Evaluation of an aged care nurse practitioner service: quality of care within a residential aged care facility hospital avoidance service

Enablers and barriers to nurse practitioners working in Australian aged care: A scoping review

OBJECTIVE

To identify evidence reporting on nurse practitioners working in aged care in Australia and to categorise the reported factors found to be barriers or facilitators to operation in terms of establishment, sustainability, and expansion.

INTRODUCTION

Nurse practitioners work in a variety of aged care contexts throughout Australia but are underutilised and uncommon. Despite evidence for their effectiveness, it is unclear what barriers or enabling factors contribute to the successful and sustainable implementation of nurse practitioners working in this sector.

METHODS

Based on an a-priori protocol the JBI methodology for scoping reviews was used and the review reported against the PRISMA extension for scoping reviews (PRISMA-ScR). Databases searched included MEDLINE, Embase, Emcare, Web of Science, and Scopus. Peer reviewed and grey literature describing the role of Australian nurse practitioners in aged care were included.

RESULTS

Of 2968 retrieved sources, 18 were included representing studies of a variety of designs from all Australian states and territories. Residential care and in-home care contexts as well as metropolitan, regional, and remote locations were represented. Overall, 123 individual barriers and facilitators were identified across seven inductively derived categories: staff/individual, organisational, system, operational, resource, data, and consumers/clients/residents. In many cases, factors appeared across both positive (facilitators) and negative (barriers) categories.

CONCLUSIONS

Nurse practitioners can improve the quality of care being provided to older people accessing aged care in Australia. When establishing or maintaining nurse practitioner roles in aged care knowledge users should have a comprehensive understanding of the range of factors potentially contributing to or limiting success or sustainability. As implementation is highly contextual, various types of organisational and sectoral factors as well as individual and overarching factors related to the regulation of nurse practitioners practice should be considered.

Current situation, strengths and problems in intra- and interprofessional collaboration in German nursing homes - A holistic multiple case study

BACKGROUND

The increasing care complexity of nursing home residents living with dementia requires new care models that strengthen professional collaboration. To contribute to the sustainable implementation of new care models, it is important that they are linked to the care reality. However, little is known about intra- and interprofessional organization and provision of care in German nursing homes. Therefore, the aim of this study was to explore the current care situation, problems and strengths regarding intra- and interprofessional collaboration in the care of residents living with dementia.

METHODS

We conducted a holistic multiple case study. The individual care units in which residents living with dementia are cared for were defined as cases. The context was built by the respective nursing homes and their regional affiliation to the federal state of North Rhine-Westphalia. We used qualitative face-to-face interviews, documents and context questionnaires for data collection. The different sources of evidence served to capture complementary perspectives and to validate the findings. First, the collected qualitative data were analyzed using deductive-inductive content analysis. Second, similarities and differences between the cases were identified to elaborate case-specific and cross-case patterns and themes. The reporting followed the EQUATOR reporting guideline for organizational case studies.

RESULTS

We included four care units comprising 21 professionals (nurses, physicians, social worker, physiotherapist, pharmacist) and 14 relatives of residents living with dementia. The analysis revealed four categories to describe current intra- and interprofessional collaboration in all cases: actors and their roles, service delivery, coordination and governance, and communication channel. Moreover, we identified three categories that relate to the strengths and problems of intra- and interprofessional collaboration in all cases: role understanding, teamwork, and communication and exchange. Although we examined similar care units, we found differences in the realization of professional collaboration and resulting problems and strengths that are connected to the organizational contexts and strategies used.

CONCLUSIONS

Even though professional collaboration follows given patterns; these patterns do differ context-specifically and are perceived as problematic and fragmentary. Therefore, the identified differences and problems in collaboration need to be addressed in future research to develop and successfully implement tailored innovative care models.

Advanced practice nurses' daily practices delivering primary care to residents in long-term care facilities: a qualitative study

BACKGROUND

Globally, there is a growing shortage of primary care professionals, including those who serve residents in long-term care facilities (LTCFs). In recent decades, numerous new care models have been implemented to improve these residents' care. Many incorporate Advanced Practice Nurses (APNs) into interprofessional healthcare teams. In Switzerland, little is known about how these models function, and few facilities have integrated APNs. This study aims to explore the everyday practice of APNs employed at a medical centre in the Bernese Seeland region delivering care to LTC residents and collaborating with LTCFs staff.

METHODS

This qualitative study uses the "Interpretive Description" methodology, which builds on existing knowledge and examines phenomena interpreted through a social constructivist approach. We conducted six semi-structured individual interviews, one semi-structured focus group interview, and an examination of secondary data. Our thematic analysis followed Braun and Clarke's guidelines for data analysis.

RESULTS

In LTCFs, APNs perform tasks similar to those of primary care physicians, e.g., patient visits and therapy adjustments, within the limits set by their supervising physicians. In addition, they contribute significantly to facility-wide quality improvement. We identified three fundamental elements for successful collaboration between APNs and LTCF staff: 1) clarifying roles and responsibilities; 2) establishing well-defined communication methods and pathways; and 3) building and maintaining trust. Together with LTCF staff, APNs provide multidimensional, person-centred care that focuses on medical, social, and nursing issues with the goal of maintaining the residents' best possible quality of life.

CONCLUSIONS

Our results suggest that integrating APNs into the LTCF care system improves care quality for residents and increases staff members' job satisfaction.

Models for delivery and co-ordination of primary or secondary health care (or both) to older adults living in aged care facilities

BACKGROUND

The number of older people is increasing worldwide and public expenditure on residential aged care facilities (ACFs) is expected to at least double, and possibly triple, by 2050. Co-ordinated and timely care in residential ACFs that reduces unnecessary hospital transfers may improve residents' health outcomes and increase satisfaction with care among ACF residents, their families and staff. These benefits may outweigh the resources needed to sustain the changes in care delivery and potentially lead to cost savings. Our systematic review comprehensively and systematically presents the available evidence of the effectiveness, safety and cost-effectiveness of alternative models of providing health care to ACF residents.

OBJECTIVES

Main objective To assess the effectiveness and safety of alternative models of delivering primary or secondary health care (or both) to older adults living in ACFs. Secondary objective To assess the cost-effectiveness of the alternative models.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers (WHO ICTRP, ClinicalTrials.gov) on 26 October 2022, together with reference checking, citation searching and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included individual and cluster-randomised trials, and cost/cost-effectiveness data collected alongside eligible effectiveness studies. Eligible study participants included older people who reside in an ACF as their place of permanent abode and healthcare professionals delivering or co-ordinating the delivery of healthcare at ACFs. Eligible interventions focused on either ways of delivering primary or secondary health care (or both) or ways of co-ordinating the delivery of this care. Eligible comparators included usual care or another model of care. Primary outcomes were emergency department visits, unplanned hospital admissions and adverse effects (defined as infections, falls and pressure ulcers). Secondary outcomes included adherence to clinical guideline-recommended care, health-related quality of life of residents, mortality, resource use, access to primary or specialist healthcare services, any hospital admissions, length of hospital stay, satisfaction with the health care by residents and their families, work-related satisfaction and work-related stress of ACF staff.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. The primary comparison was any alternative model of care versus usual care.

MAIN RESULTS

We included 40 randomised trials (21,787 participants; three studies only reported number of beds) in this review. Included trials evaluated alternative models of care aimed at either all residents of the ACF (i.e. no specific health condition; 11 studies), ACF residents with mental health conditions or behavioural problems (12 studies), ACF residents with a specific condition (e.g. residents with pressure ulcers, 13 studies) or residents requiring a specific type of care (e.g. residents after hospital discharge, four studies). Most alternative models of care focused on 'co-ordination of care' (n = 31). Three alternative models of care focused on 'who provides care' and two focused on 'where care is provided' (i.e. care provided within ACF versus outside of ACF). Four models focused on the use of information and communication technology. Usual care, the comparator in all studies, was highly heterogeneous across studies and, in most cases, was poorly reported. Most of the included trials were susceptible to some form of bias; in particular, performance (89%), reporting (66%) and detection (42%) bias. Compared to usual care, alternative models of care may make little or no difference to the proportion of residents with at least one emergency department visit (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.84 to 1.20; 7 trials, 1276 participants; low-certainty evidence), but may reduce the proportion of residents with at least one unplanned hospital admission (RR 0.74, 95% CI 0.56 to 0.99, I2 = 53%; 8 trials, 1263 participants; low-certainty evidence). We are uncertain of the effect of alternative models of care on adverse events (proportion of residents with a fall: RR 1.15, 95% CI 0.83 to 1.60, I² = 74%; 3 trials, 1061 participants; very low-certainty evidence) and adherence to guideline-recommended care (proportion of residents receiving adequate antidepressant medication: RR 5.29, 95% CI 1.08 to 26.00; 1 study, 65 participants) as the certainty of the evidence is very low. Compared to usual care, alternative models of care may have little or no effect on the health-related quality of life of ACF residents (MD -0.016, 95% CI -0.036 to 0.004; I² = 23%; 12 studies, 4016 participants; low-certainty evidence) and probably make little or no difference to the number of deaths in residents of ACFs (RR 1.03, 95% CI 0.92 to 1.16, 24 trials, 3881 participants, moderate-certainty evidence). We did not pool the cost-effectiveness or cost data as the specific costs associated with the various alternative models of care were incomparable, both across models of care as well as across settings. Based on the findings of five economic evaluations (all interventions focused on co-ordination of care), we are uncertain of the cost-effectiveness of alternative models of care compared to usual care as the certainty of the evidence is very low.

AUTHORS' CONCLUSIONS

Compared to usual care, alternative models of care may make little or no difference to the number of emergency department visits but may reduce unplanned hospital admissions. We are uncertain of the effect of alternative care models on adverse events (i.e. falls, pressure ulcers, infections) and adherence to guidelines compared to usual care, as the certainty of the evidence is very low. Alternative models of care may have little or no effect on health-related quality of life and probably have no effect on mortality of ACF residents compared to usual care. Importantly, we are uncertain of the cost-effectiveness of alternative models of care due to the limited, disparate data available.

From pilot to a multi-site trial: refining the Early Detection of Deterioration in Elderly Residents (EDDIE +) intervention

BACKGROUND

Early Detection of Deterioration in Elderly Residents (EDDIE +) is a multi-modal intervention focused on empowering nursing and personal care workers to identify and proactively manage deterioration of residents living in residential aged care (RAC) homes. Building on successful pilot trials conducted between 2014 and 2017, the intervention was refined for implementation in a stepped-wedge cluster randomised trial in 12 RAC homes from March 2021 to May 2022. We report the process used to transition from a small-scale pilot intervention to a multi-site intervention, detailing the intervention to enable future replication.

METHODS

The EDDIE + intervention used the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework to guide the intervention development and refinement process. We conducted an environmental scan; multi-level context assessments; convened an intervention working group (IWG) to develop the program logic, conducted a sustainability assessment and deconstructed the intervention components into fixed and adaptable elements; and subsequently refined the intervention for trial.

RESULTS

The original EDDIE pilot intervention included four components: nurse and personal care worker education; decision support tools; diagnostic equipment; and facilitation and clinical support. Deconstructing the intervention into core components and what could be flexibly tailored to context was essential for refining the intervention and informing future implementation across multiple sites. Intervention elements considered unsustainable were updated and refined to enable their scalability. Refinements included: an enhanced educational component with a greater focus on personal care workers and interactive learning; decision support tools that were based on updated evidence; equipment that aligned with recipient needs and available organisational support; and updated facilitation model with local and external facilitation.

CONCLUSION

By using the i-PARIHS framework in the scale-up process, the EDDIE + intervention was tailored to fit the needs of intended recipients and contexts, enabling flexibility for local adaptation. The process of transitioning from a pilot to larger scale implementation in practice is vastly underreported yet vital for better development and implementation of multi-component interventions across multiple sites. We provide an example using an implementation framework and show it can be advantageous to researchers and health practitioners from pilot stage to refinement, through to larger scale implementation.

TRIAL REGISTRATION

The trial was prospectively registered with the Australia New Zealand Clinical Trial Registry (ACTRN12620000507987, registered 23/04/2020).

Reducing unplanned hospital admissions from care homes: a systematic review

Background

Care homes predominantly care for older people with complex health and care needs, who are at high risk of unplanned hospital admissions. While often necessary, such admissions can be distressing and provide an opportunity cost as well as a financial cost.

Objectives

Our objective was to update a 2014 evidence review of interventions to reduce unplanned admissions of care home residents. We carried out a systematic review of interventions used in the UK and other high-income countries by synthesising evidence of effects of these interventions on hospital admissions; feasibility and acceptability; costs and value for money; and factors affecting applicability of international evidence to UK settings.

Data sources

We searched the following databases in December 2021 for studies published since 2014: Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews; Cumulative Index to Nursing and Allied Health Literature; Health Management Information Consortium; Medline; PsycINFO; Science and Social Sciences Citation Indexes; Social Care Online; and Social Service Abstracts. 'Grey' literature (January 2022) and citations were searched and reference lists were checked.

Methods

We included studies of any design reporting interventions delivered in care homes (with or without nursing) or hospitals to reduce unplanned hospital admissions. A taxonomy of interventions was developed from an initial scoping search. Outcomes of interest included measures of effect on unplanned admissions among care home residents; barriers/facilitators to implementation in a UK setting and acceptability to care home residents, their families and staff. Study selection, data extraction and risk of bias assessment were performed by two independent reviewers. We used published frameworks to extract data on intervention characteristics, implementation barriers/facilitators and applicability of international evidence. We performed a narrative synthesis grouped by intervention type and setting. Overall strength of evidence for admission reduction was assessed using a framework based on study design, study numbers and direction of effect.

Results

We included 124 publications/reports (30 from the UK). Integrated care and quality improvement programmes providing additional support to care homes (e.g. the English Care Homes Vanguard initiatives and hospital-based services in Australia) appeared to reduce unplanned admissions relative to usual care. Simpler training and staff development initiatives showed mixed results, as did interventions aimed at tackling specific problems (e.g. medication review). Advance care planning was key to the success of most quality improvement programmes but do-not-hospitalise orders were problematic. Qualitative research identified tensions affecting decision-making involving paramedics, care home staff and residents/family carers. The best way to reduce end-of-life admissions through access to palliative care was unclear in the face of inconsistent and generally low-quality evidence.

Conclusions

Effective implementation of interventions at various stages of residents' care pathways may reduce unplanned admissions. Most interventions are complex and require adaptation to local contexts. Work at the interface between health and social care is key to successful implementation.

Limitations

Much of the evidence identified was of low quality because of factors such as uncontrolled study designs and small sample size. Meta-analysis was not possible.

Future work

We identified a need for improved economic evidence and the evaluation of integrated care models of the type delivered by hospital-based teams. Researchers should carefully consider what is realistic in terms of study design and data collection given the current context of extreme pressure on care homes.

Study registration

This study is registered as PROSPERO database CRD42021289418.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (award number NIHR133884) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 18. See the NIHR Journals Library website for further project information.

Turnover intention and coping strategies among older nursing assistants in China: a qualitative study

Introduction

With the increasing aging population, older nursing assistants have made significant contributions to institutional eldercare. However, there is a high turnover rate among these workers, and it is crucial to address this issue and find ways to stabilize the workforce. This study aimed to explore the factors influencing turnover intention and coping strategies among older nursing assistants, in order to provide targeted assistance and guidance to reduce their intention to resign and ultimately lower the turnover rate.

Methods

Qualitative research methods were employed to conduct semi-structured interviews with older nursing assistants in Changsha. The data obtained from these interviews were then analyzed using a phenomenological analysis approach and NVIVO (QSR International, Doncaster, Australia) software version 11.0.

Results

It is found that several factors influence turnover intention among older nursing assistants. Which include work pay, work environment, professional identity, external motivation, and work pressure. Additionally, the coping strategies employed by these individuals in relation to their intention to resign include self-regulation, seeking support, self-improvement, and exploring motivation.

Discussion

It is also evident from our study that reducing the turnover intention of older nursing assistants requires a collaborative effort from older adult care institutions, functional departments, and eldercare nursing assistants themselves. By addressing the factors influencing turnover intention and providing support and resources for coping strategies, we can work towards stabilizing the workforce and improving institutional eldercare.

Stakeholders' perspectives of mobile x-ray services in support of healthcare-in-place in residential aged care facilities: a qualitative study

Background

There is interest in reducing avoidable emergency department presentations from residential aged care facilities (RACF). Mobile x-ray services may enable the delivery of healthcare in residential aged care facilities. Accordingly, the Australian Government in November 2019 introduced a Medicare Benefit Schedule rebate providing for a ‘call-out’ fee payable to radiology service providers.

This study aims to understand stakeholder perspectives on the benefits of mobile x-ray services and the factors influencing their adoption by RACFs.

Design, setting, participants

Twenty-two semi-structured interviews were conducted between October 2020 and February 2021 with a range of stakeholders involved in healthcare delivery to residents: a) general practitioners; b) emergency department clinicians; c) paramedic clinicians; d) a hospital avoidance clinician; e) radiology clinicians and managers; and f) aged care clinicians and managers. Thematic analysis was conducted.

Results

Mobile x-ray services were considered valuable for RACF residents. Lack of timely general practitioner in-person assessment and referral, as well as staffing deficits in residential aged care facilities, reduces optimal use of mobile x-ray services and results in potentially unnecessary hospital transfers.

Conclusions

The use of mobile x-ray services, as a hospital avoidance strategy, depends on the capacity of RACFs to provide more complex healthcare-in-place. However, this requires greater access to general practitioners for in-person assessment and referral, adequate staffing numbers and appropriately skilled nursing staff within residential aged care facilities.

Core elements and potential of nurse-led care models in residential long-term care: A scoping review

AIMS AND OBJECTIVE

To identify and summarise core elements, resident-, staff- and process-related outcomes and challenges of nurse-led care models in residential long-term care.

BACKGROUND

Due to demographic trends, the complexity of residential long-term care has increased. To address this complexity, the implementation of nurse-led care models has been recommended.

DESIGN

Scoping review.

METHODS

A systematic search was conducted of English and German articles in CINAHL via EBSCO, MEDLINE via PubMed, Cochrane Library and Scopus. Forward and backward citation tracking via reference lists and Google Scholar supplemented the search. The final update was made on 19 January 2021. To draw conclusions about the potential of nurse-led care models, evaluation studies of the described models for residents in nursing homes were included. Full texts were independently screened and assessed for methodological quality. Data were extracted and summarised in tables and synthesised for analysis. The core elements of the models were described using the Sustainable intEgrated chronic care modeLs for multimorbidity: delivery, FInancing and performancE (SELFIE) framework. The review followed the PRISMA-ScR guideline.

RESULTS

We included 13 studies of 12 nurse-led care models. The different models comprised many of the core elements suggested in the SELFIE framework, particularly in the components service delivery, workforce, and leadership and governance. The studies reported a broad range of resident-, staff- and process-related outcomes and challenges considered relevant to the success of the models.

CONCLUSIONS

Studies evaluating nurse-led care models in nursing homes are limited and of moderate quality. This review demonstrates that nurse-led care models include many elements for care coordination and could improve resident-, staff- and process-related outcomes.

RELEVANCE TO CLINICAL PRACTICE

This review highlights that nurse-led care models share common core elements despite their heterogeneity. It also shows that highly qualified nurses in nurse-led care models can advance nursing practice in nursing homes.

Impact of an acute geriatric outreach service to residential aged care facilities on hospital admissions

INTRODUCTION

Residential aged care facility (RACF) residents frequently present to the emergency department (ED) and are often admitted to hospital. Some presentations and admissions may be avoidable. In 2013, Bankstown-Lidcombe Hospital introduced a subacute geriatric outreach service (SGOS), which had little impact on reducing ED presentations. In 2015, Bankstown-Lidcombe Hospital introduced an acute geriatric outreach service (AGOS), a geriatrician-led team that assesses and treats acutely unwell patients in RACFs. We aim to determine whether the AGOS reduces the risk of hospital admission for RACF residents.

METHODS

Hospital admissions data from 2010 to 2019 were used to conduct an interrupted time series (ITS) analysis. AGOS activity data were also summarized.

RESULTS

The average number of admissions from RACF per month declined from 42.8 during the SGOS period to 27.1 during the AGOS period. The difference of 15.7 admissions from RACF per month was statistically significant (95% CI 12.1-19.2; P < .001). After the introduction of the AGOS, the risk of admission to our geriatric department from RACFs was reduced by 36.1% (incidence rate ratio =0.64; 95% CI: 0.58-0.71; P < .001) compared to the SGOS period, adjusting for seasonality.

DISCUSSION

The AGOS probably reduced the risk of hospital admission for RACF residents.

Factors impacting hospital avoidance program utilisation in the care of acutely unwell residential aged care facility residents

Background

An existing hospital avoidance program, the Aged Care Rapid Response Team (ARRT), rapidly delivers geriatric outreach services to acutely unwell or older people with declining health at risk of hospitalisation. The aim of the current study was to explore health professionals’ perspectives on the factors impacting ARRT utilisation in the care of acutely unwell residential aged care facility residents.

Methods

Semi-structured interviews were conducted with two Geriatricians, two ARRT Clinical Nurse Consultants, an ED-based Clinical Nurse Specialist, and an Extended Care Paramedic. Interview questions elicited views on key factors regarding care decisions and care transitions for acutely unwell residential aged care facility residents. Thematic analysis was undertaken to identify themes and sub-themes from interviews.

Results

Analysis of interviews identified five overarching themes affecting ARRT utilisation in the care of acutely unwell residents: (1) resident care needs; (2) family factors; (3) enabling factors; (4) barriers; and (5) adaptability and responsiveness to the COVID-19 pandemic.

Conclusion

Various factors impact on hospital avoidance program utilisation in the care of acutely unwell older aged care facility residents. This information provides additional context to existing quantitative evaluations of hospital avoidance programs, as well as informing the design of future hospital avoidance programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06575-1.

Predictive factors of the general public's willingness to be seen and seek treatment from a nurse practitioner in Australia: a cross-sectional national survey

BACKGROUND

Health care delivery in Australia is experiencing challenges with services struggling to keep up with the increasing demands of an aging population, rising levels of chronic disease and limited funding for care. Where adjunct models of health care such as the Nurse Practitioner (NP) have the potential to address this gap, in Australia, they remain an underutilised service. Clarifying the nature of the consumers 'willingness' to be seen by NPs warrants further investigation.

METHODS

Australia-wide, cross-sectional population-based survey was undertaken using computer-assisted telephone interviewing technique.

RESULTS

While just over 53% of the general public participants (n = 1318) had heard of an NP, once they became aware of their scope of practice, the majority agreed or strongly agreed they were willing to be seen by an NP in the community (91.6%), the emergency department 88.2%), to manage chronic conditions (86%), to have scrips written and referrals made (85.3%), and if they did not have to wait so long to see a medical doctor (81%). Factors significantly predicting willingness were being: female, less than 65 years of age, native English speakers, or residents from town/regional and rural settings.

CONCLUSION

Despite limited awareness of the NP role, a large proportion of the Australian population, across different demographic groups, are willing to be seen and treated by an NP. Expansion of this role to support medical services in areas of need could improve healthcare delivery.

Predictive factors of the general public's willingness to be seen and seek treatment from a nurse practitioner in Australia: a cross-sectional national survey

BACKGROUND

Health care delivery in Australia is experiencing challenges with services struggling to keep up with the increasing demands of an aging population, rising levels of chronic disease and limited funding for care. Where adjunct models of health care such as the Nurse Practitioner (NP) have the potential to address this gap, in Australia, they remain an underutilised service. Clarifying the nature of the consumers 'willingness' to be seen by NPs warrants further investigation.

METHODS

Australia-wide, cross-sectional population-based survey was undertaken using computer-assisted telephone interviewing technique.

RESULTS

While just over 53% of the general public participants (n = 1318) had heard of an NP, once they became aware of their scope of practice, the majority agreed or strongly agreed they were willing to be seen by an NP in the community (91.6%), the emergency department 88.2%), to manage chronic conditions (86%), to have scrips written and referrals made (85.3%), and if they did not have to wait so long to see a medical doctor (81%). Factors significantly predicting willingness were being: female, less than 65 years of age, native English speakers, or residents from town/regional and rural settings.

CONCLUSION

Despite limited awareness of the NP role, a large proportion of the Australian population, across different demographic groups, are willing to be seen and treated by an NP. Expansion of this role to support medical services in areas of need could improve healthcare delivery.

Reshaping healthcare delivery for elderly patients: the role of community paramedicine; a systematic review

Background

Healthcare systems are overloaded and changing. In response to growing demands on the healthcare systems, new models of healthcare delivery are emerging. Community paramedicine is a novel approach in which paramedics use their knowledge and skills beyond emergency health response to contribute to preventative and rehabilitative health. In our systematic review, we aimed to identify evidence of the community paramedicine role in care delivery for elderly patients, with an additional focus on palliative care, and the possible impact of this role on the wider healthcare system.

Methods

A systematic review of peer-reviewed literature from MEDLINE, Embase, CINAHL, and Web of Sciences was undertaken to identify relevant full-text articles in English published until October 3, 2019. Additional inclusion criteria were studies focussing on extended care paramedics or community paramedics caring for elderly patients. Case studies were excluded. All papers were screened by at least two authors and underwent a quality assessment, using the Joanna Briggs Institute appraisal checklists for cross sectional, qualitative, cohort, and randomised controlled trial studies to assess the methodological quality of the articles. A process of narrative synthesis was used to summarise the data.

Results

Ten studies, across 13 articles, provided clear evidence that Community Paramedic programs had a positive impact on the health of patients and on the wider healthcare system. The role of a Community Paramedic was often a combination of four aspects: assessment, referral, education and communication. Limited evidence was available on the involvement of Community Paramedics in palliative and end-of-life care and in care delivery in residential aged care facilities. Observed challenges were a lack of additional training, and the need for proper integration and understanding of their role in the healthcare system.

Conclusions

The use of community paramedics in care delivery could be beneficial to both patients’ health and the wider healthcare system. They already play a promising role in improving the care of our elderly population. With consistent adherence to the training curriculum and effective integration within the wider healthcare system, community paramedics have the potential to take on specialised roles in residential aged care facilities and palliative and end-of-life care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-06037-0.

Integrating nurse practitioners into primary care: policy considerations from a Canadian province

Background

The integration of nurse practitioners (NPs) into primary care health teams has been an object of interest for policy makers seeking to achieve the goals of improving care, increasing access, and lowering cost. The province of Alberta in Canada recently introduced a policy aimed at integrating NPs into existing primary care delivery structures. This qualitative research sought to understand how that policy – the NP Support Program (NPSP) – was viewed by key stakeholders and to draw out policy lessons.

Methods

Fifteen semi-structured interviews with NPs and other stakeholders in Alberta’s primary care system were conducted, recorded, transcribed and analyzed using the interpretive description method.

Results

Stakeholders predominantly felt the NPSP would not change the status quo of limited practice opportunities and the resulting underutilization of primary care NPs in the province. Participants attributed low levels of NP integration into the primary care system to: 1) financial viability issues that directly impacted NPs, physicians, and primary care networks (PCNs); 2) policy issues related to the NPSP’s reliance on PCNs as employers, and a requirement that NPs panel patients; and 3) governance issues in which NPs are not afforded sufficient authority over their role or how the key concept of ‘care team’ is defined and operationalized.

Conclusions

In general, stakeholders did not see the NPSP as a long-term solution for increasing NP integration into the province’s primary care system. Policy adjustments that enable NPs to access funding not only from within but also outside PCNs, and modifications to allow greater NP input into how their role is utilized would likely improve the NPSP’s ability to reach its goals.

A survey identifying leadership and research activities among Nurse Practitioners

Background: Nurse Practitioners are identified as the ideal conduit to transform healthcare delivery internationally. Healthcare transformation requires the application of leadership and research skills. Current literature has limited information on NPs as leaders or researchers in the nursing profession.Objectives: Determine if Nurse Practitioners identify themselves as leaders in nursing. Identify the leadership and research activities and influencing characteristics of Nurse Practitioners in Ireland and Australia. Establish similarities in leadership and research activities between Nurse Practitioners in Ireland and Australia. To identify if there is a relationship between leadership and research activities.Design: A quantitative electronic survey.Methods: A survey instrument was developed by combining two previously validated instruments. Nurse Practitioners in Ireland or Australia that had practiced within the last five years, and members of the respective professional association were included. Descriptive statistics were used to describe the findings and explore relationships in the data.Results: 14% (n = 96) of Nurse Practitioners responded to the survey. Nurse Practitioners in Ireland and Australia identified themselves as leaders of the nursing profession. Nurse Practitioners work practices, leadership and research activities are similar in Ireland and Australia. The majority (n = 55, 57%), of participants reported being research active. There was an association between perceived leadership and research activities among participants.Conclusion: Nurse Practitioners in both Ireland and Australia identify themselves as leaders of the nursing profession. There is no difference in reported work practices, leadership or research activities of Nurse Practitioners in both Ireland and Australia. There is an association between perceived leadership and research activity.Impact Statement: Nurse Practitioners in Ireland and Australia percieved themselves as leaders in nursing and this perception increases with research activity.

Structure evaluation of the implementation of geriatric models in primary care: a multiple-case study of models involving advanced geriatric nurses in five municipalities in Norway

Background

The Advanced Geriatric Nurse role recently has been introduced into Norway’s primary healthcare system, and our study’s purpose was to examine the implementation of models of care developed for Advanced Geriatric Nurse in primary care. With a structure evaluation, we tried to identify conditions that affect the implementation of different models of care and understand how these conditions affected the realisation of each model’s intentions and goals.

Methods

An embedded multiple-case study was used that included five Norwegian municipalities and seven AGNs. The study included data from August 2014 through September 2018. We used data from 25 semi-structured face-to-face interviews with AGNs and stakeholders, documents and statistical information. We used a cross-case procedure with an emphasis on case findings for the analysis of the multiple case study.

Results

We analysed the structure-related conditions on two levels: the meso-level and the micro-level. On the meso-level, we found that the conditions that affected the implementation of the different models of care were related to each municipality’s structure characteristics, stakeholders’ involvement in the design of the models of care, the clarity of the models and their goals, the evaluation of the models and their adaptation. At the micro-level, we found that the conditions that affected the models’ implementation were related to the collaboration within the implemented models of care, the role clarity of Advanced Geriatric Nurses themselves and adjustments within the models.

Conclusions

The implementation of the AGN role in Norway seems to have been implemented in ways that can impact patients and municipalities positively. Potential improvements include extensive stakeholder involvement, improved roles, goal clarity and better documentation of structures and outcomes. The models’ dynamic nature seemed to be a beneficial characteristic, but adaptation should be systematic and a necessary time should be considered for a new model of care to be integrated and produce results.

Effectiveness for introducing nurse practitioners in six long-term care facilities in Québec, Canada: A cost-savings analysis

BACKGROUND

Internationally, most studies have focused on quality and safety in long-term care. However, studies focusing on the economic evaluation of quality and security in long-term care are sparse. Moreover, the economic evaluation of nurse practitioner care in long-term care is lacking, particularly in Québec Canada where roles are new.

PURPOSE

To evaluate the effectiveness of introducing nurse practitioners in six long-term care facilities in Québec using a cost-savings analysis in terms of reduction of nurse practitioner sensitive events (NPSEs).

METHODS

A cost savings analysis was completed using a prospective observational study. All residents (n = 538) under the care of teams that included nurse practitioners who experienced at least one of the following NPSEs: falls, pressure ulcers, short-term transfers, and a change in the time needed to administer the medications consumed were included. Data were collected from September 1st 2015 to August 31st 2016. Descriptive statistics identified numbers of cases for falls, pressure ulcers, short-term transfers, and the number of medications consumed. A literature analysis was used to estimate excess median long-term care facility related costs of these NPSEs. Costs were calculated in 2016 Canadian dollars. The cost savings with the reductions that occurred for falls, pressure ulcers, short term transfers, and the time needed to administer medications after the implementation of a primary healthcare nurse practitioner role in the six long term care facilities were also estimated.

FINDINGS

The median cost of 341 cases of falls, 32 cases of pressure ulcers and 53 cases of short-term transfers in the six long-term facilities would range between CAD 4,516,337.8 and CAD 5,281,824.4. Moreover, the total costs savings from the reduction of adverse events including the reduction of nursing administration time for medications would be between CAD 1,942,533.6 and CAD 3,254,403.4.

DISCUSSION

This is the first study to present the financial consequence of adverse events sensitive to nurse practitioner care in long-term care. Important cost savings were generated from the reduction of adverse events after the implementation of nurse practitioner roles in long-term care. Government should consider these results for prevention and improvements in quality and safety in long-term care.

Towards personalized care: Factors associated with the quality of life of residents with dementia in Australian rural aged care homes

Quality of dementia care improves with a personalized approach to aged care, and knowledge of the disease process and unique care needs of residents with dementia. A personalized model of care can have a significant impact on the overall organizational culture in aged care homes. However, the dimensions of personalized aged care relating to dementia often remain under-managed. We aim to explore the factors that shape the dimensions of personalized dementia care in rural nursing homes using qualitative data of a mixed-method ‘Harmony in the Bush’ dementia study. The study participants included clinical managers, registered nurses, enrolled nurses and care workers from five rural aged care homes in Queensland and South Australia. One hundred and four staff participated in 65 semi-structured interviews and 20 focus groups at three phases: post-intervention, one-month follow-up and three-months follow-up. A multidimensional model of nursing home care quality developed by Rantz et al. (1998) was used in data coding and analysis of the factors. Three key themes including seven dimensions emerged from the findings: resident and family [resident and family centeredness, and assessment and care planning]; staff [staff education and training, staff-resident interaction and work-life balance]; and organization [leadership and organizational culture, and physical environment and safety]. A lack of consideration of family members views by management and staff, together with poorly integrated, holistic care plan, limited resources and absence of ongoing education for staff, resulted in an ineffective implementation of personalized dementia care. Understanding the dimensions and associated factors may assist in interpreting the multidimensional aspects of personalized approach in dementia care. Staff training on person-centered approach, assessment and plan, and building relationships among and between staff and residents are essential to improve the quality of care residents receive.

The Impact of Nurse Practitioners on Hospitalizations and Discharges from Long-term Nursing Facilities: A Systematic Review

The objective of this study was to increase the understanding of the role a nurse practitioner (NP) has in reducing the risk of hospitalizations and improving quality outcomes among nursing facility residents. This was explored by the research team conducting a systematic literature review via Cumulative Index of Nursing and Allied Health Literature, PubMed (MEDLINE), and Academic Search Ultimate. This is of concern because of the increased rate of hospital readmissions from skilled nursing facilities. The study found that utilization of NPs as primary care providers resulted in decreased unnecessary hospitalizations, increased access to healthcare, and improved health outcomes. NPs are fundamental in building relationships with residents and families and providing them information for decision making. The utilization of NPs in a long-term care setting should be encouraged to improve access to care, decrease hospitalizations, and enhance quality of care. States with reduced or restrictive scope of practice for NPs should revisit the regulations to provide unrestricted scope of practice for NPs.

Implementation of an older person's nurse practitioner in rural aged care in Victoria, Australia: a qualitative study

BACKGROUND

There are staff shortages nation-wide in residential aged care, which is only predicted to grow as the population ages in Australia. The aged care staff shortage is compounded in rural and remote areas where the health service workforce overall experiences difficulties in recruitment and retention. There is evidence that nurse practitioners fill important service gaps in aged care and rural health care but also evidence that barriers exist in introducing this extended practice role.

METHODS

In 2018, 58 medical and direct care staff participated in interviews and focus groups about the implementation of an older person's nurse practitioner (OPNP) in aged care. All 58 interviewees had previously or currently worked in an aged care setting where the OPNP delivered services. The interviews were analysed using May's implementation theory framework to better understand staff perceptions of barriers and enablers when an OPNP was introduced to the workplace.

RESULTS

The major perceived barrier to capacity of implementing the OPNP was a lack of material resources, namely funding of the role given the OPNP's limited ability to self-fund through access to the Medicare Benefits Schedule (MBS). Staff perceived that benefits included timely access to care for residents, hospital avoidance and improved resident health outcomes.

CONCLUSION

Despite staff perceptions of more timely access to care for residents and improved outcomes, widespread implementation of the OPNP role may be hampered by a poor understanding of the role of an OPNP and the legislative requirement for a collaborative arrangement with a medical practitioner as well as limited access to the MBS. This study was not a registered trial.

Development of a Gerontology Graduate Certificate in Post-Acute and Long-Term Care

Nurse practitioners (NPs) can provide safe, effective, quality care to older adults in post-acute and long-term care (PALTC) settings. However, there is a paucity of exposure to PALTC settings in most NP educational programs. Therefore, the current authors developed an elective graduate certificate in gerontology with an emphasis in PALTC for NP students. The graduate certificate curriculum was developed by faculty with expertise in nursing and gerontology education. The PALTC certificate comprises 15 credit hours of online didactic courses, 80 leadership hours, 200 clinical hours, and a scholarly project dedicated to PALTC. Completion of a graduate certificate in PALTC is a novel model for preparing NP students for practice in PALTC settings. The current article serves as a framework for other programs to reference as they develop individualized graduate certificate PALTC programs in their academic institutions. [Journal of Gerontological Nursing, 45(10), 47-52.].

Improving eye care in residential aged care facilities using the Residential Ocular Care (ROC) model: study protocol for a multicentered, prospective, customized, and cluster randomized controlled trial in Australia

Background

Older adults in residential aged care facilities have unnecessarily high levels of vision impairment (VI) which are largely treatable or correctable. However, no current comprehensive eye health service model exists in this setting in Australia. We aimed to determine the clinical, person-centered, and economic effectiveness of a novel eye care model, the Residential Ocular Care (ROC).

Methods/design

This protocol describes a multicentered, prospective, randomized controlled trial. A total of 395 participants with distance vision < 6/12 (0.30 LogMAR) and/or near vision N8 (1.00 M) or worse will be recruited from 38 urban and rural aged care facilities across Victoria, Australia. Aged care facilities will be randomized (1:1) to one of two parallel groups. Participants in the ROC group will receive a comprehensive and tailored eye care pathway that includes, as necessary, refraction and spectacle provision, cataract surgery, low vision rehabilitation, and/or a referral to an ophthalmologist for funded treatment. Usual care participants will be referred for an evaluation to the eye care service associated with the facility or an eye care provider of their choice. The primary outcome will be presenting near and distance vision assessed at the two- and six-month follow-up visits, post baseline. Secondary outcomes will include vision-specific quality of life, mobility, falls, depression, and eye care utilization at two and six months. An incremental cost-effectiveness analysis will also be undertaken.

Discussion

The ROC study is the first multicentered, prospective, customized, and cluster randomized controlled trial in Australia to determine the effectiveness of a comprehensive and tailored eye care model for people residing in aged care facilities. Results from this trial will assist health and social care planners in implementing similar innovative models of care for this growing segment of the population in Australia and elsewhere.

Trial registration

Australian and New Zealand Clinical Trials Registry, ACTRN12615000587505. Registered on 4 June 2015 – retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3025-5) contains supplementary material, which is available to authorized users.