CareSearch Blog: Palliative Perspectives

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Working as a Specialist Palliative Care Nurse Practitioner in RAC

A Guest Blog Post from Peter Jenkin, Nurse Practitioner (Palliative Care), Resthaven Incorporated

  • 3 May 2016
  • Author: CareSearch
  • Number of views: 6634
  • 7 Comments

Nurse Practitioners (NP) work in many roles in residential aged care: general primary care, wound care, memory disorders, mental health, heart failure and palliative care.  

A Nurse Practitioner is a Registered Nurse who has completed both advanced university study at a Masters Degree level and extensive clinical training to expand upon the traditional role of a Registered Nurse. They use extended skills, knowledge and experience in the assessment, planning, implementation, diagnosis and evaluation of care required.1 

As far as I know, I am still (unfortunately) the only specialist palliative care nurse practitioner employed by an aged care provider in Australia. Why is that you ask? Primarily it comes down to money. NP services are not funded via the aged care funding system (ACFI), and the income I can generate from bulk billing residents via Medicare covers only a small proportion of my salary. So it relies on an organisation like Resthaven seeing the non-monetary benefits and improved outcomes that stem from a role like this. 

My role ‘adds value’ to what is normally done very well by GPs, nurses and other members of the aged care team. Sometimes I do 'fill a gap' when the GP is unavailable but the prescribing and other extended activities remain secondary to the specialist nursing focus I bring to clinical encounters. More often, I’m there to help when things get complicated.

A good example is 86 year old 'Beth', who lives with severe heart failure. She collapsed and was resuscitated six months ago and subsequently had a pacemaker inserted. Sincer then her function had declined leading to multiple falls and increased care needs. She now needs two people to assist with transfers and is increasingly sleepy during the day. A 1.2 litre fluid restriction and numerous medications were keeping her breathlessness and oedema 'relatively' stable. She was referred by frustrated nursing staff who were having difficulty managing her increasing insomnia and more general agitation and distress. This was being treated with benzodiazepine sleeping tablets that left her sleepy during the day, especially when given in the early hours of the morning. Multiple cups of hot chocolate at night were also playing havoc with her fluid restriction. 

A benefit of my role is the ability to undertake longer and more in-depth consultations, not only undertaking a comprehensive history and examination from the resident, but also reading back through months of clinical notes and talking to the family, doctor, nurses and care-workers. This enables a 'big picture' view of the situation that can yield information not always evident to staff involved with the day-to-day care.     

In Beth's case, this led to the discovery that while not depressed, her agitation and trouble sleeping was primarily due to anxiety about her failing physical health. She disclosed, for the first time, her fear of not being able to finish writing her life story on her beloved computer. This was so important to her that she expressed a desire to be hospitalised (and even be resuscitated again) if it gave her more time. This is despite her written advance care directive stating a wish for 'palliative approach' to all care. 

So what did I contribute to a solution:

  • Giving Beth the opportunity to express her concerns and fears.
  • Facilitating a conversation with her family about her desire to temporarily amend her advance care directive.
  • Amending her care plan so Beth was given the opportunity to sit at the computer each morning for as long as she could tolerate.
  • Teaching relaxation/breathing techniques and sourcing a handheld fan to use when anxious/breathlessness.
  • Getting her radio fixed so she could listen to talkback at night.
  • Providing education to the nurses and careworkers about the assessment and management of existential/emotional distress.
  • Prescribing a trial of melatonin as an alternative to sedating benzodiazepines.

My role allows me to spend the time needed to facilitate and take part in conversations, less encumbered than GPs for whom ‘time is money’, or RNs who are usually responsible for 50 or more residents on a shift.  “...done well, these conversations are the engine that drives the elucidation and treatment of suffering...".2

And my approach remains firmly rooted in the nursing paradigm.  It is an autonomous role but not independent, relying on  collaboration with all members of the health care team.

As a palliative care nurse practitioner who works within the aged care organisation, I am not just an external consultant, making suggestions and hoping for the best. The ability to provide direct care, model best practice and influence clinical practice improvement increases the opportunity for improved outcomes for the older people and their families we care for.
 
Three years ago this month I was endorsed as a Nurse Practitioner. Would I do it all again, knowing what I do now about the study and work needed? Absolutely. It’s the best job I’ve ever had!

 

[1] ACNP 2016 What is a Nurse Practitioner? https://www.acnp.org.au/aboutnursepractitioners

[2] Weiner J , Roth J. Avoiding Iatrogenic Harm to Patient and Family while Discussing Goals of Care Near the End of Life. J Palliat Med. 2006;9(2):451-463. https://www.ncbi.nlm.nih.gov/pubmed/16629574
 


 

 

  Peter Jenkin is a Nurse Practitioner (Palliative Care), Resthaven Incorporated

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7 comments on article "Working as a Specialist Palliative Care Nurse Practitioner in RAC"

Judy Deimel

7/05/2016 11:43 AM

Thank you Peter for articulating the Nurse Practitioner (NP) role in RCF so clearly.

The NP represents a 'newish' extended nurse practice role for Australia (the NP is 25 years young in our country) and for varying reasons, the diverse scopes and extension of NP practice has not always been easily understood by the health care team.

Articles such as this, presented with a case study is very much needed from the NP profession. Championing the 'value add' to improve outcomes for both consumer and health care system will resonate more efficiently with voice and promotion.

Greater aged care uptake of nurses choosing the NP role will only happen with organisational support via clinical governance, let us hope the organisations are listening.

Judy Deimel NP Cognitive Health


bernadette burke

6/06/2016 2:43 PM

Hi Peter Great to hear you are still in the industry. Bushland Health Group in Taree has employed an NP since 2009 & we like you were selected in the NP Project. Since then our NP service has gone from strength to strength. Sharyn operates across our three RACF sites ( n 263) Examples of good outcomes across these sites are the increasing numbers of hospital preventions which is as a result of a number of programs we have introduced. I agree with Judys comments however I would like to see some recognition & support for those of us who 'step up' & recognise that good care costs.NPs are yet to be recognised in ACFI? Bernadette Burke Director of Care Bushland Heath GRoup Taree NSW 2430 .


Bernadette Burke

6/06/2016 3:31 PM

Hi Peter Great to hear you are still in the industry. Bushland Health Group in Taree has employed an NP since 2009 & we like you were selected in the NP Project. Since then our NP service has gone from strength to strength. Sharyn operates across our three RACF sites ( n 263) Examples of good outcomes across these sites are the increasing numbers of hospital preventions which is as a result of a number of programs we have introduced. I agree with Judys comments however I would like to see some recognition & support for those of us who 'step up' & recognise that good care costs.NPs are yet to be recognised in ACFI? Bernadette Burke Director of Care Bushland Heath Group Taree NSW 2430 .


sue mcdonald

7/06/2016 7:48 AM

Great to read the article. I am also an RACF employed NP (2014) in pallaitive care in Qld. I work across 7 sites in Hervey bay, 4 in Maryborough and 7 sites in Bundaberg (travel there once per week).

My issues are around gaining GP approval of the role and feel comfortable with working in a shared care agreement. Renumeration would be the other bug bear with limited item numbers being provided by medicare.

Currently working with Qld Health facilities to raise the profile of NP and reducing presentations and re-presentations to Emergency.

One step at a time but in 18 months I have witness a change in acceptance of the role within the health care system.


tanya ponceti

26/08/2016 2:10 AM

i'm a 51 yrs old. retired/disabled RN in Louisiana. i am now a patient. through my research i found PC. just had 1st visit. would love to have more info. i have right heart failure, pulmonary hypertenrion, mechanical mitral valve. recently had torrsades and coded b/c of 2.1 potassium level. i want to access every aspect of PC, bur sometimes you need to know what to ask for - ya know. tanya


Jawahar Thomas

2/07/2017 3:46 PM

Great and informative article, Hoping to read you future article! Thankyou


Kathleen Wurth

12/10/2017 3:01 PM

Hi Peter,

Is there a chance to talk to you further re your role as NP in RACFs? I have heard that you are doing good work!

kathleen.wurth1@health.nsw.gov.au

Many thanks,

Kathleen

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