An NP in the community

1 March 2010

FIONA CASSIE talks to DEB GILLON, one of the country’s newest NPs in one of the rarest roles – an aged care NP in the community

One suspects that “Nurse Maude” might approve of Deb Gillon. Back in 1896 feisty nursing pioneer Sibylla Maude left her job as Christchurch Hospital matron to take nursing to the community. Nearly 115 years later, Deb Gillon and the Nurse Maude Association have pioneered a community role for its first aged care nurse practitioner (NP).

Like Sibylla back in 1896 there is currently only one of Deb but Nurse Maude’s association now has 1300 staff offering a diverse range of district and specialist nursing and support services. (And a fleet of cars rather than bicycles or foot as first favoured by the stalwart Sibylla.)

Also like Sibylla, Deb is focused on some of the community’s most vulnerable members – in Deb’s case the frail elderly with complex health and social needs. She brings her specialist skills to people’s homes to work with them and their family to help better meet their needs and, frequently, their desire to remain independent as long as possible.

It’s a job she relishes. “I just simply love working with older people…there’s something magic about it.”

Deb and Nurse Maude first began developing an NP role in February 2005 but a change in pathway meant Deb did not seek and receive Nursing Council approval until February this year.

With two decades or more of aged care nursing and education under her belt, Deb has been interested in advanced nursing roles since they were first discussed in the 1990s. So when Nurse Maude unsuccessfully advertised for NP and decided to grow its own, the master’s graduate was quick to put her name forward.

Initially the part-time NP “intern” role was focused on working in Nurse Maude Memorial Hospital, with patients requiring long-term hospital-level care, and early results showed an overall trend toward reduction in infection rates, falls and the use of restraints. Deb also continued to teach advanced nursing assessment and – because her master’s was by thesis rather than a clinical degree – she completed a postgraduate diploma in clinical nursing.

She was readying herself to present her portfolio to the Nursing Council when, in 2008, it was decided that the NP role could have more impact if working out in the community. It was the right decision, according to Deb, but she had to take a deep breath and start again to build the clinical and support networks to work across the community.

She has no regrets about the move and says supporting the frail and vulnerable in the community is worthwhile.

Now full-time, she has a caseload of 12 to 20 cases on her books at one time and five to six patient-related contacts a day. Her patients can be referred by any one of Nurse Maude’s specialist nursing services (from wound care to continence) or from GPs, but most come via the association’s extensive district nursing service.

The patients have in common that they are frail with complex needs. They may not be coping living alone and their problems can be compounded by loneliness and social isolation. They are patients who require more time and assessment than a busy district nurse or GP can often provide and the aim is to reduce preventable hospital admissions and to keep them healthily and happily at home.

An example is a woman referred to Deb by a GP. The woman had cellulitis and, with no support in the home, was not managing her medication or feeding herself adequately. Her family were worried about her but she was reluctant to let anybody into the home.

“I was able to support her to accept a short hospital placement for her cellulitis and then to work with her and her family to plan her discharge and return home.”

The woman’s wound healed but she was very fragile and it was recommended that she move into permanent residential aged care. But Deb, with her family, supported her decision to return home and set up support services to provide personal care, meal support and medication management systems. “It was important to her dignity.” The support meant she had six more months at home and it gave her time to accept change on her own terms and also support the family to work through the process.

Deb says a lot of stories are similar. Using her advanced clinical assessment skills and experience, she works alongside the elderly and their families or whanau to better manage their often multiple chronic conditions and help identify what supports they need.

Building networks were essential so she could refer, collaborate and seek advice from other health professionals in the multi-disciplinary team and also with the myriad of services, particularly the district health board’s, and support organisations involved in the aged care sector.

Deb praises the foresight of Nurse Maude in creating the intern position and giving her the flexibility and opportunity to build those networks and to deepen and widen her clinical skills. Pivotal to that was having a geriatrician doing a fortnightly case review of her work.

With the support of Kathy Peri, Canterbury District Health Board’s director of nursing for older person’s health services, she spent time working with their community team and a geriatrician on the orthopaedic ward. There was also a stint at the board’s memory clinic and working with its psychiatric services for the elderly, looking at depression and delirium services.

The networking has also helped her work across the primary and secondary sectors as she will follow her patients if they are transferred into hospital, usually meeting with the nurse and doctor team on the ward and being closely involved with discharge planning and family meetings.

Deb’s role includes quality initiatives in Nurse Maude itself like auditing services, a recent example being the examination of the prevalence of pressure ulcers in the community, and developing new nursing assessment documentation.

Like all working in the aged care sector, there is no shortage of work, just a shortage of hours and staff. “There is only one of me and we need more.”

Which is one of the reasons Deb remains committed to educating the next generation – both through teaching an advanced nursing assessment course for the University of Otago and supporting professional development for Nurse Maude staff and beyond.

Attracting and retaining staff in aged care is always an issue but Deb believes creating a career pathway through to geriatric nurse specialist and on to nurse practitioner is a big step forward.

As an educator as well as aged care specialist, she has been keen to showcase to young and emerging nurses that there are advanced roles in aged care.

But she acknowledges that for the often fragmented nursing workforce in the residential aged care sector it can be a struggle to keep enough staff let alone foster professional development.

She points to the wonderful job being done by aged care NP Dr Michal Boyd in Waitemata DHB in setting up a geriatric nurse specialist service that supports nurses in residential aged care. “I think that’s been a tremendous step forward and more emulation of that would be great for both nurses and patients.”

In her own role Deb supports the development of district nursing staff so they too can extend their practice and know how to access help from the wider service network.

Asked for advice on how to follow in her footsteps in becoming an aged care NP, Deb initially just laughs, as it is has been just days since she became an. NP herself.

She says you need a supportive employer, support from the wider nursing community and to develop networks with the multi-disciplinary team and beyond.

Having senior nurse leaders supportive of her journey opened doors and in Christchurch she has been part of a bunch of would-be NPs with Deb being the fourth in Christchurch to succeed so far.

But if you ask her whether the journey was worth it Deb – who says she “couldn’t stop smiling” when told she had become the country’s 66th NP – smiles again and says “it’s great”.

Sibylla Maude would probably have agreed.