Is there a need for the geriatric nurse practitioner?

Is there a need for the geriatric nurse practitioner? Ken Burgin! 6/6/06 1:40 PM Formatted: Left Eric Staples, RN, BAA(N), MSN, ACNP, ND, 1 Margaret Black, RN, PhD 2, Meaghan Turner, RN, BScN, BA(English) 3 1 Regional Coordinator, Ontario Primary Health Care Nurse Practitioner Program, Assistant Professor, School of Nursing, McMaster University 2 Associate Professor, School of Nursing, McMaster University, and Public Health Consultant, Public Health, Research, Education and Development Program. 3 BScN Level IV student when the project was initiated, McMaster University Acknowledgements: To Shelly Gdanski, RN, Post Diploma BScN/NP,Kristen Hogan, Level IV BScN,Sharon Rodrigues, Level IV, Karen Posadas, Level IV for their contributions in the data collection, analysis and report writing while completing a research course with the School of Nursing, McMaster University 1

Introduction Canada s population is aging. It is estimated that by the year 2011, 16 percent of the population will be over age 65, with these numbers increasing to 24 percent by the year 2031 (Statistics Canada, 2003). Life expectancy is also on the rise. Canada ranks within the top 3 developed countries in the world in relation to life expectancy. Canadian women have an average life expectancy of 81.4 years compared to men at 75 years (Statistics Canada, 2003). Ontarians 60 years and older will account for half of the projected population growth of 3 million by 2021, even though they make up only 17% of the population (Thompson, Gow & Associates, 2000). With increased life expectancy comes the inevitability that many of the elderly will have one or more medical conditions requiring the care of a geriatrician. Put into context, it is estimated that 25% of people over age 65 and 45% of those over 85 can expect to have one disability. Of interest is that one-third of deaths from ischemic heart disease among women occurs in those over the age of 85 (Heart and Stroke Foundation of Canada, 1999). The period of disability accompanying the later years requires that the frail elderly receive specialized geriatric medical services aimed at preserving functional independence (Carlson, 1998). Unfortunately, there are critical shortages in geriatric health care services in Ontario (Turpie, 2001). The paper will describe a project to identify perceived gaps in health service delivery for aging persons and the perceived need for the GNP role. Dr. Turpie, Associate Professor at McMaster University and practicing geriatrician has documented the inadequacy of geriatric health care services available in the Hamilton- Wentworth area. According to Dr. Turpie (2001), restructuring of the Ontario health care system has resulted in shorter hospital stays, an increase in acuity of elderly patients 2

returning to the community, a shortage of long-term care beds, and an increased need for CCAC services. Long-term care (LTC) facilities are therefore required to care for increasingly medically fragile seniors without the appropriate support provisions. The Ontario government s LTC Redevelopment Project has promised a 20,000 long-term care bed expansion to be completed by 2004 (MOHLTC, 2003). Although this initiative provides support in one aspect of the necessary continuum of care services required for the elderly, there are too few clinicians to manage the elderly clients already in the system. Program Directors for the Regional Geriatric Programs (RGPs) of Ontario recently estimated that these programs saw only about 1% of those 75 years and older in 2001/02 (Borrie, Dalziel, Fisher, Molloy & Puxty, 2003). In addition, wait times for specialized geriatric assessments and care in the Hamilton-Wentworth Region range from six weeks to seven months (Turpie, 2001). The supply of physicians with geriatric training is not sufficient to meet this projected demand (Borrie et al., 2003). Nevertheless, encouraging improvements have been made in funding agreements to three RGPs in 2004 (MOHLTC) to provide recruitment funds to assist in attracting new geriatricians. In order to accommodate existing and future demands, Dr. Turpie (2001) and others in the USA (Dyer, Hyer, Feldt et al, 2003; Kovner, Mezey & Harrington, 2002) have recommended that geriatric services would be best served by focusing on the nurse practitioner role and developing geriatric nurse practitioner positions to work collaboratively within interdisciplinary patient care teams. The Ontario Ministry of Health and Long Term Care (MOHLTC), acknowledged the gaps in geriatric care delivery, and developed a LTC Nurse Practitioner Pilot Project in 1999. The study sought to document the impact of nurse practitioners engaged in patient care activities in long-term care facilities as well as in the community. Early outcomes from the Barrie, Ontario pilot project have confirmed that nurse practitioners improve the quality 3

of primary care services to the frail elderly population (Blay, Clifford-Middel & McCuaig, 2001). The Toronto, Ontario pilot project demonstrated similar findings, including improvements in timely clinical interventions, improved skin and wound management, enhanced palliative care services, and contributing to care provision through collaboration with off-site physicians. The authors recommended that the Province of Ontario make a permanent commitment to fully fund the nurse practitioner program in LTC facilities in Ontario (City of Toronto, 2002). Unlike the United States (USA) where specialty NP programs abound, in Ontario, NP preparation is at the generalist level. The Ontario Primary Health Care Nurse Practitioner (PHCNP) Program does provide some focus within the curriculum on the older adult and there are some opportunities for clinical placements in geriatric settings. PHCNP graduates may have come from geriatric settings or may specialize in gerontology after graduation. The Acute Care Nurse Practitioner (ACNP) Program, although more specialized than the PHCNP program in terms of the role, has a generalist curriculum but clinical placements can be solely completed in a geriatric setting if the learner wants this specialty practice. However, neither program currently delivers a comprehensive geriatric nursing curriculum. An analysis of six U.S. clinical outcome studies on the impact of GNPs on resident care conducted between 1978 and 1993 demonstrated a consistently favourable impact on six categories of clinical outcomes; hospitalization rates, cost-effectiveness, quality of care, case mix admissions, morale and satisfaction of the elderly, and discharge outcomes (McDougall & Roberts, 1993). As noted in the 1993 Report of the Institute of Medicine, geriatrics is an interdisciplinary specialty and specialized GNPs are vital to the delivery of primary health care of the elderly (Carlson, 1998). In 2000, acknowledging the benefits of nurse practitioner specialization, the U.S. provided funding to develop consensus-based 4

primary care competencies for nurse practitioners in the fields of adult, family, gerontological, pediatric and women s health. The intention was for nurse practitioner programs to utilize these specialty competencies in addition to the domains and competencies of nurse practitioner practice to shape nurse practitioner core curricula (National Organization of Nurse Practitioner Faculties [NONPF], 2002). Recently, the Ontario government, through the RGP, funded eight Geriatric Emergency Management (GEM) positions in three cities (Toronto, London and Hamilton) in the hospital emergency department, although not all are held by NPs. (Downing, 2004). Purpose The purpose of this research project was to assess the perceived gaps in geriatric care services and to determine the need for GNP preparation within Ontario s health care sector generally and in the Hamilton-Wentworth Region specifically as one solution to the increasing demands on the health care sector Method In this study, the researchers developed a survey to determine awareness of the GNP role, perceived gaps in geriatric service delivery where the gaps existed and how GNPs might facilitate closing those gaps (see Figure 1). The survey questionnaire asked participants to identify the activities a GNP could undertake in practice. Participants were also asked to identify barriers that nurses might face in pursing a career as a GNP and what could be done to reduce those barriers. The survey items were reviewed for face validity by a gerontological nurse clinician who was an experienced researcher. The survey was initially administered in person to a variety of health care professionals (i.e., nurses, psychologists, social workers, dieticians, clinical nurse specialists) specializing in gerontology. These professionals were attending a local chronic 5

care hospital s annual research poster session that attracted nurses and others working with older persons in various settings. The survey was also sent via email to 38 NPs identified through an Acute Care Nurse Practitioner (ACNP) membership list, which listed ACNPs specifically working in gerontology throughout Ontario. Due to the generalist nature of the PHCNP role and the lack of a similar data base to draw upon, the location and practice of PHCNPs was not widely known so that the survey could not be administered to this group without access to sufficient research funding. ACNPs who received their surveys via email were also sent two email reminders. Surveys were sent in July 2001 and November 2002. (Questions related to barriers facing implementation of a GNP role were not included on the July 2001 survey and thus only available for analysis with 24 respondents). A total of 46 surveys were completed, including responses from three geriatricians who were interviewed using the survey instrument. Two nursing students summarized the categorical responses, and with training in content analysis, identified preliminary themes from the open-ended responses. Two faculty independently reviewed the raw data, identified themes and reached consensus with the students on final themes (Burnard, 1991). Results Forty-six health care professionals with experience in gerontology completed the survey. Fifty % of the respondents had worked with an NP in the past in various settings, although not every respondent stated where they had worked with an NP. Ninety-six % of the respondents agreed there was a need for a GNP role, with two abstentions. When asked to identify gaps in service delivery within the Hamilton-Wentworth Region and surrounding areas, three themes emerged: (1) System Inadequacies, (2) Lack of Resources and (3) Knowledge Related to Aging 6

System Inadequacies and Lack of Resources: Participants identified shorter hospital stays, longer waiting lists, inadequate staffing of nurses and physicians in gerontology, lack of communication related to discharge planning and the lack of coordination of in-patient and out-patient services as problems affecting service delivery. There was also a perceived lack of community resources related directly to geriatric services available within the Hamilton-Wentworth Region. Practitioners and clients had difficulty accessing known available resources in a timely manner. A lack of specialized services was perceived to be affecting the quality of care for the Hamilton-Wentworth Region s geriatric population. Knowledge Related to Aging: Respondents identified that physicians and nurses lacked specialized knowledge related to gerontology and issues facing the elderly client. Participants were also asked for ideas to improve service delivery. The following themes were identified: (1) Increased Staffing, (2) Improved Utilization, (3) Education (4) Funding and Increased Resources (5) GNP Role Promotion Increased Staffing, Improved Utilization and Education. Participants indicated that there was an overall need for more health care practitioners in gerontology and these practitioners needed to be available and easily accessible to employers and clients. There was a perceived need for increased staff education on the complex issues surrounding gerontology and how to care for the elderly in a holistic manner. Increased education for geriatric health care practitioners was an issue that needed to be addressed in order to improve the services available to the elderly in the Hamilton-Wentworth Region and surrounding areas. Those health care practitioners already involved in the field of gerontology needed to continue their professional education in order to meet the growing and complex health needs of their client population. 7

Funding and Increased Resources. Participants felt that increased funding for community resources and LTC could improve available services, allowing for faster and more effective service delivery. Resources such as home care, home visits and Community Care Access Centre (CCAC) services would be essential to provide complete care to the growing elderly population. Salaries for GNPs that reflected their true worth within the health care system was also an area of concern. Given the complex health needs of the geriatric population and the time and effort needed to investigate and care for these problems, a salary that would compensate GNPs properly could attract more candidates. As well, with more services available and fewer waiting lists, discharge care could be co-ordinated more efficiently than at present. GNP Role Promotion: The respondents felt that there needed to be a clearer definition of the NP role generally and the GNP role specifically. As well, education for the public around expectations of health care providers and the care providers role within the health care system should be initiated. All survey respondents thought a GNP could help improve the care of older people. They identified the following GNP role functions to improve the care of the geriatric population: holistic primary care, prescribing/reviewing medications, direct access and increased appointment time, improved specialized care and program development, collaborative practice and appropriate referrals. There were a number of barriers that respondents identified related to implementing the GNP role. These included: (1) Lack of Support, (2) Funding, and (3) Access to Education 8

Lack of Support: There was a perceived lack of support for GNPs from the public, the government, physicians and other health care professionals as well as within the nursing community. (Authors note: Funding has been available for PHCNPs in LTC positions, but the MOHLTC has been slow in securing permanent funding for NP positions and there have been long standing problems associated with NP practice and physician payment mechanisms, specifically fee for service payment, questions of malpractice coverage, not to mention the lack of a public marketing campaign about the NP role (Nurse Practitioner Association of Ontario [NPAO], 2003; Registered Nurses Association of Ontario [RNAO], 2002; 2003). This lack of support might make it difficult to attract people to the role of GNP. Increased support from government and within the health care field would assist in attracting and increasing the number of candidates to a specialized role) Funding and Access to Education: Participants felt that the wages and programs currently available for GNPs do not make this career attractive. In addition to salary discrepancies (i.e., current salary variance is $55-90,000/yr), there are currently no specialty GNP programs within Canada, making preparation difficult and costly to obtain if students move to or take specialty NP programs in the U.S.. The salaries offered do not reflect the time and preparation needed for this role that is necessary in order to provide safe, effective health care that includes assessing, diagnosing, reviewing and evaluating care provided. Finally, participants were asked to suggest strategies to encourage interested persons to pursue a career as a GNP. These strategies included: (1) Education 9

Opportunities and Reimbursement, (2) Recognition and Support from the Nursing Community and others. Education Opportunities and Reimbursement: Bursaries, scholarships, placement opportunities, flexible schedules to accommodate work and school, and access to local education programs were all cited by participants as ways to make this career more attractive. As well, increased salaries for GNPs, whose role is a blend of nursing and medicine, were cited as a way to encourage more people to consider GNP as a viable career choice. Recognition and Support from the Nursing Community and others: Some participants suggested that increased support from the government, the public, physicians and other health care professionals would increase interest in the role of GNP. The College of Nurses of Ontario (CNO) and the Registered Nurses Association of Ontario (RNAO) support, as well as marketing of the role and identified role models within the NP community were identified by participants as ways to make the role of the GNP more attractive to interested parties. Discussion The study clearly demonstrated that health care professionals practicing in gerontology perceive there is a need for GNPs locally and in Ontario. Healthcare providers are becoming increasingly unable to meet the complex and ongoing demands related to caring for the elderly. The results of the survey and the themes generated are not surprising, given evidence from the literature supporting the NP role and support from the current MOHLTC for NP positions. Funding, access to education, and support from other professionals are common barriers and are not easily breached in today s political climate. 10

Based on the results of this survey, the following suggestions and recommendations were generated. 1. Increased funding from the MOHLTC to implement a GNP program. While there are approximately 300 GNP programs in the USA (Fulmer, Flaherty & Medley, 2001), there are currently no specialized NP programs within Canada. This makes specialization within a specific discipline difficult, timely and expensive to achieve. The implementation of a specialized GNP program could potentially help alleviate some of the barriers found from the survey. Funding continues to be an issue facing the healthcare system and for NP preparation. Currently, the College of University Programs in Nursing (COUPN) has started offering continuing education nation-wide for NPs or RNs working in expanded roles. One of the courses offered is Continuing Care of the Elderly. This course could be complementary to practitioners practicing in gerontology and could lead the way for more specialized preparation in NP programs in the future. The results of this survey could be used as a basis for seeking additional provincial funding for the COUPN program and continuing education of NPs. 2. Increased publicity about the role of the GNP to increase public support and support from other healthcare professionals There has been until recently a clear lack of support for GNPs within the healthcare system. Role development in LTC and emergency settings is promising but needs to be sustained. Physicians, nurses and other healthcare professionals and organizations, such as the RNAO, could lobby with government for GNPs. Additionally, the role of the GNP, because it does not formally exist in the province, is not clearly defined. Such role confusion contributes to a lack of support and understanding from the general population. Marketing of the GNP role and scope of practice and how the GNP can fill current system 11

gaps would increase understanding and awareness for the general public and among other healthcare providers. The CNO could also be approached regarding their position on regulation of specialty NP roles such as the GNP 3. A clear and accurate definition of the GNP role within the provincial healthcare system As was previously mentioned, the lack of a clear definition of the GNP and scope of practice is partly responsible for the lack of support. The CNO and other regulatory bodies need to define the GNP role and regulate GNP practice. 4. Work/study cooperative opportunities to allay some of the costs incurred during study and increased grants, bursaries and scholarships for educational preparation. Time and money are necessary for the pursuit of a career as a GNP. Work/study cooperative opportunities that are flexible and accommodate other personal commitments such as family and employment and increased financial aid would make this a more attractive career for interested candidates and would also alleviate some of the financial burdens faced by those pursuing a GNP career. Changes in salary structure to reflect the value of the GNP role would also assist in attracting GNPs. Current salary structures do not reflect the work of the GNP and make this career less attractive than others within the healthcare system. 5. Increased communication between community resources to facilitate follow-up and discharge recommendations. Currently, communication between community and in-patient resources is lacking, making follow-up with the elderly client difficult. This further complicates discharge planning for the GNP and the client. A more streamlined and seamless system, where all have access to available services could make discharge planning and community follow up 12

easier and more efficient and may reduce the need for readmissions, thus reducing overall healthcare costs. Strengths and Limitations The survey was developed through a collaborative process among faculty, BScN students and health care providers with a background in research and gerontology. While the survey instrument did not undergo stringent validity and reliability testing, the consistency of answers throughout data collection suggests respondents had a good understanding of the survey s purpose. Data analysis identified clear and consistent themes. Technical difficulties with regard to filling out the email form and incorrect email addresses were possible reasons for the low response rate from ACNPs. Additionally, this project was conducted with no additional funding and relied on students to collect data and recruit respondents. The sample size was small and therefore findings may not be generalizable to all parts of Ontario or to Canada. Since ACNPs were included in the sample, their views may have been favourably biased toward the need for a GNP. A future survey restricted to non-nps involved with geriatric care and/or including known PHCNPs and ACNPs working in geriatric care would be helpful to compare findings with our survey. Conclusion Ontario needs more healthcare providers that are familiar with the unique and often complicated needs of the elderly population. A specialized NP program stream, offering preparation as a GNP could assist in filling the current service gaps and eliminate some of the barriers currently faced by nurses interested in pursuing such a career. The overall benefits of such a program would be seen not only in patient satisfaction, but also in the value of specialized knowledge that may reduce readmissions to hospital and improve the 13

overall health of the elderly population. As the population continues to age, the implementation of GNPs within the healthcare system becomes an increasingly urgent issue. Current shortages in healthcare will continue to increase unless new and cost effective strategies are developed and implemented. Promoting and encouraging the GNP within Ontario s communities is one of these strategies. 14

References Blay, S., Clifford-Middel, M. & McCuaig, J. (2001). Integrating the nurse practitioner into long-term care: A collaborative partnership. Perspectives, 25(4), 12 18. Burnard, P. (1991). A method of analysing interview transcripts in qualitative research. Nurse Education Today, 11, 461-466. Borrie, M.J., Dalziel, W., Fisher, R., Molloy, W. & Puxty, J. (2003). Letter to the editor. Canadian Medical Association Journal, 169(8),752. Carlson, E. (1998). What s happening: Emerging roles for the gerontological nurse practitioner. Journal of the American Academy of Nurse Practitioners, 10(9), 403-405. City of Toronto, (2002, October 1-3). Community Services committee report No. 8, Clause No. 6. Toronto City Council. Retrieved July 19, 2003, from: http://www.city.toronto.on.ca/legdocs/2002/agendas/council/cc021001/cms8rpt/c 1006.pdf. Downing, T. (2004, June). Geriatric emergency management. Hospital News. Retrieved July 8, 2004 from http://www.hospitalnews.com/modules/magazines/ Dyer, C.B., Heyer, K., Feldt, K.S., Lindemann, D.A., Busby-Whitehead, J., Greenberg, S., Kennedy, R.D.& Flaherty, E. (2003). Frail older patient care by interdisciplinary teams: A primer for generalists. Gerontology & Geriatrics Education. 24(2), 51-62. Fulmer, T., Flaherty, E. & Medley, L. (2001). Geriatric nurse practitioners: Vital to the future of healthcare for elders. Generations, 25(1), 72-75. Heart and Stroke Foundation of Canada. (1999). The changing face of heart disease and stroke in Canada. Ottawa: The Foundation. Kovner, C.T., Mezey, M. & Harrington, C. (2002). Who cares for older adults? Workforce implications of an aging society. Health Affairs, 21(5), 78 McDougall, G. & Roberts, B. (1993). A gerontological nurse practitioner in every nursing home: A necessary expenditure. Geriatric Nursing, 14(4), 218 220. Ministry of Health and Long Term Care. (2003). Ernie Eves government s commitment to long-term care in Ontario. Retrieved July 19, 2003, from: http://www.health.gov.on.ca/english/public/updates/archives/hu_03/hu_ltc.html. National Organization of Nurse Practitioner Faculties (NONPF) (2002). Nurse Practitioner Primary Care Competencies in Specialty Areas: Adult, Family, Gerontological, Pediatric, and Women s Health. Washington, DC: NONPF. 15

Nurse Practitioner Association of Ontario (2003). Annual General Meeting Report. Toronto: NPAO. Retrieved February 21, 2005 from http://www.npao.org Registered Nurses Association of Ontario (2002, September 24). Government funding for Nurse Practitioners excellent - and obvious - answer to improving public access to health-care services (media release). Toronto: Registered Nurses Association of Ontario Retrieved February 21, 2005 from http://www.rnao.org/media_room/releases/ma_092402_nurse_practitioner_anno uncement.asp Registered Nurses Association of Ontario (2003, May 15). Government s roll out of 117 nurse practitioner positions important step to improving public access to healthcare services (media release). Toronto: Registered Nurses Association of Ontario. Retrieved February 21, 2005 from http://www.rnao.org/media_room/releases/ma_150503_nurse_prac.asp Statistics Canada. (2003). Population aging. Retrieved August 12, 2003, from: http://www.statcan.ca. Thompson Gow & Associates. (2000, February 11). Impact of population aging on health care spending in Ontario. Prepared for the Ontario Hospital Association. Retrieved July 19, 2004, from: http://www.oha.com/oha/reports.nsf Turpie, I. (2001) Provision of geriatric medical services. Unpublished manuscript, McMaster University, Regional Geriatric Program, Hamilton, Ontario. 16

Figure 1 Survey Perceptions of the Need for the Geriatric Nurse Practitioner Your area of practice (optional): 1. What do you think are the gaps in service delivery in care of the elderly today? 2. What do you think could be done to improve service delivery? 3. Have you worked with a nurse practitioner in the past? Check the box that matches your answer. Yes No If yes, where? 4. Do you think there is a need for a Geriatric Nurse Practitioner in primary health care? Check the box. Yes No 5. Do you think the Geriatric Nurse Practitioner could help improve care to older people? Yes No If yes, what kinds of activities do you see the Nurse Practitioner doing? 6. What do you think stops most nurses from pursuing gerontology as a nurse practitioner specialty? 7. What do you think are the three most significant barriers to implementing the GNP role? 17