Aged care supporting NP interns

1 November 2011

FIONA CASSIE interviews two nurses appointed to the country’s first NP intern positions in the residential aged-care sector at providers Bupa and Selwyn.

From Dublin with love

A lilting Irish accent has won over many a patient for NP- in-the-making Claire Mooney. “They love it, they absolutely love it,” says Mooney who moved from Dublin to Auckland in 2010. The gerontology nurse specialist joined Bupa in April this year to take up the provider’s newly created clinical nurse specialist/nurse practitioner intern position.

For Mooney it was a logical step to start on the nurse practitioner pathway after 13 years working in gerontology back in Ireland, the last three as a clinical nurse specialist in the field.

Her new job with BUPA sees her working locally to give clinical support to nurses in Bupa’s 12 Auckland care homes and nationally to support policy development and the professional development of Bupa’s 300 qualified nurses. She is based in the Auckland office where she reports to Gina Langlands, quality and risk general manager.

Belfast-trained Mooney was drawn to working with the elderly early in her career following a transfer from intensive care to a continuing care ward in a major acute hospital in Dublin. “Just after a few weeks of working there is when I realised it was where I was meant to be.” She not only enjoyed the work, she very much enjoyed the people. “I found them very wise and they’ve got so much we can learn from.”

Clinically she found it “hugely challenging” and very rewarding. “I found in gerontology you need to have skills in every condition ­– orthopaedics, haemotology – you are encompassing the whole spectrum of illnesses and conditions.”

She went on to do further study in Dublin, completing her degree and a postgraduate diploma in gerontological nursing. Her jobs in gerontology have included working as a clinical nurse manager in an Alzheimer’s clinical trial and time in a cognitive studies clinic. Her last post was three years as a clinical nurse specialist in the residential sector, before moving here to take up a needs assessor position at Auckland District Health Board.

She says if she had stayed on in Ireland, her next step would have been to become what Ireland calls an advanced nurse practitioner, so the Bupa position seemed a good step.

Her new role is still very much a work in progress as she familiarises herself with Bupa homes and her new national role, before formally stepping on the NP pathway early next year as she starts her master’s degree studies.

Mooney says all of the clinical issues in residential aged care in New Zealand appear to be very similar to those in Ireland. The one major difference is that the vast majority of residential aged care in Ireland is provided by the public sector rather than private or NGO providers.

In 2008, the Fair Deal initiative saw Ireland’s health inspectorate service set up new residential care standards across the public and private sectors, including setting guidelines on how older people should be treated, how they should have their medical needs met, and the need for person-centred care. “It was to raise standards across the board in the Irish residential aged-care sector.”

The two countries also have the same dynamic of increased support to keep people in the community, leading to higher acuity when people did enter the residential care sector.

Just six months into the job, Mooney has already run nine nurse training sessions across the country in her role as clinical advisor to the 45 Bupa homes. Plus she has initiated a two-monthly clinical newsletter – first topic: pain – which will include a clinical crossword as a fun way to promote learning.

In her local role, she is spending as much of the week as she can week visiting the Auckland homes where she is supporting senior nurses in multidisciplinary resident reviews, offering advice on healing complex wounds, teaching on requested topics and generally trying to see what gaps in clinical support she can help fill.

With her orientation nearly complete, she is readying herself to start her NP internship in earnest next year by attending a weekly ‘earlybird’ gerontology nurse specialist group run by aged-care NP Michal Boyd.

“My aim is to submit my portfolio to Nursing Council within two years.”

She starts her clinical master’s papers with The University of Auckland next year and will also start to tailor her daily work accordingly as she builds her portfolio of evidence to prove she has met the Nursing Council competencies for NPs. It is going to be busy, but Mooney says she is happy to be back using and developing her specialist skills to help the elderly. Even if the Kiwi hard of hearing don’t always pick up what she says first time. Mooney laughs and recalls one resident saying, “I don’t know what she said but I like how she said it.”

Isabella Wright is a nurse with a passion for gerontology who saw a gap she’s keen to help bridge. That gap was in the health services for aged-care residents created by the GP shortage in Auckland – particularly after-hours care.

Wright is now a nurse practitioner intern for Selwyn who aims to improve in-house care of the elderly as a prescribing nurse practitioner.

She had decided that NPs were the future for residential aged care when, nearly two years ago, Selwyn advertised for a clinical nurse specialist, possibly on the NP pathway. Wright jumped at the chance. Within a few months, the position became an NP internship and she is now determinedly heading down the pathway to seeking registration as a prescribing NP in aged care.

The enthusiastic advocate for the elderly says her internship has not only seen her clinical skills deepen but she is also making a profound change to the nursing culture in Selwyn.

The first NP was registered in 2001, but it was only relatively recently that Wright decided it was the role for her. She has been nursing for more than 20 years, largely in gerontology, and her previous role was as a clinical nurse specialist overseeing the clinical care of 90 residents.

The provider and Wright wanted to offer the best possible care to residents, but doctor shortages meant GPs were increasingly unavailable after hours or at the weekend. Being able to keep residents home when their condition was not complex or severe enough to need acute hospital care was the aim and a prescribing nurse practitioner seemed an answer.

“Sending elderly residents – particularly with dementia – to a big hospital is quite distressing for them. It can increase their delirium and cause other problems,” Wright said. “If we can do as much as we can in-house that’s a big step… of course you have to know your limitations, but people needing chest x-rays or intravenous antibiotics, that can be done in-house at residential facilities.”

Wright made contact with gerontology NP Michal Boyd – like Claire Mooney she also attends Boyd’s ‘earlybird’ gathering of gerontology nurse specialists – and decided becoming an NP was the goal for her.

“She’s pretty inspirational for encouraging and supporting people to achieve their goals,” says Wright. “She’s just been a breath of fresh air really.” Wright had already completed a master’s degree in public health, but was grateful for the support of Boyd and her other NP mentor Helen Bowen in helping to guide her through the additional clinical and prescribing papers she needed to seek NP status.

Also important was the backing of Selwyn’s head of residential care services, Hilda Johnson-Bogaerts, and CEO Duncan Macdonald, to ensure she had the clinical experience to support her academic study and the time to meet weekly with her medical mentor, Selwyn’s head of medical services Dr Bart Nuysink.

“Aligning your clinical practice and academic study is very important as the study can be overwhelming... but if you can line it up, you won’t be so overwhelmed by what’s in front of you.” Eighteen months into her internship, she can now see the light at the end of the tunnel and hopes to be ready to submit her portfolio in the second half of next year.

Wright is also clear that her role and training is making its mark. “It’s been really astounding watching the nursing culture in the organisation change.”

She says as part of her role, she has done a lot of bedside teaching as well as large group teaching to Selwyn’s nursing staff in its 11 homes in Auckland, Hamilton and Whangarei. “For them to know that there’s someone they can refer to… the strength in clinical leadership has made a huge difference to the nurses.”

Wright says there was no resistance to the role from facility managers, and in a very short time she was receiving referrals to help resolve chronic wounds that wouldn’t heal or behaviour management problems.

Teaching nurses how to assess and treat chronic wounds was a win-win situation for facilities, as wounds healing faster not only saves time and expensive dressings but also improveds the quality of life for residents, Wright says.

About two-thirds of Wright’s time is clinical, with much of the rest of her time spent working on quality and management issues – like reviewing operating procedures.

She has also organised two annual gerontology conference with prominent guest speakers for Selwyn nurses. About 100 registered nurses attended the last gathering which Wright says played an important role in bringing nurses from diverse facilities together to bond as a team.

Meanwhile, she keeps working away on her NP portfolio, following a wise piece of advice from her mentors to collect clinical studies and evidence as she progresses along the NP pathway.

She is keen for others to follow her but is conscious that the biggest deterrent for more NP internships in residential aged care is having to fund the training themselves. Also, once registered, NPs working in the residential aged-care sector are not eligible for the same funding streams as GPs called in to see a resident. “You really have to have that strong drive to make an impact on nursing practice… you have to have that passion. And a lot of support is required. I get that from Selwyn and my colleagues,” says Wright. “It’s not an easy pathway but it is incredibly rewarding.” She remains optimistic that other potential NPs will join the pathway to help close that care gap.