Japanese nurse practitioner practice and outcomes in a nursing home M. Ono1 RN, PhD, S. Miyauchi2,3 MA (TEFL/TESL), Y. Edzuki4 RN, PHN, MSN, K. Saiki5 PhD, H. Fukuda6 RN, PhD, M. Tonai7 RN, PhD, J.K. Magilvy8 RN, PhD, FAAN & S. Murashima9,10,11 RN, PHN, PhD 1 Professor, 4 Assistant Professor, Division of General and Gerontological Nursing, Department of Specialized Nursing, 2 Reader, 3 Associate Professor, Division of Linguistics, 5 Professor, Division of Health Informatics and Biostatistics, Department of Human Sciences, 7 Professor, Division of Nursing Assessment, Department of Basic Nursing Sciences, 6 Associate Professor, The Center for Nursing Education, Research and Collaboration, 10 President, 11 Chair of the Board of Directors, Oita University of Nursing and Health Sciences, Oita, 9 Professor Emerita, Department of Community Health Nursing, University of Tokyo, Tokyo, Japan, 8 Professor Emerita, College of Nursing, University of Colorado, Aurora, CO, USA
ONO M., MIYAUCHI S., EDZUKI Y., SAIKI K., FUKUDA H., TONAI M., MAGILVY J.K. & MURASHIMA S. (2015) Japanese nurse practitioner practice and outcomes in a nursing home. International Nursing Review 62, 275–279 Aim: By describing the practice of a Japanese nurse practitioner, this descriptive case study discusses role development and outcomes before and after the intervention. Background: One of the first Japanese nurse practitioners intervened at a nursing home during the government-designated trial period for nurse practitioner practice. Conclusion: Because of the nurse practitioner’s meticulous observation and timely care provision to the residents in collaboration with the physician and the other staff in the facility, comparative data showed improvement in daily health status management of every resident and decreased deterioration of residents’ health conditions requiring ambulance transfer and hospitalization. Keywords: Ambulance Transfer, Hospitalization, Nurse Practitioner Role Development, Nursing Home Residents, Skilled Nursing Care
Introduction: development of the first Japanese nurse practitioners (NPs) Geriatric nursing plays a crucial role in coping with the pressing health problems of older people (Mezey & Fulmer 2002). A geriatric nursing home represents an important facet of geriatric nursing care. In this setting, a variety of professionals work together, including advanced practice nurses such as NPs, to Correspondence address: Shinji Miyauchi, Division of Linguistics, Department of Human Sciences, Oita University of Nursing and Health Sciences, 2944-9 Megusuno, Oita 870-1201, Japan; Tel: (81) 97-586-4480; Fax: (81) 97-586-4395; E-mail: [email protected].
Conflict of interest: We declare that we have no conflicts of interest.
provide comprehensive and well-coordinated care to the older residents. Bakerjian (2008) argues that NPs are evident workforce of nursing homes in the USA. Canada started using NPs at nursing homes in the early 2000 (Klaasen et al. 2009). Australia (Thompson 2014) and Britain (Goldberg et al. 2014) also introduced NPs at nursing homes. These reports claimed that NPs contributed to providing effective care to frail older populations, reducing emergency transfer and preventing hospitalization. In Japan, Oita University of Nursing and Health Sciences (OUNHS) established the first NP graduate programme in 2008, graduating the first student in 2010 (Fukuda et al. 2014). Concurrently, the Japanese government initiated discussion of
© 2014 The Authors. International Nursing Review published by John Wiley & Sons Ltd on behalf of International Council of Nurses. 275 This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
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NP training programme development and conducted the NP Clinical Trial Practice in 2011, which led to specifying 41 items of medical practice that NPs are allowed to perform according to protocols with physicians’ comprehensive directives after finishing the NP education courses accredited by the government. This descriptive case study adopts a structure-processoutcome model to present findings by describing the newly designed NP role and practice in Japan, highlighting one NP who worked in a nursing home during the governmentdesignated clinical trial period. The purpose was to highlight several outcomes of the NP’s interventions, that is reduction of hospitalization and ambulance transfer, compared with usual practice prior to initiation of the role.
Structure: a geriatric health service nursing home before NP intervention The setting was one geriatric health service nursing home in a rural city in southwestern Japan with a population of about 80 000 including 32.4% over the age of 65. The nursing home, established in 2007, has 68 beds for long-term stay and 23 short-term beds. The staff consisted of one full-time physician, 19 nurses and other healthcare and social workers. The facility accepted participation in the governmental trial project for the training of NP and employed the first graduate of the OUNHS NP course in a full-time contract. The primary subjects of this study were all residents admitted to the nursing home during the period between 1 April 2009 and 15 March 2013. The NP and staff were also participants in the study. Data collection occurred during the period between January and March 2013. To compare outcomes of care prior to the initiation of NP practice and following implementation of the role, several variables were examined in the chi-square tests with regard to the number of hospitalizations, the cases of ambulance transfer and the symptoms/events for hospitalization, using the software SPSS Statistics-20, produced by IBM Japan, Tokyo Japan. All residents and their family members were notified beforehand that their clinical data might be used for academic purposes under the facility’s regulation. For ethical consideration, all information and chart data of the primary participants were de-identified and codified on the facility side for confidentiality and anonymity. All staff of the institution involved in this study were consented to participate in the research. This study was approved by the ethical committee of the authors’ university.
Structure: pre-intervention facility description The 260 nursing home residents admitted between April 2009 and March 2011 were identified as the pre-intervention group.
Table 1 Attribute of residents: pre- and post-intervention Pre-intervention (n = 260) Age (± SD) Sex Male Female Degree of care need Length of facility stay
Post-intervention (n = 219)
82.3 ± 8.9
84.0 ± 9.2
78 182 3.36 5.6 months
63 156 3.21 6.5 months
P-value
0.04** 0.76
0.03** 0.005**
**P < 0.001. Age, degree of care need, length of facility stay: Student’s t-test; Sex: χ2-square test.
Table 2 Cases of hospitalization and ambulance transfer: pre- and postintervention
Hospitalization Ambulance transfer
Pre-intervention (n = 260)
Post-intervention (n = 219)
P-value
119 (45.8%) 19 (7.3%)
66 (30.1%) 5 (2.3%)
0.001** 0.006**
Fisher’s exact test, **P < 0.001.
The total numbers in the data are cumulative as some residents were repeatedly admitted to and discharged from the facility. Table 1 shows that, during the pre-intervention data collection period, there were 260 residents, 78 male and 182 female, with the average age of 82.3 years (standard deviation ± 8.9). In Japan’s long-term care system, the degree of care required is ranked from Level 1 (lowest) to 5 (most necessary). During this period, the average degree of care required for the residents was 3.36. The average length of stay at the facility was 5.6 months. Of the 260 residents, 119 (45.8%) left the nursing home for hospitalization and 19 residents (7.3%) were transferred to hospital by ambulance (Table 2). The main precipitating factors for hospitalizations were: fever (33, 12.7%), bone fracture (15, 5.8%), consciousness disorder (12, 4.6%), dyspnoea and pneumonia (10, 3.8%), chest pain (8, 3.1%) and high/low blood pressure (5, 1.9%) (Table 3).
Process: description of the NP practice The NP, also a collaborator of this case study, was a registered nurse with a bachelor’s degree in nursing, employed as a registered nurse in the designated nursing home since it opened in 2007. In 2008, she entered the first cohort in the OUNHS NP
© 2014 The Authors. International Nursing Review published by John Wiley & Sons Ltd on behalf of International Council of Nurses
Japanese NP practice outcomes in a nursing home
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Table 3 Symptoms/events for hospitalization: pre- and post-intervention Symptoms/events
Pre-intervention n = 260 (%)
Fever Bone fracture Consciousness disorder Dyspnoea/Pneumonia Chest pain High/low blood pressure
33 15 12 10 8 5
Post-intervention n = 219 (%) (12.7) (5.8) (4.6) (3.8) (3.1) (1.9)
17 7 4 7 1 2
P-value
(7.8) (3.2) (1.8) (3.2) (0.5) (0.9)
0.053 0.131 0.073 0.449 0.034 0.301
ns ns ns ns * ns
Fisher’s exact test, *P < 0.05. ns, not significant.
master’s course. The Japanese government began the NP Clinical Trial Practice for administration of NPs in 2011 and this facility was selected to participate in the trial. The nurse continued working for the facility during her graduate study and following completion of her master’s degree, she began to work there as an NP. The NP serves the entire facility without belonging to any specific department. Therefore, she is free to meet each resident to check and assess their health status. When a resident presents with a health problem, she conducts a medical interview and/or physical assessment to evaluate the situation. After reviewing results of the primary medical examination, she consults with the facility’s full-time physician as well as the resident. Then, the NP performs permitted specific medical practice according to the designated protocols. For example, she may perform designated medical tests, select and/or administer medication, change gastrostomy tubes or debride a decubitus ulcer. The NP also meets or consults with residents’ family members to explain about their current health status, needs and treatments.
Outcomes: post-NP intervention results The residents admitted between 1 April 2011 and 31 March 2013 were identified as the post-intervention group because the NP began to work for the nursing home in full-time employment on 1 April 2011. Table 1 shows that during the postintervention data collection period, 219 residents lived in the nursing home, 63 male and 156 female, with the average age of 84.0 years (standard deviation ± 9.2). The average degree of care needed was 3.21 (care levels 1 through 5). The average length of stay was 6.5 months. Of the 219 residents, 66 (30.1%) left the nursing home for hospitalization during the post-intervention period and five (2.3%) were transferred to the hospital by ambulance (Table 2). The main precipitating factors for hospitalizations included: fever (17 residents, 7.8%), bone fracture (7,
3.2%), consciousness disorder (4, 1.8%), dyspnoea and pneumonia (7, 3.2%), chest pain (1, 0.5%) and high/low blood pressure (2, 0.9%) (Table 3). The rate of hospitalized residents significantly decreased from 45.8% before the NP intervention to 30.1% postimplementation (Fisher’s exact test, P < 0.001). The rate of emergency ambulance transfer also indicated significant reduction from 7.3% to 2.3% (Fisher’s exact test, P = 0.006). The rates of several precipitating factors for hospitalization were reduced in terms of fever, bone fracture, consciousness disorder, chest pain and high/low blood pressure. The comparison of rates of chest pain shows significant difference (Fisher’s exact test, P < 0.05).
Discussion Outcomes of this case study showed statistically significant differences, through Student’s t-test, in the average length of stay, the average age and the average degree of the residents’ care need at the nursing home comparing the pre- and postintervention periods. Related to the increased length of stay and differences in age and average level of care needed in pre- and post-intervention periods, several hypotheses are offered. Because of the prevention of hospitalizations, the residents could stay at the same facility as long as possible, likely prolonging the average length of stay from 5.6 to 6.5 months (P = 0.005). This situation may also contribute to an increased average age of the residents from 82.3 ± 8.9 in the preintervention period to 84.0 ± 9.2 years in the post-intervention period (P = 0.04). Finally, we suggest that the result of quality care with the NP’s intervention might have contributed to the decreased average degree of care needed from 3.36 preintervention to 3.21 post-intervention by the NP (P = 0.03). The results of this investigation showed very little difference in resident characteristics; that is the two groups had similar
© 2014 The Authors. International Nursing Review published by John Wiley & Sons Ltd on behalf of International Council of Nurses
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M. Ono et al.
fragility or vulnerability. But a significant reduction was observed in hospitalization and transfer statistics between the pre- and post-intervention resident groups. Therefore, the reduction of the hospitalizations and ambulance transfers was likely to be due to the effect of team approach reinforced by the introduction of the NP that resulted in prompt onsite assessments (Klaasen et al. 2009) and a better-organized symptom/ event management of the residents (Bakerjian 2008), for example, reducing fever cases between the two groups. Older adults are reported to suffer from bone fracture, mainly caused by falling. It is reported that bone fracture is one of the major risk factors for hospitalization in Japan (Kato et al. 2008). Wagner et al. (2007) argue that advanced practice nurses provide consultation to other staff in the facility, reducing the falling accidents that lead to bone fracture. While the present study did not focus on falls, it might be suggested that the reduction of hospitalizations because of bone fracture could be caused by the decrease of falling accidents. Although further investigation is warranted, we believe the present findings may have been related to the NP’s meticulous observation and timely care provision in collaboration with the physician and the other facility staff, leading to the reinforcement of daily health status management for every resident and the decrease of deterioration of residents’ health condition and hospitalization.
associated with poor communication and associated delays in effective care planning (Goldberg et al. 2014). This skill set will contribute to improving nursing care and the patients’ quality of life and to preventing deterioration of patients’ health conditions and unnecessary hospitalization. Japanese nursing is young in the initiation of NP practice but the new legislation will ensure the expansion of the NP role. This legislation thus contributes to a new advanced clinical career path for nurses and unique opportunities for nursing career development. The NP role further enables retention of high caliber nurses as workforce and beneficial outcomes for patient care as seen in Western countries where the role is more widely utilized (Arbon et al. 2008; Goldberg et al. 2014).
Implications for health policy Improved quality of daily life of fragile older adults and prevention of unnecessary emergency transfers and hospitalizations are the hallmarks and goals of emerging NP practice in Japan. These contributions will likely also lead to the significant containment of medical expenditures of the society. The potential consequence of this role development is investment of new nursing careers, leading to recruitment of advanced practice nurses as advocates who shape and direct healthcare policy on behalf of frail older populations (Mezey & Fulmer 2002). Therefore, the development and employment of more NPs in Japan is inevitable, profitable and indispensable.
The limitations of the study
Acknowledgements
The nursing home in the present study was the only facility that employed an NP in Japan during the research period of this study, necessitating the single case-study design. Therefore, the sample size is limited and it is not suitable to generalize the results of this study. Furthermore, confidentiality would be potentially compromised if the facility were named in government reports.
The present authors express our greatest gratitude to Dr Nakahara, the facility managing physician, Ms Hirose, NP, and all the other staff of the nursing home in this study for their kind and sincere collaboration and contribution to this study.
Implications for nursing The higher the nurses’ educational qualifications are, the more benefits patients will receive (Aiken et al. 2014). Regarding care for frail older patients, Goldberg et al. (2014) argue that staffing NPs is one solution to pressing care requirements. While further research is needed, such conditions and situations seem to be similar at nursing homes in Japan. With higher level of knowledge, especially in terms of physical assessment, pharmacology and pathophysiology and advanced skills, NPs in Japan are anticipated to provide better care to frail older residents at nursing homes than before. NPs are also expected to integrate and lead other nursing staff and other medical professionals by having a thorough understanding of medical and nursing roles and minimizing risks
Author contributions All authors contributed to making this manuscript. MO contributed to the study design, writing, collection, analysis and interpretation of data and literature research. S. Miyauchi contributed to the writing including language translation from Japanese into English and literature research. YE, HF and MT contributed to the collection/analysis of data and literature research. KS contributed to the data analysis and interpretation. JKM contributed to the language editing, some writing and interpretation. S. Murashima contributed to the study design, data analysis and interpretation and literature research. All authors contributed to the discussion and have seen and approved the final version of the study.
References Aiken, L.H., et al. (2014) Nursing staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet, 383, 1824–1830.
© 2014 The Authors. International Nursing Review published by John Wiley & Sons Ltd on behalf of International Council of Nurses
Japanese NP practice outcomes in a nursing home
Arbon, P., et al. (2008) Reporting a research project on the potential of aged care nurse practitioners in the Australian Capital Territory. Journal of Clinical Nursing, 18, 255–262. Bakerjian, D. (2008) Care of nursing home residents by advanced practice nurses: a review of literature. Research in Gerontological Nursing, 1 (3), 177–185. Fukuda, H., et al. (2014) The first nurse practitioner graduate programme in Japan. International Nursing Review, 61(4), 487–490. Available at: http://onlinelibrary.wiley.com/doi/10.1111/inr.12126/pdf (accessed 3 September 2014). Goldberg, S., Cooper, J. & Russell, C. (2014) Developing advanced nursing skills for frail older people. Nursing Older People, 26 (4), 20–23. Kato, C., et al. (2008) Relation of falls efficacy scale (FES) to quality of life among nursing home female residents with comparatively intact
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cognitive function in Japan. Nagoya Journal of Medical Science, 70, 19–27. Klaasen, K., Lamont, L. & Krishnan, P. (2009) Setting a new standard of care in nursing homes. The Canadian Nurse, 105 (9), 24–30. Mezey, M. & Fulmer, T. (2002) The future history of gerontological nursing. Journal of Gerontology: Medical Sciences, 57A (7), M438–M441. Thompson, J. (2014) For frail elderly care, there’s no place like home. British Journal of Nursing, 23 (5), 252. Wagner, L.M., et al. (2007) Description of advanced practice nursing consultative model to reduce restrictive siderail use in nursing homes. Research in Nursing and Health, 30, 131–140.
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ONO M., MIYAUCHI S., EDZUKI Y., SAIKI K., FUKUDA H., TONAI M., MAGILVY J.K. & MURASHIMA S. (2015) Japanese nurse practitioner practice and outcomes in a nursing home. International Nursing Review 62, 275–279 Aim: By describing the practice of a Japanese nurse practitioner, this descriptive case study discusses role development and outcomes before and after the intervention. Background: One of the first Japanese nurse practitioners intervened at a nursing home during the government-designated trial period for nurse practitioner practice. Conclusion: Because of the nurse practitioner’s meticulous observation and timely care provision to the residents in collaboration with the physician and the other staff in the facility, comparative data showed improvement in daily health status management of every resident and decreased deterioration of residents’ health conditions requiring ambulance transfer and hospitalization. Keywords: Ambulance Transfer, Hospitalization, Nurse Practitioner Role Development, Nursing Home Residents, Skilled Nursing Care
Introduction: development of the first Japanese nurse practitioners (NPs) Geriatric nursing plays a crucial role in coping with the pressing health problems of older people (Mezey & Fulmer 2002). A geriatric nursing home represents an important facet of geriatric nursing care. In this setting, a variety of professionals work together, including advanced practice nurses such as NPs, to Correspondence address: Shinji Miyauchi, Division of Linguistics, Department of Human Sciences, Oita University of Nursing and Health Sciences, 2944-9 Megusuno, Oita 870-1201, Japan; Tel: (81) 97-586-4480; Fax: (81) 97-586-4395; E-mail: [email protected].
Conflict of interest: We declare that we have no conflicts of interest.
provide comprehensive and well-coordinated care to the older residents. Bakerjian (2008) argues that NPs are evident workforce of nursing homes in the USA. Canada started using NPs at nursing homes in the early 2000 (Klaasen et al. 2009). Australia (Thompson 2014) and Britain (Goldberg et al. 2014) also introduced NPs at nursing homes. These reports claimed that NPs contributed to providing effective care to frail older populations, reducing emergency transfer and preventing hospitalization. In Japan, Oita University of Nursing and Health Sciences (OUNHS) established the first NP graduate programme in 2008, graduating the first student in 2010 (Fukuda et al. 2014). Concurrently, the Japanese government initiated discussion of
© 2014 The Authors. International Nursing Review published by John Wiley & Sons Ltd on behalf of International Council of Nurses. 275 This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
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276
M. Ono et al.
NP training programme development and conducted the NP Clinical Trial Practice in 2011, which led to specifying 41 items of medical practice that NPs are allowed to perform according to protocols with physicians’ comprehensive directives after finishing the NP education courses accredited by the government. This descriptive case study adopts a structure-processoutcome model to present findings by describing the newly designed NP role and practice in Japan, highlighting one NP who worked in a nursing home during the governmentdesignated clinical trial period. The purpose was to highlight several outcomes of the NP’s interventions, that is reduction of hospitalization and ambulance transfer, compared with usual practice prior to initiation of the role.
Structure: a geriatric health service nursing home before NP intervention The setting was one geriatric health service nursing home in a rural city in southwestern Japan with a population of about 80 000 including 32.4% over the age of 65. The nursing home, established in 2007, has 68 beds for long-term stay and 23 short-term beds. The staff consisted of one full-time physician, 19 nurses and other healthcare and social workers. The facility accepted participation in the governmental trial project for the training of NP and employed the first graduate of the OUNHS NP course in a full-time contract. The primary subjects of this study were all residents admitted to the nursing home during the period between 1 April 2009 and 15 March 2013. The NP and staff were also participants in the study. Data collection occurred during the period between January and March 2013. To compare outcomes of care prior to the initiation of NP practice and following implementation of the role, several variables were examined in the chi-square tests with regard to the number of hospitalizations, the cases of ambulance transfer and the symptoms/events for hospitalization, using the software SPSS Statistics-20, produced by IBM Japan, Tokyo Japan. All residents and their family members were notified beforehand that their clinical data might be used for academic purposes under the facility’s regulation. For ethical consideration, all information and chart data of the primary participants were de-identified and codified on the facility side for confidentiality and anonymity. All staff of the institution involved in this study were consented to participate in the research. This study was approved by the ethical committee of the authors’ university.
Structure: pre-intervention facility description The 260 nursing home residents admitted between April 2009 and March 2011 were identified as the pre-intervention group.
Table 1 Attribute of residents: pre- and post-intervention Pre-intervention (n = 260) Age (± SD) Sex Male Female Degree of care need Length of facility stay
Post-intervention (n = 219)
82.3 ± 8.9
84.0 ± 9.2
78 182 3.36 5.6 months
63 156 3.21 6.5 months
P-value
0.04** 0.76
0.03** 0.005**
**P < 0.001. Age, degree of care need, length of facility stay: Student’s t-test; Sex: χ2-square test.
Table 2 Cases of hospitalization and ambulance transfer: pre- and postintervention
Hospitalization Ambulance transfer
Pre-intervention (n = 260)
Post-intervention (n = 219)
P-value
119 (45.8%) 19 (7.3%)
66 (30.1%) 5 (2.3%)
0.001** 0.006**
Fisher’s exact test, **P < 0.001.
The total numbers in the data are cumulative as some residents were repeatedly admitted to and discharged from the facility. Table 1 shows that, during the pre-intervention data collection period, there were 260 residents, 78 male and 182 female, with the average age of 82.3 years (standard deviation ± 8.9). In Japan’s long-term care system, the degree of care required is ranked from Level 1 (lowest) to 5 (most necessary). During this period, the average degree of care required for the residents was 3.36. The average length of stay at the facility was 5.6 months. Of the 260 residents, 119 (45.8%) left the nursing home for hospitalization and 19 residents (7.3%) were transferred to hospital by ambulance (Table 2). The main precipitating factors for hospitalizations were: fever (33, 12.7%), bone fracture (15, 5.8%), consciousness disorder (12, 4.6%), dyspnoea and pneumonia (10, 3.8%), chest pain (8, 3.1%) and high/low blood pressure (5, 1.9%) (Table 3).
Process: description of the NP practice The NP, also a collaborator of this case study, was a registered nurse with a bachelor’s degree in nursing, employed as a registered nurse in the designated nursing home since it opened in 2007. In 2008, she entered the first cohort in the OUNHS NP
© 2014 The Authors. International Nursing Review published by John Wiley & Sons Ltd on behalf of International Council of Nurses
Japanese NP practice outcomes in a nursing home
277
Table 3 Symptoms/events for hospitalization: pre- and post-intervention Symptoms/events
Pre-intervention n = 260 (%)
Fever Bone fracture Consciousness disorder Dyspnoea/Pneumonia Chest pain High/low blood pressure
33 15 12 10 8 5
Post-intervention n = 219 (%) (12.7) (5.8) (4.6) (3.8) (3.1) (1.9)
17 7 4 7 1 2
P-value
(7.8) (3.2) (1.8) (3.2) (0.5) (0.9)
0.053 0.131 0.073 0.449 0.034 0.301
ns ns ns ns * ns
Fisher’s exact test, *P < 0.05. ns, not significant.
master’s course. The Japanese government began the NP Clinical Trial Practice for administration of NPs in 2011 and this facility was selected to participate in the trial. The nurse continued working for the facility during her graduate study and following completion of her master’s degree, she began to work there as an NP. The NP serves the entire facility without belonging to any specific department. Therefore, she is free to meet each resident to check and assess their health status. When a resident presents with a health problem, she conducts a medical interview and/or physical assessment to evaluate the situation. After reviewing results of the primary medical examination, she consults with the facility’s full-time physician as well as the resident. Then, the NP performs permitted specific medical practice according to the designated protocols. For example, she may perform designated medical tests, select and/or administer medication, change gastrostomy tubes or debride a decubitus ulcer. The NP also meets or consults with residents’ family members to explain about their current health status, needs and treatments.
Outcomes: post-NP intervention results The residents admitted between 1 April 2011 and 31 March 2013 were identified as the post-intervention group because the NP began to work for the nursing home in full-time employment on 1 April 2011. Table 1 shows that during the postintervention data collection period, 219 residents lived in the nursing home, 63 male and 156 female, with the average age of 84.0 years (standard deviation ± 9.2). The average degree of care needed was 3.21 (care levels 1 through 5). The average length of stay was 6.5 months. Of the 219 residents, 66 (30.1%) left the nursing home for hospitalization during the post-intervention period and five (2.3%) were transferred to the hospital by ambulance (Table 2). The main precipitating factors for hospitalizations included: fever (17 residents, 7.8%), bone fracture (7,
3.2%), consciousness disorder (4, 1.8%), dyspnoea and pneumonia (7, 3.2%), chest pain (1, 0.5%) and high/low blood pressure (2, 0.9%) (Table 3). The rate of hospitalized residents significantly decreased from 45.8% before the NP intervention to 30.1% postimplementation (Fisher’s exact test, P < 0.001). The rate of emergency ambulance transfer also indicated significant reduction from 7.3% to 2.3% (Fisher’s exact test, P = 0.006). The rates of several precipitating factors for hospitalization were reduced in terms of fever, bone fracture, consciousness disorder, chest pain and high/low blood pressure. The comparison of rates of chest pain shows significant difference (Fisher’s exact test, P < 0.05).
Discussion Outcomes of this case study showed statistically significant differences, through Student’s t-test, in the average length of stay, the average age and the average degree of the residents’ care need at the nursing home comparing the pre- and postintervention periods. Related to the increased length of stay and differences in age and average level of care needed in pre- and post-intervention periods, several hypotheses are offered. Because of the prevention of hospitalizations, the residents could stay at the same facility as long as possible, likely prolonging the average length of stay from 5.6 to 6.5 months (P = 0.005). This situation may also contribute to an increased average age of the residents from 82.3 ± 8.9 in the preintervention period to 84.0 ± 9.2 years in the post-intervention period (P = 0.04). Finally, we suggest that the result of quality care with the NP’s intervention might have contributed to the decreased average degree of care needed from 3.36 preintervention to 3.21 post-intervention by the NP (P = 0.03). The results of this investigation showed very little difference in resident characteristics; that is the two groups had similar
© 2014 The Authors. International Nursing Review published by John Wiley & Sons Ltd on behalf of International Council of Nurses
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M. Ono et al.
fragility or vulnerability. But a significant reduction was observed in hospitalization and transfer statistics between the pre- and post-intervention resident groups. Therefore, the reduction of the hospitalizations and ambulance transfers was likely to be due to the effect of team approach reinforced by the introduction of the NP that resulted in prompt onsite assessments (Klaasen et al. 2009) and a better-organized symptom/ event management of the residents (Bakerjian 2008), for example, reducing fever cases between the two groups. Older adults are reported to suffer from bone fracture, mainly caused by falling. It is reported that bone fracture is one of the major risk factors for hospitalization in Japan (Kato et al. 2008). Wagner et al. (2007) argue that advanced practice nurses provide consultation to other staff in the facility, reducing the falling accidents that lead to bone fracture. While the present study did not focus on falls, it might be suggested that the reduction of hospitalizations because of bone fracture could be caused by the decrease of falling accidents. Although further investigation is warranted, we believe the present findings may have been related to the NP’s meticulous observation and timely care provision in collaboration with the physician and the other facility staff, leading to the reinforcement of daily health status management for every resident and the decrease of deterioration of residents’ health condition and hospitalization.
associated with poor communication and associated delays in effective care planning (Goldberg et al. 2014). This skill set will contribute to improving nursing care and the patients’ quality of life and to preventing deterioration of patients’ health conditions and unnecessary hospitalization. Japanese nursing is young in the initiation of NP practice but the new legislation will ensure the expansion of the NP role. This legislation thus contributes to a new advanced clinical career path for nurses and unique opportunities for nursing career development. The NP role further enables retention of high caliber nurses as workforce and beneficial outcomes for patient care as seen in Western countries where the role is more widely utilized (Arbon et al. 2008; Goldberg et al. 2014).
Implications for health policy Improved quality of daily life of fragile older adults and prevention of unnecessary emergency transfers and hospitalizations are the hallmarks and goals of emerging NP practice in Japan. These contributions will likely also lead to the significant containment of medical expenditures of the society. The potential consequence of this role development is investment of new nursing careers, leading to recruitment of advanced practice nurses as advocates who shape and direct healthcare policy on behalf of frail older populations (Mezey & Fulmer 2002). Therefore, the development and employment of more NPs in Japan is inevitable, profitable and indispensable.
The limitations of the study
Acknowledgements
The nursing home in the present study was the only facility that employed an NP in Japan during the research period of this study, necessitating the single case-study design. Therefore, the sample size is limited and it is not suitable to generalize the results of this study. Furthermore, confidentiality would be potentially compromised if the facility were named in government reports.
The present authors express our greatest gratitude to Dr Nakahara, the facility managing physician, Ms Hirose, NP, and all the other staff of the nursing home in this study for their kind and sincere collaboration and contribution to this study.
Implications for nursing The higher the nurses’ educational qualifications are, the more benefits patients will receive (Aiken et al. 2014). Regarding care for frail older patients, Goldberg et al. (2014) argue that staffing NPs is one solution to pressing care requirements. While further research is needed, such conditions and situations seem to be similar at nursing homes in Japan. With higher level of knowledge, especially in terms of physical assessment, pharmacology and pathophysiology and advanced skills, NPs in Japan are anticipated to provide better care to frail older residents at nursing homes than before. NPs are also expected to integrate and lead other nursing staff and other medical professionals by having a thorough understanding of medical and nursing roles and minimizing risks
Author contributions All authors contributed to making this manuscript. MO contributed to the study design, writing, collection, analysis and interpretation of data and literature research. S. Miyauchi contributed to the writing including language translation from Japanese into English and literature research. YE, HF and MT contributed to the collection/analysis of data and literature research. KS contributed to the data analysis and interpretation. JKM contributed to the language editing, some writing and interpretation. S. Murashima contributed to the study design, data analysis and interpretation and literature research. All authors contributed to the discussion and have seen and approved the final version of the study.
References Aiken, L.H., et al. (2014) Nursing staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet, 383, 1824–1830.
© 2014 The Authors. International Nursing Review published by John Wiley & Sons Ltd on behalf of International Council of Nurses
Japanese NP practice outcomes in a nursing home
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