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Nurse practitioners build relationships with personal care residents to deliver better care

Nurse practitioners build relationships with personal care residents to deliver better care
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Enhancing patient safety

What is a nurse practitioner?

Winnipeg Health Region
Wave, January / February 2011

The morning is still young when Preetha Krishnan enters the room of a resident at the Lions Care Centre on Sherbrook Street.

"How was your sleep last night?" she asks 91-year-old Bette Donegani.

"It was good," Donegani replies. "It's always good."

"Do you have any pain?"

"I don't have any complaints at all," Donegani says, adding with a laugh: "I'm looking forward to bingo tonight."

The conversation then turns to an upcoming party, visits by Donegani's daughter, and her trip earlier in the year to the lake.

During this relaxed exchange, Krishnan is able to watch for subtle signs about her patient's condition. Today, everything looks good.

All health-care providers work to develop a good rapport with residents or patients. But Krishnan's relationships with her residents tend to be bit different. That's because she is a nurse practitioner, a registered nurse with specialized training in primary care and skilled in the diagnosis and management of common medical conditions and chronic diseases.

Nurse practitioners are a relatively rare breed in the health-care system, but they are growing in numbers because they can do many of the things doctors can do, such as write prescriptions, perform minor invasive procedures such as suturing minor wounds and order diagnostic tests.

The Winnipeg Health Region is experimenting with the use of nurse practitioners in a variety of settings. Krishnan, for example, was hired by the Region in 2007 to work at Lions, while nurse practitioner Amanda Adams-Fryat was hired in 2008 to work at Kildonan Care Centre. In both cases, the Region wanted to see whether having full-time nurse practitioners working in personal care homes could improve the quality of care for residents. Previously, these personal care homes had a physician visit once a week to see patients.

Because they are based at the personal care homes, Krishnan and Adams-Fryatt are able to get to know their patients personally while working collaboratively with nursing staff and medical directors for each of the homes.

Krishnan sees 116 residents at Lions on a regular schedule of check-ups, but since she is there all day every work day, she sees and interacts with the residents all the time. As well, Krishnan consults the nurses' communication book every day to find out if anything has come up with any of the residents. If so, she's easily able to fit in an additional visit.

Early results suggest this innovative approach to care has been a huge success. Since the nurse practitioners were assigned, emergency department visits by residents living at the two centres has dropped 43 per cent. The percentage of residents on anti-psychotic medication has dropped from 15.3 per cent to 6.7 per cent at Lions and from 35.2 to 11.5 per cent at Kildonan.

"This has been successful beyond our expectations," says Lori Lamont, the Region's Chief Nursing Officer, and one of the original developers of the initiative. "The integration in the PCH team has been very smooth and we have seen strong collaborative practice relationships established with family physicians who helped to mentor the nurse practitioners and are available for consultation when needed by them." The Region is planning to place at least one more nurse practitioner in a personal care home in 2011 as the model is expanded.

Avoiding hospital visits is especially important for care centre residents with dementia, says Adams-Fryatt. "If you take somebody with dementia out of their familiar environment it can lead to delirium," she says.

Other effects of the nurse practitioner model of care are harder to quantify - but evident in the way Krishnan and the centre's residents interact.

Both nurse practitioners work collaboratively with physicians, in Krishnan's case it's Dr. Ian Maharaj, Medical Director at Lions, who also provides on-call care during Krishnan's off hours. Adams- Fryatt works under Dr. Paul Sawchuck, who is Medical Director at Kildonan.

Under the terms of the College of Registered Nurses of Manitoba, nurse practitioners require a Master's degree in nursing, with a nurse practitioner specialization. They must also have at least two years of nursing experience before becoming nurse practitioners, though they may have much more experience, like Adams-Fryatt, who had more than two decades of experience, much of it in emergency and intensive care, before becoming a nurse practitioner.

In addition to their patients, the two nurse practitioners each have 20 other residents assigned to their care at neighbouring personal care homes.

After three years of having nurse practitioners based in personal care homes, the Region sees the practice as one worthy of emulating elsewhere, says Cynthia Sinclair, Manager of Initiatives with the Region's Personal Care Program. Surveyors from Accreditation Canada - the organization responsible for reviewing health-care practices - visited Winnipeg in the fall and highlighted the use of NPs at the two centres, she notes.

The nurse practitioner model has a strong supporter in another Lions resident, 102-year-old Reta McRuer.

"I think it's wonderful," says the articulate and energetic centenarian. "I'm in contact with her (Krishnan) frequently. I see her whenever I need her or my sister needs her. I tell her what the problem is and she looks after it. I think it's much better to have a nurse practitioner."

The two have a friendly talk about Reta's family history, her travels, the art work on her walls and the charitable works she supports (organizations that help African AIDS orphans). And during the conversation, Krishnan is also able to assess the pain in Reta's knees and the effectiveness of a cortisone shot she gave her earlier.

Reta makes it clear that she feels well cared for. "Besides that, I love her and I love her little son," she adds, referring to the nurse practitioner's 12-year-old son, Sam, who volunteers at the care centre.

Reta sees the benefit of the nurse practitioner model from two points of view: both as a resident of the personal care home and as the family member of a resident, her 100-year-old sister Marion.

The sisters only moved out of their own apartment a few years ago when Marion fell and broke her foot. Marion's health wasn't as robust and Reta says, "I was getting pretty old to look after my sister."

Now she's able to stay up-to-date on Marion's condition, thanks to the greater family communication made possible by having a nurse practitioner based full-time at the personal care home.

"Both the residents and the family are more confident," says Judy Lewadny, a social worker at Lions Care Centre. That takes away a lot of the anxiety family members may feel about personal care homes, and about aging and senior care in general.

"Sometimes a resident will take a turn for the worse, and the family will ask, 'What can you do for Mom here?'" notes Adams-Fryatt. "I'll say, 'I can do tests and check them regularly.' That's a comfort to a lot of people. They'll say, 'As long as you're here, we don't need to send Mom to the hospital.'"

Part of improving communication with the family means that family members are able to consider end-of-life issues well before they become a crisis.

The reality of personal care homes is that most of the residents live there only for the final years of their lives, and many are experiencing dementia. Unless end-of-life care matters are discussed in advance, the resident may be unable to fully understand the issues when matters finally come to a head.

By taking part in family conferences, Krishnan is able to bring up subjects like do-not-resuscitate orders and the consequences of performing CPR on a frail, extremely aged patient.

She's also able to take part in other care meetings. "We have care conferences six to eight weeks after a resident arrives. Preetha attends every one of those," says Lewadny.

"Because she sees the residents so often, she's able to recognize the changes," says Heather Williams, Director of Care at Lions.

At both care centres, having a nurse practitioner on site means continuity of care. "Their needs are being addressed on a daily basis instead of a weekly basis," says Keri Robinson, Director of Care at Kildonan.

That continuity of care extends even when a resident at Kildonan needs to go to nearby Concordia Hospital. Nurse practitioner Adams-Fryatt recently acquired hospital privileges at Concordia so that she could do check-ups there, providing both a familiar face and previous knowledge of the patient's condition.

Lions social worker Lewadny points to a recent incident that shows the advantage of having a nurse practitioner on staff. One recent day, a patient had a fall and suffered a gash to his forehead.

"Within three minutes, Preetha was there with her container of suturing material," says Lewadny.

The wound wasn't serious but needed suturing. Because nurse practitioners are able to perform such procedures, the resident was able to avoid a trip to emergency for the wound. That meant less stress and disruption for the resident, but it also meant substantial savings for the health-care system - transporting the resident to emergency for a few stitches would have required a Lions Care Centre staff member to leave the centre and would have entailed one more person in an already busy emergency room.

Nurses at the personal care home see big convenience benefits from having a nurse practitioner on staff. Under the old system, a nurse would need to call a physician's office if a new prescription was needed. Since the physicians had their own patients, the nurse would likely need to leave a message and wait for a return call. With a nurse practitioner on staff, an answer is easily available just down the hall.

Because they are able to see patients personally and assess subtle changes in their condition, nurse practitioners don't need to write as many prescriptions for infections or behavioural problems. They're able to monitor the resident more closely to see if an infection will go down without an antibiotic or if a behavioural problem can be resolved some other way.

The drop in anti-psychotic medication is often a matter of addressing the underlying conditions that may cause a resident - typically one with dementia - to act out, says Adams-Fryatt.

People with dementia can't express pain, anxiety or other feelings the way others can, so behaviours like calling out or even hitting may be their method of expression. Having the nurse practitioner at the personal care home allows her to look more carefully at the resident who is acting out and find some other way of dealing with the behaviour.

In some cases, pain medication may prevent the acting out. In other cases, the resident may be suffering from depression and need to take anti-depressants.

"If you treat the underlying condition, you can reduce the acting out. They may still be on medication, but now they're on the right medication," says Adams-Fryatt.

Depression in the elderly - whether with or without dementia - is an issue that intrigues Adams Fryatt, who has recently published a paper on the subject in the research journal Annals of Long-Term Care.

Seniors tend not to display depression the same way younger people do, she says. Perhaps because experiences like the Great Depression and the Second World War encouraged a more stoic attitude towards feelings, they are less likely to say, "I'm feeling blue." Instead, they are likely to display depression through weight loss, loss of appetite, trouble sleeping or irritability.

Adams-Fryatt believes it's important to deal with depression just as she would treat physical conditions. "It's a quality-oflife issue. If you treat the depression they eat, they interact with friends, they don't act out. I've got 90 year olds here who are busy playing bingo and hanging out with their friends. People here are engaged in being well."

At both personal care homes, the nurse practitioners work in close collaboration with other staff to support all aspects of care.

Both are involved in on-going professional education for staff, presenting workshops and sitting on committees. Krishnan speaks of the importance of considering all of the needs of residents - from their medical needs to recreation, pet therapy or music therapy. A researcher with nearly a dozen published articles to her credit, she also shares her expertise with the Alzheimer Society and Palliative Care Society.

Adams-Fryatt, meanwhile, talks of the importance of listening to all of the other staff who come in contact with residents. "I ask the health-care aides a lot of questions," she says.

"Amanda has been an integral part of our interdisciplinary team approach," adds Robinson.

End-of-life care is an important part of the job for the two nurse practitioners and for all the staff at the personal care homes.

Since having nurse practitioners based at the centres, the two facilities have seen 98 per cent of deaths among residents occur in the home setting of the centre rather than in hospital. They have also seen a 26 per cent increase in do-not-resuscitate orders, as residents and their families have learned more about end-of-life care and have been encouraged to make plans in advance.

Caring for residents in their final weeks and days is very much part of the nurse practitioners' focus on the whole life of residents.

"I like the caring," says Krishnan. "You're there to listen to them, and to help ensure they have the highest quality of life possible."

Bob Armstrong is a Winnipeg writer.


About Wave

Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books.

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