There Are Solutions at Hand … What Are We Waiting For?
Discussions of seniors with complex co-morbid conditions "clogging up" or "blocking" acute care beds have been persistent over the last two decades. In reality, many of these hospital admissions are likely avoidable with the allocation of appropriate resources to manage their care in the community. While promises of enhanced community-based care and support have been touted for years, the solutions have been inadequate, and continue to fall short of the mark. Notwithstanding the likely need for more long-term residential care beds in the face of Canada's aging demographic, it is clear that much more could be done to maintain seniors in their own homes or within residential care facilities – that is to say, out of the hospital!
The focus of this issue is on the role of nurse practitioners (NPs) in primary, acute and residential care settings. Our authors provide a glimpse into the work of NPs nationally and within several Canadian jurisdictions. The take-aways are clear – despite evidence that NPs providing primary and residential care to seniors reduces emergency room visits and hospital admissions and avoids numerous potential risks, they are a resource that remains largely underutilized and undervalued in our healthcare system.
McAiney and her colleagues (2017) offer perspectives on NP–physician (MD) collaboration as derived from the first national survey of NPs working in long-term care (LTC) homes. It is notable that, at the time of this study, five provincial jurisdictions had no NPs practicing in LTC settings. More research is needed to understand the impact of NP–MD collaboration, factors that facilitate or impede it, and the benefits for residents, especially given some of the recent legislative changes that have extended the scope of NP prescribing and other practices. The new legislation allowing for the designation of NPs as the "most responsible provider" (MRP) in hospitals, is addressed by Hurlock-Chorostecki and Acorn (2017). They describe the NP-as-MRP experience of one community hospital and the benefits realized, particularly in relation to the admission and discharge of seniors. Although there are definite positives to be realized, it is yet unknown why there is a lack of widespread adoption of this innovation in other hospitals.
Bringing a view from Newfoundland and Labrador, Mathews et al. (2017) describe the findings of their study of LTC settings with and without a primary care provider, family physician (FP) and/or NP. Their findings indicate support for the NP role among LTC administrators, a belief that NP-FP collaborative practice enhances continuity of care and that the presence of NPs decreases emergency room visits and admissions. Supporting evidence of the latter is provided in the case study by a former residential care NP in New Brunswick. Cole (2017) describes her experience in an NP–MD collaborative care model. In her view, the continuous presence, knowledge and skill of an NP has netted this organization and its residents better outcomes. Averting hospitalizations and potentially debilitating complications of co-morbid conditions, the NP role in LTC has also undoubtedly netted the healthcare system significant cost avoidance.
Providing insights for nurse leaders in LTC, or any setting for that matter, Spenceley and colleagues (2017) describe findings arising from their study of moral distress among nursing caregivers of people with dementia in residential care facilities in Alberta. Factors deemed to mitigate moral distress included: having adequate resources and peer support, educational opportunities, taking time for self-care, and not surprisingly, leadership support. Leaders taking the time to listen to staff concerns and engage in resident care activities were seen to be particularly helpful in mitigating the moral distress of nursing staff. Caring for the caregivers ultimately translates into better care.
Focused on primary care settings in Nova Scotia, Callaghan et al (2017) examined access to NPs in three different team structures: NP's working in consultative, dyad or multiprofessional team structures. Having NPs working within multiprofessional teams appears to be the optimal model leading to greater satisfaction among providers and patients – improving access, outcomes and coordination of care – in contrast to having access to any single provider.
A recent essay by John (2017) highlighted many of the health challenges currently faced by Canada's growing population of seniors; he notes that none of these were explicitly addressed in the recent federal budget. He cites the principles identified in the 2016 Declaration Concerning a National Health Care Strategy for Seniors, which should underpin a seniors' healthcare strategy (see: https://files.nlta.nl.ca/wp-content/uploads/public/documents/rtanl/declaration.pdf). Not surprisingly, some of the key areas requiring investment and new policy directions included: primary care, wellness and prevention, home and community care, LTC and assisted living, palliative care, end-of-life care, and care integration. We have enough evidence that the role of the NP in partnership with others can be very effective in addressing all of these areas of need. Although there is more research to be done, we have insights into the efficacy of different models of care, actual and potential impacts on continuity and care transitions, and clinical outcomes. And so I ask you, what are we waiting for? How much evidence is enough? We are all getting old waiting for the execution of supportive solutions for our aging demographic – what will it take to help ourselves? More aggressive policy directions are needed now!
In this issue, our contributors have highlighted several possibilities for nursing to inform effective directions for future health policy with regard to the care of our aging demographic. Speaking of policy, be sure to read Stevenson and Byres' (2017) review of Villeneuve's new book, Public Policy and Canadian Nursing: Lessons from the Field. This practically grounded book is a requisite for every nurse leader's library. Read the review, then the book, and then, learned leaders – take action!
Lynn M. Nagle, RN, PhD, FAAN
Lawrence S. Bloomberg Faculty of Nursing
University of Toronto
Hurlock-Chorostecki, C., and M. Acorn. 2017. "Diffusing Innovative Roles Within Ontario Hospitals: Implementing the Nurse Practitioner as the Most Responsible Provider." Nursing Leadership 30(4): 60–66. doi:10.12927/cjnl.2017.25448.
John, H. 2017. Budget 2017: Response From an Aging Population. Retrieved March 28, 2018. <https://nationalpensionersfederation.ca/wp-content/uploads/2017/03/Budget-2017-Press-release_Article.pdf>.
Callaghan, K., R. Martin-Misener, C. O'Connell, F. Burge and E. Gard Marshall. 2017. "Comparison of Access to Nurse Practitioners in Primary Healthcare across Three Team Structures." Nursing Leadership 30(4): 67–79. doi:10.12927/cjnl.2017.25447.
Cole, M.S. 2017. "Case Study: Realizing the Value of Nurse Practitioners in Long-Term Care." Nursing Leadership 30(4): 39–44. doi:10.12927/cjnl.2017.25450.
Mathews, M., D. Ryan and M. Power. 2017. "The Role of Nurse Practitioners in Long-Term Care Settings in Newfoundland and Labrador." Nursing Leadership 30(4): 26–38. doi:10.12927/cjnl.2017.25451.
McAiney, C.A., J. Ploeg, A. Wickson-Griffiths, S. Kaasalainen, R. Martin-Misener, N. Akhtar-Danesh, F. Donald, N. Carter, E. Sangster-Gormley, K. Brazil, A. Taniguchi and L. Schindel Martin. 2017. "Perspectives of Nurse Practitioner–Physician Collaboration among Nurse Practitioners in Canadian Long-Term Care Homes: A National Survey." Nursing Leadership 30(4): 10–25. doi:10.12927/cjnl.2017.25452.
Spenceley, S., S. Caspar and E. Pijl. 2017. "Mitigating Moral Distress in Dementia Care: Implications for Leaders in the Residential Care Sector." Nursing Leadership 30(4): 45–59. doi:10.12927/cjnl.2017.25449.
Stevenson, L. and D. Byres. 2017. "Public Policy and Canadian Nursing: Lessons from the Field by Michael J. Villeneuve." Nursing Leadership 30(4): 8–9. doi:10.12927/cjnl.2017.25453.
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