A bunch of brave nurses and their NGO employers are “pioneers” for the nurse practitioner role in aged care. FIONA CASSIE finds out more
Back in 2003, American-trained Michal Boyd became the country’s first gerontology NP. By early 2009 the country had 50 NPs but only one more had joined her in aged care... and fellow-US-trained Liz Langer specialised in older adult mental health.
The NP movement has been slow to get off the ground in all fields and in the already stretched aged care sector Boyd says it has been a “hard, hard row to hoe”.
But momentum has been building. Last month Deb Gillon (see other story) became the country’s 66th NP and the seventh in aged care, giving the sector five generalists plus two in mental health.
As Boyd puts it, the aged care NP movement is starting to tumble forward as more people in the sector grasp the vision.
“I think there’s more of an understanding and much more of an appreciation of what NP can bring to the mix.”
But until Deb Gillon it has always been those candidates backed by district health boards that have made the leap. For the non-DHB sector “it’s just a lot more difficult”.
Pioneers for developing an NP role in the NGO (non-governmental organisation) sector got a boost with government-backed innovation funding in 2008. But the last of the NP facilitation/innovation grants was given out in 2009 and, while the Ministry of Health says it fully supports the role of NPs in the aged care sector, there is no similar government funding on the horizon.
Among the proposals funded under the NP Facilitation programme in 2008 was the joint proposal by Masonic Villages Trust and Presbyterian Support Central to support developing an NP role. And also a proposal by Presbyterian Care Southland to develop a business case for an aged care nurse practitioner working in the community.
Sylvia Meijer of Masonic Villages Trust recalls people looking at her sideways when she first talked about becoming NP. That was just five years ago. But slowly and steadily one of the pioneers for the role in the NGO-sector has gained the employer, funding and wider network support she needed to submit her portfolio for Nursing Council approval. So now, in just a few months time, she faces the final hurdle to becoming a prescribing nurse practitioner – the Nursing Council interview panel.
Meijer likens it to a “cottage industry” approach, slowly building a path for herself rather than asking for or expecting change tomorrow, but with 25-plus years, experience in aged care nursing she believes the commitment will be worth it.
Meijer originally trained and worked as a registered nurse in the Netherlands. On arriving in New Zealand she was first a supervisor at a local hospital and then added palliative care and district nursing to her bow before working for Levin’s Masonic Villages Trust where she is clinical services manager.
Over her nursing career she started to see the gaps in care for older people and so focused her master’s degree study on the assessment of older people. Her study highlighted the frustrations that could arise from fragmented services and older people – suffering from chronic conditions, depression and loneliness – falling through the gaps and adding to the burden of health care. She started to see the NP role’s real potential to make a difference.
Her employer, Masonic Villages Trust chief executive Warick Dunn, first heard of NP during a conference presentation by Michal Boyd a number of years ago and became convinced it was the right thing for the residential care sector – because of, rather than despite, the chronic nursing workforce shortages.
“I think from a future workforce development view it is crucial that we can attract capable and talented people into aged care,” Dunn says. “I think having a clear career pathway is part of that.”
The catalyst for action was accessing the innovation funding, though he says it still felt like a big step for the trust and its project partner in developing a NP role, Presbyterian Support.
“But I think if the residential aged care sector is going to progress and continue to improve the clinical aptitude of its nursing staff then somebody needs to make the step.”
Meijer quickly found that she could not fulfil her goal in isolation and built on close links with the local PHO and supportive district health board, as well as developing her clinical skills with local GPs, NPs and senior clinicians serving the area.
Dunn acknowledges the process has been more time-consuming and complex then first envisaged, and as a small NGO with tight resources he was aware that Sylvia had to put in an “enormous amount of personal time” to get to the stage they were at.
Julia Russell, one of the initiators of the Presbyterian Support Southland NP proposal, is also very aware of how short time is in the pressured NGO sector when they are “constantly battling not having enough staff at all levels”.
The registered nurse and director of services for older people said it would have been “very easy” to have put pursuing the NP role in the too hard basket, but through their master’s study she and prospective NP candidate Margaret O’Connor saw the great potential for the NP role in aged care.
Also helping the momentum was access for nurses in the non-DHB sector to Clinical Training Agency funding, which has fostered a number of staff into postgraduate study. And Russell has nothing but praise for the work of Michal Boyd in Waitemata in sharing the resources developed as part of its programme of taking geriatric nurse specialists (GNS) into the residential aged care sector.
But it was the innovations grant funding that gave the pair the opportunity to do a “huge amount” of learning about what NP services could provide for Southland, and they found enough service gaps and fragmentation issues in their own organisation to employ far more than one NP.
The goal of their innovation project was to develop a business case for launching a NP-provided community service – a big step for the predominantly facility-based organisation, but one for which they saw a distinctly real need.
The business case is ready but Russell acknowledges the last two hurdles are daunting – getting the funding to create the service that the NP position would deliver, and getting their candidate successfully through the registration process. “We’ve watched excellent candidates not getting through the process the first time.”
They are not alone in their concern. Boyd supports a Nurse Practitioner Advisory Committee proposal to formalise and fund an “intern” or “registrar” process for NP candidates to give them the clinical training, supervision and support needed to be successful candidates. Waitemata District Health Board – where Boyd is employed – and MidCentral District Health Board have already developed their own intern programmes but NPAC is proposing a standardised model similar to the government-funded registrar models for training surgeons and medical consultants.
Getting funding for such an intern programme is “absolutely essential”, says Boyd, particularly for the residential aged care sector.
As pioneer nurses and employers in the NGO sector both Meijer and Dunn definitely see the merit of such support.
Sylvia acknowledges resources – workforce and financial – are always tight in the sector but that does not mean change should not happen. For NPs to become mainstream, she argues, action has to happen so that the sector can see the value of the role at a time when the older population is set to increase dramatically.
The stalwart pioneer wants to be there as a role model: monitoring, treating and preventing those exacerbations which can see residents become so terribly unwell. That is, after all, one reason why she completed extra prescribing papers and practicum – so she can prescribe the much-needed antibiotic on a Friday afternoon that stops an infection getting out of control.
But she also completed that area of education in order to learn about polypharmacy – the impact of the combination of drugs that older people are often prescribed. By being informed, she can have a good discussion with the whole health team – including GP and pharmacist – about the necessity or otherwise of the different drugs in the mix. And she can increase the education of RN staff about medication use in general and the reasons for stopping or changing various drugs. “Prescribing makes the picture complete.”
Boyd agrees, saying research in the US and Canada shows the NP model in aged care can have a positive impact on older adults’ health. “Over and over again it’s about family satisfaction,” says Boyd. “Families love working with NPs – it just increases family satisfaction greatly.”
She says the development of NPs in the sector is not about replacing GPs, it is about having a dedicated aged care service that can help out hard-pressed GPs.
The other hurdle faced by the NP movement in general, but particularly aged care, is getting the funding to provide a NP service. Boyd says a positive move would be to review DHB contracts for residential aged care to allow NPs to do work currently restricted to GPs.
Martin Taylor, chief executive of the New Zealand Aged Care Association, says the organisation is very supportive of the NP role as there are GP supply problems in some areas and an increasing number of prescribing NPs could fill that gap.
Likewise Dwayne Crombie, chief executive of BUPA which runs 45 rest homes and hospitals nationwide, says the “incredibly variable” level of GP support available to the sector means it must find an alternative. He says the problem is the lack of NPs being trained and acknowledges that it will take a combined effort by boards, the ministry and larger employers like his own to support NP candidates.
Taylor and Crombie are both hoping, like Boyd, to see DHBs’ Aged Resident Care (ARC) contracts revised to allow NPs as well as GPs to meet regular medical review requirements. The ministry, in response to Nursing Review questions, said it was open – where appropriate – to the contracts being reviewed. It pointed out that reference is made in the current contract to NP prescribing rights but “would support consideration of any other constraints to nurses fully practising in their role”. However, the contract was a DHB document, not a ministry document.
Meanwhile, the pioneers want that momentum to keep on tumbling forward and creating more NPs in the aged care sector.
NPs in Aged-Care/Older Person’s Health
Dr Michal Boyd – Waitemata DHB
Katie Bolton – MidCentral DHB
Mary Daly – Hutt Valley DHB
Denise Thatcher – Auckland DHB
Deb Gillon – Nurse Maude, Christchurch
NPs in Older Adult Mental Health
Liz Langer – Otago DHB
Trish Rasmussen – Canterbury DHB
NP candidates before Nursing Council this year
Janet Parker – Waitemata DHB
Sylvia Meijer – Masonic Villages Trust
