data, however, there were still many cases for which data was missing. For example the mode response in NPC sites was ‘unknown’ for all four items. Due to these very large gaps in the dataset, the amount spent by residents will be excluded from the more detailed examination of the SF-12 health and general satisfaction data.


Table 15 Summary of responses to amount spent by residents in the last six months at control sites and nurse practitioner candidate sites. Mode response is formatted in bold Control sites

Item $0-20 $21-40 $41-60 $61-80 $81-100 $100-150 $>150 U/k Pharmaceutical products

4 8 4 7 6 15 24 12

Non-prescription meds

39 12 1 2 0 2 1 23

Other products

40 1 4 0 1 0 3 31

Out of pocket fees

30 5 1 2 3 1 5 33

Nurse practitioner candidate sites

Item $0-20 $21-40 $41-60 $61-80 $81-100 $100-150 $>150 U/k Pharmaceutical products

3 7 2 6 12 17 29 31

Non-prescription meds

29 5 12 1 1 2 8 49

Other products

33 15 6 0 0 0 4 49

Out of pocket fees

24 7 5 8 4 3 9 47

9.2.3 Short form health survey SF-12 The responses to the short form health survey (SF-12) are summarised in Table 16, Table 17 and Table 18. The results show a population of older people that is in reasonably good health. For example, the mode response to the first question about the residents’ general health was ‘good’ in both control and NPC sites. All of the mode responses were at least in the middle of the LIkert-scale, and many were in the upper scores indicating that health was in general positive. The pattern of mode responses to questions in Table 16 was similar for control and NPC sites. For example, questions 9, 10, 11 and 12 exhibited the same mode response. Table 16 Summary of the number of responses to the Short Form Health Survey (SF-12), questions 1,8,9,10,11,12 for both control (GP) and nurse practitioner candidate (NPC) sites. Data are the number of responses, the mode response is presented in bold Item 1 In general would you say your health is… Item 8 During the past week, how much did pain interfere with our normal

work or other activities? Item 9 Have you felt calm and peaceful? Item 10 Did you have a lot of energy? Item 11 Did you feel downhearted?


Item 12 How much of the time have your physical health or emotional problems interfered with your social activities?

Control site NPC site Qn Poor Fair Good Very

good Excellent

u/k Poor Fair Good Very good

Excellent

u/k

sf1 7 20 24 20 9 0 12 28 36 24 7 0

All Most Moderately

Little Not u/k All Most Moderately

Little Not u/k

sf8 2 8 13 23 30 4 7 16 14 37 33 0

Not Little Moderately

Most All u/k Not Little Moderately

Most All u/k

sf9 4 5 19 39 13 0 2 8 23 58 16 0

sf10 11 15 26 21 7 0 9 29 40 22 7 0

All Most Moderately

Little Not u/k All Most Moderately

Little Not u/k

sf11 4 7 27 14 26 2 4 12 38 26 27 0

sf12 6 14 15 10 31 4 4 10 21 25 47 0

Table 17 is a summary of responses to questions about limitations to activities of daily living caused by health problems. The control site residents tended to be slightly more limited in their activities compared to NPC site residents. Table 17 Summary of Short Form Health Survey (SF-12), questions 2 and 3 for both control (GP) and nurse practitioner candidate (NPC) sites. Data are the number of responses, the mode response is presented in bold Item 2 Does your health now limit moderate activities such as moving a

wheelchair, pushing a walking frame, exercising or dressing? Item 3 Does your health now limit your ability to get in or out of bed by

yourself?

Control site NPC site Qn A lot A little No u/k A lot A little No u/k sf2 34 28 16 2 33 53 21 0

sf3 32 17 29 2 30 32 45 0

Questions 4, 5, 6 and 7 of the SF-12 are summarised in Table 18. These questions relate to limitations to health caused by physical or emotional problems and show a similar pattern between nurse practitioner candidate and control sites. It is apparent, particularly at the nurse practitioner candidate site, that residents are more constrained in their activities by physical limitations than emotional problems.


Table 18 Summary of Short Form Health Survey (SF-12), questions 4,5,6,7 for both control (GP) and nurse practitioner candidate (NPC) sites. Data are the number of responses, the mode response is presented in bold During the past 4 weeks have you had any of the following problems with your regular daily activities as a result of your physical health? Item 4 Accomplished less than you would like Item 5 Were limited in work or other kinds of activities During the past 4 weeks have you had any of the following problems with your regular daily activities as a result of any emotional problems? Item 6 Accomplished less than you would have liked? Item 7 Didn’t do activities as carefully as usual?

Control site NPC site

No (better)

Yes (poorer)

u/k No (better)

Yes (poorer)

u/k

sf4 41 36 3 50 57 0

sf5 38 39 3 44 63 0

sf6 49 27 4 70 37 0

sf7 54 21 5 87 20 0

As mentioned previously, each SF-12 was given a score out of 44, with higher scores indicative of better health. This data is summarised in Table 19 on a site-by-site basis and overall. The mean score at control sites was 30.9 ± 6.5 and 31.1 ± 5.7 at NPC sites. The total SF-12 data were shown to have a normal distribution (Shapiro-Wilk test; W=0.98, V=1.74, P=0.10) thereby allowing parametric analysis. A two factor ANOVA was used to initially explore the dataset and to examine if there was any difference in total SF-12 score between RACFs and between treatment groups (ie NPC and control sites). The overall ANOVA was significant (F=2.83, P=0.0029). The difference between RACFs was significant (F=3.30, P=0.007) indicating that the SF-12 total varied significantly between RACFs. However, there was no difference between nurse practitioner candidate and control sites (F=0.06, P=0.81) and no interaction between treatment (NPC/control) and RACF (F=2.13, P=0.079).


Table 19 Summary statistics for total SF-12 score for control and nurse practitioner candidate sites. Data (mean, sample size (n), standard error (SE) and range (minimum, maximum) are presented for each of the NPC sites and overall for all sites RACF Data Control site NPC site 4 mean 29.7 27.9 n 20 20 SE 1.6 1.5 Min-Max 17-40 13-40 5 mean 31.2 n 20 SE 1.3 Min-Max 18-40 6 mean 27.5 30.8 n 18 18.0 SE 1.1 1.6 Min-Max 19-35 17-41 7 mean 32.0 34.5 n 9 21 SE 2.1 0.9 Min-Max 24-42 21-39 10 mean 33.3 29.9 n 17 17 SE 1.5 0.9 Min-Max 24-42 23-36 11 mean 33.9 32.2 n 11 11 SE 1.8 1.4 Min-Max 26-43 24-40 Overall 30.9 31.1 n 75 107.0 SE 6.5 5.7 Min-Max 17-43 13-41

Potential variables affecting the health of residents (as measured by the SF-12) were included in multiple regression. The independent variables included in the regression were: age (years), gender (female=0, male=1), treatment (control=0, NPC=1), number of times serviced used in the last 6 months ‘nsu’, quality of life ‘qol’, length of stay ‘los’, general satisfaction (as measured by the general satisfaction questionnaire) and site identification. There were five variables included which identified the site (labelled RACF5, RACF6, RACF7, RACF10, RACF11). These variables were scored as ‘1’ if the site was the site named by the label, and ‘0’ if not. The indicator variable was RACF4, which scored ‘0’ for all of the RACF labels. The overall regression was highly significant (n=116, r2=0.49, F12,103=8.08, P=0.000). Note that the sample size included in the regression was lower than the total number of SF-12 completed questionnaires (182) because missing


values (in either the dependent or independent variables) meant that the entire record was excluded from the analysis, as Stata software (v9, Statacorp LP) uses list-wise exclusion of missing data. The bulk of the exclusions (33) were due to data missing from the general satisfaction questionnaire. These missing data were caused when one or more of the questions in the general satisfaction questionnaire were not filled out or were filled out as being ‘not applicable’. In contrast, only five of the SF-12 questionnaires were incomplete. Careful attention was paid to ensuring that the assumptions of the multiple regression (homogeneity of residuals, normality of residuals, non-independence of residuals) were met (Cox & Cohen, 1985; Zar, 1996). The results of these tests are included in Appendix XIII. The assumptions of the linear regression were all met in this case. The summary statistics for the independent variables are presented in Table 20. As shown, the only significant predictors of total SF-12 score were quality of life (qol) and general satisfaction (as measured by the general satisfaction questionnaire). The quality of life score was positively related to health score – an increase in quality of life of one unit (out of 10,) leads to an increase in the SF-12 total of one point. The general satisfaction score was also positively correlated with health, with each additional general satisfaction point leading to an increase in the total SF-12 score of 0.16. Given that the general satisfaction score ranged from 27-108, in highly satisfied people, an increase in satisfaction of 1 is about equivalent to 1%; and an increase in SF-12 of 0.16 is about equivalent to 0.5% of the average SF-12 score of 31. Thus the relationship between general satisfaction and health, when adjusted for other variables, is relatively strong. Of all variables, the treatment (ie control/NPC) site was one of the least closest to significance (P=0.737) indicating that there was no relationship between a resident’s health and whether they were receiving treatment at a control site or nurse practitioner candidate site. Similarly, resident age, gender, number of times the service was used, and length of stay were not significantly related to total SF-12 score. The coefficients for the RACF identifiers are interpreted relative to a single RACF (RACF 4 in this case). For example, the coefficients indicate that RACF 5 scored higher (approximately 3.1 points higher) than RACF4 when the total SF-12 scores are adjusted for all of the independent variables. However, none of the RACF identifiers were significant predictors of the total SF-12 score when adjusted for independent variables. This suggests that the significant difference in total SF-12 score between RACFS found in the ANOVA above (F=3.30, P=0.007) is most likely due to confounding in one or more of the independent variables (most likely general satisfaction) between the sites, rather than reflecting a true difference in SF-12 between RACFs. However, it must also be considered that the ANOVA was conducted on the full SF-12 data-set (n=182), whereas the multiple regression sample size is much lower (n=116). This issue of differences in the general satisfaction of residents between RACFs will be examined in more detail in the next section (9.2.4, p. 54).


Table 20 Summary of coefficients of multiple regression using the total SF-12 score as dependent variable. The coefficients, standard errors, t values, probabilities and 95% confidence intervals of the coefficients are presented. Significant predictors are formatted in bold Coef. Std. Err. t P>|t| [95% Conf.Interval]

age 0.01 0.05 0.28 0.779 -0.09 0.12

gen 0.20 1.04 0.2 0.845 -1.86 2.26

ns -0.34 1.00 -0.34 0.737 -2.32 1.65

nsu -0.09 0.09 -1.03 0.304 -0.27 0.09

qol 1.37 0.25 5.41 0.000 0.87 1.87

los 0.00 0.00 0.46 0.649 0.00 0.01

Gen sat 0.16 0.04 3.53 0.001 0.07 0.25

RACF5 3.10 1.92 1.61 0.11 -0.72 6.92

RACF6 -0.26 1.35 -0.19 0.847 -2.93 2.41

RACF7 2.19 1.89 1.16 0.248 -1.55 5.94

RACF10 -0.57 1.5124 - 0.38 0.706 -3.57 2.43

RACF11 -1.47 2.08 -0.71 0.482 -5.60 2.66

_cons 5.93 5.26 1.13 0.263 -4.51 16.36

As there were a large number of cases excluded from this analysis due to missing values, particularly in the general satisfaction dataset, the multiple regression was repeated without the general satisfaction scores. Although the sample size included in the regression was greater (n=141), the variance explained by the predictors was considerably lower than the previous regression (r2 = 0.37). For this reason the original analysis will be retained.

9.2.4 General satisfaction survey The general satisfaction questionnaire consisted of 27 questions, as listed below (Table 21). For all bar one question, participants were asked to rank their agreement with these questions using a 4-point Likert scale. In question 21, a visual analog scale was used, but converted to a four point scale in analysis.


Table 21 Summary of the 27 items in the general satisfaction survey # Qn

1 In an overall, general sense, how satisfied are you with the service (GP or NPC) you havereceived?

2 How would you rate the quality of service you have received?

3 How did you feel about your reception when you first met the staff?

4 How do you feel about the way staff spoke to you on the phone or in person?

5 Do you get the kind of service from the GP or NPC you wanted?”

6 How do you feel about the effect of the service in helping to relieve your symptoms?

7 How do you feel about the effect of the service in helping you with your other problems?

8 If a friend were in need of similar help would you recommend the service to him or her?

9 How satisfied are you that the person who helped was competent and knowledgeable?

10 Are you satisfied that the person who helped you listened to an understood your problem?

11 How satisfied are you with the amount of help you received from the service?

12 Have the services you received helped you to deal more effectively with your problems?

13 If you were to seek help again would you come back to the service?”

14 How satisfied are you with the range of activities available to you through this service?

15 How do you feel about the waiting time between when you ask to be seen and when you are seen?

16 How do you feel about the waiting when you are seen or when you keep an appointment with a member of staff?

17 How satisfied are you with the way staff in the service seemed to work together as a team?

18 How satisfied are you with ease of access to the service?”

19 To what extent has the service’s help met your needs?

20 How do you feel about the arrangements made for emergency and urgent help during andafter office hours?

21 Please put a cross (x) on the line to represent how you feel about the service you have received?”

22 The service provided an accurate and rapid diagnosis of my condition?

23 I have not experienced any problems arising from the treatment I have received

24 I feel the treatment prescribed was correct and appropriate?

25 I feel that my symptoms were recognised and that treatment was begun as soon as possible?

26 I feel that adequate explanations were given for treatments I received

27 I feel that appropriate methods were used to reach a finding?

Examination of the responses to the general satisfaction questionnaire indicated that in general, residents were more satisfied than less satisfied


(Table 22, Table 23). For example, at both control and NPC sites the mode response of all questions was either ‘mostly satisfied’ or ‘very satisfied’. Some of the questions that residents expressed less satisfaction at include questions relating to waiting time (question 15,16) and emergency arrangements (question 20). Some of the questions that indicated high levels of support were questions 9 and 10 which related to the competence, knowledge and understanding of the practitioner candidate (Table 22), and questions 22-27 which relate to the diagnosis, treatment and symptom management of particular problems (Table 23). Table 22 General satisfaction questionnaire (questions 1-21) responses of 80 residents from a control (GP) RACFs and 104 residents from the NPC sites. Mode is in bold

Control sites Nurse practitioner candidate sites Qn Very

dissatisfied Mildly

dissatisfied Mostly

satisfied Very

satisfied u/k Very

dissatisfied Mildly

dissatisfied Mostly

satisfied Very

satisfied u/k

1 7 10 28 35 0 7 2 26 71 1

2 5 9 34 32 0 1 8 35 62 1

3 1 4 53 21 1 1 0 54 51 1

4 1 12 23 42 2 4 3 25 74 1

5 2 10 36 32 0 1 1 46 58 1

6 3 4 44 24 5 2 3 52 48 2

7 5 5 40 22 8 0 3 61 41 2

8 4 10 23 38 5 0 2 29 75 1

9 0 5 20 49 6 0 2 20 84 1

10 3 5 26 41 5 0 0 24 82 1

11 4 7 31 34 4 0 3 29 73 2

12 4 4 37 29 6 0 5 47 53 2

13 6 7 16 47 4 0 2 35 69 1

14 1 5 40 31 3 0 2 64 38 3

15 2 13 51 10 4 0 4 64 36 3

16 3 13 44 13 7 0 6 60 38 3

17 0 9 30 37 4 2 4 48 51 2

18 2 7 39 28 4 7 7 42 49 2

19 2 9 37 28 4 1 5 53 47 1

20 3 14 44 16 3 3 9 73 19 3

21 2 13 15 50 0 0 5 16 83 3


Table 23 General satisfaction questionnaire (questions 22-27) responses of 80 residents from a control (GP) RACFs and 104 residents from the NPC sites. Mode is in bold. Answers were framed “In terms of the treatment provided to you by the (GP/NPC) service”

Control sites Nurse practitioner candidate sites Qn Disagree

completely Disagree

somewhat Agree

somewhatAgree

completely u/k Disagree

completely Disagree

somewhat Agree

somewhatAgree

completely u/k

22 1 3 15 44 17 0 1 28 68 10

23 4 1 11 47 17 0 0 12 86 9

24 2 3 14 47 14 0 0 17 78 12

25 4 2 11 46 17 0 0 21 77 9

26 2 2 19 41 16 0 0 18 80 9

27 2 3 9 49 17 0 0 20 68 19

Comparison of the mode responses between control sites and nurse practitioner candidate sites are difficult. By and large, the pattern of modes between the control and nurse practitioner candidate sites was fairly consistent across the 27 questions of the general satisfaction questionnaire, particularly for questions 22-27. More detailed comparison will involve examination of the total general satisfaction scores. As mentioned previously, the general satisfaction questionnaires were given a total score out of 108, with higher scores indicative of higher satisfaction. This data is summarised in Table 24 on a site-by-site basis and overall. The mean total general satisfaction score at control sites was 90.3 ± 1.9 and 95.3 ± 0.9 at NPC sites. The mean score was greater at the NPC site for all RACFs except RACF 10. The total general satisfaction data were shown to have a non-normal distribution (Shapiro-Wilk test; W=0.86, V=15.7, P=0.000) caused by both kurtosis and a negative skew. As this violation of normality was severe, standard transformations (eg cubic, square, square root, reciprocal) were unsuitable. Box-Cox regression (Box & Cox, 1964) indicated that raising the scores to the fourth power was the most suitable transformation. This transformation helped to improve the normality of the data distribution (Shapiro-Wilk test; W=0.98, V=1.9, P=0.07). A two factor ANOVA was conducted on the transformed data, exploring the general satisfaction data for differences between RACFs and between treatment groups (NPC/control sites). The overall ANOVA was significant (F=3.91, P=0.0001). There was a significant difference between RACFs (F=3.57, P=0.005) and between the NPC and control sites (F=5.95, P=0.016). Additionally, the interaction term between RACF and site (NPC/control) was significant (F=3.43, P=0.011) indicating that the effect of the different models of care (NPC/control) varied at the different RACFs. This effect is most pronounced at RACF 10, which showed the opposite effect to other sites and had lower satisfaction levels at the NPC site than the control site.


Table 24 Summary statistics for total general satisfaction score for control and nurse practitioner candidate sites. Data (mean, sample size (n), standard error (SE) and range (minimum, maximum) are presented for each of the NPC sites and overall for all sites site Data Control sites NPC site 4 Mean 83.4 88.1 N 10 18 SE 6.1 2.2 Min-Max 39.2-99.6 70-105.6 5 Mean 96.8 N 17 SE 2.3 Min-Max 75.4 6 Mean 86.6 98.8 N 18 17 SE 4.0 1.6 Min-Max 41.2-108 88.6-106.6 7 Mean 87.9 98.2 N 6 10 SE 5.5 1.6 Min-Max 69-103 92-106 10 Mean 97.4 92.6 N 15 15 SE 1.8 1.6 Min-Max 84.2-107.6 82.2-106 11 Mean 95.4 101.0 N 9 9 SE 2.8 1.7 Min-Max 82.6-106.2 92.4-108 Overall mean 90.3 95.3 N 58 86 SE 1.9 0.9 Min-Max 39.2-108 70-108

As per the previous analysis of the SF-12 data, independent variables potentially affecting the general satisfaction of residents were included in multiple regression. The independent variables included in the regression were: age (years), gender (female=0, male=1), treatment (control=0, NPC=1), number of times serviced used in the last 6 months ‘nsu’, quality of life ‘qol’, length of stay ‘los’, total SF-12 score and site identification. There were five variables included which identified the site (labelled RACF5, RACF6, RACF7, RACF10, RACF11). These variables were scored as ‘1’ if the site was the site named by the label, and ‘0’ if not. The indicator variable was RACF4, which scored ‘0’ for all of the RACF labels. The overall regression was highly significant (n=116, r2=0.38, F12,103=5.21, P=0.000). Note that the sample size included in the regression was lower than the total number of completed questionnaires (144) because missing values (in either the dependent or independent variables) meant that the entire record was excluded from the analysis, as Stata software (v9, Statacorp LP) uses list-wise exclusion of missing data. These missing data were caused


when one or more of the questions in the general satisfaction questionnaire were not filled out or were filled out as being ‘not applicable’. Careful attention was paid to ensuring that the assumptions of the multiple regression (homogeneity of residuals, normality of residuals, non-independence of residuals) were met (Cox & Cohen, 1985; Zar, 1996). The results of these tests are included in Appendix XIII. The assumptions of the linear regression were all met in this case. The two significant independent variables were the sum of SF-12 (P=0.000) and RACF6 (P=0.020) (Table 25). Additionally, length of stay was very close to significance (P=0.052) and thus will be included in the discussion of important predictors of resident satisfaction. Table 25 Summary of coefficients of multiple regression using the total general satisfaction score, raised to the fourth power, as dependent variable. The coefficients, standard errors, t values, probabilities and 95% confidence intervals of the coefficients are presented. Significant predictors are formatted in bold Coef. Std. Err. t P>|t| [95% Conf. Interval]

age 69141 276705 0.25 0.803 -479638 617921

gen 3520175 5569538 0.63 0.529 -7525691 1.46e+07

treatment 7197507 5280469 1.36 0.176 -3275058 1.77e+07

nsu 238356 484482 0.49 0.624 -722500 1199213

qol 2689025 1512701 1.78 0.078 -311059 5689110

los 32640 16591 1.97 0.052 -265 65546

Sum SF-12 1854894 501906 3.70 0.000 859481 2850306

RACF5 5535039 1.05e+07 0.53 0.599 -1.53e+07 2.64e+07

RACF6 1.68e+07 7123393 2.36 0.020 2695072 3.10e+07

RACF7 2937022 1.03e+07 0.29 0.775 -1.74e+07 2.33e+07

RACF10 1.39e+07 8005242 1.73 0.086 -2007219 2.97e+07

RACF11 1.87e+07 1.11e+07 1.68 0.095 -3309172 4.07e+07

_cons -3.07e+07 2.58e+07 -1.19 0.236 -8.18e+07 2.04e+07

Interpretation of the coefficients of the independent variables is complicated because the total general satisfaction score has been raised to the fourth power, thus coefficients, standard errors and confidence intervals are extremely large. The focus of this discussion of the results will therefore be the direction of any relationships, rather than the size. The positive coefficients of all three variables indicates that they are positively correlated with general satisfaction. For example, residents with better health (as measured by the SF-12) have higher satisfaction levels. Interestingly, as


length of stay increases, satisfaction also increases. A subtly alternative interpretation is that residents with short length of stays are less satisfied than those with long length of stays. This could indicate difficulties and dissatisfaction during the early stages of admission to a RACF, as new residents struggle to adapt to their new environment. It would seem likely that residents’ satisfaction levels increase as they become more familiar with the surroundings, routine, culture and other residents of the RACF. The finding of RACF6 being a significant predictor of general satisfaction supports the initial two factor ANOVA, which found a significant difference between RACFS and between treatment. Examination of the other RACF identifiers included in the multiple regression indicates that other sites (particularly RACF 10 and RACF 11) also contributed to the variance of the overall regression model. In fact, RACF 11 has a higher coefficient and therefore stronger influence over the dependent variable; however, larger error terms for RACF 10 and 11 mean that these variables are not significant. The effects of RACF 4 on the model are included as part of the constant term which is not significant. The results of the multiple regression strongly suggest that there is a real statistical variation between RACFs in general satisfaction, once other independent variables (principally health, total SF-12 score) have been adjusted for. It is important to remember that the RACF identifier includes both NPC and control sites within the same identifier. Interpretation of a difference in general satisfaction is therefore not related to the resident’s treatment group. One possible interpretation, which cannot be ruled out, is that the data indicate geographical differences in satisfaction. Another possibility which must be considered is that the differences in satisfaction levels reflect the fact that the questionnaires were mostly administered by different investigators at each of the sites. Despite efforts made to counteract this possibility (the general satisfaction questionnaire being a valid and reliable tool for measurement of satisfaction levels and the questionnaire administrators being centrally supported through the process) it is possible that the questionnaire was differently administered at different RACFs. If this were the case, then a key assumption of multiple regression – the independence of error terms – would be violated. The independence of error terms assumes that the errors associated with a variable are not related to the errors of another variable. If for any reason, a RACF was generating higher satisfaction scores or lower length of stays (for example) then the errors for these terms would be related to the RACF identifier and the violation would be violated. It is difficult to test this assumption; the standard technique is to plot residuals against the independent variable thought to be influencing the independence of the error terms, in this case RACF identifier. This plot is shown in Appendix XIII. Examination of the plot does not immediately trigger cause for alarm. There does appear a slight clumping of a few points above the 0 mark for RACF 6 and RACF 10; however, the pattern is not pronounced. Thus the assumption is cautiously accepted as being met. However, alternative explanations of causes of RACF being a significant predictor of satisfaction are not readily apparent.


9.3 Qualitative analysis Focus groups were conducted at the nurse practitioner candidate site to discuss the experiences of those involved with the NPC project. Two distinct groups were involved in focus group discussions: residents exposed to the NPC and/or their families, and stakeholders/collaborators of the NPC. The main issues discussed during the focus groups included: perceptions of the quality of the service provided by the NPC, feasibility of the service, access to the service, appropriateness of the service and scope for improving and broadening the current practice of the NPC. Residents and their families were additionally asked about their experiences as consumers of health care, symptom relief, complications, satisfaction, educational value and unexpected outcomes. Stakeholders were asked about their experiences of collaborative practice including the identification of professional roles and boundaries, participation in case conferencing, referrals and initiation of care plans. There are a number of acknowledged weaknesses and strengths with using focus groups to understand group experiences. Some of the strengths include:

• Spontaneity in the volunteering of experiences, opinions and reactions,

• Subjectivity in the expression of personal opinion and reactions in their own vocabulary shows what is most important to them as individuals,

• Stimulation through the experience of participating in a focus group can lead to greater engagement with the group,

• Focus groups can be conducted in a short time frame,

• Selective sampling – participation is voluntary; seeking equal numbers or site wide representation is not required. Simply accept interested persons up to a comfortable number for a group discussion that still enables individuals time to give input.

Limitations to the use of focus groups include:

• A lack of generalisability; however, that is not considered a limit in this project, as we are not seeking to generalise,

• Moderating can be difficult, balancing control and direction with freedom for individuals to speak freely takes some learning, and constant awareness of what level of contribution all individuals in the group are making

• Protecting the individuals view point from the tendency toward conformity of opinion is also difficult

9.3.1 Methods The focus groups were conducted on site, by project staff attached to the specific site. The intent of this approach was to ensure that the residents were not taken outside of their comfort zone, or familiar surrounds. This was in recognition of the potential for residents to feel less secure in an unknown


environment, and for this to have an impact on their level of interaction and openness during the focus groups. Due to the expected variation in site resources for the conduct of the focus groups, each site was given the same background information and instructions on the conduct of the focus groups; these instructions were for the presenting the questions, supporting the participants and providing good moderation. 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 first level coding and higher level categorization and synthesis. Meta synthesis in JBI-NOTARI is a process of combining the conclusions of discourse to create summary statements that authentically describe meaning. It is an interpretive process that includes the identification and extraction of the conclusions from text; the categorisation these conclusions; and aggregation in to a synthesis. The following results were developed using this process. Five sites provided recordings of their focus group interviews for residents/family (RACF 10, RACF 5, RACF 4, RACF 6, with three recordings from RACF 11), while six sites also provided recordings of their focus group interviews for stakeholders (RACF 7, RACF 6, RACF 10, RACF 11, RACF 5, and RACF 4). The tape recording provided by RACF 5 ended part way through the focus group, producing only two pages of transcription. This site was contacted and informed of the malfunction in their recording; unfortunately, further focus groups were unable to be conducted within the time frame required for inclusion in this report. Due to malfunction of equipment, one focus group on residents/family from Perth was sent as a hand written transcription, and thus was not a verbatim representation of the interview. All remaining focus group interviews were transcribed verbatim, and the data within analysed using thematic analysis. Presented below are the conclusions extracted from each focus group interview site, for both residents and relatives, and stakeholders, with an illustration from the interview to support that conclusion.

9.3.2 Findings The results presented here represent the higher level analysis of all conclusions from all NPC sites into aggregated groups (‘categories’) and further aggregation of categories into ‘syntheses’. The conclusions from all NPC sites have been presented previously for each individual site and will not be repeated here to save space.

9.3.2.1 Resident focus groups The conclusions of all resident/relatives focus group interviews were combined together to form a total of five categories. These are outlined below:

1. Availability


• The medical practitioners are seen as being hard to get a hold of, where the nurse practitioner candidates are seen mostly to be readily available, and to be able to deal with issues sooner. There is a greater demand from the residents for NPCs to be more available

2. Avoiding unnecessary resource use:

• Through intervention by the nurse practitioner candidate, use of resources such as admission to hospital and use of GPs are often avoided

3. Confidence and Security

• Clients often express satisfaction with the care provided by the NPC, and feel more secure with them there

4. Knowledge and skill

• Nurse practitioner candidates have a level education and practical skill base that is evident to those around them

5. Perceptions of the role

• There have been mixed perceptions around the role of the nurse practitioner candidate, mostly at the start of the project

The five categories were further analysed to produce two syntheses:

1. Improved resident care (Table 26) • With increased knowledge and skill, and greater availability,

health care of residents is improved, and unnecessary resource use avoided

2. Initial Perceptions (Table 27) • The perceptions about the nurse practitioner candidate were

initially hesitant, however residents have grow to accept the role as they become familiar with it.

Table 26 Tabular display of Synthesis 1 from focus group interviews of residents and/or relatives Synthesised finding Category Conclusion

Absence (C) Improved resident care With increased

Availability

Availability (C)


Fortunate (C)

Greater demand (C)

Immediacy (C)

Immediacy of care (C)

Lack of staff (C)

Limited hours (C)

Limited medico time (C)

Presence (C)

Spread thinly (C)

Staffing inadequacies (C)

Unavailability of doctor (C)

Unavailability of GP (C)

Avoidance of health facility visit (C)

Potential to avoid hospital (C) Avoiding unnecessary resource use Resource use (C)

Caring (C)

Comfort (C)

Commitment (C)

Content (C)

Familiarity (C)

Feelings of Confidence (C)

Needed (C)

Positive (C)

Reassurance (C)

Satisfaction (C)

Satisfaction with service (C)

Satisfied (C)

Security (C)

Confidence and security

Security (C)

Approachable (C)

Communication (C)

Educating residents (C)

Education of residents (C)

Explaining (C)

knowledge and skill, and greater availability, health care of residents is improved, and unnecessary resource use avoided.

Knowledge and skills

Explanations (C)


Knowledge (C)

Listener (C)

Professionalism (C)

Qualified (C)

Resident education (C)

Skills (C)

Thorough (C)

Thoroughness (C)

Table 27 Tabular display of Synthesis 2 from focus group interviews of residents and/or relatives Synthesised finding Category Conclusion

Clarity of role (C)

Confusion around role (C)

Initial hesitancy (C)

Initial perception (C)

Initial perceptions The perceptions of the nurse practitioner candidate were initially hesitant, however residents have grow to accept the role as they become familiar with it

Perceptions of the Role

Limited understanding (C)

9.3.3 Stakeholder focus groups The conclusions of all stakeholders’ focus group interviews were combined together to form a total of seven categories. These are outlined below:

6. Knowledge & skills

• The nurse practitioner candidate has an increased level of knowledge and skills that enhances care provided to clients, and passed on to co-workers

7. Immediacy of care

• Having the nurse practitioner candidate present and available allows for prompt and immediate care to be provided to the clients, in the absence of the GP

8. Satisfaction and reassurance

• Clients express a feeling of safety and satisfaction in the care of the Nurse Practitioner candidate

9. Avoiding unnecessary resource use


• The nurse practitioner candidate is often able to avoid unnecessary hospitalisations and calling in of GPs

10. Collaboration between health care professionals

• The nurse practitioner candidate forms a partnership with the GP and other health care professional

11. Evolution of the role

• The role of the nurse practitioner candidate has been evolving 12. Limitations of the process

• There are number of boundaries for nurse practitioner candidate to overcome in their role

The seven categories were further analysed to produce two synthesised conclusions:

3. Accepting and collaborating with the nurse practitioner candidate • All multidisciplinary staff need to understand the role of the

nurse practitioner candidate in order to collaborate with them in providing effective care for residents

4. Improved health care provision

• With an increased level of training and knowledge, the presence of the nurse practitioner candidate can often lead to the avoidance of unnecessary resource use, and a greater level of satisfaction and confidence from staff, relatives and residents

Table 28 Tabular display of Synthesis 3 from focus group interviews of stakeholders

Synthesised finding Category Conclusion

Building relationships (C)

Collegiality (C) Collaboration

Partnership (C)

Acceptance from medical (C)

Accepting and collaborating with the nurse practitioner candidate All multidisciplinary staff need to understand the role of the nurse practitioner

Role of the Nurse Practitioner

Awareness (C)


Awareness of role (C)

Developing role (C)

Evolution of nursing (C)

Evolution of role (C)

GP resistance (C)

Individual (C)

Initial scepticism (C)

Knowledge base (C)

Limitations in role (C)

Misunderstanding of role (C)

Not replacing (C)

Nursing framework (C)

Retention (C)

Uncertainty of role (C)

candidate in order to collaborate with them in providing effective care for residents

candidate

Understanding of role (C)


Table 29 Tabular display of Synthesis 4 from focus group interviews of stakeholders Synthesised finding Category Conclusion

Availability (C)

Availability of time (C)

Doctors unavailable (C)

Early treatment (C)

Enhancing care (C)

GP lack of time (C)

GPs not available (C)

Hasten management (C)

Holistic care (C)

Immediacy (C)

Improved care (C)

Availability of Care Provision

Starting treatment earlier (C)

Advanced skills (C)

Backup resource (C)

Commitment (C)

Communication (C)

Continuity (C)

Education (C)

Education provision (C)

Perspective (C)

Resource for staff (C)

Skill base (C)

Knowledge and Skills

Teaching of staff (C)

Advocate (C)

Confidence (C)

Family approval (C)

Feeling of Security (C)

Recognition (C)

Reward (C)

Satisfaction and Support

Support (C)

Access to nurse practitioner candidate (C)

Improved health care provision With an increased level of training and knowledge, the presence of the nurse practitioner candidate can often lead to the avoidance of unnecessary resource use, and a greater level of satisfaction and confidence from staff, relatives and residents. With greater acc

Thin on the Ground

Greater demand (C)


Spread too thinly (C)

Thin on the ground (C)

Avoidance of hospital (C)

Avoiding admission to hospital (C) Unnecessary resource use

Hospital avoidance (C)

9.3.4 Discussion The findings from the resident/relative focus group and the stakeholder focus group will be discussed separately.

9.3.4.1 Residents/Relatives From the analysis of the focus groups conducted with the residents and relatives of the aged care facilities, it is evident that the participants saw the nurse practitioner candidate as a positive addition to the aged care environment. The results of the thematic analysis and synthesis of conclusions and categories produced the synthesised findings of “Improved Resident Care” and “Initial Perceptions”. The components of these syntheses are discussed further below.

9.3.4.1.1 Improved Resident Care The residents and relatives demonstrated their awareness of the nurse practitioner candidate’s increased levels of knowledge and skills, shown through traits such as enhanced communication and explanations to residents and relatives, being more approachable, education of residents, and conducting more thorough assessments. This was emphasised by the observation that “I was impressed by her thoroughness...She did the total sort of picture, overall health picture”. This demonstrates that these residents understood the ‘expert practitioner’ scope of practice associated with the nurse practitioner candidate was based on a particular level of knowledge. The observation of advanced knowledge and skills benefiting care provision was common across all sites involved. The perception from residents was that the availability of the nurse practitioner candidates enabled them to provide more immediate care, particularly with the relative unavailability and access to the services of general practitioners. "You just sit and wait for the doctor to come and if there is nobody else there and sometimes the doctor perhaps couldn't come straight away...and I think it is great to have someone there. If you want someone in a hurry, well she is here". It was thought that this timely care provided by the nurse practitioner candidate could also often avoid the unnecessary use of other resources, namely the admission to hospital for treatment of a condition that could be handled at the point of care; "for a similar reason I had to go to hospital again,


they still didn't find it and it was the same thing. I went to the clinic and my goodness me, I would say in minutes [ ] picked my problem". With the combination of knowledge, skills and presence, residents and relatives expressed a sense a great deal of satisfaction with the service, with feelings of reassurance and security; “It is nice to have that preliminary treatment...I think it does give you a sense of security" As beneficial as the nurse practitioner candidate was seen to be to residents and their relatives, it was widely recognised that they were still only present for limited times, and that greater numbers were required to reap the real benefits of the service; “24-hour service, 7 days…Perhaps that is asking too much".

9.3.4.1.2 Initial perceptions The second synthesis was taken from the one category. Residents and their relatives showed limited understanding of the nurse practitioner candidate role, which lead to some initial hesitancies of being treated by them. These perceptions changed as the residents and relatives became more aware and familiar with the role; "Well I was wondering what it was all about, nurse practitioner, is that a nurse is it? I was told there were no nurses here anymore, they have all got different names now".

9.3.4.2 Stakeholders The categories and synthesis that were developed from the Stakeholder focus groups held many similarities to those of the Resident/ Relative focus groups. The stakeholders involved in the interviews saw the presence of the nurse practitioner candidate as benefiting the care provided to residents, and also had some misunderstandings of the role. The results of the thematic analysis and synthesis of conclusions and categories produced the synthesised findings of “Improved Health Care Provision” and “Accepting and collaborating with the nurse practitioner candidate”. The components of these syntheses are discussed further below.

9.3.4.2.1 Improved health care provision It was evident that stakeholders were aware of the increased level of knowledge and superior skill set the nurse practitioner candidate possessed. This was displayed through their ability to carry out advanced assessments, acting as a resource and providing education to other staff, and the ability to communicate effectively with other allied heath staff, particularly at the general practitioner level. One stakeholder aptly described this by; "I think we can talk to her, she sort of relays it in probably medical terms to the doctor, it might make him a little more understanding". The nurse practitioner candidates’ ability to practice at an expert level allowed them to initiate treatment earlier rather than wait for direction from medical staff, which were often seen as a very limited resource. The combination of the GP unavailability and the greater access to the nurse practitioner


candidate, lead the stakeholders to see nurse practitioner candidates as providing an enhanced level of holistic care. This also feeds into the perception of stakeholders that through more timely health care provision, that there can be an avoidance of unnecessary resource use, namely admission to hospital. This sentiment was best illustrated by one stakeholder in particular; "You know she has helped a huge lot with assessing transfers to hospital, whether they are really needed or not, like, you know, before everybody especially at the hostel just went to the hospital regardless and 13 hours later seen". The stakeholders expressed feelings of security and confidence with the presence of the nurse practitioner candidate, most often exemplified by the thoughts that staff had a back-up resource person, someone they could gain direction, knowledge and experience from if they were not sure of the direction that should be taken; "If an RN wasn’t available for me, she could come down as well, and give me backup on illnesses that I wasn’t 100% sure on". These positive perceptions of the nurse practitioner candidate were thought to only be of real benefit to residents and stakeholders if the program was to continue in a stronger way in the future. The view of the stakeholders was that the nurse practitioner candidate was spread “thin on the ground”, and there was a greater demand for more advanced practitioners such as these, with a wider access to those that are available; "I'm not sure of the sustainability of it with just one person when she has already taken on the other roles. I think her time is too much in demand".

9.3.4.2.2 Accepting and collaborating with the nurse practitioner candidate

The relatively new nature of the nurse practitioner candidate in aged care was reflected in observations about the need for clarity of the role, through gaining understanding and overcoming initial scepticisms. The use of the term “evolution” was linked to the notion that stakeholders saw the role of the nurse practitioner candidate beginning to grow, and expand to complement nursing, and other health care teams involved in the care of the resident. There was a readily identifiable tendency to come up against some barriers that hindered full implementation of the role, particularly the acceptance of the role by medical practitioners. This was illustrated by the observation that some GPs were resistant to the idea; "one of the frustrating things has been the narrow base of doctors that [____] has been able to perform a locum service for, if I can put it that way, and it is a shame that the doctors that haven't come on board are the doctors who really most need to". For those staff that understand and see the benefits of the role, also see the benefits of collaboration with the nurse practitioner candidate, through building relationships and forming partnerships that lead toward providing enhances care to residents. A general practitioner present at one of the stakeholder focus groups, had recognised the benefits of collaborating with the nurse practitioner candidate; "I have really enjoyed being able to bounce possibilities around with the nurse practitioner candidate. I get a whole lot of background information instead of just a message from [other staff]".


9.3.5 Conclusion From the focus group interviews conducted with both residents and their relatives, and stakeholders associated with residential aged care facilities where the Nurse Practitioner Candidate trial has been in place, it is apparent that the perceptions of both population groups are very similar in their conclusions. Both population groups identified conclusions that lead to the categories around the availability of someone to provide care, avoidance of unnecessary resource use, an increased level of knowledge and skill, and a feeling of satisfaction and security with the program. There was also initial hesitation of the nurse practitioner candidate role, mainly through a misunderstanding of what the role involved. Overall, the views of participants were that the nurse practitioner candidate was, and would be in the future as the role continues to grow, a positive addition to the health care team within the residential aged care facility.


10 Discussion, Conclusion and Recommendations

The current trial was commissioned by the Australian Government Department of Health and Ageing and reflects the Department’s interest in evaluating the potential benefits of introducing Aged Care Nurse Practitioners. Although there is increasing evidence of the effectiveness of the nurse practitioner in relation to access to care and the achievement of optimal health outcomes, there is, to date, little high level evidence generated through Australian studies. Each of the six study sites in the current trial were funded to participate and a component of this funding was to employ a project officer to collect data and produce a site report for submission to the Australian Government Department of Health and Ageing. This report complements the individual site reports and presents the findings of an external evaluation of six nurse practitioner-like services involving seven nurse practitioner candidates across four Australian jurisdictions. Like other Australian nurse practitioner “trials” reported on elsewhere, and because of the complexity of conducting rigorous, empirical research into the relationships between a newly developed role and outcomes, the Aged Care Nurse Practitioner national trial is plagued with limitations. The seven nurse practitioners candidates all had different preparation and none, at the commencement of the trial, were licensed as nurse practitioners and therefore the prescription of medications and ordering of diagnostic tests – although central to the new role being evaluated – were not able to be part of the role. Some nurse practitioners did become licensed during the course of the trial, but current health policy related to Medicare and the Pharmaceutical Benefit Scheme (PBS) meant that, although they could have legitimately prescribed, funding prevented this from occurring. Furthermore, differences between jurisdictional regulations and jurisdictional variability in prescribing and treatment patterns limited attempts to control the practices of the nurse practitioner candidates so that each of the six services evaluated were not the same. The short time frame for the trial and the resources available to conduct it meant that no randomisation of residents to the nurse practitioner-like service occurred and that, therefore, a comparison of results between those serviced by the new role and an appropriate control group was not possible (although data were collected from a “comparator group”). All other trials of nurse practitioner roles conducted in Australia demonstrate similar limitations. Furthermore, processes of licensure in some jurisdictions assign specific, detailed role descriptions to individual nurse practitioners indicating that, for the foreseeable future, the likelihood of generating robust, high quality evidence related to the effects of nurse practitioner services is not promising. 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. Because of the limitations of the trial, it is not possible to present high quality evidence of the effectiveness of the role; or 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. The findings suggest that if an appropriately prepared nurse, with prescribing and diagnostic investigation rights, is allocated a caseload of residents in aged care facilities this may be effective in complementing the role already played by general practitioners in:

• providing 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,

• providing timely initiation of treatment eg directly ordering diagnostic investigations, commencing medications (oral antibiotics),

• providing enhanced communication, coordination and monitoring of care for other health care providers, the client and/or their carers.

Aged Care Nurse Practitioner roles are well established in the United States (where the role is funded on a fee-for-service basis in conjunction with affiliated medical practitioners or Health Maintenance Organisations and practitioners have prescribing and diagnostic test ordering rights) and the United Kingdom (where the role is funded through the National Health Service and practitioners have fully funded NHS prescribing and diagnostic test ordering rights). There is robust evidence that suggests that the introduction of such roles in the USA and the UK 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 Nurse Practitioners have been found to be 20% less costly, with nurse practitioners’ performance comparable or superior to other health professionals. In the light of this international evidence; the findings of this trial in relation to the acceptability of the role to service users and other health professionals; and the identified need to improve services to older people living in residential care facilities, it is possible to:

• Delineate the role of the nurse practitioner in aged care;

• Identify the clinical leadership potential of Aged Care Nurse Practitioners in the Aged Care Sector;

• Report on impact of Aged Care Nurse Practitioners on resident outcomes;

• Report on the acceptability of the Aged Care Nurse Practitioner role;

• Suggest strategies for the development of appropriate national clinical practice protocols and guidelines;

• Suggest strategies for the development of a national Aged Care Nurse Practitioners Formulary;


• Identify costs associated with prescribing and ordering diagnostics;

• Consider barriers and enablers to the introduction of Aged Care Nurse Practitioners;

• Examine issues that impact on the sustainability of a nurse practitioner role within the context of education, legislation and the different aged care settings throughout the aged care sector;

• Describe options to identify a preferred, national service delivery model for Aged Care Nurse Practitioner services;

• Make recommendations on the role, scope and preparation of Aged Care Nurse Practitioners;

• Make recommendations on the potential of introducing an aged care nurse practitioner role in Australian aged care; and

• Make recommendations for further research, policy and practice.

10.1 Role of the nurse practitioner in aged care

The trial set out to evaluate the introduction of a service delivered by a registered nurse with additional preparation (though not, at the beginning of the trial, having completed an approved program of preparation to become a nurse practitioner) that included the safe and sustainable initiation and maintenance of practices (referred to as the “core interventions”) 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


• 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

• Others as identified by the project team. The expected outcomes of this service were reductions in impact and cost of acute medical conditions and improved general health condition and management of chronic conditions. Implementing this role consistently across all of the trial sites was not possible because of the variations in the knowledge and skills of the nurse practitioner candidates (some had almost completed a formal program of education; some were enrolled in formal study; and some were about to commence formal study); variations in the policy and regulatory frameworks across the four jurisdictions; and variations in local conditions such as employer (publicly funded health services, private-for-profit aged care providers, charitable aged care prividers) and the access to resources such as prescribables etc. In spite of these uncontrollable variations, as the trial progressed, most of the core role activities were apparent in the data entered into the study, albeit that some of these roles had to be implemented within various frameworks to comply with varying requirements. For example, in some cases, nurse practitioner candidates could initiate prescriptions and the ordering of diagnostic tests, but in others, they could only suggest them to a medical practitioner who would then formally sign the required documentation. Notwithstanding these difficulties, the most commonly recorded core intervention across the trial sites was ‘implementing treatments/medications for acute conditions’, and this accounted for 16.4% of interventions. The next most commonly recorded core interventions were ‘Co-ordination of a winter flu strategy’ (12.9%), ‘Referring to specialists’ (6.2%), ‘Pain management’ (6.0%), ‘Engaging in collaborative review of resident pharmacotherapy’ (5.7%), ‘Complex wound management’ (5.1%) and ‘Managing other infections including ordering tests and medications’ (5.0%). None of the nurse practitioners were involved in ‘Managing physical restraint authorisation’, and there were only three cases (across the entire study) where anxiolytics were ordered in emergency situations. The trial results suggest that the “core interventions” adequately describe the essential elements of a national Aged Care Nurse Practitioner role. Although nurse practitioner candidates frequently reported that the role included many more activities such as counselling, teaching and assisting residents; and it can be assumed that, as registered nurses, Aged Care Nurse Practitioners will engage in a far broader range of resident care activities but the “core interventions” differentiate the Nurse Practitioner role from the expert registered nurse role.


10.2 The clinical leadership potential of Aged Care Nurse Practitioners in the Aged Care Sector

Data related to non “core interventions” was largely captured and analysed at the trial site level and does not form part of this report. However, these site reports consistently refer to the role the nurse practitioner candidates play in educating, encouraging and supporting staff and in liaising with other stakeholders such as general practitioners, allied health professionals and pharmacists. Additionally, there is anecdotal evidence that a component of consultation with residents was client teaching and coaching. The site reports are characterised by frequent references to the clinical leadership role played by nurse practitioner candidates.

10.3 The impact of Aged Care Nurse Practitioners on resident outcomes

Because residents in the trial were not randomised to an intervention (Nurse Practitioner Candidate) and a control group; and the “intervention” was not consistent in that there was variation between nurse-practitioner-like services; the effects of the services on resident outcomes are largely not identifiable. However, resident outcomes in terms of health status, quality of life and satisfaction were captured from residents entered into the study and a comparison group of residents who did not have access to the nurse practitioner-like services. Analysis of these data suggest that, on most measures, there were no significant differences between the groups and therefore that these services were as effective on the outcomes measured as GP services. A statistically significant difference between groups was found in the total General Satisfaction Score with the mean total general satisfaction score at comparator sites at 90.3 ± 1.9 and 95.3 ± 0.9 at nurse practitioner-like service sites (P=0.016). Moreover, the general satisfaction score was also positively correlated with health scores, with each additional general satisfaction point leading to an increase in the total SF-12 score of 0.16; and the quality of life score was found to be positively related to health score – an increase in quality of life of one unit (out of 10,) leads to an increase in the SF-12 total of one point. Thus, it appears that receiving nurse-practitioner-like services may be associated with higher general satisfaction scores; higher satisfaction is associated with higher health scores; and higher quality of life scores are associated with higher health scores.

10.4 The acceptability of the Aged Care Nurse Practitioner role

The role was generally well accepted by managers, general practitioners, registered nurses, enrolled nurses, care workers and other key professionals and support for the role following involvement in the trial, with the level of complete support for the role increasing from 65% (ie 40/62) before involvement with a nurse practitioner candidate to 82% (51/62) after


collaboration. Of the 62 collaborators surveyed after working with the nurse practitioner candidates, only one opposed the role. The role was also well accepted by residents. In the satisfaction survey, satisfaction with the nurse practitioner-like service was highly rated and the qualitative data captured in resident focus groups, residents and their families referred to the increased knowledge and skills of the nurse practitioner candidate, greater availability of diagnostics and treatment, improvement in the health care of residents, and the avoidance of unnecessary resource. Resident and family perceptions of the nurse practitioner candidate were initially hesitant, however residents accepted the role as they became familiar with it.

10.5 Strategies for the development of appropriate national clinical practice protocols and guidelines

Practice guidelines and standing orders/practice protocols were developed in the first stages of the trial, based on a common process, by each site with the input of a locally constituted Protocol Development Group. Although some variation between trial sites was expected (and legitimate), the common process of guideline/protocol development utilised, and a reliance on international evidence, resulted in far greater commonalities than differences between the jurisdictionally developed documents. This supports a possibility of establishing national practice guidelines for Aged Care Nurse Practitioners and, thus, potential to minimise variability in practice and improve outcomes. The content analysis of the guidelines and protocols could form the basic framework for consideration by a national group of nurse practitioners, geriatricians, general practitioners, pharmacists, radiologists and pathologists to develop and endorse national guidelines.

10.6 Strategies for the development of a national Aged Care Nurse Practitioners Formulary

Some nurse practitioner candidates were unable to prescribe certain medications via standing orders from GPs. However, during the course of the evaluation, some 118 different medications were prescribed in this fashion. Fluvax was the most prescribed medication (236 prescription events), followed by microlax (47), trimethoprim (42), panadol/paracetamol (33), Keflex (31), morphine (31) and Movicol (28). The data on medications identified as appropriate by nurse practitioners provides a useful framework for a national group, made up of nurse practitioners, geriatricians, general practitioners and pharmacists to develop and endorse a national formulary for Aged Care Nurse Practitioners which could, in turn, be submitted to the PBS to seek approval of Aged Care Nurse Practitioners as legitimate prescribers as part of the PBS.


10.7 Costs associated with prescribing and ordering diagnostics

10.7.1 Prescribing

Consistent with the international evidence, the results of this current trial suggest that the prescribing patterns of nurse practitioner-like staff are less costly than those of general practitioners. A total of 927 prescription events were recorded in the MDS, at the rate of 29.5 prescriptions per 100 visits compared to an estimated 86 prescriptions for every 100 consultations with general practitioners in 2005-2006 (Britt et al., 2007). This does not represent, of course, a clear comparison given that general practitioners are often consulted by service users specifically for prescribed medication. In the current trial, nurse practitioner candidates were asked to submit data when they decided which medication they would prescribe, the dose, the dosage and the route to be administered. They were asked to record the date and time that the decision was made. Then, as per their standing orders requirements, they informed the GP about the condition and medication requirements of the resident. Of the 67 valid cases included in the analysis, there was no difference between the NP and the MO in terms of the drug prescribed, the route of delivery, its dose or dosage.

10.7.2 Ordering diagnostic tests

A total of 211 diagnostic tests were ordered during the trial, equivalent to a rate of 6.7 tests per 100 visits (6.7%). The majority of these tests were pathology screening tests (3.4%). The next most frequently occurring were pathology tests (2%) and imaging (1.3%). Seven ultrasounds and one ECG were also ordered. This compares with 2005/2006 figures reported for general practitioner consultations where at least one pathology test order was recorded at 16.4% of consultations and at least one imaging test was ordered at 7.8% of consultations (Britt et al., 2007). Again, this does not represent, of course, a clear comparison and should be interpreted with caution. However, the findings suggest that access to ordering diagnostic tests to nurse practitioner-like services is unlikely to increase costs.

10.8 Costs associated with the nurse practitioner

The major cost associated with nurse practitioner-like services is the direct costs of salary and other overheads in relation to length and number of consultations. The current trial commenced with nurse practitioner candidates with little previous experience in such a role, an environment where the role was also not previously known and, in most cases, where the candidate was concurrently studying as well as establishing a new and controversial service. Not surprisingly, the amount of time spent on a consultation at the start of the NP trial was longer than later points. Overall, a mean of 62 minutes per consultation was reported in 2006 compared to 38.8 minutes in 2007, giving


an overall ratio of 0.6 (P=0.0006). The cost per consultation averaged $42.20 – but the change in time spent over the course of the trial suggests that the cost per consultation for licensed Aged Care Nurse Practitioners would be lower than this. The salary cost per day (of conducting NP assessments and interventions) averaged $50.60. However, such a calculation considers only the time spent on consultations and ignores the actual cost per consultation. Given that nurse practitioner candidates recorded an average of 1.34 consultations per day and the average salary plus on costs per day was $328, the actual cost per nurse practitioner candidate consultation becomes $245. The provision of services by nurse practitioners or general practitioners involves, of course, more than direct consultation and time spent on indirect activities (such as liaison/consultation with others, documentation etc) may exceed that spent on direct care. Thus, the actual costs per consultation include both the costs of time spent on both direct and indirect care. Medicare rebates payable to vocational trained general practitioners are: under 20 Minutes $32.10; 20 to 40 Minutes $60.95; over 40 Minutes $89.75 and for non-vocationally trained: under 20 Minutes $21; 20 to 40 Minutes $38; over 40 Minutes $61. Notionally, the direct costs of an Aged Care Nurse Practitioner consultation are the actual cost per nurse practitioner candidate consultation which was $245. In addition to subsidies for consultation time, general practitioners are also eligible for a number of payments related to procedures, report etc. Of concern is that nurse practitioner candidates appeared to have spent only 15% of their time on core interventions. If “nurse practitioner reviews” of residents (a category added to the MDS in the last six months of the trial) are also considered, then 17% of their time appears to be related to direct service delivery. Of course, indirect activities, such as liaison with other professionals, telephone calls, meetings and documentation occupy a significant amount of daily work but the results show that this constituted over 80% of time available. It is also possible that the “reviews” part of the MDS was underutilised such that the reported number of reviews is lower than the actual number. Why direct client care is such a low proportion of the time available is difficult to explain. Possible explanations include the enrolment of all nurse practitioner candidates in masters degrees related to nurse practitioner licensure; the nature and dominant values of nursing work; the need for frequent liaison with medical practitioners in relation to prescribing or ordering investigations; the newness of the role; and the requirement for documentation associated with the aged care sector in Australia. All nurse practitioner candidates were, at some stage in the trial, studying to attain nurse practitioner licensure; however, four of the sites had practitioners that completed formal education during the trial with no identifiable increase in direct care activities. Most studies of nursing work report that a high proportion of available nursing hours are associated with indirect care and organisational activities. Numerous work-studies show that nurses spend less than half of their time delivering direct patient care (Linden & English, 1994; Urden & Roode, 1997). In a study of registered nurses in six acute care settings, Pearson et al (1999,


2003) found that only 33% of available nurse time was associated with direct care. Of the remaining 67% of time available, 14% was spent on indirect care (such as handwashing, social conversation, medication preparation and telephone conversations); 13% documentation; 13% personal time; 11% professional interaction; 8% organisation related (such as fire drills, orientation and activities required managerially); 1% on family interaction; and 8% other (p. 58). However, the proportion of available time spent on direct care was found to be as low as 21.5% in two of the units observed. The findings from these more recent studies support earlier studies which reported direct care representing 30-35% of nursing time (Smith & Molzahn-Scott, 1986). For nurse practitioners in acute care, research is limited. One study published in 1997 showed that acute care nurse practitioners spent 39% of their time in direct care (mainly in clinic visits and follow-up) and 31% of their time in indirect care (mainly in-patient rounds with physicians) (Knaus et al., 1997). A more recent study has shown that acute care nurse practitioners spend just over 50% of their time in direct patient care (eg examining, assessing or developing a care plan) and 32% of their time in indirect care activities, such as consultation with other healthcare professionals or discharge planning (Rosenfeld et al., 2003). There are few work studies in long term settings for either registered nurses or nurse practitioners. Poppleton and Cox (1988) estimated that registered nurses provided only 12 minutes of direct care per resident per day in long term facilities, substantially less than the estimated 2.5 hours per day per patient in acute care. The majority of direct care to residents in long term care is provided by personal carers (nursing assistants), not registered nurses (Janz, 1992; Richardson & Martin, 2004). In Australia, personal carers make up nearly 60% of the direct care workforce, a proportion that is increasing as new staff are hired (Richardson & Martin, 2004). Bowers, Lauring and Jacobsen (2000), in a descriptive study of staff work practices in long term care that involved staff interviews and participant observation, describe practices similar to those reported in the acute setting and a similar impact of work environment and external regulatory forces on “non-value added work” as described by Capuano et al (2004). However, one of the distinguishing characteristics of nursing in long term settings is the focus on detailed and in-depth documentation of resident care, as accreditation and funding is tied to documentation. The burden of documentation within the sector is well recognised and has been consistently reported (Government of Western Australia, 1998; Government of Western Australia, 1999; New South Wales Health Department, 2000; New South Wales Nurses Association, 2000; NSW Minister of Health, 2000; Office of the Chief Nurse, 1998; Queensland Health, 1999, Pearson et al 2002). Whether or not this is also true for nurse practitioners in aged care is unclear. Although their focus is extended practice, they are still operating in a high documentation setting; therefore it seems likely that the proportion of time spent by aged care nurse practitioners on documentation will be higher than an acute care practitioner but lower than a typical aged care nurse.


For the reasons outlined above, it seems likely that the proportion of time spent in direct care by nurses in residential care would be less than in the acute care setting. Given that estimates of time spent in direct care range in the acute setting range from approximately 30-50% of total time, 20-40% of time spent in direct care may be a reasonable estimate for nurses working in residential aged care. The defining feature of the nurse practitioner role is the ability to legitimately prescribe interventions and order diagnostic investigations. Nurse practitioner candidates were not able to do this independently on any of the trial sites because of restrictions associated with federal and state regulations related to funding (through the Medicare and Pharmaceutical Benefit Schemes), and the regulation of the scope of practice of the nurse. Nurse practitioner candidates were therefore frequently required to seek the endorsement of medical practitioners for any interventions or requests for diagnostic tests. Although nurse practitioner candidates were employed in a new role, they were still practicing within a context where factors that encourage high indirect care activities predominate. Given the added burden on nurse practitioner candidate time associated with the need for frequent liaison with medical practitioners necessitated by the inability of many candidates to prescribe or order diagnostics; the newness of the role; and the requirements for documentation imposed on them, the apparently low proportion of time spent on direct care (17%) is perhaps not surprising. As reported by the sites themselves in their submissions to the Commonwealth Department of Health and Ageing, a number of indirect care activities were conducted by nurse practitioner candidates during the trial. These activities included: clinical leadership and mentoring, developing clinical guidelines and assessment tools, attendance at workshops and training, meetings, quality indicator projects, nurse led clinics, continuing nurse practitioner studies, attendance at conferences and other professional development and training, planning health promotion activities and research. The effectiveness of time spent in these activities, particularly time spent in clinical leadership, mentoring, studying, professional development and training is supported by the results of the collaborator questionnaires. For example, all 60 collaborators agreed with the notion that the nurse practitioner candidates were adequately qualified. Similarly, a large number of comments were made by collaborators about the important role of the nurse practitioner candidates in mentoring and teaching other nursing and allied health staff (see section 9.1).


10.9 Barriers, enablers and other issues that impact on the introduction and sustainability of a nurse practitioner role within the context of education, legislation and the different aged care settings throughout the aged care sector

10.9.1 Jurisdictional differences in policy and regulation

Residential Aged Care – unlike hospital and community care – is administered under an Act of the Commonwealth Parliament and is funded and regulated federally. As such, there is an expectation that service delivery will be largely consistent across States and Territories; thus, the introduction of an Aged Care Nurse Practitioner role is more likely to be effective if it is developed, funded and promoted nationally. However, the regulation of health professionals and poison’s acts are regulated by the States and Territories (although national regulation and registration of health professionals is now planned) and employment and industrial relations, including the career structure and salary setting, are matters for States and Territories. This division of regulation and decision making creates major, ongoing difficulties in negotiating a national Aged Care Nurse Practitioner role in the States and Territories. For example, in the present study, registration authorities, those administering State/Health policies and those administering Poison’s Acts all required specific protocols related to the role of the Aged Care Nurse Practitioner; presented requirements in relation to “standing orders” and other processes that were in conflict with other jurisdictions; and required State or Territory specific practice guidelines. Registration bodies in some jurisdictions licence individual practitioners to engage in detailed practices specific to that nurse in a particular role (including a specific list of medications they may prescribe and diagnostic test they may order). Establishing a national Aged Care Practitioner role across a nationally funded and regulated industry such as Residential Aged Care requires, at the highest level, investigation and resolution of these clearly unnecessary obstacles

10.9.2 Medicare Funding

Apart from Hospital funding, Commonwealth funding for Medicare is largely restricted to subsidies for prescribed medicines and free or subsidised treatment by medical doctors, optometrists and dentists. Limited funding has recently been introduced for some allied health services. Residents in Aged Care Homes largely access the services of doctors, optometrists and dentists through the Medicare system and many are exempt from being charged a co-payment. Nurse practitioners, even if providing a service equivalent to a general practitioner, are not eligible to be given a Medicare Provider Number – and, thus, the costs of their services are not recoverable from the funding stream designed to support such services. During the course of the present study, advice was sought on the likelihood of a change to policy that would grant Medicare provider status to duly licensed nurse practitioners, and it appears that this is not an anticipated development. Medicare benefits are


payable for services by nearly all doctors currently registered in an Australian State or Territory and the Medicare Benefits Schedule lists a wide range of consultations, procedures and tests, and the Schedule fee applicable for each of these items. If the Aged Care Nurse Practitioner role is to be fully introduced in Australia, the inclusion of specific procedures and interventions delivered by recognised Aged Care Nurse Practitioners needs to be assessed by the Medical Services Advisory Committee on the basis of evidence of safety, cost-effectiveness and benefit to residents.

10.9.3 Pharmacetical Benefit Scheme Funding

Medicines or pharmaceuticals prescribed by doctors and dispensed in the community by independent private sector pharmacies are directly subsidised by the Commonwealth Pharmaceutical Benefits Scheme (PBS). Public hospitals provide medicines to inpatients free of charge and do not attract PBS subsidies. Prescriptions of medications on the PBS list by an Aged Care Nurse Practitioner, even if authorised to prescribe, are not eligible for the PBS subsidy. Residents availing themselves of an Aged Care Nurse Practitioner service would therefore be liable for the full, non-subsidised costs of any medications subscribed. This is clearly a significant barrier to the introduction of this new role. The findings of the current trial provide evidence to the PBS that the inclusion of Aged Care Nurse Practitioners within the PBS framework offers benefits to aged care clients: specifically, no increase in prescribing was evident; no apparent differences between the nurse practitioner candidates and general practitioners were identified; and the timeliness of prescribing and administering pharmaceuticals was improved when a candidate was involved. This latter benefit is of some importance in treating older, frail people.

10.9.4 Knowledge and attitudes towards new roles

As was the case some 10-20 years ago in the USA and the UK, the nurse practitioner role is still misunderstood in the general community and amongst health professionals. Some health professional groups oppose the role and are vigorous in advancing their opposing views across the community. Although argument and debate is, of course, legitimate within the Australian context, the opposing view is very evident in the public domain but there is little evidence of well reasoned counter arguments. Although the present study found little opposition to the nurse practitioner-like service studies from residents, their families and other health professionals, none of these groups had any real awareness of the role; the additional education and training required by a registered nurse to be licensed to adopt the role; the place of the role within a national residential aged care system; the benefits that may accrue from offering such a service; or the experiences of other countries. A focused campaign designed to describe and explain the role and its benefits would be an important precursor to its widespread implementation.


10.9.5 Workforce issues

There were 71 nurse practitioners practicing in NSW in 2006, mainly in emergency, mental health, diabetes and pain management. Approximately 60 new positions will be filled in 2007 in mental health, aged care, emergency medicine, paediatrics, diabetes, renal, dementia care and respiratory care. Numbers are smaller in other states, but numbers enrolled in university programs that lead to licensure are increasing steeply and there are likely to be more “qualified” nurse practitioners than available positions in the future. Because of few opportunities for employment as a nurse practitioner in aged care, the licensure of such practitioners is relatively recent and most of the 250+ nurse practitioners licenced in Australia are in the acute specialties. The recruitment of nurses to the aged care sector has been problematic for some time and the creation of aged care nurse practitioner roles is likely to provide an attractive component of a career ladder and act as a recruitment incentive in future. However, the current numbers of nurse practitioners registered to work in aged care is extremely low, and a clear barrier to further expansion of the role in the short term.

10.10 Potential national service delivery models for Aged Care Nurse Practitioner services

Five of the seven nurses involved in the trial were employed by an Approved Aged Care Provider under a State/Territory nurses award and two were employed by a Territory Health Department. Were the role to be implemented nationally, the employment status of the practitioners and their source of funding requires clarification. In considering the international literature and the Australian context, six options for a national service delivery model for Aged Care Nurse Practitioner services were identified:

10.10.1 Primary Health Care Based

As the services and interventions that made up the core of the Aged Care Nurse Practitioner are currently (to a large extent) delivered by General Practitioners, the Aged Care Nurse Practitioner could be located within a General Practice where a desire to provide such services has been expressed and a service agreement formalised. In this model, the Practitioner would be able to service residents in one or more nursing homes (either residents registered as patients of the GPs in the practice or all residents regardless of their chosen GP). Integration into General Practice would create opportunities for collaboration with medical practitioners and, if Medicare Provider and PBS status were granted, funding could be from the Commonwealth to the General Practice. Practice Nurses (although not formally prepared or licenced to do so) are increasingly undertaking some activities similar to those of the Aged Care Nurse Practitioner and locating the new role in General Practice may obviate these trends.


10.10.1.1 Advantages

Co-location with general practitioners may improve collaboration and ongoing professional development; the Aged Care Nurse Practitioners services are comprised of activities currently seen to be the province of primary health care; Medicare and PB Schemes relate closely to general practice.

10.10.1.2 Disadvantages

Not all aged care facilities are close to general practices (eg: rural and remote); lack of senior leadership and mentorship from other nurses; remoteness from point of care in aged care facilities.

10.10.2 Health service based as part of Geriatric Services

Central to the role of the Aged Care Nurse Practitioner is expertise in the care of older people. Locating a team of nurse practitioners within health-service based Geriatric Medicine Teams may enhance continued learning and the development of expertise. In this model, the practitioners would be able to service residents in one or more nursing homes regardless of resident’s GPs. Integration into specialist Geriatric teams would create opportunities for collaboration with medical specialists and funding for service delivery, prescribing and diagnostics could be from the Commonwealth to the States as part of the existing Medicare funding scheme.


Co-location with geriatricians may improve collaboration and ongoing professional development; the Aged Care Nurse Practitioners services are comprised of activities similar to that of geriatric services.


Not all aged care facilities are close to specialist geriatric services; lack of senior leadership and mentorship from other nurses; remoteness from point of care in aged care facilities.

10.10.3 Australian Government Department of Health and Ageing-Based

Although the Australian Government Department of Health and Ageing is generally not involved in direct service delivery, Aged Care Nurse Practitioners could be employed as part of a national service with caseloads assigned through State Offices of the Department as a transitional scheme pending further consideration on the most appropriate model of service delivery. In this model, the Department would be able to capture data and evaluate impact as


well as monitor the service as a prelude to devolving responsibility to other parties over time.


This model would enable close monitoring and national data capture and consistency across jurisdictions.


Direct service provision is not considered a legitimate role of the Department; lack of senior leadership and mentorship from other nurses; remoteness from point of care in aged care facilities.

10.10.4 Regionally based as part of a consortium of providers

A large Residential Aged Care Facility or a consortium of smaller facilities could employ an Aged Care Nurse Practitioner. In this model, the Practitioner would be able to service residents in the facility(ies) regardless of the resident’s GP. Integration into the culture of the facility(ies) would create opportunities for collaboration with residents, their families and the staff. Were Medicare Provider and PBS status in place, the Approved Provider employing the Practitioner could be reimbursed through funding from the Commonwealth through Medicare.


The model incorporates linkage to provider agencies allowing services to be embedded within a service delivery framework; sufficiently flexible to maximise time use.


Not all aged care facilities are sufficiently close to others to form a “region”; supervision and reporting may be difficult.

10.10.5 Facility based as part of nurse-staffing

Aged Care Facilities could employ, as part of their nurse-staffing profile, a licensed Aged Care Nurse Practitioner. In this model the Practitioner would combine undertaking nursing duties with providing Nurse Practitioner services to residents. Funding of the role could be from the Commonwealth subsidy to the Facility but additional funds would be required to relieve the Practitioner of some general nursing duties. If PBS status was granted, prescribing could occur.



The nurse practitioner is embedded in service delivery; immediate access to service for residents and staff; maximises opportunities for clinical leadership.


Risk of time being absorbed into nursing care delivery rather than nurse practitioner services; potential isolation from other facilities and health professionals.

10.10.6 Independent contractor status

Licensed Aged Care Nurse Practitioners, if they had Medicare Provider and PBS status, could operate as independent contractors, contracting their services to Aged Care Providers. In this model, the Practitioner would be able to service residents in one or more nursing homes; establish effective liaison with GPs; and compete with others to gain such contracts.


This model is sufficiently flexible to allow demand to drive the supply of suitable practitioners.


Coverage in rural or remote areas would be problematic under this model.


10.11 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.

10.11.1 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.

10.12 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.


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