National_Evaluation_NP_Like_Services_in_Aged_Care

NURSE PRACTITIONER-LIKE SERVICES IN
RESIDENTIAL AGED CARE SERVICES
EVALUATION REPORT

NATIONAL EVALUATION OF NURSE
PRACTITIONER-LIKE SERVICES IN
RESIDENTIAL AGED CARE SERVICES
FINAL REPORT
PREPARED BY THE JOANNA BRIGGS INSTITUTE
DECEMBER 2007

© Commonwealth of Australia 2007
ISBN: 1-74186-541-7
Online ISBN: 1-74186-542-5
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National Aged Care Nurse Practitioner Trial: Final Report, vol. 1 — Evaluation Report Page i
Contents
List of tables...................................................................................................v
Executive Summary.....................................................................................vii
Acronyms .....................................................................................................xii
1 Introduction ..............................................................................................1
1.1 International Perspectives....................................................................1
1.2 Nurse Practitioners in Aged Care ........................................................2
1.2.1 Aims, significance and benefits of the aged care nurse
practitioner trial...........................................................................2
2 The National Aged Care Nurse Practitioner Trial ..................................4
2.1 Overall trial design ...............................................................................4
2.1.1 Trial sites.......................................................................................4
2.2 Methods and procedures .....................................................................4
2.2.1 Trial stages....................................................................................4
2.2.2 Stage 1: Education, training and assessment of nurse
practitioner candidates ...............................................................5
2.2.3 Stage 2: Development of agreed clinical
guidelines/protocols....................................................................6
2.2.4 Stage 3: Establishment of Nurse Practitioner-like Services...........6
2.2.5 Stage 4: Evaluation of nurse practitioner services
(concurrent with stage 3)............................................................7
2.2.6 Stage 5: Development of Report to the Australian
Government..............................................................................11
3 The Trial Sites.........................................................................................12
3.1 Warrabrook, NSW..............................................................................12
3.1.1 The locality ..................................................................................12
3.1.2 The facilities ................................................................................12
3.1.3 The nurse practitioner candidate.................................................12
3.2 Australian Capital Territory ................................................................12
3.2.1 The locality ..................................................................................13
3.2.2 The Canberra Hospital and Calvary Healthcare..........................13
3.2.3 Mirinjani Retirement Village.........................................................13
3.2.4 Nurse Practitioner/Nurse Practitioner Candidates.......................14
3.2.5 Aged Care Clinical Practice Guidelines.......................................14

National Aged Care Nurse Practitioner Trial: Final Report, vol. 1 — Evaluation Report Page ii
3.3 Barossa Village, SA ...........................................................................15
3.3.1 The locality ..................................................................................15
3.3.2 The facility...................................................................................15
3.4 Resthaven, Paradise, SA...................................................................15
3.4.1 The locality ..................................................................................15
3.4.2 The facilities ................................................................................16
3.5 Clarence Estate Residential Health and Aged Care ..........................16
3.5.1 The locality ..................................................................................16
3.5.2 The facility...................................................................................16
3.6 Kensington Park and McDougall Park Aged Care Home, Perth,
WA ...................................................................................................17
3.6.1 The locality ..................................................................................17
3.6.2 The facilities ................................................................................17
4 Designing and establishing the trial.....................................................19
5 Nurse Practitioner Orientation ..............................................................21
5.1 Introduction to the need for orientation ..............................................21
5.2 The Orientation training materials......................................................22
5.3 Identifying knowledge/skill deficits and learning needs......................22
5.4 The self-directed learning process.....................................................24
6 Developing Practice Guidelines............................................................25
6.1 Practice Guidelines and Standing orders/practice protocols..............25
6.2 Purpose of practice guidelines and protocols in the trial....................25
6.3 The guideline and protocol development process:.............................25
6.3.1 Warrabrook .................................................................................26
6.3.2 ACT.............................................................................................26
6.3.3 Resthaven...................................................................................26
6.3.4 Barossa.......................................................................................26
6.3.5 Clarence Estate, Albany and Kensington Park, Perth .................27
6.3.6 Discussion...................................................................................27

National Aged Care Nurse Practitioner Trial: Final Report, vol. 1 — Evaluation Report Page iii
7 Developing the Minimum Data Set........................................................29
8 Piloting of the Instruments....................................................................32
9 Integrated trial results: Evaluation .......................................................34
9.1 Collaborator survey............................................................................34
9.2 Resident health and satisfaction........................................................44
9.2.1 Analysis of questionnaire data ....................................................46
9.2.2 Demographics .............................................................................46
9.2.3 Short form health survey SF-12 ..................................................48
9.2.4 General satisfaction survey.........................................................53
9.3 Qualitative analysis............................................................................60
9.3.1 Methods ......................................................................................60
9.3.2 Findings.......................................................................................61
9.3.3 Stakeholder focus groups............................................................64
9.3.4 Discussion...................................................................................68
9.3.5 Conclusion ..................................................................................71
10 Discussion, Conclusion and Recommendations ................................72
10.1 Role of the nurse practitioner in aged care.......................................74
10.2 The clinical leadership potential of Aged Care Nurse
Practitioners in the Aged Care Sector ..............................................76
10.3 The impact of Aged Care Nurse Practitioners on resident
outcomes..........................................................................................76
10.4 The acceptability of the Aged Care Nurse Practitioner role..............76
10.5 Strategies for the development of appropriate national clinical
practice protocols and guidelines.....................................................77
10.6 Strategies for the development of a national Aged Care Nurse
Practitioners Formulary ....................................................................77
10.7 Costs associated with prescribing and ordering diagnostics ............78
10.7.1 Prescribing ................................................................................78
10.7.2 Ordering diagnostic tests...........................................................78
10.8 Costs associated with the nurse practitioner....................................78
10.9 Barriers, enablers and other issues that impact on the
introduction and sustainability of a nurse practitioner role................82
10.9.1 Jurisdictional differences in policy and regulation......................82
10.9.2 Medicare Funding......................................................................82
10.9.3 Pharmacetical Benefit Scheme Funding ...................................83
10.9.4 Knowledge and attitudes towards new roles .............................83
10.9.5 Workforce issues.......................................................................84

National Aged Care Nurse Practitioner Trial: Final Report, vol. 1 — Evaluation Report Page iv
10.10 Potential national service delivery models for Aged Care Nurse
Practitioner services.........................................................................84
10.10.1 Primary Health Care Based ......................................................84
10.10.2 Health service based as part of Geriatric Services ...................85
10.10.3 Australian Government Department of Health and
Ageing-Based...........................................................................85
10.10.4 Regionally based as part of a consortium of providers .............86
10.10.5 Facility based as part of nurse-staffing .....................................86
10.10.6 Independent contractor status ..................................................87
10.11 Conclusions......................................................................................88
10.11.1 Barriers identified in the trial .....................................................88
10.12 Recommendations ...........................................................................89
11 References..............................................................................................90

National Aged Care Nurse Practitioner Trial: Final Report, vol. 1 — Evaluation Report Page v
List of tables
Table 1 Learning plan format ................................................................................ 23
Table 2 Guidelines used by different sites in the nurse practitioner-like service
national evaluation ................................................................................... 27
Table 3 The survey form sent to collaborators. Respondents were asked to
assess their agreement with the following statements, on a scale from 1
(Disagree completely), 2 (Disagree somewhat), 3 (Agree somewhat) and
4 (Agree completely) ................................................................................ 34
Table 4 Summary of the professions of the 62 collaborators included in the
evaluation. Allied health, enrolled nurses, general practitioners,
managers/administrators, pastoral, personal care assistants and
registered nurses are presented. Profession was not recorded in four
cases........................................................................................................ 35
Table 5 Summary of 62 collaborator surveys (all NPC sites, except NPC 8). The
mode is in bold. ........................................................................................ 36
Table 6 Summary of responses to question 3 in the Collaborator survey “I
support the concept of NPCs”, grouped according to profession............. 37
believe that NPCs will enhance health care service provision”, grouped
according to profession. ........................................................................... 37
believe that NPC models will be sustainable in the long term”, grouped
according to profession. ........................................................................... 38
Table 9 Responses to the question “Please identify the strengths, if any, of this
Nurse Practitioner model”......................................................................... 38
Table 10 Responses to the question “Please identify the weaknesses, if any, of
this Nurse Practitioner candidate model”.................................................. 41
Table 11 Responses to the question “Please identify any improvements that could
be made to this Nurse Practitioner model” ............................................... 43
Table 12 Responses to the question “Please provide any further comments on
this Nurse Practitioner model not covered by earlier questions” .............. 44
Table 13 Summary of the total number of health and satisfaction questionnaires
returned from NPC and control sites ........................................................ 45
Table 14 Demographic summary of residents from control and NPC facilities
included in the assessment of health and satisfaction ............................. 47
Table 15 Summary of responses to amount spent by residents in the last six
months at control sites and nurse practitioner candidate sites. Mode
response is formatted in bold ................................................................... 48
Table 16 Summary of the number of responses to the Short Form Health Survey
(SF-12), questions 1,8,9,10,11,12 for both control (GP) and nurse
practitioner candidate (NPC) sites. Data are the number of responses,
the mode response is presented in bold................................................... 48

National Aged Care Nurse Practitioner Trial: Final Report, vol. 1 — Evaluation Report Page vi
Table 17 Summary of Short Form Health Survey (SF-12), questions 2 and 3 for
both control (GP) and nurse practitioner candidate (NPC) sites. Data are
the number of responses, the mode response is presented in bold......... 49
Table 18 Summary of Short Form Health Survey (SF-12), questions 4,5,6,7 for
both control (GP) and nurse practitioner candidate (NPC) sites. Data are
the number of responses, the mode response is presented in bold......... 50
Table 19 Summary statistics for total SF-12 score for control and nurse
practitioner candidate sites. Data (mean, sample size (n), standard error
(SE) and range (minimum, maximum) are presented for each of the
NPC sites and overall for all sites............................................................. 51
Table 20 Summary of coefficients of multiple regression using the total SF-12
score as dependent variable. The coefficients, standard errors, t values,
probabilities and 95% confidence intervals of the coefficients are
presented. Significant predictors are formatted in bold ............................ 53
Table 21 Summary of the 27 items in the general satisfaction survey .................... 54
Table 22 General satisfaction questionnaire (questions 1-21) responses of 80
residents from a control (GP) RACFs and 104 residents from the NPC
sites. Mode is in bold................................................................................ 55
Table 23 General satisfaction questionnaire (questions 22-27) responses of 80
residents from a control (GP) RACFs and 104 residents from the NPC
sites. Mode is in bold. Answers were framed “In terms of the treatment
provided to you by the (GP/NPC) service” ............................................... 56
Table 24 Summary statistics for total general satisfaction score for control and
nurse practitioner candidate sites. Data (mean, sample size (n),
standard error (SE) and range (minimum, maximum) are presented for
each of the NPC sites and overall for all sites.......................................... 57
Table 25 Summary of coefficients of multiple regression using the total general
satisfaction score, raised to the fourth power, as dependent variable.
The coefficients, standard errors, t values, probabilities and 95%
confidence intervals of the coefficients are presented. Significant
predictors are formatted in bold................................................................ 58
Table 26 Tabular display of Synthesis 1 from focus group interviews of residents
and/or relatives......................................................................................... 62
Table 27 Tabular display of Synthesis 2 from focus group interviews of residents
and/or relatives......................................................................................... 64
Table 28 Tabular display of Synthesis 3 from focus group interviews of
stakeholders ............................................................................................. 65
Table 29 Tabular display of Synthesis 4 from focus group interviews of
stakeholders ............................................................................................. 67

National Aged Care Nurse Practitioner Trial: Final Report, vol. 1 — Evaluation Report Page vii
Executive Summary
Introduction
Aged Care Nurse Practitioner roles are well established in many overseas
jurisdictions and there is evidence from these jurisdictions to suggest that the
introduction of such roles increases service-users satisfaction, improves
outcomes (timely access, assessment and client interventions), reduces the
prescription of pharmaceuticals, decreases readmission to acute care and
reduces costs. The Australian Government Department of Health and Ageing
announced funding to pilot Aged Care Nurse Practitioner services to examine
the introduction of the aged care nurse practitioner role in the Australian
context. In April 2005, the JBI Research Unit was contracted to work with
interested Approved Providers and ACT Health to assist them to develop
proposals within a framework that would facilitate a national evaluation; and to
conduct an external evaluation across all sites. Subsequently, seven nurse
practitioner candidates on six sites were funded to participate in the trial which
commenced in August 2005 and received initial funding for a period of eleven
months. In May 2006, additional funding was secured – until June 2007 – to
enable further data to be collected. This Report presents the findings of the
external evaluation conducted by the JBI Research Unit from inception to
June 2007. Site-specific reports were also submitted to the Australian
Government Department of Health and Ageing by each site.
The Trial
The national trial sought to establish and evaluate each of the seven pilot
nurse practitioner-like services.
The term “nurse practitioner-like services” was adopted to accommodate the
delivery of nurse practitioner services by registered nurses working toward
establishing their eligibility for licensure/registration as a nurse practitioner.
The trial involved the establishment of nurse practitioner-like roles and broadly
evaluating these roles. The evaluation component focused on the
implementation process and on the views of older people, the community,
provider agencies and members of multidisciplinary teams associated with
aged care to inform the Australian Government Department of Health and
Ageing, the Aged Care Sector, the nursing and medical professions and
legislative and regulatory bodies.
Results
Resident demographics/health
• Over two thirds of residents who participated in the trial were female,
and aged 80 or over.

National Aged Care Nurse Practitioner Trial: Final Report, vol. 1 — Evaluation Report Page viii
• Over 20% were born outside Australia, and over 10% spoke a
language other than English as their first language.
• On average, residents had about six co-morbidities and were currently
taking eight medications.
• Data on residents’ admissions to hospitals/emergency departments
was scarcely reported during a six months reporting period.
Practitioner interventions
• A total of 3146 visits were entered into the study from 510 residents.
Both the number of residents recruited to the project and the number of
visits entered into the study varied significantly between the seven
sites.
• The mean number of visits to the Nurse Practitioner Candidates
(NPCs) per resident was 6.2 ± 0.3; most residents had 1-4 visits.
• Symptom management was cited most frequently as the main problem
being addressed during visits to the NPC.
• NPCs categorised the intervention conducted during the visit according
to 12 core interventions. Implementing treatments/medications for
acute conditions was the most commonly cited core intervention.
• The total time spent per visit averaged 50 ± 0.7 minutes across all sites
and ranged from a mean of 25.3 minutes (site 5) to 87.6 minutes (site
8). However, the total time spent per visit decreased at most sites
between 2006 and 2007.
• NPCs initiated almost half of the visits, and registered nurses initiated
almost 20%.
• NPCs made a referral to a specialist in just over 13 of every 100 visits.
Referrals to GPs made up half of all referrals. The rate of referral was
similar between 2006 and 2007.
• NPCs ordered a diagnostic test in 7 of every 100 visits. Pathology
screening tests made up more than half of these diagnostics.
Practitioners tended to order less tests in 2007 compared to 2006.
• NPCs prescribed medications at the rate of 29.5 prescriptions per 100
visits. This tended to increase in 2007 compared to 2006.
• NPCs ordered consumables at the rate of 9.7 consumables per 100
visits. This tended to decrease in 2007 compared to 2006.
• The study recorded 67 cases where a NPC’s hypothetical prescribing
pattern (date, time, drug, dose, dosage, route of administration) was
compared directly to a medical officer’s actual prescribing pattern. In all
but one case the NPC’s hypothetical prescription was written before, or
at the same time as, the medical officer. On average, the NPC’s
prescription was written some 11 hours before the medical officer.

National Aged Care Nurse Practitioner Trial: Final Report, vol. 1 — Evaluation Report Page ix
Evaluation of service
• NPC collaborators (eg general practitioners, registered nurses, allied
health professionals, care staff) were highly supportive of the
practitioner and her role in the site.
• The health of a sample of residents at each of the seven sites was
measured using the SF-12 questionnaire and compared to a group of
residents in a nearby control site. In general, the health of the residents
was good. The following independent variables were included in
multiple regression analysis to determine if they were significantly
related to resident health: age, gender, treatment (NPC or control),
number of times service used in last 6 months, quality of life, length of
stay, general satisfaction and site. The only significant predictors of
resident health were quality of life and general satisfaction. This
indicates that a resident’s health was not related to whether they were
receiving care at a NPC or control facility.
• The satisfaction of a sample of residents at each of the seven sites was
measured using the general satisfaction questionnaire and compared
to a group of residents in a nearby control site. In general, residents
were more satisfied with their care than less satisfied. The following
independent variables were included in multiple regression analysis to
determine if they were significantly related to resident health: age,
gender, treatment (NPC or control), number of times service used in
last 6 months, quality of life, length of stay, resident health (SF-12
score) and site. The only significant predictors of resident satisfaction
were resident health, length of stay and site. This indicates that a
resident’s satisfaction was not related to whether they were receiving
care at a NPC or control facility.
• Analysis of focus group discussions of residents and their families led
to two syntheses: (i) the NPCs had led to improved health care for
residents, and (ii) residents and their families had grown to accept the
residents during trial as they became more familiar with NPCs.
• Analysis of focus group discussions of staff working with the NPCs
(general practitioners, nurses, allied health professionals etc) led to
another two syntheses: (iii) an acceptance of the role of the NPC and
the importance of collaboration between multidisciplinary staff, and (iv)
improved health care provision to residents through avoidance of
unnecessary resource use and greater satisfaction and confidence of
both residents and staff of Aged Care Facilities.
• A large number of factors (described fully in the report) imposed
considerable limitations on the trial and, as a result, no high quality
evidence of the effectiveness of the role was identified.
• Given the limitations of the trial, it is not possible to make definitive
recommendations for policy and service delivery, other than to strongly
recommend the initiation of a large, multi-site, well designed
comparative study of the effects of defined interventions delivered by

National Aged Care Nurse Practitioner Trial: Final Report, vol. 1 — Evaluation Report Page x
licensed nurse practitioners with the ability to prescribe and order
diagnostic tests on a range of well defined outcomes
• Notwithstanding these limitations – and in no way dismissing them –
the trial results suggest that a nurse practitioner-like role in aged care
is generally acceptable to residents, their families, medical practitioners
and other members of the health care team.
Conclusions
Overall, the role of Aged Care Nurse Practitioner candidates was viewed
positively by residents, their families and key stake holders; and sites
consistently reported that nurse practitioner candidates played an important
role in educating, encouraging and supporting staff and in liaising with other
stakeholders such as general practitioners, allied health professionals and
pharmacists. The trial was complicated by the variability across sites related
to jurisdictional variation in practice patterns and the regulation of practice and
the findings are tentative and equivocal and should be treated with caution.
There is no evidence that the introduction of a nurse-practitioner-like service
compromises the quality of care or health outcomes in residents and some
evidence to suggest that it improves health status. In line with the international
evidence, the nurse practitioner candidates prescribed and ordered
diagnostics appropriately and tended to do so less frequently than medical
practitioners. Given the relative success of this trial in organisational and
service delivery terms on the one hand; and the lack of evidence in relation to
effectiveness, a larger, multi-site randomised clinical trial involving licensed
Aged Care Nurse Practitioners who are able to prescribe is clearly warranted.
Barriers identified in the trial
Further investigation should consider the limitations and findings of the
present trial and, specifically, address the following issues identified in this
trial:
• The Aged Care Nurse Practitioner role needs to be well defined as a
generic role in aged care rather than a person-specific role.
• The need for National Clinical Practice Guidelines for the Aged Care
Nurse Practitioner, rather than State/Territory specific guidelines. This
could be achieved by the establishment of a national group of nurse
practitioners, geriatricians, general practitioners, pharmacists,
radiologists and pathologists to develop and endorse national clinical
practice guidelines for the Aged Care Nurse Practitioner.
• The need for a national curriculum (including clinical education) for
Aged Care Nurse Practitioners to minimise variability in the preparation
of Aged Care Nurse Practitioners across Australian Higher Education
institutions.
• The lack of continuity between States and Territories in terms of
licensure and regulation of nurse practitioners prevents simple

National Aged Care Nurse Practitioner Trial: Final Report, vol. 1 — Evaluation Report Page xi
movement of practitioners between jurisdictions. Additionally, the very
low numbers of currently registered Aged Care Nurse Practitioners is a
significant barrier to the advancement of the role in the short term.
• The requirement for access to “best practice” resources and ongoing
professional development in aged care for all practicing Aged Care
Nurse Practitioners.
• The need to recognise and promote the clinical leadership potential of
Aged Care Nurse Practitioners in the aged care sector.
• The need to conduct a well designed, large scale, multi-site, national
study to establish the relationship between the delivery of services by
licensed Aged Care Nurse Practitioners on specified outcomes and
costs, compared to services of other providers of such services.
• The need for debate and endorsement of national policy on the role of
the Aged Care Nurse Practitioner, developed jointly with older people,
nurses, GPs, Pharmacists, Pathologists and Radiologists.
• The issue of access to Medicare Provider status for Aged Care Nurse
Practitioners.
• The need to develop and endorse a national formulary for Aged Care
Nurse Practitioners
• Aged Care Nurse Practitioners’ ability to prescribe medications as part
of the PBS.
• The need to identify a preferred model of service delivery.
• The need to identify strategies to overcome current knowledge deficits
of the health professions and the general Australian population about
the role of the Aged Care Nurse Practitioner.
Recommendations
The study findings show high levels of acceptance of the trial’s nurse
practitioner-like service by service users and other health professionals and
high levels of resident satisfaction. However, findings related to the cost
effectiveness of the role are equivocal and suggest a need for further
rigorous, large scale, multi-factorial investigation.
Recommendation 1
The barriers to implementation identified in the trial be considered by the
Australian and state and territory governments and the aged care sector.
Recommendation 2
The introduction of a nurse practitioner role in aged care be further
investigated at a national level.

National Aged Care Nurse Practitioner Trial: Final Report, vol. 1 — Evaluation Report Page xii
Acronyms
ACT Australian Capital Territory
ANOVA Analysis of variance
CPG Clinical practice guideline
DHA Department of Health and Ageing
EN Enrolled nurse
GP General practitioner
GSQ General satisfaction questionnaire
INPRAC Implementing the Nurse Practitioner Role in residential
aged care
JBI Joanna Briggs Institute
JBI-NOTARI Joanna Briggs Institute Narrative Opinion and Text Review
Instrument
MDS Minimum data set
n Sample size
NP Nurse practitioner
NPC Nurse practitioner candidate
NSW New South Wales
OT Occupational therapist
PCA Personal care assistant
PBS Pharmaceutical Benefits Scheme
RACF Residential aged care facility
RN Registered nurse
SA South Australia
SF-12 12-item short form health questionnaire
UK United Kingdom
USA United States of America
WA Western Australia

National Aged Care Nurse Practitioner Trial: Final Report, vol. 1 — Evaluation Report Page 1
1 Introduction
Internationally, nurse practitioners (NPs) have been employed in acute care
services for at least the last 60 years, contributing to health care provision and
related services across a range of specialties. As nursing education and
training has developed, the notions of what a nurse practitioner is, and what
they do, have been defined and refined to meet the changing needs and
contexts of patient care and the varied settings in which care is delivered.
By the 1990s the potential for the NP role in the Australian health care setting
had gained credence through consultation, discussion and debate on how the
role could be applied. A number of significant trends (such as the changing
demographics of the population, changing workforce demographics, shifts in
emphasis from acute to community/primary health care and rising consumer
expectations) necessitated a move in this direction. Not the least of these
trends is the need to deliver suitable health services to a number of sectors in
the community.
The NP role has been mainly introduced into the acute care sector, with rapid
expansion of the role across acute care specialities, particularly those
associated with outpatient, clinic or specialist nursing care elements such as
emergency, diabetes and respiratory. However, in Australia and New Zealand
the NP role is still evolving (ACT Health, 2002; Gardner et al., 2004). The
development of the role is influenced by differing health care agendas but with
an emphasis on the potential benefits that NPs can provide in the delivery of
health care services (ACT Health, 2005).
1.1 International Perspectives
The international literature suggests that establishment of the nurse
practitioner role facilitates a more diverse health service with greater flexibility
and increased access to health care, and increased satisfaction and flexibility
in health care delivery. Although the role itself has developed across a range
of settings, with specific criteria for practice, therapeutic medication
management; referral to other health professionals; and ordering certain
diagnostic tests and procedures are the defining characteristics of the role that
differentiate it from other advanced nursing practice roles.
In the UK, the NP role was developed to address the lack of appropriately
qualified and experienced medical staff; client dissatisfaction with quality of
care, including consultation time and choice of available treatments; and poor
access to primary health care (Reveley, 2001; United Kindom Assembly,
2002). In the US there has been a focus on developing a nursing career path,
and the development of strategies to better meet client health needs (Walsh,
1999). Overall, research has identified positive benefits from the NP role
especially in terms of client outcomes and consumer satisfaction (Kinnersley et
al., 2000; MacLellan, 2002; Rhee & Dermyer, 1995; Sakr et al., 1999).

1.2 Nurse Practitioners in Aged Care
Aged care NP roles are well established in the United States and the United
Kingdom and there is robust evidence that suggests that the introduction of
such roles increases service-users’ satisfaction, improves outcomes (timely
access, assessment and client interventions), reduces the prescription of
pharmaceuticals and decreases readmission to acute care. Furthermore, aged
care NPs have been found to be 20% less costly, with nurse practitioners’
performance comparable or superior.
As part of its commitment to improving services for older people, the
Australian Government Department of Health and Ageing called for
expressions of interest in 2004 from approved providers of residential aged
care services to pilot the introduction of nurse practitioners in this sector.
The raison d'etre for exploring the formalised establishment and evaluation of
the NP role in aged care in Australia was to establish what the potential
benefits might be for residents in relation to safety, quality, satisfaction,
clinical care and outcomes. Over a period of almost fourteen months, a
number of Approved Providers responded to the call for expressions of
interest.
In April 2005 the JBI Research Unit was contracted to work with interested
Approved Providers and ACT Health to assist them to develop proposals
within a framework that would facilitate a national evaluation. All of the
Approved Providers submitted proposals in July 2005 based on the core
framework for implementation and evaluation developed by the JBI Research
Unit team. The JBI Research Unit focused on methods that sought to:
• standardise implementation of the NP role,
• promote collaborative models of practice with other health professions
providing care to residents,
• promote evidence based practice through development of guidelines
based on international evidence independent,
• standardised data collection,
• promote more robust evaluation through the use of control sites and
validated instruments for health, wellbeing and satisfaction of residents
with the model.
The national trial commenced in August 2005 and received initial funding for a
period of eleven months. In May 2006, additional funding was secured – until
June 2007 – to enable further data to be collected. This report presents the
findings of the study from inception to June 2007.
1.2.1 Aims, significance and benefits of the aged care nurse
practitioner trial
This national trial sought to establish and evaluate each of the seven pilot
nurse practitioner-like services. The term “nurse practitioner-like services” has
been used to accommodate the delivery of nurse practitioner services by
registered nurses working toward establishing their eligibility for
licensure/registration as a nurse practitioner. The trial involved the

establishment of nurse practitioner-like roles and broadly evaluating these
roles. The evaluation component focused on the implementation process and
on the views of older people, the community, provider agencies, the health
care workforce (in the aged care sector the NPC or NPs work with a variety of
health care workers and professionals (eg: dieticians, nutritionists, therapists,
social workers etc) not just the medical and nursing profession) to inform the
Australian Government Department of Health and Ageing, the aged care
sector, the nursing and medical professions and legislative and regulatory
bodies.
All of the nurse practitioner-like services were provided by experienced
registered nurses with specialist knowledge, skills and competencies in
gerontological nursing. During the course of the evaluation some candidates
completed the requirements for registration as a nurse practitioner and were
recognised by their State licensing bodies. However, this did not impact
significantly on the evaluation as Federal Government requirements for
prescribing have not been changed to facilitate full use of the skills,
knowledge and abilities gerontological NPs would otherwise be able to use. In
addition to their previous experience in gerontological nursing, all nurse
practitioner candidates were assessed to ensure competence before
undertaking a range of activities normally associated with extended practices
sufficient to deliver services to:
• enhance the health care of aged care residents by
monitoring/managing their chronic conditions,
• provide early health care assessment, detection and prompt treatment
of symptoms/conditions that would ordinarily lead to an acute medical
episode and possible admission/readmission to the acute care sector,
• provide timely initiation of treatment eg directly ordering diagnostic
investigations, commencing medications (oral antibiotics),
• provide enhanced communication, coordination and monitoring of that
care to other health care providers, the client and/or their carers,
• as a consequence of early detection and intervention, reduce hospital
admissions (to Casualty or as an in-patient; both in frequency and
length of hospital stay); and
• reduce complications related to less than prompt commencement of
treatment/s

2 The National Aged Care Nurse Practitioner Trial
2.1 Overall trial design
The trial was designed to apply a common methodology across each of six
sites so that a common minimum data set could be utilised. In accordance
with previous research it was decided to use an approach that encompassed
both qualitative and quantitative approaches to capture the complexity and
scope of the NP role.
2.1.1 Trial sites
Seven nurse practitioner candidates, providing six nurse practitioner-like
services, participated in the aged care nurse practitioner trial based on six trial
sites:
1. Baptist Community Services, Newcastle, New South Wales (service sited
at the Warabrook Centre for Aged Care);
2. Hall and Prior Aged Care, Albany, Western Australia (service sited at
Clarence Estate Residential Health and Aged Care);
3. Hall and Prior Aged Care, Perth, Western Australia (service sited at
Kensington Park and McDougall Park Aged Care Home);
4. Barossa Village Incorporated, South Australia (service sited at Barossa
Village Residency);
5. Resthaven, South Australia (service sited at Resthaven, Paradise,
extended to include Leabrook and the 15 community Extended Aged Care
in the Home (EACH) packages from late 2006);
6. Australian Capital Territory, Canberra. There were two sites within the
ACT. One position was in the public sector within the Aged Care and
Rehabilitation Service and worked across the acute, community and
residential aged care sectors; and one position was within the private
residential aged care sector Uniting Care Ageing at Mirinjani Retirement
Village.
2.2 Methods and procedures
2.2.1 Trial stages
The first phase of the trial consisted of five stages:
Stage 1: Education, training and assessment of the Nurse Practitioner
Candidates
Stage 2: Development of agreed clinical guidelines/protocols
Stage 3: Establishment of Nurse Practitioner-like Services
Stage 4: Evaluation of Nurse Practitioner candidate Services

Stage 5: Development of Report to the Australian Government
2.2.2 Stage 1: Education, training and assessment of nurse
practitioner candidates
All NPCs were experienced registered nurses who had extensive experience,
knowledge and skills related to gerontological nursing and the aged care
sector. Of the seven participating NPC, three had almost completed the
educational and clinical requirements for the award of a Masters degree
related to licensure as a Nurse Practitioner at their respective universities to
enable licensure/registration as a nurse practitioner (two in the ACT, and one
in South Australia).
Two NPCs completed the requirements for licensure/registration as actual
NPs (ACT (public sector) and Barossa) during the trial. There was therefore
wide variation in the knowledge and skills of the candidates.
An education and training program was designed to identify and address the
knowledge and skills needed for the achievement of maximum health and
independence of the clients referred to the NPC. The NPCs at an advanced
stage in their tertiary NP studies were not required to undertake the additional
education and training program. However, their respective universities were
required to declare/state that this level of competency had been achieved.
At the beginning of the aged care NP trial all NPCs were provided with an
orientation package (Appendix I) and attended a four day orientation program
at the Joanna Briggs Institute in Adelaide.
An individual educational learning plan was developed for each of the NPCs
to address the core competencies that were required within the educational
and training program. Those NPCs who had not yet commenced tertiary
studies subsequently accessed a range of health professionals over an
intensive six week period to acquire the specified knowledge and skills.
Completion of the individualised learning plans required verification, by
signature, by all health care professionals who assisted the NPC, and this
verification included an indication that the candidate had demonstrated
competency in each of the specified learning tasks.
The individual training program, while tailored to the learning needs of each
individual, included standardised modules that addressed:
• Physical examination of the aged care client;
• Diagnostic reasoning (including the evaluation of signs and symptoms; and
the ordering and interpretation of diagnostic tests),
• The pharmacology (including indications, contraindications, pharmaco-
kinetics, prescribing etc) of specified medications,
• The management of specified medical conditions, and
• The case management of older people (including referrals to other health
professionals)

2.2.3 Stage 2: Development of agreed clinical guidelines/protocols
In Stage 2 of the project an interdisciplinary steering committee was
established at each site consisting of at least: a senior nurse, a medical
practitioner, a pharmacist, a radiologist, and a pathologist. This group was
responsible for assisting in developing guidelines, policies and protocols that
set parameters for safe practice in relation to the specific areas of the NPC’s
extended practice. Parameters for safe practice were to be actioned through
the development of guidelines (eg prescribing guidelines, diagnostic services
guidelines, referral to medical specialist guidelines). An example of
parameters that were established through guidelines is prescribing from a
limited list, with capacity to review and adjust dosage and frequency of
medications.
The ACT utilised the clinical practice guidelines that were developed during
the Aged Care Nurse Practitioner Pilot Project for each of their NP/NPCs. In
terms of diagnostic investigations and medications, each NPC discussed this
with the client’s appropriate medical officer who wrote the script or diagnostic
test (and was therefore legally responsible for follow-up). The NPC monitored
the client’s progress and provided communication to the multi-disciplinary
team that included the medical officer. Each NP/NPC was supported by a
clinical support team which met on a fortnightly basis to provide both clinical
and professional education and support.
Extension of the current role being undertaken by nurses to that of a nurse
practitioner-like role also required supportive and developmental processes.
These included:-
• developing and trialing guidelines for prescribing;
• developing and trialing guidelines for initiating diagnostic tests and
investigations;
• developing and trialing guidelines for referring to other health care
professionals;
• involvement in admission and discharge of residents to/from the local
hospital.
All sites developed site-specific guidelines/protocols (Appendix II-VI). Again
the ACT utilised the clinical practice guidelines that were developed during the
Aged Care Nurse Practitioner Pilot Project. The level of collaboration on
guideline/protocol development increased over the duration of the project,
with sharing and localisation of resources occurring between jurisdictions.
2.2.4 Stage 3: Establishment of Nurse Practitioner-like Services
Ethical approval and support for the national aged care nurse practitioner trial
was obtained through the Royal Adelaide Hospital Research Ethics
Committee for the trial as a whole, and, specifically, for sites that did not have
access to an ethics committee constituted according to national requirements
in Australia.
The nurse practitioner-like services on each site were developed through a
consultative process with residents, families, care staff and other health care
professionals. The model of practice across sites incorporated holistic care

directed by a specialist NPC who liaised with, and directed care for, residents
who were acutely or chronically ill, linking care with GPs and other health care
professionals.
The model enabled safe, sustainable and timely initiation of practices such as:
• Coordination of a winter flu strategy within the facility eg initiating fluvax;
• Identification and treatment of symptomatic urinary tract infections including
the ordering of investigations and the prescribing of antibiotics according to
identified sensitivity;
• Wound Management including ordering investigations and prescribing
treatment / medications;
• Managing other infections including ordering tests and prescribing
medications (eg diarrhoea, upper respiratory tract infections);
• Prescribing and administering treatments/medications for acute conditions
(eg antiemetics, anti-diarrhoea, aperients, medicated creams);
• Ordering medical imaging eg for suspected fractures;
• Prescribing complementary therapies & managing their therapeutic
benefits;
• Evaluating and adjusting existing medication regimes (in consultation)
including alteration of dosage, rewriting medication charts;
• Referring to specialists - eg PGAT, Speech pathology, ophthalmology,
dental, palliative care, wound specialists;
• Managing physical restraint authorisation;
• Prescribing and administering anti-psychotics in emergency situations
(after development of protocols / standing orders);
• Initiating increases in dosages of medication (eg prednisolone for
asthmatics in clinical case of increasing shortness of breath); and
• Other as identified by the project team.
Expected outcomes were reductions in impact and cost of acute medical
conditions and improvement in general health conditions and monitoring and
management of chronic conditions.
2.2.5 Stage 4: Evaluation of nurse practitioner services
(concurrent with stage 3)
The evaluation strategy included the development of a minimum data set that
was designed to apply a common methodology across the seven trial
locations. This allowed the simultaneous exploration of issues relevant to
each of the individual sites, as well as the collection and analysis of activity
data. In addition a series of five discrete Sub Projects were conducted.
2.2.5.1 Activity analysis/Minimum Data Set (MDS)
A modification of the Minimum Data Set created for the NSW Nurse
Practitioner Trials and the Victorian Nurse Practitioner project (Phase 1 and
Phase 2 evaluations) was used to collect activity data. The MDS was
designed to serve two purposes. Firstly, to standardise data collection related
to the functions and extent of the role; and secondly to provide a comparison

point for future evaluations to the NSW and Victorian Nurse Practitioner trials
that essentially collected similar data.
The database for the NSW and Vic studies was originally designed as a
Microsoft Access Database with two components. The front end incorporated
the forms for data collection while the data was stored in a separate location.
In initial trials within the Victorian project team, this was problematic as it
required that both the components be installed to the local hard drive in
prescribed folders, and would not allow installation to a more secure location
such as a server. This meant that the data collected could not be securely
protected by regular backing up.
The core fields of these previous minimum data sets were maintained,
additional fields added according to the specific needs of this national
evaluation and the MDS was redesigned as an online database maintained by
the Joanna Briggs Institute. The new program enabled sites to enter data;
improved the stability of the tool; allowed installation to a server where secure,
24 hour access could be established for legitimate users; allowed reports to
be more easily run; and improved the merging of data so that analysis could
be conducted more readily (Appendix VII).
Each NPC was trained in the use of the MDS via a teleconference call or an
onsite visit prior to the commencement of data collection. During the data
collection phase the project team were available Monday to Friday to answer
queries and solve problems related to the MDS and other aspects of the
evaluation.
There were five sub projects relating to the data collection: (i)
Resident/Consumer Focus Group, (ii) Stakeholder Focus Group, (iii)
Comparative Survey, (iv) Collaborator Questionnaire and (v) Economic
Evaluation.
2.2.5.1.1 Sub Project 1: Resident/Consumer Focus Group
In this Sub Project, consumer views on nurse practitioner-like services were
elicited through focus group discussions conducted by site project staff
(Appendix VIII).
Residents/consumers views on the following were canvassed:
• quality of the service provided by the NPC including the consumer’s
experience, choice and values;
• the ongoing feasibility of the NPC role;
• access to the Nurse Practitioner-like service;
• appropriateness of the Nurse Practitioner-like service provided;
• outcomes, including consumer experience, symptom relief,
complications, consumer satisfaction, educational value and
unexpected outcomes; and
• scope for improving and broadening current practice of the NPC.
Residents/Consumers were accessed via the relevant facilities and times and
locations were advertised for several weeks prior to the date of the focus
group. In the ACT, information sessions were held and letters and posters

were distributed to all residents in the facility to discuss the national aged care
nurse practitioner trial and the data that was required to be collected. This
provided an opportunity for residents to ask questions.
Verbatim transcripts of the focus groups were subjected to thematic analysis
utilising the JBI-NOTARI software. JBI-NOTARI is designed to assist
qualitative researchers to integrate coding with qualitative linking, shaping and
modelling. This is a commonly used approach to data analysis in qualitative
research.
2.2.5.1.2 Sub Project 2: Stakeholder Focus Group
In this Sub Project, key-stakeholder views on Nurse Practitioner like-services
were elicited through focus group discussion conducted by site project staff
using a focus group guide (Appendix IX). Key-stakeholders included general
practitioners, nurses, administrators, pharmacists, and other allied health
professionals.
Key stakeholder views on the following were sought regarding:
• quality of the service provided by the NPC;
• feasibility of the NPC role;
• access to the Nurse Practitioner-like service;
• appropriateness of the Nurse Practitioner-like service provided;
• collaborative practice including the identification of professional roles
and boundaries, participation in case conferencing, referrals to and
from other health care workers, initiation of care plans and health
professional experience;
• outcomes including impact on other services;
• scope for improving and broadening current practice of the NPC; and
• the sustainability and the cost-effectiveness of the NP model of
practice.
As both sets of focus groups were conducted by staff from the facilities,
support and training materials were developed and provided to each site.
Telephone support was also provided to sites on an as needed basis by JBI
Research Unit staff familiar with the conduct and analysis of focus groups.
2.2.5.1.3 Sub Project 3: Comparative Survey
The comparative Sub Project was designed to allow a direct comparison
between the individual Nurse Practitioner-like service trials under evaluation
and organisations that provided similar aged care services. In the early stages
of the evaluation members of the research team met with members of staff of
individual trial sites to identify potential comparable organisations to approach
to be included as comparisons in the evaluation process.
Questionnaire packages were distributed to each trial site and a comparator
group in sealed envelopes. These contained the following:
• the General Satisfaction Questionnaire, the SF-12, and a short
demographic questionnaire (Appendix X);
• a stamped self-addressed envelope;

• instructions on how to complete the questionnaires; and
• a justification for the study.
This approach assured anonymity of respondents, minimised costs to the
participant, and kept the required time commitment to a minimum. The
primary objective was to elicit the level of resident health and satisfaction with
the service provided by the NPC and compare this with a comparable aged
care facility where no Nurse Practitioner-like service existed.
The 12 Item Short Form Health Survey (SF-12®) has been widely used
internationally, and is a derivative of the SF-36®, both of which have been
extensively published and reported in health care literature, including
evaluations of reliability and validity. The SF-12® scoring algorithms involve
weighted item responses, and has the added benefit of improving efficiency
and lowering cost for both profiles and summary scales where the objective is
to monitor overall physical and mental health outcomes. As with the GSQ, a
number of changes were made to descriptors used in the SF-12® as not all
the activities were appropriate for older adults in residential care settings. The
discussion on the wording of descriptor terms used in the SF-12® concluded
with a series of changes being made to the form prior to its full implementation
across all sites. This process, as with the GSQ was begun prior to the 3 day
orientation in Adelaide, at a round table meeting of site project coordinators,
and which continued with site project managers over a period of time.
The General Satisfaction Questionnaire (GSQ) is a tool used commonly to
assess client satisfaction with a given service using a questionnaire and 4
point Likert type scale. This was re-formatted and the qualitative component
was removed. This generated a numeric value to determine client satisfaction.
The client satisfaction score ranges from 27, which indicates the lowest level
of satisfaction, to 108, which indicates the highest level of satisfaction with the
service. A number of the items were reverse scored allowing for the
calculation of a global satisfaction score derived by summing each of the 27
items.
2.2.5.1.4 Sub Project 4: Collaborator Questionnaire
The various nursing, medical and allied health care professionals who
participated in interdisciplinary collaborative care with the NPCs were asked
to complete a structured postal questionnaire. This included information about
the evolving collaborative relationships between the roles and functions of the
nursing and medical/allied health professions, their different foci and any
overlap of activities (Appendix XI). The purpose of Sub Project 4 was to
establish the level of collaboration experienced by those who worked with the
individual NPCs.
2.2.5.1.5 Sub Project 5: Economic Evaluation
One of the main purposes of a project such as this is to evaluate the cost-
effectiveness of the NP model vis-á-vis the current model with its pre-existing
services delivered by medical officers and nurses (with a more limited role in
delivery of these services). This study included a simple cost-benefit analysis
of the NP model, which, under our assumptions, was consistent with a ‘cost

effectiveness’ analysis. Using budget information contained in the individual
project reports, in combination with data extracted from an Economic
Evaluation questionnaire (Appendix XII), conclusions were drawn about the
overall cost-effectiveness of the Nurse Practitioner model.
2.2.6 Stage 5: Development of Report to the Australian
Government
The first interim report was submitted to the Commonwealth Department of
Health and Ageing was submitted in June 2006.
This document represents the final report, and includes an examination of the
NP role from the commencement of the project (June 2005) until the end of
data collection (April 2007).

3 The Trial Sites
It should be noted that this background is derived from information available
from the sites and represents the intent of the sites, but not necessarily actual
practice.
3.1 Warrabrook, NSW
3.1.1 The locality
This trial site is located in the Hunter region of New South Wales. There are
37 General Practitioners who service Warabrook Centre for Aged Care.
There is also access to three pharmacies that service the facility via
communication of resident needs through care staff and residents. There are
no onsite Allied Health professionals but access can be arranged through
appropriate referral processes. Examples of regular Allied Health
Professionals who service Warabrook include Mental Health for Older
Persons Team, Podiatrist, Speech Pathologist and Pathology Services.
3.1.2 The facilities
The Warabrook Centre for Aged Care is a 151 bed facility with a client mix
that includes 51 High Care and 100 Low Care Residents including 2 respite
places. Residents have complex health care needs, and chronic illnesses
which compound their care requirements. The facility is operated by a church-
related, charitable, not-for-profit organisation. Throughout this report, the
Warabrook Centre for Aged Care will also be identified as RACF 6.
3.1.3 The nurse practitioner candidate
The NPC had completed 75% of a masters degree linked to licensure as a
nurse practitioner in New South Wales when the trial commenced and has
since completed. The Nurse Practitioner-like service included the use of
agreed protocols and standing orders by the NPC to initiate diagnostic
investigations and referral to other health professionals. Throughout this
report, the NPC from Warabrook Centre for Aged Care will also be identified
as NP 6.
3.2 Australian Capital Territory
The ACT had been previously undertaking research into the potential of the
role of the aged care nurse practitioner. Thus, the national ‘Aged Care Nurse
Practitioner Trial’ was deemed a ‘nested’ project for ACT Health, ie, the ACT
provided data and information to JBI who were undertaking the evaluation
component on behalf of the Australian Government.
During this period, ACT Health continued to research the role of the nurse
practitioner in aged care with ‘Implementing the Nurse Practitioner Role in
Aged Care (INPRAC)’ project which is a jointly funded initiative between the

Australian Government (Department of Health and Ageing, Quality Outcomes
Branch) and ACT Health to implement the NP role in Aged Care. The project
resulted from negotiations between representatives of ACT Health and the
Department of Health and Ageing to extend the parameters of the 2004-05
Aged Care Nurse Practitioner Pilot Project.
3.2.1 The locality
The ACT and surrounding regions has a population of over 500,000 people
and provides a wide range of health care services. The primary and
community care system is a fundamental part of the ACT health care system.
This sector provides a range of care including aged care, drug and alcohol,
dental and indigenous health services, community-based allied health
services, mental health services, alcohol and drug services, home and
community care support services, health promotion services and community
nursing. General Practitioners play an integral role with about 85 per cent of
people seeing a GP each year (ACT Government 2002). In any given year
there are about 65,000 separations from public hospitals (ACT Health 2004-
5). All these services play a vital role in preventing and reducing the need for
hospital admissions, maintaining the wellbeing of the community outside of
the hospital setting and supporting consumers following discharge from
hospital (ACT Government 2002). There are currently twenty-eight residential
aged care facilities (includes both low and high level) in the ACT.
3.2.2 The Canberra Hospital and Calvary Healthcare.
The Canberra Hospital is a major national tertiary hospital that provides a full
range of medical, surgical and obstetric services as well as the provision of
complex services such as major cardiac surgery and intensive care services.
Calvary Public Hospital also provides a comprehensive range of surgical,
medical and obstetric services and is a major centre for elective surgery.
Services at both acute hospitals are moving towards clinical streaming,
increasing the emphasis on a client centred health system. Clinical streaming
builds upon a networking of services to focus on the provision of services
across the care continuum. Streamed services operate under one
management model and provide services such as health promotion, early
intervention, community and outpatient services through to acute care
services. Areas that are already established as service networks include ACT
pathology, cancer services and aged care and rehabilitation (ACT
Government 2003-2004). Throughout this report, the Canberra Hospital and
Calavary Healthcare will also be referred to as RACF 8.
3.2.3 Mirinjani Retirement Village
Uniting Care Ageing has provided the clinical placement for the NPC through
the Implementing the Nurse Practitioner Role in Aged Care (INPRAC) project.
Uniting Care Ageing is a not for profit organisation. The Uniting Church in
Australia Property Trust (NSW) has been providing quality aged care services
for over 40 years and has a long-term commitment to continue to meet the
growing needs of the community. The Church’s aged care services group,

UnitingCare Ageing NSW/ACT, is one of the largest aged and community
care providers in Australia, operating some 92 residential aged care facilities
containing 5771 places, 72 community care services providing for over 4000
clients and 3000 self care units located at 80 different sites. The total annual
turnover of these operations is in excess of $300 million. UnitingCare Ageing
NSW/ACT employs in excess of 5000 staff to support these operations.
Throughout this report, the Mirinjani Retirement Village will also be referred to
as RACF 7.
3.2.4 Nurse Practitioner/Nurse Practitioner Candidates
Within the national Aged Care Nurse Practitioner trial and the INPRAC project
there were two NPCs. One position was placed with ACT Health (public
sector) within the Aged Care and Rehabilitation Service. Although this position
was physically located at the Canberra Hospital, the role worked across the
acute (The Canberra Hospital and Calvary Healthcare), the community and
the residential aged care sectors. Throughout this report, this NPC will also be
identified as NP 8.
The other NPC position was placed with the private residential sector with the
organisation of Uniting Care Ageing at Mirinjani Retirement Village, Weston
Creek, ACT. Throughout this report, this NPC will also be identified as NP 7.
At the beginning of the national aged care NP trial, the two NPC were
finalising the requirements for the Master of Nurse Practitioner degree at the
University of Canberra. Both had completed the required lectures and clinical
viva, however needed to complete a thesis that would fulfil the final
component. Both candidates successfully completed all requirements and are
continuing in NP positions following the completion of this trial.
3.2.5 Aged Care Clinical Practice Guidelines
Aged Care Clinical Practice Guidelines were developed by the NPCs during
the ACNPPP and have been reviewed and updated during the INPRAC
project. During these clinical placements the NPCs enhanced the clinical
practice guidelines that were developed as part of the Aged Care Nurse
Practitioner Pilot Project, 2004-2005. These included the scope of practice,
diagnostic investigations and medication formulary for the Aged Care NP.
(Appendix III).
Clinical Practice Guidelines are regulated in the ACT. Before the NP is able to
enact and practice within the full scope of the role, such as prescribing,
ordering diagnostic tests and referring to other health care professions, written
endorsement of the multidisciplinary stakeholders who have been involved in
the development/adaptation of the guidelines including the medication
formulary is required. Additionally, formal agreement and signed approval is
required from the CEO and General Manager of the health service in which
the NP is employed. Therefore, after assessment of the client/resident any
initiation of medication or diagnostic tests (those activities normally associated
with the extension of the NP role) was conducted in consultation with the
appropriate medical officer.

3.3 Barossa Village, SA
3.3.1 The locality
The facility is located in the Barossa Valley, South Australia.
3.3.2 The facility
The Barossa Village Residency is an 80 bed facility with a client mix that
includes 49 high care beds and 24 low care beds, and seven unfunded beds
being used for rehabilitation services and other care. Residents at Barossa
Village Residency have complex health care needs and chronic illnesses that
compound their care requirements. The facility is operated by a community
managed, charitable, not-for-profit organisation that provides a wide range of
other services to the ageing population including, 54 Community Aged Care
Packages, 5 Extended Care at Home Packages some of whom have already
been seen by the Nurse Practitioner (though not as part of this trial), 7
Extended Care at Home (Dementia) packages and approximately 200 people
in small groupings of retirement cottages across the region. It enables socially
isolated residents of the region to attend congregate programmes at a
Nuriootpa based Community Centre and works collaboratively with many
other service providers within the region to achieve the best range of options
for care possible within funding availability. Throughout this report, the
Barossa Village Residency will also be identified as RACF 11.
The NPC had completed a masters degree linked to licensure as a NP in
South Australia when the trial commenced and has since been licensed as a
NP by the Nurses Board of South Australia as the first Aged Care Nurse
Practitioner in South Australia. The NP has previously operated as a Clinical
Nurse and deputy Residential Services Manager at Barossa Village for a
number of years and has shown a great passion for this quality service for the
better health treatment of residents and clients. The NP service included the
use of agreed protocols and standing orders by the NP to initiate medications,
diagnostic investigations and referral to other health professionals.
Throughout this report, this NPC will also be identified as NP 11.
3.4 Resthaven, Paradise, SA
3.4.1 The locality
The Resthaven nurse practitioner-like service is in North East Adelaide.
Pharmacy services are provided by a local pharmacy and allied health
services from Resthaven are been used. GP involvement for the project has
concentrated on the two primary GPs who have the majority of the residential
facility resident numbers. The outer northern suburbs of Adelaide are
identified areas of GP shortage. During phase 2 of the national evaluation, a
further site was added to the candidate’s jurisdiction – Resthaven Leabrook is

situated on the corner of Kensington and Glynburn Roads in Adelaide’s
Eastern suburbs.
The Resthaven Paradise site has 40 high care and 87 low care residents. The
service is operated by a church-related, charitable, not-for-profit organisation.
The Resthaven Leabrook site has 40 high care and 71 low care beds,
including a 14 place low dependency secure dementia care unit and two low
dependency respite care places. Throughout this report, this facility will also
be identified as RACF 10.
The NPC had no previous education or training in the NP role when the trial
commenced. The Nurse Practitioner-like service introduced included the use
of agreed protocols and standing orders by the NPC to initiate medications,
diagnostic investigations and referral to other health professionals.
Throughout this report, this NPC will also be identified as NP 10.
3.5 Clarence Estate Residential Health and Aged Care
3.5.1 The locality
The facility is located in Albany, a regional centre in the south-west of
Western Australia which serves a population of 31900 thousand people.
Albany is a retirement destination for many Western Australians, and the
proportion of its population aged 65+ is greater than 18%, compared with the
state average of 11%. It is expected that Albany’s aged will comprise 30% of
the population by 2012.
Residents at Clarence Estate have the right and opportunity to allocate a
pharmacy or pharmacist of their choice. There are approximately eight
pharmacies in Albany. The facility uses an artromick system. As with the
choice of pharmacist, residents also nominate a General Practitioner of their
choice. They have approximately 33 General Practitioners to choose from and
usually nominate the General Practitioner who had cared for them in the
community.
Clarence Estate has an on-site physiotherapist and occupational therapist. A
podiatrist visits six-weekly. Clarence Estate also has a dietitian and social
worker, who are based centrally. Clarence Estate’s residents can be referred
to any private allied health worker they wish to see in the community.
3.5.2 The facility
Clarence Estate Residential Health is an 86 bed facility with a client mix that
includes 36 high care beds; 18 dementia-specific standard high care beds; 16
extra services high care beds; and 16 extra services low care beds.
Residents have complex health care needs, and chronic illnesses which

compound their care requirements. The facility is operated by a private, for-
profit organisation. Throughout this report, this facility will also be identified as
RACF 5.
of agreed protocols by the NPC to make recommendations to participating
medical practitioners regarding the ordering of medications, diagnostic
investigations and referral to other health professionals. Because of
restrictions to the use of standing orders in Western Australia, it was not
possible to use standing orders on this site and, thus, the nurse practitioner-
like service was mediated through medical practitioners.
3.6 Kensington Park and McDougall Park Aged Care Home,
Perth, WA
3.6.1 The locality
Both of these facilities are located in Perth, Western Australia and together
serve around 10% of the total population of Perth which is 1, 292 297. Access
to pharmacy and allied health services is good and GP services are in the
vicinity. A doctor service gap is evident after hours and on the weekends.
While a locum service is operating it does mean that the resident often has to
wait some time before the locum can visit the resident.
Kensington Park Aged Care Home is a 60 bed high care facility. All residents
admitted to this facility have dementia and it is essentially a dementia specific
facility. Additionally, residents have complex health care needs, and chronic
illnesses which compound their care requirements.
McDougall Park Aged Care Home is a 52 bed high care facility. The client mix
includes residents with complex care health needs, chronic diseases including
dementia which compound their care.
Residents at Kensington Park and McDougall Park homes are offered the
services of the organisation’s allocated pharmacy services. The Artromick
system is used. Residents have a choice to nominate their own general
practitioner however it is more likely that the resident uses the services of a
general practitioner nominated by the facility, ie a general practitioner who has
already agreed to take on another client.
Both facilities use an on site Physiotherapist, Occupational Therapist,
Podiatrist and the organisation employs a Dietician and Social Worker. Both
facilities are operated by a private, for profit organisation. Throughout this
report, these facilities will also be collectively identified as RACF 4.

of agreed protocols by the NPC to make recommendations to participating
medical practitioners regarding the ordering of medications, diagnostic
investigations and referral to other health professionals. Because of
restrictions to the use of standing orders in Western Australia, it was not
possible to use standing orders on this site and, thus, the nurse practitioner-
like service was mediated through medical practitioners. Throughout this
report, this NPC will also be identified as NP 4.

4 Designing and establishing the trial
The national project involved six, self-nominated trial sites across different
jurisdictions and with differing clientele and service plans. Each site varied in
its understanding and application of the trial intervention. To achieve a degree
of uniformity across sites, the Joanna Briggs Institute provided initial cross-
site support to the National Aged Care Nurse Practitioner Trial. This support
consisted of:
1. Providing initial input on trial design and evaluation for trial sites in
Western Australia; South Australia; the Australian Capital Territory and
New South Wales, and assisting with protocol development [Component
1];
2. Providing baseline orientation to the nurse practitioner candidates located
in Western Australia; South Australia; Australian Capital Territory and New
South Wales [Component 2];
3. Assisting with the development of agreed Practice Guidelines in all sites
[Component 3];
4. Designing and testing a Minimum Data Set for use in these, and future,
trials [Component 4]; and
5. Conducting an external evaluation of the trials in Western Australia; South
Australia; Australian Capital Territory and New South Wales [Component
5].
This chapter discusses the first component of the support provided by JBI.
Subsequent chapters address the other four components to JBI’s involvement
in the project.
The Aged Care Nurse Practitioner Trial aimed to establish and evaluate pilot
nurse practitioner-like services across four Australian jurisdictions. The
potential impact of these trials on aged care policy and the improvement of
resident outcomes merited a rigorous approach to trial objectives and design;
consistency between sites in terms of the development and use of guidelines
and protocols; consistency between sites in terms of ordering investigations,
prescribing to a limited formulary and to a medical “standing order”; and
consistency between sites in terms of collection of process, outcome and cost
data. While these guiding principals framed the design of the evaluation, the
varied jurisdictions and legal requirements, including the lack of prescribing
rights, and varied state licensing and practice requirements meant it was not
possible to achieve the level of consistency between sites as would be
desirable. However, this evaluation does illustrate that standardisation is
currently possible and practicable for core elements of the NP role and how
data collection can be managed, particularly in the event that future trials may
be considered.
It was therefore essential that the trial focused on the piloting of identifiable
Nurse Practitioner-like Services provided by experienced gerontological
nurses who were all subjected to a common orientation and assessment to
demonstrate competence in a number of identified extended practices
sufficient to deliver services. The alternative, to establish trials that vary
according to the interests of the Nurse Practitioner Candidates and the

varying approaches of both nursing regulatory bodies and higher education
providers of nurse practitioner programs would not have provided the degree
of consistency between sites that enabled standardisation of practice and of
data collection. Further work at the polocy level may achieve greater gains for
residential care by working within the Nurses Acts of all jurisdictions that
permit nurses to initiate extended role functions if they can demonstrate
competence and if they are complying with a standing order authorised by a
medical practitioner. The broad aim of all of the sites was to establish and
deliver, in collaboration with general practitioners, pharmacists, radiography
groups and pathology groups, services that:
• enhanced the health care of residents by managing chronic conditions
• provided early detection and prompt treatment of underlying symptoms
that would ordinarily lead to an acute medical episode
• provided improved coordination of prevention, detection and treatment
of illness through an increase in the capacity of the nurse to initiate
actions eg directly ordering investigations
• reduced hospital admissions (to Casualty or as an in-patient; both in
frequency and length of hospital stay) as a consequence of early
detection and intervention
• improved outcomes without increased costs for treatment regimes (eg
wound care).
The Joanna Briggs Institute Research and Development team worked across
the trial sites to develop proposals for all sites that were based on a common
core program. The proposals consisted of two sections, one (Part A) for the
sites to complete a series of fields related to the specific persons involved in,
or advising on the project, and a second section (Part B) that detailed the
scope and process of the national evaluation. Staff of the JBI Research Unit
worked with the nominated project managers in each site to assist with the
completion of Part A.
JBI provided a template which incorporated consistent structures for all sites,
but enabled sites to accommodate variations in legislative requirements, as
well as for the committees advising the project to give input while ensuring
local variation was not incongruent with the national evaluation.
To assist sites in completing their proposals, staff of the JBI Research Unit
worked with the project managers to guide and inform proposal development.
A meeting in Adelaide for project leaders from the participating sites was also
held early in the project to talk though the draft proposals and ensure that all
sites had an opportunity to discuss and raise questions around their site’s
needs, and to review the process for the national evaluation component.
Each site completed the templates to specification, including budgetary
requirements and individually submitted them to the Department of Health
and Ageing. The proposals (with budgets) were delivered on time to the
Department of Health and Ageing. Subsequently, the proposals were
accepted by the Department.

5 Nurse Practitioner Orientation
5.1 Introduction to the need for orientation
To ensure that the design of the services across the trial sites would be
robust and comparable, it was considered essential that all of the
participating Nurse Practitioner Candidates shared a similar understanding of
the preferred role in aged care; that they all demonstrated a core set of
requirements assessed in similar ways; and that they all practiced to
protocols and standing orders developed collaboratively with local general
practitioners, pharmacists, radiography groups and pathology groups prior to
the commencement of the trial services.
The Joanna Briggs Institute Research and Development team delivered a
three-day self-directed orientation program that also involved a six week
worksite project for each candidate to establish liaison with local general
practitioners, pharmacists, medical imaging groups and pathology groups.
This included seeking practical training from these collaborating health
professionals and verification of meeting the core requirements of the project.
The orientation program included six specific subject areas, which are
summarised below. Each day concluded with open discussion of the day’s
learning activities. It was important for the candidates to gain a good
understanding of the nature and purpose of the trial, so that they could act as
advocates in their jurisdictions, and work effectively with their project
managers. On the final day, the site project managers were brought to
Adelaide to participate in presentations by the candidates on their learning
experience, ongoing self directed learning plans, and to participate in a
question and answer style forum to ensure any questions or concerns they
may have had were raised and responded to.
This orientation program consisted of:
Introduction to the orientation program
This session outlined the structure and expectations of the nurse
practitioner/candidates learning experiences and outcomes as well as giving
an overview of the national evaluation project.
Introduction to Evidence Based Practice
This overviewed the principals of evidence based practice and required the
candidates to reach an agreement on common guidelines for common
project related interventions
Evidence Based Clinical Guidelines
This module outlined the difference between traditional methods, and EB
methods, and lead to discussion of issues that may impact on the
implementation of guidelines in the trial.
Introduction to the emerging role of the nurse practitioner, nationally and
internationally

This considered the role of the nurse practitioner in the US, the UK, and
Australia. The legislation and endorsement processes were reviewed and the
place of the Nurse practitioner within the health care system explored.
Pharmacology
This consisted of a self-directed program on pharmacological issues in aged
care, requiring the Nurse Practitioner to meet a number of objectives. Library
resources were made available to assist with this module. It was
subsequently completed during the following 4-6 week self-directed learning
phase by the candidates.
The Identification of Skill and Knowledge Deficits and Development of an
Individual Learning Plan
In this component of the orientation, the candidates were required to produce
a detailed description of diagnostic, referral and treatment activities they
anticipated engaging in. They were also required to identify specific learning
needs that would need to be met to engage in these activities safely and
effectively. These learning plans formed the basis of the candidate’s learning
activity on return to their respective sites over a 6 to 8 week period following
the orientation. Candidates were encouraged to maintain the learning plan
and continue to expand it over the duration of the trial as evidence of ongoing
learning (although this was not a specific requirement of the evaluation).
5.2 The Orientation training materials
The candidates were provided with a learning resource package included
readings and self directed learning modules (Appendix I).
5.3 Identifying knowledge/skill deficits and learning needs
Given the variation in knowledge and skills within the group, each candidate
was required to identify the knowledge and skills needed to carry out the core
nurse practitioner-like role. The purpose of this was to assist all Nurse
Practitioner Candidates in the trial to deliver a common core of interventions
to generate valid evidence for future policy and practice development. Given
current priorities in Australian health and aged care policy, the core
interventions related to the minimisation of preventable disease and the
management of chronic illnesses and conditions. Potential interventions were
those that enable safe & sustainable initiation of practices such as:
• Coordination of a winter flu strategy within the facilities eg initiating fluvax
(following agreed protocols / standing orders);
• Identification & treatment of symptomatic urinary tract infections including
the ordering of investigations and the prescribing of antibiotics according to
identified sensitivity (following agreed protocols / standing orders);
• Wound Management including ordering investigations and prescribing
treatment / medications (following agreed protocols / standing orders);
• Managing other infections including ordering tests and prescribing
medications (eg diarrhoea, upper respiratory tract infections);

• Prescribing and administering treatments/medications for acute conditions
(eg antiemetics, anti-diarrhoea, aperients, medicated creams) (following
agreed protocols / standing orders);
• Ordering medical imaging for suspected fractures (following agreed
protocols / standing orders);
• Prescribing complementary therapies & managing their therapeutic
benefits;
• Evaluating and adjusting existing medication regimes for chronic diseases
(in consultation with the general practitioner and pharmacist) including
alteration of dosage, rewriting medication charts (following agreed
protocols / standing orders);
• Referring to specialists - eg speech pathology, ophthalmology, dental,
palliative care, wound specialists;
• Managing physical restraint authorisation;
• Prescribing and administering anti-psychotics in emergency situations
(following agreed protocols / standing orders); and
• Initiating increases in dosages of medication (eg prednisolone for
asthmatics in clinical case of increasing shortness of breath) (following
agreed protocols / standing orders).
Expected outcomes were reduction in impact & cost of acute medical
conditions and improved general health condition and management of chronic
conditions.
Candidates were asked to consider the knowledge and skills needed to
engage in the above core activities and to develop a learning plan to address
any knowledge or skill deficits identified. The learning plan required
candidates to:
• identify specific activities (for example, listening to the chest or prescribing
a named medication);
• state the knowledge and skills needed to effectively carry out the activity;
• set learning objectives; and
• identify an appropriate “trainer” accessible on their own work site.
This learning plan was formatted in table form (Table 1) and included space
for the nominated “trainer” to verify that the candidate had achieved the
objective.
Table 1 Learning plan format
Intervention/
Diagnostic
Activities
(eg:
Auscultation:
Path Tests)
Knowledge
Needed
Knowledge
Objective(s)
Skills
Needed
Skill
Objective(s)
Nominated
Trainer
Verification
of
Achievement
of
Objectives
by Trainer

5.4 The self-directed learning process
Based on the learning plan developed in the core program, each participant
accessed a range of health professionals to acquire specified knowledge and
skills over a period of six weeks. Completion of this learning plan was
verified, by signature, by all health professionals who assisted the participant.
Individual self directed learning programs included components that
addressed areas of clinical practice and knowledge such as:
• Physical examination;
• Diagnostic reasoning (including the evaluation of signs and symptoms; the
ordering of diagnostic tests; and the interpretation of the results of
diagnostic tests);
• The pharmacology (including indications, contraindications, pharmaco-
kinetics, prescribing etc) of specified medications;
• The management of specified medical conditions; and
• The case management of older people (including referrals to other health
professionals)

6 Developing Practice Guidelines
6.1 Practice Guidelines and Standing orders/practice
protocols
Although some variation between trial sites was expected (and legitimate), a
common process of guideline/`protocol development was considered to be
essential.
6.2 Purpose of practice guidelines and protocols in the trial
The development and use of evidence-based guidelines served to:
• minimise practice variability between trial sites;
• enable key stakeholder involvement in the evolution of the aged care nurse
practitioner role; and
• establish an evidence based framework for the development of national
consistency in designing and delivering nurse practitioner services in aged
care.
Practice protocols – that is, clear practice parameters – were identified as an
important component of a trial such as these, where none of the service
providers (nurse practitioner candidates) were licensed as nurse practitioners.
6.3 The guideline and protocol development process:
Concurrent with Stage 2, the Joanna Briggs Institute Research and
Development team developed brief summaries of appraised evidence for all
of the identified nurse practitioner interventions and forwarded these to the
clinical advisory panels on each site (that included - but was not limited to -
local general practitioners, pharmacists, radiography groups and pathology
groups.) A member of the Joanna Briggs Institute Research and
Development team was made available to attend an initial Protocol
Development Group meeting on trial sites to facilitate the protocol and
standing order development process and present the evidence to support it.
The topics for guideline development were discussed with the candidates
during the 3 day orientation program, based on the agreed core interventions
for the national evaluation. Summaries were sourced from international
sources and a series of summaries were identified for each core intervention,
following appraisal for rigour of methodological development, recency of
update/publication, and how evidence was managed and incorporated, one
summary was chosen for each core intervention.
It was expected that sites would, on receiving the summaries, contextualise
them to meet local legislative and clinical imperatives and contexts and then
develop guidelines and associated protocols. This process generated a
healthy level of discussion and debate between the sites and JBI, which
stimulated the sharing of resources between sites, and lead to cooperative
development of guidelines, saving time and resources across participating
sites involved in guideline development.

6.3.1 Warrabrook
Eleven guidelines/protocols were developed by this site (Appendix II):
• Upper Respiratory Tract Infections;
• Urinary Tract Infections;
• Pain;
• Eye Conditions;
• Hip Fractures;
• Ear Conditions;
• Bronchitis, Nursing Home Acquired Pneumonia and Influenza;
• Diarrhoea;
• Dermatologic manifestations;
• Constipation; and
• Delirium.
6.3.2 ACT
Six comprehensive clinical guidelines and a comprehensive medication
formulary were developed by this site (Appendix III):
• Comprehensive Geriatric Assessment;
• Cognition;
• Pain Management;
• Continence;
• Mobility and Falls; and
• Infections.
6.3.3 Resthaven
Nine guidelines/protocols were developed by this site (Appendix IV):
• Vaccination;
• Urinary Tract Symptoms;
• Constipation;
• Falls and Injury Prevention;
• Medication management;
• Diabetes mellitus;
• Acute Pain;
• Eye/ Visual Symptoms; and
• Diarrhoea.
6.3.4 Barossa
Eight guidelines/protocols were developed by this site (Appendix V):
• Vaccination;
• Urinary Tract Symptoms;

• Restraint;
• Falls;
• Diabetes Mellitus;
• Dehydration;
• Conjunctivitis; and
• Acute Pain.
6.3.5 Clarence Estate, Albany and Kensington Park, Perth
Ten guidelines/protocols were developed by these sites (Appendix VII) :
• Constipation
• Bacteremia
• Diarrhoea
• Oral candidiasis
• Respiratory – pneumonia
• Skin infections
• Genito-urinary – urinary tract infection
• Venous leg ulcers
• Uro-genital – vulvo-vaginal candidiasis
• Pain and medication management/review.
6.3.6 Discussion
Some sites shared resources and all sites developed guidelines for pain
management (Table 2). All guidelines were subjected to content analysis in
Phase 2 of the trial (see section 2.12 of volume 2).
Table 2 Guidelines used by different sites in the nurse practitioner-
like service national evaluation
Topic NSW SA WA ACT
Pain
Urinary tract infection
Constipation
Diarrhoea
Fall prevention
Atopic dermatitis
Cellulitis
Conjunctivitis
Fungal infection
Medication review
Pneumonia
Scabies
Anaphylaxis

Topic NSW SA WA ACT
Bacteremia
Bacterial skin infection
Balanitis
Blepharitis
Candidiasis
Ceruminosis
Chronic wounds
Cognition
Common cold
Continence
COPD
Dehydration
Delirium
Dermatophyte infect
Dermatophyte skin infection
Diabetes mellitus
Dry eyes
Dry skin
Ear infection
Eyes
Faecal impaction
Hip fracture
Infected wounds
Infections
Inflammatory/seborrheic dermatoses
Influenza
Oral thrush
Pharyngitis
Pruritis vulvae
Restraint
Seborrheic dermatitis
Sinusitis
Skin infection
Subcutaneous drug reaction
Vaccination
Vaginal thrush
Venous leg ulcers
Wound management

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