Research
Role of the nurse practitioner in providing palliative care in long-term care homes Sharon Kaasalainen, Jenny Ploeg, Carrie McAiney, Lori Schindel Martin, Faith Donald, Ruth Martin-Misener, Kevin Brazil, Alan Taniguchi, Abigail Wickson-Griffiths, Nancy Carter, Esther Sangster-Gormley
© 2013 MA Healthcare Ltd
A
s populations age, more people will die in long-term care (LTC) homes. Canadian estimates suggest that as many as 39% of residents will die in an LTC home by the year 2020 (Fisher et al, 2000; Jayaraman and Joseph, 2013). Similar trends have been noted from other countries including the USA (US Department of Health and Human Services, 2003), the UK (Lievesley et al, 2011), and Australia (Australian Institute of Health and Welfare, 2007). However, there are several challenges to providing quality palliative care in LTC, such as high rates of cognitive impairment, low ratios of physicians and licensed nurses to residents, and large proportions of unregulated care providers with limited preparatory training or practice development opportunities specific to palliative care (Proctor and Hirdes, 2001; Miller et al, 2004). To offset some of these challenges, the nurse practitioner (NP) role is gaining increasing attention in LTC. NPs are ‘registered nurses with additional educational preparation and experience who possess and demonstrate the competencies to autonomously diagnose, order and interpret diagnostic tests, prescribe pharmaceuticals and perform specific procedures within their legislated scope of practice’ (Canadian Nurses Association, 2009). This Canadian definition is consistent with international views about the core characteristics and scope of practice of the NP role (International Council of Nurses, 2002; 2008). Palliative care is one area that NPs could, given their advanced practice skills, potentially improve outcomes for both staff, including other nurses, and residents. NPs may act as an added resource for LTC nurses, supporting and mentoring them to improve their palliative care practices. However, little is known about the NP role in palliative care.
Background Palliative care is a philosophy and a unique set of care processes that aims to enhance quality of life
International Journal of Palliative Nursing 2013, Vol 19, No 10
Abstract
Aim: The purpose of this study, which was part of a large national case study of nurse practitioner (NP) integration in long-term care (LTC), was to explore the NP role in providing palliative care in LTC. Methods: Using a qualitative descriptive design, data was collected from five LTC homes across Canada using 35 focus groups and 25 individual interviews. In total, 143 individuals working in LTC participated, including 9 physicians, 20 licensed nurses, 15 personal support workers, 19 managers, 10 registered nurse team managers or leaders, 31 allied health care providers, 4 NPs, 14 residents, and 21 family members. The data was coded and analysed using thematic analysis. Findings: NPs provide palliative care for residents and their family members, collaborate with other health-care providers by providing consultation and education to optimise palliative care practices, work within the organisation to build capacity and help others learn about the NP role in palliative care to better integrate it within the team, and improve system outcomes such as accessibility of care and number of hospital visits. Conclusions: NPs contribute to palliative care in LTC settings through multifaceted collaborative processes that ultimately promote the experience of a positive death for residents, their family members, and formal caregivers. Key words: Palliative care l Long-term care l Nurse practitioner
for people with a life-limiting condition and to provide support for their families. Part of this is providing high quality end-of-life care to help ensure that people can have a ‘good death’, ideally in the place of their choosing (Kehl, 2006). Many barriers to providing palliative care and a good death in LTC have been identified, including a lack of knowledge among the workforce, workload demands, residents having advanced dementia, and a failure to implement a timely end-of-life care plan (Brazil et al, 2004; Kehl, 2006; Kaasalainen et al, 2007a). Unfortunately, decisions to implement such a plan are usually made after the hospitalisation of an LTC resident or exacerbation of a chronic condition, without knowledge of where the resident and/or family would prefer death occur.
For a list of author affiliations, see Box 1. Correspondence to: Sharon Kaasalainen [email protected]
477
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 130.237.122.245 on November 16, 2015. For personal use only. No other uses without permission. . All rights r
Box 1. Author affiliations Sharon Kaasalainen is Associate Professor, School of Nursing, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Jenny Ploeg is Professor, School of Nursing, and Associate Member, Department of Health, Aging and Society, McMaster University; Carrie McAiney is Associate Professor, Department of Psychiatry & Behavioural Neurosciences, McMaster University, and Director of Research and Evaluation, Geriatric Psychiatry Service, St Joseph’s Healthcare, Ontario, Canada; Lori Schindel Martin is Associate Professor and Associate Director– Scholarship, Research and Creativity, Daphne Cockwell School of Nursing, Ryerson University, Ontario, Canada; Faith Donald is Associate Professor, Daphne Cockwell School of Nursing, Ryerson University, and Affiliate Faculty, Canadian Centre for Advanced Practice Nursing Research, McMaster University; Ruth Martin-Misener is Associate Professor, School of Nursing, Dalhousie University, Nova Scotia, Canada, and Co-Director, Canadian Centre for Advanced Practice Nursing Research, McMaster University; Kevin Brazil is Professor of Palliative Care, School of Nursing and Midwifery, Queen’s University Belfast, UK; Alan Taniguchi is Assistant Clinical Professor, Department of Family Medicine, McMaster University; Abigail WicksonGriffiths is PhD student, School of Nursing, McMaster University; Nancy Carter is Assistant Professor, School of Nursing and Canadian Centre for Advanced Practice Nursing Research, McMaster University; Esther Sangster-Gormley is Associate Professor, University of Victoria School of Nursing, British Columbia, Canada
Lack of knowledge has been a commonly reported barrier to providing quality palliative care, particularly among nurses and unregulated care providers (e.g. personal support workers (PSWs) and health-care aides). Kaasalainen et al (2007a) found that nurses often use creative strategies with limited resources to provide palliative care to residents who have dementia, but are challenged by insufficient education and lack of expertise. In addition, more preparatory education and practice development related to palliative care is needed for PSWs, who may be excluded from continuing education initiatives within their facility or not supported by their employers to attend outside educational initiatives (Stolee et al, 2005). There is a need to increase the capacity of LTC staff to effectively manage the complex issues related to palliative care. Hockley et al (2005) used action research to promote quality end-of-life care in eight nursing homes in the UK. As the study progressed, there was an increasing realisation that palliative and end-of-life care and dying are central to LTC work. Part of the success of this study involved identifying key champions in each facility, providing education, and creating collaborative learning groups for staff. These findings suggest that staff empowerment, collaboration, and teamwork are key features of capacity development interventions related to palliative care. The effectiveness and sustainability of continuing education in LTC can be enhanced by providing enabling or reinforcing factors such as mentors or coaches (Stolee et al, 2005; McAiney et al, 2007). For example, Hanson and Henderson (2000) suggested that the addition of an NP can facilitate
478
and improve palliative care processes. NPs can be positioned to supervise care delivery by other nurses, coordinate care across settings, and act as consultants for staff and residents (Weggel, 1997; Hanson and Henderson, 2000; Froggatt and Hoult, 2002). An emerging role, particularly in the UK, is the advanced nurse consultant or ‘link nurse’ role, whereby nurses who are specialised in palliative care can act as consultants to several LTC homes (Froggatt and Hoult, 2002). In this role, nurses can undertake direct (e.g. as an expert practitioner who provides clinical care to residents or acts as a patient advocate) and indirect (as change agent, educator, role model, researcher, resource person) activities with the goal of improving palliative care practices (Hamric et al, 2009). More recently, innovative programmes have been developed to advance the care standards for LTC residents related to palliative care while optimising the NP role, including the Gold Standards Framework in the UK (Hockley et al, 2005; Badger et al, 2007), the Foundations in Palliative Care programme (developed previously by Macmillan Nurses) in Scotland (Hall et al, 2011), and the Australian Palliative Residential Aged Care Project (Edith Cowan University, 2006), which includes evidence-based guidelines to support and guide the delivery of a palliative approach in the 3000 residential aged care facilities across Australia. These programmes offer innovative ways to deliver quality palliative care while drawing from the expertise of NPs. Research conducted in the USA supports the effectiveness of the NP role in LTC. In a survey of all physician members of the American Medical Directors Association, Rosenfeld et al (2007) found a high level of satisfaction with the NP role in LTC among physicians (90%), residents (87%), and families (85%). NPs in LTC have been shown to reduce hospital admissions, visits to the emergency department, and costs while improving access to primary care (Burl et al, 1998; Intrator et al, 1999; Kane et al, 2003; Aigner et al, 2004). A model that included NP interventions at two levels—direct care provision and staff education about use of protocols, and collaboration and involvement in facility committees—found significant improvements in resident outcomes (i.e. incontinence, pressure ulcers, aggression, depression) (Krichbaum et al, 2005). The emergence of NPs in LTC has been slower in Canada than in other countries. In 2000, the Ontario Ministry of Health and Long Term Care funded the first 20 NP positions in LTC in Canada. This was in response to the complexity of needs of the resident population, including
© 2013 MA Healthcare Ltd
Research
International Journal of Palliative Nursing 2013, Vol 19, No 10
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 130.237.122.245 on November 16, 2015. For personal use only. No other uses without permission. . All rights r
Research
Table 1. Details of the nurse practitioner (NP) cases Characteristics
Case 1
Case 2
Case 3
Case 4
Funding model for LTC setting
For-profit
Not-for-profit
For-profit
Not-for-profit
Funding source for NP role
Government
Mixed government/ LTC setting
LTC setting
Mixed government/ LTC setting
Location
Rural/suburban
Urban
Suburban
Urban
Number of LTC homes in case
Two
One
One
One
Setting’s bed capacity
200 plus
200 plus
200 plus
200 plus
Years NP in position
>5 years
2–5 years
>5 years
Role of the nurse practitioner in providing palliative care in long-term care homes Sharon Kaasalainen, Jenny Ploeg, Carrie McAiney, Lori Schindel Martin, Faith Donald, Ruth Martin-Misener, Kevin Brazil, Alan Taniguchi, Abigail Wickson-Griffiths, Nancy Carter, Esther Sangster-Gormley
© 2013 MA Healthcare Ltd
A
s populations age, more people will die in long-term care (LTC) homes. Canadian estimates suggest that as many as 39% of residents will die in an LTC home by the year 2020 (Fisher et al, 2000; Jayaraman and Joseph, 2013). Similar trends have been noted from other countries including the USA (US Department of Health and Human Services, 2003), the UK (Lievesley et al, 2011), and Australia (Australian Institute of Health and Welfare, 2007). However, there are several challenges to providing quality palliative care in LTC, such as high rates of cognitive impairment, low ratios of physicians and licensed nurses to residents, and large proportions of unregulated care providers with limited preparatory training or practice development opportunities specific to palliative care (Proctor and Hirdes, 2001; Miller et al, 2004). To offset some of these challenges, the nurse practitioner (NP) role is gaining increasing attention in LTC. NPs are ‘registered nurses with additional educational preparation and experience who possess and demonstrate the competencies to autonomously diagnose, order and interpret diagnostic tests, prescribe pharmaceuticals and perform specific procedures within their legislated scope of practice’ (Canadian Nurses Association, 2009). This Canadian definition is consistent with international views about the core characteristics and scope of practice of the NP role (International Council of Nurses, 2002; 2008). Palliative care is one area that NPs could, given their advanced practice skills, potentially improve outcomes for both staff, including other nurses, and residents. NPs may act as an added resource for LTC nurses, supporting and mentoring them to improve their palliative care practices. However, little is known about the NP role in palliative care.
Background Palliative care is a philosophy and a unique set of care processes that aims to enhance quality of life
International Journal of Palliative Nursing 2013, Vol 19, No 10
Abstract
Aim: The purpose of this study, which was part of a large national case study of nurse practitioner (NP) integration in long-term care (LTC), was to explore the NP role in providing palliative care in LTC. Methods: Using a qualitative descriptive design, data was collected from five LTC homes across Canada using 35 focus groups and 25 individual interviews. In total, 143 individuals working in LTC participated, including 9 physicians, 20 licensed nurses, 15 personal support workers, 19 managers, 10 registered nurse team managers or leaders, 31 allied health care providers, 4 NPs, 14 residents, and 21 family members. The data was coded and analysed using thematic analysis. Findings: NPs provide palliative care for residents and their family members, collaborate with other health-care providers by providing consultation and education to optimise palliative care practices, work within the organisation to build capacity and help others learn about the NP role in palliative care to better integrate it within the team, and improve system outcomes such as accessibility of care and number of hospital visits. Conclusions: NPs contribute to palliative care in LTC settings through multifaceted collaborative processes that ultimately promote the experience of a positive death for residents, their family members, and formal caregivers. Key words: Palliative care l Long-term care l Nurse practitioner
for people with a life-limiting condition and to provide support for their families. Part of this is providing high quality end-of-life care to help ensure that people can have a ‘good death’, ideally in the place of their choosing (Kehl, 2006). Many barriers to providing palliative care and a good death in LTC have been identified, including a lack of knowledge among the workforce, workload demands, residents having advanced dementia, and a failure to implement a timely end-of-life care plan (Brazil et al, 2004; Kehl, 2006; Kaasalainen et al, 2007a). Unfortunately, decisions to implement such a plan are usually made after the hospitalisation of an LTC resident or exacerbation of a chronic condition, without knowledge of where the resident and/or family would prefer death occur.
For a list of author affiliations, see Box 1. Correspondence to: Sharon Kaasalainen [email protected]
477
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 130.237.122.245 on November 16, 2015. For personal use only. No other uses without permission. . All rights r
Box 1. Author affiliations Sharon Kaasalainen is Associate Professor, School of Nursing, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada; Jenny Ploeg is Professor, School of Nursing, and Associate Member, Department of Health, Aging and Society, McMaster University; Carrie McAiney is Associate Professor, Department of Psychiatry & Behavioural Neurosciences, McMaster University, and Director of Research and Evaluation, Geriatric Psychiatry Service, St Joseph’s Healthcare, Ontario, Canada; Lori Schindel Martin is Associate Professor and Associate Director– Scholarship, Research and Creativity, Daphne Cockwell School of Nursing, Ryerson University, Ontario, Canada; Faith Donald is Associate Professor, Daphne Cockwell School of Nursing, Ryerson University, and Affiliate Faculty, Canadian Centre for Advanced Practice Nursing Research, McMaster University; Ruth Martin-Misener is Associate Professor, School of Nursing, Dalhousie University, Nova Scotia, Canada, and Co-Director, Canadian Centre for Advanced Practice Nursing Research, McMaster University; Kevin Brazil is Professor of Palliative Care, School of Nursing and Midwifery, Queen’s University Belfast, UK; Alan Taniguchi is Assistant Clinical Professor, Department of Family Medicine, McMaster University; Abigail WicksonGriffiths is PhD student, School of Nursing, McMaster University; Nancy Carter is Assistant Professor, School of Nursing and Canadian Centre for Advanced Practice Nursing Research, McMaster University; Esther Sangster-Gormley is Associate Professor, University of Victoria School of Nursing, British Columbia, Canada
Lack of knowledge has been a commonly reported barrier to providing quality palliative care, particularly among nurses and unregulated care providers (e.g. personal support workers (PSWs) and health-care aides). Kaasalainen et al (2007a) found that nurses often use creative strategies with limited resources to provide palliative care to residents who have dementia, but are challenged by insufficient education and lack of expertise. In addition, more preparatory education and practice development related to palliative care is needed for PSWs, who may be excluded from continuing education initiatives within their facility or not supported by their employers to attend outside educational initiatives (Stolee et al, 2005). There is a need to increase the capacity of LTC staff to effectively manage the complex issues related to palliative care. Hockley et al (2005) used action research to promote quality end-of-life care in eight nursing homes in the UK. As the study progressed, there was an increasing realisation that palliative and end-of-life care and dying are central to LTC work. Part of the success of this study involved identifying key champions in each facility, providing education, and creating collaborative learning groups for staff. These findings suggest that staff empowerment, collaboration, and teamwork are key features of capacity development interventions related to palliative care. The effectiveness and sustainability of continuing education in LTC can be enhanced by providing enabling or reinforcing factors such as mentors or coaches (Stolee et al, 2005; McAiney et al, 2007). For example, Hanson and Henderson (2000) suggested that the addition of an NP can facilitate
478
and improve palliative care processes. NPs can be positioned to supervise care delivery by other nurses, coordinate care across settings, and act as consultants for staff and residents (Weggel, 1997; Hanson and Henderson, 2000; Froggatt and Hoult, 2002). An emerging role, particularly in the UK, is the advanced nurse consultant or ‘link nurse’ role, whereby nurses who are specialised in palliative care can act as consultants to several LTC homes (Froggatt and Hoult, 2002). In this role, nurses can undertake direct (e.g. as an expert practitioner who provides clinical care to residents or acts as a patient advocate) and indirect (as change agent, educator, role model, researcher, resource person) activities with the goal of improving palliative care practices (Hamric et al, 2009). More recently, innovative programmes have been developed to advance the care standards for LTC residents related to palliative care while optimising the NP role, including the Gold Standards Framework in the UK (Hockley et al, 2005; Badger et al, 2007), the Foundations in Palliative Care programme (developed previously by Macmillan Nurses) in Scotland (Hall et al, 2011), and the Australian Palliative Residential Aged Care Project (Edith Cowan University, 2006), which includes evidence-based guidelines to support and guide the delivery of a palliative approach in the 3000 residential aged care facilities across Australia. These programmes offer innovative ways to deliver quality palliative care while drawing from the expertise of NPs. Research conducted in the USA supports the effectiveness of the NP role in LTC. In a survey of all physician members of the American Medical Directors Association, Rosenfeld et al (2007) found a high level of satisfaction with the NP role in LTC among physicians (90%), residents (87%), and families (85%). NPs in LTC have been shown to reduce hospital admissions, visits to the emergency department, and costs while improving access to primary care (Burl et al, 1998; Intrator et al, 1999; Kane et al, 2003; Aigner et al, 2004). A model that included NP interventions at two levels—direct care provision and staff education about use of protocols, and collaboration and involvement in facility committees—found significant improvements in resident outcomes (i.e. incontinence, pressure ulcers, aggression, depression) (Krichbaum et al, 2005). The emergence of NPs in LTC has been slower in Canada than in other countries. In 2000, the Ontario Ministry of Health and Long Term Care funded the first 20 NP positions in LTC in Canada. This was in response to the complexity of needs of the resident population, including
© 2013 MA Healthcare Ltd
Research
International Journal of Palliative Nursing 2013, Vol 19, No 10
onal Journal of Palliative Nursing. Downloaded from magonlinelibrary.com by 130.237.122.245 on November 16, 2015. For personal use only. No other uses without permission. . All rights r
Research
Table 1. Details of the nurse practitioner (NP) cases Characteristics
Case 1
Case 2
Case 3
Case 4
Funding model for LTC setting
For-profit
Not-for-profit
For-profit
Not-for-profit
Funding source for NP role
Government
Mixed government/ LTC setting
LTC setting
Mixed government/ LTC setting
Location
Rural/suburban
Urban
Suburban
Urban
Number of LTC homes in case
Two
One
One
One
Setting’s bed capacity
200 plus
200 plus
200 plus
200 plus
Years NP in position
>5 years
2–5 years
>5 years
