Provision of Resident-Centered Care
NPs working in LTC facilities reflected on how their presence led to resident-centered care. Patient, client, and resident-centered care is the focus of the current Saskatchewan Ministry of Health. Reflecting on their objective, NP5 explained:
I see my role as a NP here being one where I invest the energy to get to know the resident and the family, establish where their priorities are for care, and more importantly their quality of life, and then I steer any interventions that we have around that sort of theme.
Similarly, in her full-time role, NP4 stressed the importance of having residents and their families as the central focus and stated:
The outcomes of having immediate care and immediate issues addressed without waiting, have prevented hospital admission…. Residents have had more resident-centered treatment because there is somebody there to actually see them and assess them, not to just diagnose them over the phone…. I can diagnose, treat, assess, do all of that right at their bedside and immediate treatment starts.
NPs perceived their role within the LTC facility as facilitating efforts to bring resident and family concerns into focus. NPs in their various practice settings provided resident-centered care that was congruent with their over-all mandate of health promotion, treatment, and condition management.
Timely Access to Primary Care. Timely access to primary care can be an issue for any member of the population, and LTC residents can be particularly affected by their lack of physical mobility and ability to access appropriate transportation. NP5 reported that she had reduced transfers to hospitals by “looking at optimal chronic care and having those discussions with the residents and families when a person is acutely ill to describe, you know, what we're seeing and enacting that early intervention.”
The importance of timely access to primary care for LTC residents was also highlighted by NP4, who related the following:
A resident is sitting in a nursing home, who is suffering in bed and their physician is called. But the physician isn't available to see them and maybe not for days, maybe not for weeks. “I can only manage them over the phone.” I'd like to ask policy makers if they would like to be managed over the phone…. And make no mistake, being in a nursing home and getting a doctor to call you and give you an order over the phone is not a visit, okay? And that is unacceptable.
NPs perceived that their work increased the provision of timely primary care to residents, which can prevent further complications and is one of the goals of resident-centered care.
Medication Reconciliation. NPs described reviewing residents' medications with the goal of ensuring that when they were prescribed, discontinued, or changed they were carefully evaluated. NP5 stated:
I work collaboratively with the physicians, but I'll do an onsite [medication] review whenever there's a change in status…to try to improve outcomes for the residents.
Some NPs practiced in facilities with the Eden philosophy, which stresses that medical treatment is important and needs to be the “servant and not the master of care” (Eden Alternative, n.d., para 1). NP6 stated:
Well, in the Eden philosophy you like to have them on eight medications or less. So, we've achieved that in, I think it's now at 75 of our residents…. And some of them come in [to the facility] with 32 medications. And it takes a long time to get them reduced because you don't want to reduce a whole bunch, you want to be done one at a time. You want to watch the cause and effect of all of that.
Similarly, NP3 described decreasing residents' medication, particularly anti-psychotic agents:
And I have taken a number of people off of their anti-psychotics very slowly…. I think it's now about 75% of our residents.... And it's really quite wonderful to see them interacting and brightening and feeling included and you know, even if it's just a smile here and there, it's better than not.
As the statement indicates, NPs perceive their role in ongoing medication review as essential to the health and well-being of LTC residents.
Decreased Transfers to the Hospital for Treatment or Palliative Care. Transfers to the hospital can be disruptive and detrimental for residents in LTC. Each NP found that since they started working at their facility, transfers to hospitals had decreased allowing residents to be treated in their residence. NP4 stated, “…with immediate care, we're not sending a lot of people to the hospital. Unless things are, you know, beyond what we can provide in the home, then obviously we do.” Rural LTC facilities face an added complexity in that an ED may be in another community that is ≥1 hour away, which also makes it difficult for families to be present. NP1 stated that she thought before she started in her position “a lot more people [residents] were being sent to the city…. So, I think it's my NP role that helped keep them in their community.”
Regarding palliative care, NPs were involved with facilitating the transition to comfort care with residents and families:
You know, the various medications that are needed for palliative care to keep them comfortable. And we do a lot of education with the family, so they know where we're at…. Certainly, we have, do very little emergency room visitation from our clinic, or from our LTC facility.
NP6 echoed a sentiment that was voiced by each of the NPs:
Since the NPs have started here, we've decreased hospital visits to the emergency room by about 75% because we can deal with a lot of the situations in-house. And we no longer send our residents out for palliative care or to the hospital to die.
Due to the work of NPs, residents and their family members received the care they needed in a place where residents were familiar with their surroundings. Provision of palliative care in their place of residence means residents can die in their home (i.e., LTC) rather than be moved to the hospital.
Collaborative Interprofessional Practice. NPs described how their role in LTC has led to several advantages for other health care team members including pharmacists, special care aides (SCAs), licensed practical nurses (LPNs), RNs, registered psychiatric nurses (RPNs), and physicians. Formal and informal collaborative practice among team members can enhance their knowledge and ultimately improve resident care. NP2 states she gets stopped in the hallways by SCAs who might say, “‘You know, so and so is doing this. What do you think?’ It's that kind of thing. Because I have developed that really collaborative team feel.”
NP6 made the following comment about the staff at her facility:
You know, they just appreciate having somebody there to talk to, to bounce things off, to mentor them. To explain things, to help them understand. Especially the [special] care aides, you know…. They can't go to the doctor because he's only there for five minutes. But because I am there, they can chat to me and find out all sorts of stuff.
This kind of immediate, available support and leadership is invaluable to effectively managing the complex needs of residents.
NPs also described working collaboratively with physicians, which led to a decrease in physicians' time spent in LTC settings. NP2 described a physician visiting the LTC facility who noted, “I don't know why I'm here other than just to sign my name to everybody else's [NPs] orders.” This collaborative teamwork speaks to the importance of having the right professional in the right role.
NP3 found that her relationship with physicians evolved over time:
By and large it's three physicians that come here once a week. And so that's really quite nice to have just that small group of physicians to work with on a consistent basis. And we all have a very good rapport…. Between the physicians and myself and the pharmacist and the nursing staff. And so now it's working well. And so that's actually pretty ideal to be able to have that kind of relationship with them. You know... they [the physicians] do not come here to see, you know, Mr. Joe's urinary tract infection or whatever. They really are coming here to enhance the education [of those who work with LTC residents].
NPs perceived one of their goals in LTC settings as collaborative holistic care where each member of the team is working to his/her full scope of practice. NPs' comments suggest that they free up physician time and act as mentors and educators for RNs, LPNs, and SCAs, ultimately leading to the provision of quality care for LTC residents.