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2 Implementing The Nurse Practitioner Role in Aged Care (INPRAC) Final Report to the Australian Government November 2007

3 ACT Health This work is copyright. Apart From use as permitted under the Copyright Act 1968 no part may be reproduced by any process without prior written permission from the ACT Department of Health, GPO Box 825 Canberra ACT 2601 Printed November 2007 ISBN 2

4 Table of Contents Part One Letter to Australian Government from the Chief Executive ACT Health 4 Glossary 5 Acronyms 7 Acknowledgements 8 Part Two Executive Summary 11 Background Overview of Evolving Nurse Practitioner Role 13 Part Three Project Overview Report on the Implementing the Nurse Practitioner in Aged Care Project 17 Introduction 17 Project Governance 19 Purpose and Objectives of the Project 21 Summary Comparison between outcome achievements and project objectives 22 Part Four The Nurse Practitioner Positions 25 Contextualising the Aged Care Nurse Practitioner in the Australian Capital Territory 25 Establishment, Governance & Management of the Nurse Practitioners 27 Role Development and Progress of the Nurse Practitioners 28 Residential Aged Care Facility based Nurse Practitioner 29 Tertiary Sector based Nurse Practitioner 37 Part Five Data Analysis Data Collection Process and Commentary 43 Quantitative Data ACT Health specific data 47 Discussion 51 ACT Health Qualitative Data 56 Discussion 59 Nurse Practitioner Reflective Journals 62 Residential Aged Care Nurse Practitioner 64 Tertiary-Based Aged Care Nurse Practitioner 68 Aged Care Nurse Practitioners Ongoing Professional Development 70 Identified and Contributing Factors to Successful Nurse Practitioner Implementation 72 Identified Challenges during the Project 74 Ancillary Initiatives associated with the Project 75 Recommendations 80 Part Six Description of Significant Promotional Material used During the Project 81 References 82 Bibliography 85 Part Seven Appendices (separate booklet)

5 Letter to the Australian Government, as represented by the Department of Health and Ageing from the Chief Executive, ACT Health November 2007 Ms P Swift Director Aged Care Workforce Section Quality Policy and Programs Branch Office of Aged Care Quality and Compliance Department of Health and Ageing Dear Ms Swift, It is with great pleasure that I present the final report on the jointly funded project Implementing the Nurse Practitioner in Aged Care. The document reports on the ACT Health component of the larger National study and represents the conclusion of this successful and innovative project. ACT Health has appreciated the opportunity of working with the Commonwealth and other jurisdictions in implementing the role of the Nurse Practitioner in Aged Care. The value of Commonwealth sponsorship and support enabling cross-jurisdictional research, collaboration and consultation cannot be underestimated. The achievements in the Australian Capital Territory have been significant and the role is well established with demonstrated positive outcomes which are discussed within the report. In particular the Aged Care Nurse Practitioner role has proven to provide cost effective, timely, flexible and safe Nursing care within the scope of practice of these advanced clinicians. I look forward to the future contribution that Nurse Practitioners will make in providing and improving health care to the aged. I take this opportunity to commend the report to you. Mark Cormack Chief Executive ACT Health

6 Glossary Nurse Practitioner A nurse practitioner is a registered nurse, educated and authorised to function autonomously and collaboratively in an advanced and extended clinical role. The nurse practitioner role includes assessment and management of clients using nursing knowledge and skills and may include, but is not limited to, the direct referral of patients to other health care professionals, prescribing medications and ordering diagnostic investigations. The nurse practitioner role is grounded in the nursing professions values, knowledge, theories and practice and provides innovative and flexible health care delivery that complements other health care providers. 1 Advanced Practice Nursing defines a level of nursing practice that utilises extended and expanded skills, experience and knowledge in assessment, planning, implementation, diagnosis and evaluation of the care required. Nurses practising at this level are educationally prepared at postgraduate level or equivalent, and may work in a specialist or generalist capacity. However, the basis of advanced practice is the high degree of knowledge, skill and experience that is applied within the nurse-client relationship to achieve optimum outcomes through critical analysis, problem solving and accurate decision-making. Nurses working at an advanced practice level are able to work autonomously, initiating the care process, as well as in collaboration with other health care professionals. Advanced practice nursing forms the basis for the role of the Nurse Practitioner. 2 Authorisation is the approval by the nursing regulatory authority (for example, the Nurses Board of the ACT) of the scope of practice of the Nurse Practitioner in that jurisdiction. The authorisation process invests legal authority and responsibility on the person authorised 3. Autonomous Practice involves being accountable for one s own decisions and an awareness of one s professional boundaries, knowledge and abilities. Autonomous Nurse Practitioners make clinical decisions based upon their scope of practice (which identifies these boundaries and abilities). Nurse Practitioners work as collaborative members of multidisciplinary teams, and their accountability is inherent to their role. Collaborative Practice involves multidisciplinary health care professionals and the client, family or carer jointly working together to provide coordinated, integrated care to clients through shared goals, shared decision making and mutual respect. A client centred approach is utilised with the aim of decision making that is synergistic and strives for efficiency and cost effectiveness by ensuring the provider of care is appropriate to the level required. Clinical Practice Guidelines are systematically developed statements to assist the practitioner and consumer decisions about appropriate health care for specific clinical circumstances 4. Clinical practice guidelines are a critical component of the scope of the NPs practice. They comprise an outline of the minimum accepted processes or elements that are considered necessary to incorporate into practice. Clinical practice guidelines cover a range of common clinical presentations and provide a guide for the NP in clinical assessment, clinical management, referral and clinical evaluation to provide the most appropriate, safe and effective care. Guidelines are based upon the current best available evidence of best practice and are outcome focused. 3 Episode of Care describes a new consultation for a health-related problem. The episode of care ends when the health-related problem is resolved or concluded, or no longer requires treatment.

7 Extended Nursing Practice defines a level of nursing that utilises skills and knowledge in a specific setting or specialty that is beyond the usual scope of nursing practice. Extended practice involves advanced clinical assessment including interpretation of diagnostic results, implementing and monitoring therapeutic regimes including prescribing pharmacological interventions, and initiating and receiving appropriate referrals. This extended practice is conducted according to a nursing model of health and requires appropriate legislative protection. Low-Level Care is defined as personal care services. This care includes assistance with activities of daily living, for example bathing, toileting, dressing and medications. Additionally residents classified as low level care require assistance in accessing health services, recreational therapy and rehabilitation. They may also require support with communication. High-Level Care these services are defined as those which, in addition to requiring assistance with all activities of daily living and other care of the low level category also require skilled nursing expertise to assess, plan and manage care needs. This includes administration of medication and other nursing procedures, for example management of episodic oxygen therapy. Additionally people in high-level care require specialized equipment and furnishings such as those used to assist in mobility and provision of therapy services. Medication Formulary is a list of the classifications of medications that a Nurse Practitioner can order from. The medication formulary has been collaboratively formed by the Student Nurse Practitioners and the multidisciplinary team during the project and verified by an expert panel. The medication formulary is consistent with the relevant clinical practice guidelines that relate to the scope of practice for a specific Nurse Practitioner model. 5 Nurse Regulatory Authority is the legally constituted body in each jurisdiction charged with the regulation of nursing and professional practice. The main role of the regulatory authority is the protection of the public through ensuring that nurses/midwives are appropriately qualified and demonstrates an acceptable standard of practice. 6 Scope of Practice is the definition of the extent and the parameters of practice for a specific Nurse Practitioner model. The Nurse Practitioner is able to practise with autonomy and discretion within the specified scope of practice 3. The scope of practice of the nurse practitioner is determined by the context in which the nurse practitioner is authorised to practice Occasion of Service is defined as any examination, consultation, treatment, education, counselling or other service provided by a Nurse Practitioner to any patient/client/resident during one consultation Pharmaceutical Benefits Scheme The Pharmaceutical Benefits Scheme is an Australian Government initiative which provides rebated access, to all Australian residents and some non-residents under reciprocal health care agreements, to a multitude of prescription medications. Under this scheme the Australian Government meets most of the cost of medicines with the remainder paid for by the consumer. Approximately 80 percent of prescriptions dispensed in Australia are subsidised under the PBS. Medical Benefits Scheme The MBS is a jointly funded system between the Australian Government and State & Territory Governments. It provides for free or subsidised treatment, for Australian Citizens and some non-residents by reciprocal health care agreements, by practitioners such as Doctors and Dentists.

8 Acronyms ABS ACNPPP ACT ACT Health AHMAC AIHW AMA ANF ANMC CPG HIC GP ICN IDC IAHSA MAC MBS MDS N3ET NCEPH NP NPS PBS PEG tube QUM RADAR RCNMP RCN RACF TCH UC WHO Australian Bureau of Statistics Aged Care Nurse Practitioner Pilot Project Australian Capital Territory Australian Capital Territory Department of Health Australian Health Ministers Advisory Council Australian Institute of Health and Welfare Australian Medical Association Australian Nursing Federation Australian Nursing & Midwifery Council Clinical Practice Guidelines Health Insurance Commission General Practitioner International Council of Nurses Indwelling Catheter International Association of Homes/Services for the Ageing Medication Assessment Committee Medicare Benefits Schedule Minimum Data Set National Nursing and Nursing Education Taskforce National Centre for Epidemiology & Population Health Nurse Practitioner National Prescribing Service Pharmaceutical Benefits Scheme Percutaneous Endoscopic Gastrostomy tube Quality Use of Medicines Rapid Assessment of the Deteriorating Aged At Risk Research Centre Nursing & Midwifery Practice Royal College Of Nursing Residential Aged Care Facility The Canberra Hospital University of Canberra World Health Organization 7

9 Acknowledgements Members of Committees and Advisory Groups ACT Health would like to formally acknowledge the tireless efforts and commitment members of the following committees have given throughout the INPRAC project. Their ongoing expertise, knowledge, involvement and support has been invaluable and their contribution to the successful completion of the project is greatly appreciated. Investigating Team Professor Paul Arbon Chair and Chief Investigator BSc,DipEd,GradDipHealthEd, MedStudies, PhD Professor of Nursing (Population Health) School of Nursing & Midwifery Flinders University, Adelaide Dr Jan Taylor PhD RN RM Senior Lecturer, Nursing School of Health Sciences University of Canberra Marlene Eggert PhD Student RN RM Medical School, Australian National University Nicole van Deimen RN, BN Chief Executive Officer Morshead Home Gordon Waddington BSc, BAppSc(Physio) Associate Professor GradDip Ex Sc, MAppSc(ExSc) Head of Physiotherapy MSportsPhysio, GCHE, PhD University of Canberra Anne Gardner RN, PhD Professor of Nursing James Cook University and Townsville Health Service District Christine Phillips MBBS FRACGP MA Senior Lecturer MPH DipEd Academic Unit of General Practice and Community Health Medical School, Australian National University

10 Steering Committee Jenny Beutel RN, RM Chief Nurse ACT ( ) Joy Vickerstaff RN, RM, DNE, DAN, BA, Acting Chief Nurse ACT McogSc, GradCert Health Economics Heather Austin RN, MPA Grad.Dip Pub Pol Acting Deputy ACT Chief Nurse Grad Dip Bus Man Debbie Hagen RN, Dip App Sc, NP Nursing & Midwifery Office ACT Health Jane Nolan RN, Grad Cert Gerontology Executive Director of Care Cert IV Continuous Improvement Uniting Care Ageing South Cert Cert IV Frontline Management Eastern Region Chin KF Wong RN RM BSc Nursing Medu Ministerial Appointed Board Member, ACT Health Aged Care Advisory Council Helen Shephard RN BHSc (Nursing) Principle Nurse Cert Gerontology Operations Manager Aged Care & Rehabilitation Stream Jennie Yaxley MPhysio Manager Falls Prevention Program Aged Care & Rehabilitation Services Mark Gaukroger Adjunct Prof. (UC) RN, RM Manager Nursing Services MPA, MRCNA, (AF) ACHSE Continuing Care ACT Community Health Clare Willington MB.BS (Lond) GP Adviser to ACT Health Sonia Hogan RN, RM, BN MN Project Manager, ACT Health Human Resource Management Branch Anne Baynes BA (ANU), RN, RM Program Officer Aged Care & Palliative Care Project Team Debbie Hagen RN, Dip App Sc, NP Project Manager Jane Desborough RN, RM, Dip App Sc, Research Officer Grad Dip Mid Martin Goodisson RN RM Grad Cert Crit Care Research Officer Grad Cert Mid Sonia Hogan RN RM BN MN Project Officer Kasia Bail RN BN Research Officer

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12 PART TWO Executive Summary This document is the final report on the jointly funded initiative between the Australian Government, (Department of Health and Ageing, Quality Outcomes Branch) and ACT Health on the Implementing the Nurse Practitioner in Aged Care (INPRAC) project. The project resulted from negotiations between ACT Health and the Department of Health and Ageing to extend the parameters of the Aged Care Nurse Practitioner Pilot Project. The INPRAC project has been conducted in accordance with the ACT Health submission to the Australian Government, dated 10 August 2005, and various Deeds of Variation, which extended the project until November All of the specific objectives of the project, as set out in the original contract, have been met. Since the project commenced, two student Nurse Practitioners have completed their studies and subsequently commenced practicing, as authorised Nurse Practitioners in the aged care sector, one in an ACT Health position the other in the private sector. Progress reports 1 7, delivered to the Department of Health and Ageing, documented the progress of the Nurse Practitioners as well as a number of key initiatives and strategies completed by the Project Team located within the office of the Chief Nurse, ACT Health. Throughout the project the Nurse Practitioners have established their roles and scope of practice, diversified and expanded their services. They have developed new strategies for timely interventions in health care delivery to the aged, and have collaborated in both national and local research projects. These activities, plans and strategies have resulted in significant achievements, individually for the Nurse Practitioners involved, for the clients they have treated, and for both Federal and Local Governments, particularly in terms of cost effectiveness of their service. These successful initiatives include: reduction in hospital admissions from residential aged care facilities and the community reduction in re-admission rates following discharge from acute care hospitals reduction in presentations to emergency departments from aged care facilities improvement in the management of end of life care 11

13 reduction in falls in the residential aged care decreased incidence of pressure areas successful introduction of a clinic for rapid assessment of the aged at risk of hospital admission early identification of at risk patients discharged from the acute care setting to the community Additionally, the Nurse Practitioners have established successful collaborative working relationships with medical staff and multidisciplinary teams presented various aspects of their roles at numerous conferences, workshops and forums provided clinical and professional leadership to nursing significantly contributed to the design and development of new strategies to meet the health care needs of the aged across the continuum of care. Arguably, the Nurse Practitioners have had a constructive impact on recruitment and retention of Nursing staff in the ACT, which given the current environment and focus on workforce shortages, is an extremely positive outcome. This effect has been the result of their provision of clinical and professional leadership to nursing colleagues, the increasing recognition of specialist nurse expertise, the establishment of a clear clinical nursing career pathway and by the very public support that ACT Health, at all levels, has demonstrated to the development of this important new role in the Nursing profession. Notably, these accomplishments have been recognized at an organisational level and significantly, have resulted in two prestigious awards to the private sector Nurse Practitioner;the first an international award for end of life care and the second the 2007 Ministerial award for professional development. Within the public sector the position has been so successful as to warrant the appointment of a third Aged Care Nurse Practitioner. The Project Management Team, ACT Health have closely examined and investigated the developing roles, supported the Nurse Practitioners throughout the project and importantly, have provided considerable research and evidence regarding the factors which contribute to successful implementation of the role. Evidence of this is particularly apparent in the recently completed pilot project surrounding issues of prescribing which has demonstrated and provided evidence of the potentially detrimental effects, to aged care clients, of current restrictions to practice. From a strategic perspective, the Project Team in collaboration with various committees and advisory groups, have identified both opportunities to expand Nurse Practitioner services and identified potential new models of care delivery to enhance aged care services. Within the Australian Capital Territory, the Aged Care Nurse Practitioner positions have proven to be an innovative, cost effective path towards improving the quality and timeliness of health care delivery to the aged care sector. This has been achieved through safe, clinically sound and evidence-based interventions, which take into consideration the holistic and complex needs of the aged. This report provides comprehensive information, evidence and analysis of all aspects of the INPRAC project, which collectively substantiate and confirm the necessity for maintenance of current positions and the ongoing development and establishment of further Nurse Practitioner positions. 12

14 Background Overview of Evolving Nurse Practitioner Role The role of the Nurse Practitioner in the provision of health care began to emerge in the 1960 s in countries such as Canada, the United Kingdom and the United States of America. In those countries the introduction of this advanced practice nurse was, initially, in response to limited access to primary health care services. In Australia, the role is becoming increasingly established, not only in primary care settings but also across all specialities of Nursing, with the role and scope of practice varying according to each specific practice area. Within Australian jurisdictions the Nurse Practitioner role has been introduced to provide an increase in continuity of care, at an advanced practice level, and to improve timely access to health care services by providing an innovative, integrated and flexible care strategy. In all jurisdictions the Nurse Practitioner is defined as A registered nurse educated and authorised to function autonomously and collaboratively in an advanced and extended clinical role. The nurse practitioner role includes assessment and management of clients using nursing knowledge and skills and may include but is not limited to the direct referral of patients to other health care professionals, prescribing medications and ordering diagnostic investigations. The nurse practitioner role is grounded in the nursing profession s values, knowledge, theories and practise and provides innovative and flexible health care delivery that complements other health care providers. The scope of practice of the nurse practitioner is determined by the context in which the nurse practitioner is authorised to practise. 1 International evidence from the consumer perspective, regarding the role of the Nurse Practitioner, has been positive and this is discussed in multiple studies. 7,8 The Cochrane Collaboration and others have reported on the cost effectiveness of Nurse Practitioners in providing primary care in comparison to medical officers. Nurse Practitioners were found to be cost effective, despite reported longer consultation times, for several reasons. These include, an increased provision of opportunistic health screening, increased attention to preventative health measures and an holistic approach to the health care needs of their clients Nurse Practitioner prescribing has also been observed to be both appropriate and cost-effective and numerous benefits have been described in current literature Studies have outlined how through successful implementation of Nurse Practitioner prescribing, the patient s journey is streamlined, access to health care is improved, and professionally both the Nurse Practitioners and their associated health care teams benefit These benefits are demonstrated by timely treatment of patients through optimum use of authorised clinical expertise, and the increase in expert clinical support to nursing colleagues by Nurse Practitioners. Particularly in aged care, timely treatment is achieved, thus avoiding exacerbation of health issues. The line of responsibility for treatment is clearly defined when Nurse Practitioners are able to complete an episode of care by prescribing medication as required. 18 At all levels of health care planning, both nationally and internationally, the importance of the contribution made by nurses in regards to prescribing medicines as well as other areas of advanced practice needs to be recognised in health policy and planning

15 Factors, including the degree of administrative support, high staff turnover in aged care and the importance of inter-disciplinary communication, may either facilitate or pose challenges to the implementation of the role of the Nurse Practitioner. 21 Furthermore, a lack of knowledge and understanding, at clinical and managerial levels, regarding the role of the Nurse Practitioner and a lack of mentorship have been found 22, 23 to be barriers to successful implementation. There is significant support for the Nurse Practitioner role at the levels of strategic planning and policy development within the nursing profession and in the health sector generally. However, some resistance to this emerging role has been reported. A lack of support from both traditional nursing and medical bodies has been seen to be due to a lack of clarity and understanding of this role that some believe bridges the gap between Nursing and Medicine. 23 The importance of collaboration with other health care professionals was identified as an important factor associated with the successful implementation of the Nurse Practitioner role. 24 Conversely, in Australia, a lack of access to prescribing numbers has been recognized as a barrier. 15,25,26 In response to the need for provision of health services, appropriate to the changing face of the Australian community, both Federal and State governments have seized and created opportunities for the expansion of services and increasing consumer satisfaction. This has included the optimum utilisation of Nursing knowledge and expertise by supporting the introduction of the role of the Nurse Practitioner. The significant role of Nurse Practitioners in providing expert aged care nursing is well documented internationally. 22,27,28 Specific care activities of Aged Care Nurse Practitioners have highlighted the multifaceted role, which includes assessment, treatment, intervention, case management, collaboration with other health care professionals, teaching, and prevention of adverse events. 27 In Australia in 2006 there were 2,644,477 people over the age of This accounted for 13% of the total population. In this same year there were 166,291 residential aged care places in Australia 31, representing accommodation for 6% of the total population. The most frail and disabled people within the Australian community are the residents of aged care facilities. Their health care needs are complex and they consume a significant proportion of the health budget. On 30 th June, 2006 more than half (52.8%) of the residential aged care facility residents were 85 years and over. 31 The highest annual growth rate in the population (7%) is seen in this age group, hence defining an area for health policy development and reform. 29 The interface between residential aged care facilities and acute care services has been observed and examined in three significant Australian studies One of these studies indicated an annual hospitalisation rate of 20% for residents of aged care facilities. 32 The combined data from these studies indicate that of these residents who presented to hospital Emergency Departments, 61% resulted in admission to hospital with a mean length of stay of 9.38 days These studies indicate that approximately 2.2% of all Emergency Department presentations come from residential aged care facilities, and that between 10% and 13% of these presentations could have been avoided through the provision of specialised care, and appropriate resources and actions at the originating facility

16 In one study, 24% of inappropriate emergency department presentations could have been avoided through the implementation of percutaneous endoscopic gastrostomy tube (PEG) and indwelling catheter (IDC) insertion practices at the Aged Care Facilities of origin. 33 In NSW, of 526 residents, 131 (24%) re-presented to the Emergency Department (ED) and 15% of these re-presentations were within 48 hours of discharge from the hospital. Approximately one tenth presented more than three times. 33 The reason for these re-presentations was not explored. Interestingly, the rate of hospitalisation was found to be higher amongst residents of aged care hostel accommodation than those in nursing homes. 32 North American studies have signalled the need for enhanced palliative care requirements in aged care facilities in order to avoid transfer to acute care facilities for this purpose. 35 The ACT Health Palliative Care Strategy aims to offer cohesive, readily accessible best practice, appropriate palliative care to people, their families and carers in a way that supports people to die where they want to die, wherever possible and clinically appropriate. 36 The overarching aim of the strategy is for the majority of palliative care to be provided in the primary care sector, with appropriate supports. The development of a workforce skilled in palliative care is part of this strategy, which emphasises the importance of education, experience and training for primary health care providers. Evidence shows that older people are significantly higher users of hospitals than their younger counterparts. Hospitalisation due to falls increases with age from 7.2 overnight hospitalisations per 1,000 people aged to 63.5 per 1,000 people aged 85 and over in Older patients in hospital due to injury have relatively longer stays. 30 Despite this, the evidence is compelling that for the frail aged, a hospital can be a dangerous and unfriendly place. Hazards are many and include under-nutrition, falls, confusion, deconditioning and polypharmacy. 30 The cost of these hazards and their outcomes has highlighted the importance of improving hospital outcomes for older people by the Australian Government. 30 Identification of the needs of the elderly in Australia in conjunction with the identification of the health and economic benefits of the role of the Nurse Practitioner is essential to the successful integration and implementation of Nurse Practitioners in Aged Care in Australia. The setting-specific research conducted, as well as role-specific initiatives undertaken to address the health care needs of the elderly, and observation of the quantitative and qualitative effects of these initiatives is integral to the delivery of optimum health care to our valuable elderly population in the ACT. 15

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18 PART THREE Implementing the Nurse Practitioner Role in Aged Care Introduction This final report on the Implementing the Nurse Practitioner Role in Aged Care provides a detailed examination and analysis of the project. Regular progress reports have been provided to the Australian Government, Department of Health and Ageing, in accordance with the following time line: First Progress Report 31st December 2005 Second Progress Report 31st March 2006 Third Progress Report 31st July 2006 Fourth Progress Report 30th November 2006 Fifth Progress Report 23rd March 2007 Sixth Progress Report 15th June 2007 Final Report November 2007 The ACT government has demonstrated a commitment to the development of innovative advanced nursing roles in the delivery of health care appropriate to the current needs of the community. In 2001, in conjunction with the Nurses Board of the ACT, it supported a trial of Nurse Practitioners as a new level of health service in the ACT. This study enabled the establishment of an educational and clinical framework and the foundations for legislative change for implementing the role in the ACT. The Aged Care Nurse Practitioner Pilot Project (ACNPPP) subsequently examined the potential role that Nurse Practitioners could play across the ACT Health system. To further examine this role, the Implementing the Nurse Practitioner Role in Aged Care (INPRAC) project was a jointly funded initiative between the Australian Government, (Department of Health and Ageing, Quality Outcomes Branch) and ACT Health to implement the Nurse Practitioner (NP) role in Aged Care. 17

19 The project is the result of negotiations between representatives of ACT Health and the Department of Health and Ageing to extend the parameters of the Aged Care Nurse Practitioner Pilot Project. The INPRAC project was conducted in accordance with ACT Health s submission to the Australian Government dated 10 August 2005, and the extension to the project, as identified in the Deed of Variation No.1, dated 26th June 2006 and a further Deed of Variation dated June The Joanna Briggs Institute (JBI) was contracted to design and conduct a national research project, which would involve the comprehensive collection and analysis of data to evaluate the role of the Aged Care Nurse Practitioner and its impact across a number of health services. The quantitative minimum data set provided information on the clinical activities of the Nurse Practitioners, which JBI was then responsible for collating and analysing. Qualitative data measuring client as well as collegial satisfaction with the role of the Nurse Practitioner was collected through both focus group discussions and questionnaires. Qualitative data was collected, for ACT Health, by the Nurse Practitioners in the form of semi-structured journals, which provided a formal approach to reflective practice as well as documenting the Nurse Practitioners period of transition. The objective of these journals was to identify aspects of clinical leadership, acculturation and system issues that may impact the implementation of the role. This final report comments upon the site specific data and analysis, as provided by JBI, and will also examine other initiatives and strategies of the Aged Care Nurse Practitioners since the inception of their roles in It provides a comprehensive description of the entire project, including a comparison between the outcomes achieved and the objectives and purpose of the project. An analysis of data collected during the project, both qualitative and quantitative, and the difficulties and challenges encountered are also made. Furthermore, the report provides detailed information on the development and progress of the Aged Care Nurse Practitioners in their roles and the positive outcomes achieved through implementation of their advanced practice skills. Recommendations are made regarding actions to address identified barriers to the full implementation of the role of the Nurse Practitioner. Additionally, recommendations for the continued development of the role and future actions required to achieve this will be made. 18

20 Project Governance ACT Health (Office of the Chief Nurse, Nursing & Midwifery) The project and project management team have been monitored and supervised by senior executives of ACT Health, in particular by the Chief Executive and Chief Nurse. From a human resource perspective, continuity of the project has been achieved through maintaining appropriate and qualified staffing levels, regular performance review and appraisal of the project team and through monitoring of the fiscal component of the project. Supervision and governance of the project outcomes and achievements has been accomplished by review, consideration and comment on progress reports to ensure accuracy and currency of information and by ensuring integrity of ethics and research conduct. Investigating Team An experienced multidisciplinary team coordinated the research and evaluation aspects of the project and provided elements of clinical, academic and policy support. The primary role of the investigating team was collation and analysis of both quantitative and qualitative data, specific to the ACT, collected throughout the course of the project. Additionally, this team also monitored and maintained research and ethical integrity of the project. This highly qualified team provided a wide base of knowledge, experience, expertise and skill and have made an invaluable contribution to the project. It is further acknowledged that the team submitted papers for publication in peer-reviewed journals, which in addition to reporting on aspects of the ACT Health experience, contributed to the overall understanding of the role of the Nurse Practitioner. These publications provided clarification and appreciation of the Nurse Practitioner role as valuable, skilled contributors to the improvement of health care delivery. (Copies of publications are contained in the appendices) Steering Committee The Steering Committee brought together representatives from key stakeholder groups and played an essential role throughout the project by providing expert advice on broad direction and guidance for project implementation. A further role of the committee was to monitor and appraise the developing and expanding Nurse Practitioner roles and to provide feedback to the respective organizations that members represented. Furthermore, the Steering Committee contributed knowledge and advice to facilitate the effective implementation of the Nurse Practitioner role. They monitored the project against the specified purpose and objectives and identified concerns or issues for consideration and debate. The committee also provided a forum for knowledgeable, informed and robust discussion regarding the introduction of nurse practitioner roles and the more general difficulties and issues surrounding aged care service provision. This environment of debate enabled a wide spectrum of perspectives and opinions and continued to highlight a number of concerns in the aged care sector. 19

21 Some of these concerns could be addressed within the context of the committee s terms of reference, and others assisted committee members to gain further insight into problems associated with the provision of aged care services. The final meeting of the committee was held in September However, members of the committee expressed their interest in one further meeting, to be held early in 2008 following release of the final report. The purpose of this meeting will be to review the report, to discuss the findings and to formulate a number of recommendations which will be forwarded to both ACT Health and The Australian Government, Department of Health and Ageing for consideration. Although the Terms of Reference for this committee did not specifically include final recommendations, the majority of the committee expressed their belief that they will be able to complete their commitment to the project by offering valuable recommendations, which may assist in improving the effectiveness of Nurse Practitioner roles and models of care. Australian Government Department of Health and Ageing Valuable contribution to the governance of the project was also received from the Department of Health & Ageing, Quality Outcomes Branch. In addition to monitoring the conduct and activities of the project, by consideration of Progress Reports 1 7, there were valuable regular teleconferences with Project Managers from each site. This allowed for discussion of various aspects of the project as well as clarification of issues or concerns raised by the national Project Managers. It is also acknowledged that, from the perspective of ACT Health, the Department of Health & Ageing, were readily available to discuss and provide advice to the Project Team at various stages throughout the project. ACT Health acknowledges the invaluable assistance and support generously offered by the Department of Health & Ageing, in particular the Quality Policy and Programs Branch. 20

22 Purpose and Objectives of the Project As defined in the original contract, the purpose and objectives of the project were to : 1. Contribute to a national minimum data set (Joanna Briggs Institute) for Aged Care Nurse Practitioners 2. Pilot data collection strategies and collect baseline data for assessment of the impact on quality measures with emphasis on reason for admission, length of stay, client satisfaction and other indicators that may be relevant; 3. Provide data to inform clinical support structures for newly licensed practitioners; 4. Identify potential barriers in health structures and systems that may impact on the ability of the nurse practitioner to order pathology, imaging and other diagnostic tests and develop strategies to address this; 5. Identify potential barriers in the structures and systems that may impact on the ability of the nurse practitioner to implement prescribing rights and develop strategies to address these 6. Identify health benefits associated with nurse practitioner assessment, intervention or referral in the aged care context; 7. Identify further legislative changes that may be required to allow the NP to function in the extended role, especially in relation to Schedule 8 medication; 8. Develop local protocols and policies for the effective implementation for nurse practitioner prescribing, ordering pathology, imaging and diagnostic tests; 9. Identify aspects of clinical intervention, leadership and acculturation during the transition period following endorsement to practice as a Nurse Practitioner; 10. Provide data on the extent and character of the evolving role of the nurse practitioner in aged care; 11. Identify and develop formalised supervision/mentorship strategies to support new nurse practitioners; 12. Identify the potential for improved integration, coordination, and linkages with existing services across the acute, community and residential aged care sectors. 13. Contribute to the growing body of knowledge regarding the impact of the aged care nurse practitioner role in the context of Australian Health. 21

23 Summary Comparison between Project Objectives and Project Outcomes A contractual requirement, of the joint funding agreement, specified that the final report include a comparison between the project objectives and the outcomes achieved. All objectives of the project have been met and evidence of this is contained throughout the report. In broad terms all the project objectives can be categorised under one of the following subsets Data and Information Barriers to Implementation of the Nurse Practitioner role Benefits of Aged Care Nurse Practitioner role Policy and/or Legislative Issues Nurse Practitioner Role Development The following summary addresses each of the objectives within the broader headings and provides an overview of achievements. Comprehensive evidence and discussion is contained within the remainder of this report. Data and Information Objective numbers 1,2,3 & 13 relate to data collection, analysis strategies and baseline knowledge of the Aged Care Nurse Practitioner role. Contribution, to the national minimum data set, was completed by both the Aged Care Nurse Practitioners with assistance and guidance from the Project Team. During the course of the project other data collection pilot strategies were used to measure key indicators including those of consumer satisfaction and quality outcomes. Discussion of both the tools used in data collection and the data obtained is included within this report and provides valuable information on the INPRAC project. Additionally this information may be used to inform the design and development of future projects, particularly those related to Nurse Practitioner effectiveness and impact on client outcomes, quality of health provision and cost efficiencies. Barriers to Implementation of the Aged Care Nurse Practitioner Role Objectives 4 & 5 specifically call for identification of potential barriers in health structures and systems that impact on the ability of the Nurse Practitioner to prescribe medications and order diagnostic investigations. It has been clearly identified that the significant barrier to Nurse Practitioners being able to practice to the full extent of their legal authorisation, that is to prescribe medication and order diagnostic tests, is due to inability to obtain the necessary provider and prescriber numbers. 22