Improving Care through Development of a Nurse-led

Clinic

Lesley Maskery Nurse Practitioner Candidate

Capital & Coast DHB, Wellington, NZ

Previous CPN Role

• Level of care assessment

• Nursing interventions

• Resource for Primary Care and colleagues in RACF’s

• Family/carer support

and education

Developing a Nurse Practitioner role

• Is there a need for an advanced nursing resource in your area of practice?

• Does this fit with the organisation’s strategic plans?

• The existing workforce must also be willing to change shape to accommodate this new role

• “To use Nurse Practitioners in a purely substitutive way that simply shores up the existing model of medical care is a waste not just of NP talents but of the potential to transform the way we do things.”

Prof Jenny Carryer

Preparation for NP Role • Registered Mental Nurse (UK)

• Diploma In Nursing (UK)

• Community Psychiatric Nurse Certificate (UK)

• BSc Community Health Care Nursing (UK)

• Masters degree in Health Science (UK)

• Extra papers in Pathophysiology, Clinical Assessment, Pharmacology, Therapeutics and a Prescribing Practicum (gain Comprehensive RN registration in the process) (NZ)

• 4 years minimum experience (30+ years should do it…)

• Develop business case

• Gain approval for NP Candidate position

• Develop NP role

• Present portfolio to Nursing Council NZ

Nurse Practitioner Candidacy

• 2 year “Internship” to develop an advanced nursing role within the Older Persons’ Mental Health Service

• Input into neighbouring DHB to support service with limited resources.

• Support for Aged Residential Care sector

• Educational role

Gaps in Service within High Dependency Level Care

• Specialist PG follow-up only provided on referral

• No automatic reassessment of level 2 funding

• No incentive for facilities to request reassessment of level of care

Context • 2013 - the New Zealand Framework for Dementia

Care (Ministry of Health 2013)

• Guide for development of Dementia Pathways

• Shift of emphasis from secondary to primary care

• Workforce education should be supported by the health and social support service providers.

• Family & whānau support

Areas for nursing development • Regular support for RACFs

• Collaborative care

• Non-pharmacological interventions

• Evolving role of the nurse in medicines management

•Review of psychotropics

•De-prescribing of anti-psychotics

•Education for colleagues in RACF’s

•Reporting Adverse Drug Events & encouraging colleagues

•Resource for primary care

•Resource for families & whānau

Paradigm shift

• Doctor’s Handmaiden to Autonomous Practitioner

• Requires a change of mindset – hard to do!

• E.g. “Drugs & Diagnoses are the Domain of Doctors”...

What does it look like?

Primary Care

NP

RACF

Pt & Whānau

Evolution

• Clinic documentation developed following consultation with Clinical Managers and GP

• Section on key life events included at carers request to help staff see the person not the patient

• Specific time allocated for family meetings

So Is It Useful?

• Specialist support for staff providing care to residents with the highest level of need

• Regular review of psychotropic medications

• Timely reassessment of level of care

What have we achieved?

• 158 patient reviews in 3 facilities over 10 months (56 different patients)

• 1 medication error detected

• 3 patients reassessed to Hospital Level care

• 2 patients discharged home

• 6 family case conferences

• Level 2 funding:

• 6 applications

• 43 reviews

• 3 discontinuations

References

Prof J Carryer, 2012, Executive Director College of Nurses, Aotearoa (NZ), presented at NPNZ Conference 2012

Ministry of Health, 2013, New Zealand Framework for Dementia Care.Wellington: Ministry of Health.