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Nurse Practitioners in New Zealand

Case Studies


Developing a Nurse Practitioner role in Aged Persons' Care, in Christchurch
Deb Gillon


I am a registered nurse and have been developing a nurse practitioner role with older people at the Nurse Maude Memorial hospital (NMA) since February 2005. In the wards where I work most patients require long term hospital level care and a few patients are resident in the hospital for palliative care. In this half time position I am well supported by a General Practitioner (GP) who is available to discuss my assessment and recommended treatment options and I also have professional supervision with a registered Nurse Practitioner in aged care. The other half of my time is spent in teaching and research at Christchurch Polytechnic Institute of Technology (CPIT). When I started developing the Nurse Practitioner role I had a Masters in Health Science (Nursing ) and have undertaken further courses in pharmacology, prescribing and advanced clinical practice within a clinical postgraduate programme and am working towards portfolio submission to the Nursing Council of New Zealand for Nurse Practitioner status.

At NMA I provide advanced nursing assessments for up to 40 patients in two wards during three to four days each week. In a typical week I would see around 15-20 patients who are referred to me by the nurses and caregivers on the staff. This includes diagnosing, treating and follow-up of infections in collaboration with the patients’ GP eg skin, eye, chest and urinary infections. I assess patients following falls and/or injury, with behavioural changes and on admission to the facility. In the weekly ward rounds with their GP my focus is on maintaining and promoting health and I concentrate on areas such as nutrition, skin care, wound care, bowel and urinary issues as well as assessment of mood and medication management. Early detection of any issues is paramount and care of older people is very much a team approach. We are working towards greater integration of evidence when developing patient care plans with nursing staff following these assessments.

I am available to the nurses for clinical nursing consultation for patients with complex care needs and liaise with members of the Multidisciplinary team (MDT) and colleagues at other healthcare facilities when necessary to plan care. This has enabled patients to remain in their familiar home environment rather than transfer to acute hospitals when this is appropriate. Nursing and caregiver education is an integral part of my role and includes eye care, mouth care, hand hygiene practices, wound care, hydration and nutrition, mobility, medication effect, side effects and interactions as well as documentation. I provide education in structured teaching sessions and informally as part of patient care planning. With the Registered Nurse ward leaders I provide close review of infection, pressure area, falls and restraint data which is collected monthly. From these reviews I work with nursing staff to identify and develop a management plan for patients suffering repeated nosocomial infections such as urinary tract infections (UTI’s) and eye infections. Nosocomial infections are not only debilitating for the patient and incur costs associated with treatments and the medical and nursing time involved, but also frequently result in behavioural changes which can impact on other patients as well.

An example of the difference this approach has made can be seen in the following short case exemplar
A review of the infection data showed Mrs Z was repeatedly experiencing urinary tract infections (UTI’s). A close look through her clinical notes revealed this 92year old lady had been treated with antibiotics on 12 occasions for UTI’s in the previous 10 months and 14 samples had been sent for culture and sensitivity during this time. Mrs Z was initially trialled with a small water bottle to encourage oral intake but this proved to be ineffective. She was then provided with a jug of water or juice and a plastic glass to be kept filled by her side at all times. The MDT team all agreed to share responsibility for ensuring this happened. Mrs Z has enjoyed having these beside her and filling her own glass, as a result her fluid intake significantly increased. In addition ovestin vaginal cream was prescribed twice weekly and more recently a tablespoon of Dr Arly’s yoghurt twice a day has been added to her meals. Mrs Z’s frequency of UTI’s has markedly reduced. She has required treatment for only 2 UTI’s in the 7 months since the new regime commenced.

Since I have been working in the hospital early results indicate an overall trend towards reduction in the use of restraint, infection rates and number of falls. There are less pressure ulcers occurring and we have been more effective in healing those that do occur. The data collected shows a statistically significant reduction in the severity of pressure ulcers (p=0.01) over a six month period since the introduction of this role when compared with the six months prior. This is an important contribution to patient health outcomes and reduction in health costs and is a significant team achievement given this includes patients receiving palliative care.

I am also involved in project work as part of my role. For example I have facilitated the introduction of MDT patient outcome reviews. The MDT team meet to review patients with their families six monthly, or more often if required, and develops outcome focussed care plans. This planning is directed towards providing the support for patients to live their lives as fully as they are able and for families to participate as they can and wish. I believe it is important patients live until they die…… not wait until they die. Staff and families say they enjoy this time we have together at these meetings and are finding it a worthwhile activity. Another significant initiative I have been part of has been the establishment of a benchmarking programme with a similar facility in the city to compare patient outcome data with the intention of sharing and improving clinical practices in both facilities. This group is currently working on the development of a comprehensive multidisciplinary falls management plan.

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