Research based on the appointment of a nurse practitioner (NP) older adult in the Horowhenua has found that this role is vital to effective care delivery in residential aged care. MARLENE DITCHFIELD speaks to Sylvia Meijer, New Zealand’s first NP older adult and the NP at the heart of the project about the importance of this role in aged care.
Since 2001, more than 136 nurse practitioners (NPs) have been registered in New Zealand. They practise in a variety of health settings including mental health, paediatrics, diabetes, aged care, emergency medicine, wound management and primary health care.
Shortages of GPs in rural areas have created an opportunity for NPs with advanced knowledge and skills to provide primary health care in the aged care sector. While NP roles are now well established, few studies have been undertaken to show their impact on health outcomes.
Early in 2009, The Masonic Villages Trust and Enliven Presbyterian Support Central called for a change in the way clinical services were being delivered to a growing population of older people in the Horowhenua. Of particular concern was a doctor shortage that was beginning to impact on the quality of care in residential facilities.
As a result, a nurse practitioner older adult position was established, and three years on, it has been analysed in an Auckland University study commissioned by the Central Primary Health Organisation and the MidCentral District Health Board in 2012. Sylvia Meijer, the NP at the centre of the project, is not at all surprised with the positive findings. She had been seeing the positive results of the role on a daily basis.
Aged care study highlights vital role of Nurse Practitioners
The appointment of a nurse practitioner older adult in the Horowhenua has been given the thumbs up in an evaluation study by Auckland University.
The ground-breaking initiative was aimed at improving the health of older people in residential care and was the first in New Zealand to involve non-government organisations working alongside a district health board.
“Innovative and courageous,” is how the director of nursing for MidCentral DHB, Chiquita Hansen, describes Masonic chief executive Warick Dunn and Enliven general manager Nicola Turner. “They anticipated a problem and were proactive about finding a solution.”
The MidCentral District Health Board commissioned the study in 2012 to assess the collaborative project. Results have been overwhelmingly encouraging.
It showed when a NP is involved in aged care facilities, there was a 28 per cent decrease in emergency department visits. In facilities without a NP there was a 21 per cent increase. Acute hospital admissions decreased and some unnecessary medications were also discontinued. Doctors, noting their workload decreased, said they were more attracted to supporting rest homes with a NP.
The NP role, focusing on older adults, was the brainchild of the Horowhenua Masonic Village that did not want to lose the services of its clinical nurse manager, Sylvia Meijer, when she qualified as a NP.
“With an increasing population of older people in the district and a declining number of GPs to service them, the role appeared to be the perfect solution to a growing problem,” says Horowhenua Masonic Village manager, Sue Maney.
To be a NP you need a minimum of a master’s degree and most have additional postgraduate qualifications. The Horowhenua Masonic Village supported Meijer through her studies.
She now has a Master of Philosophy on the assessment of older people in aged care facilities and has three postgraduate qualifications in nursing and aged care, as well as a management diploma.
When The Masonic Villages Trust first came up with the NP concept, it realised that it couldn’t justify employing a full-time NP. So Masonic’s Warick Dunn approached Enliven Presbyterian Support Central’s Nicola Turner, who was keen for Enliven’s two care facilities, Levin Home for War Veterans and Reevedon, to come on board.
Together, they approached the MidCentral DHB, which referred the proposal to the Central Primary Health Organisation (PHO), where the idea was met with enthusiasm.
As a result, Meijer became the country’s first NP older adult, working for the Central PHO. She works with community patients and Masonic Village and Enliven residents, and is leader of the Horowhenua Health for Older People team.
In recent years, Levin has faced a serious doctor shortage which, coupled with an ageing population (26 per cent over 65 years), has put huge pressure on medical services. GPs attempt to provide a ‘house’ doctor service to the 490 residents in Levin’s 11 aged care facilities, but they are sometimes spread too thinly.
“The NP is not just a nice-to-have, but vital,” says Maney. Staff nurses have a list of residents with concerns and Meijer is able to assess what she can do and prescribe, and what needs to go further to the doctor.
“She effectively screens the workload, so the doctor sees only those patients who need a GP’s skills.”
Meijer thrives on the collaborative nature of her work. She is in constant contact with other primary health care nurses in the district, clinicians, and support agencies.
“We have robust discussions about how we all work. We can build on each other’s strengths. It can make an enormous difference.”
Meijer trained as a nurse in the Netherlands and worked in theatre, emergency departments and intensive care. When she came to New Zealand and settled in the Horowhenua to raise a family, she initially worked part-time as a district nurse, took up post-graduate studies and eventually became a clinical nurse specialist for a care facility.
“All the things I have done in nursing up till now, have been building up to this point. From the bottom of my heart really, it’s just such the right place for me personally.
“What really grounds me and makes my day is when I am asked to see someone and I pick up that this is not straightforward and there’s something else not working for this patient. Maybe I pick up an acute glaucoma for instance. The fact that I have a bit more time to talk to a resident, research notes and maybe follow up with a doctor is hugely rewarding for all. The fact that residents also don’t have to fret for three or four days because the doctor is not available is such a good thing.”
This theme is picked up in the evaluation report. It noted the drop in anxiety among care givers and nursing staff now they are able to call on the NP for interventions and problem solving, particularly when the weekend was approaching.
Hansen says she is delighted with the report findings. She says it was especially pleasing to discover that the use of a NP had led to a decrease in acute admissions and presentations to the emergency department.
“It is important that the NP is employed by the PHO and comes from the primary health care sector, as is her involvement in management teams like the Health for Older Person team. It keeps her clinically safe and keeps lines of communication open between GPs and the aged care facilities.”
Hansen also felt using a NP was great for aged care facilities because it gave the registered nurses and staff back up, instilling confidence all round. Also good news was the indication from doctors that they were more inclined to want to support aged care facilities with a NP on staff.
Using these findings, Hansen and the Horowhenua team have approached the Minister of Health, Tony Ryall to ensure ongoing funding and to promote the service elsewhere in New Zealand.