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A nurse practitioner led protocol to address polypharmacy in long-term care. Geriatr Nurs 2020; 41:956-961. [PMID: 32718755 PMCID: PMC7380258 DOI: 10.1016/j.gerinurse.2020.07.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/06/2020] [Accepted: 07/08/2020] [Indexed: 12/01/2022]
Abstract
Polypharmacy is common in long term care facilities and frequently associated with poor outcomes. A focus on decreasing polypharmacy as part of 60-day periodic review process in long term care facilities has the potential to improve resident outcomes and assist health care providers in improved medication management. To achieve success in decreasing polypharmacy, an interdisciplinary team with shared goals and communication is needed.
Polypharmacy is common in long term care facilities and frequently associated with poor outcomes. This study sought to determine if a medication management protocol completed at four month intervals by nurse practitioners (NP) could impact polypharmacy and administration times for long term care residents. The data was collected as part of a Centers for Medicare and Medicaid Services (CMS) “Initiative to Reduce Avoidable Hospitalization among Nursing Facility Residents” grant. Residents were recruited from participating long-term care facilities. NP completed a medication management protocol on admission to the program and at subsequent 4-month intervals or with an acute change in condition. A total of 2442 non-duplicated individuals were seen for at least 1 visit. Although the protocol did not result in a reduction of regularly scheduled medications, the number of scheduled medication administration times did significantly decrease. NP polypharmacy assessments and recommendations are important but were insufficient to decrease the medication burden.
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Contandriopoulos D, Brousselle A, Dubois CA, Perroux M, Beaulieu MD, Brault I, Kilpatrick K, D'Amour D, Sansgter-Gormley E. A process-based framework to guide nurse practitioners integration into primary healthcare teams: results from a logic analysis. BMC Health Serv Res 2015; 15:78. [PMID: 25889415 PMCID: PMC4349481 DOI: 10.1186/s12913-015-0731-5] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 02/06/2015] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Integrating Nurse Practitioners into primary care teams is a process that involves significant challenges. To be successful, nurse practitioner integration into primary care teams requires, among other things, a redefinition of professional boundaries, in particular those of medicine and nursing, a coherent model of inter- and intra- professional collaboration, and team-based work processes that make the best use of the subsidiarity principle. There have been numerous studies on nurse practitioner integration, and the literature provides a comprehensive list of barriers to, and facilitators of, integration. However, this literature is much less prolific in discussing the operational level implications of those barriers and facilitators and in offering practical recommendations. METHODS In the context of a large-scale research project on the introduction of nurse practitioners in Quebec (Canada) we relied on a logic-analysis approach based, on the one hand on a realist review of the literature and, on the other hand, on qualitative case-studies in 6 primary healthcare teams in rural and urban area of Quebec. RESULTS Five core themes that need to be taken into account when integrating nurse practitioners into primary care teams were identified. Those themes are: planning, role definition, practice model, collaboration, and team support. The present paper has two objectives: to present the methods used to develop the themes, and to discuss an integrative model of nurse practitioner integration support centered around these themes. CONCLUSION It concludes with a discussion of how this framework contributes to existing knowledge and some ideas for future avenues of study.
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Affiliation(s)
- Damien Contandriopoulos
- Faculty of Nursing, University of Montreal, C.P. 6128 succ. Centre-Ville, Montréal, Québec, H3C 3J7, Canada.
| | - Astrid Brousselle
- Department of Community Health Sciences, University of Sherbrooke, 150, place Charles-Le Moyne, Bureau 200, Longueuil, Québec, J4K 0A8, Canada.
| | - Carl-Ardy Dubois
- Faculty of Nursing, University of Montreal, C.P. 6128 succ. Centre-Ville, Montréal, Québec, H3C 3J7, Canada.
| | - Mélanie Perroux
- Faculty of Nursing, University of Montreal, C.P. 6128 succ. Centre-Ville, Montréal, Québec, H3C 3J7, Canada.
| | - Marie-Dominique Beaulieu
- Department of Family Medicine and Emergency Medicine, University of Montreal, Pavillon Roger-Gaudry, 2900, boul Édouard Montpetit, Montréal, Québec, H3T 1J4, Canada.
| | - Isabelle Brault
- Faculty of Nursing, University of Montreal, C.P. 6128 succ. Centre-Ville, Montréal, Québec, H3C 3J7, Canada.
| | - Kelley Kilpatrick
- Faculty of Nursing, University of Montreal, C.P. 6128 succ. Centre-Ville, Montréal, Québec, H3C 3J7, Canada.
| | - Danielle D'Amour
- Faculty of Nursing, University of Montreal, C.P. 6128 succ. Centre-Ville, Montréal, Québec, H3C 3J7, Canada.
| | - Esther Sansgter-Gormley
- School of Nursing, University of Victoria, PO Box 1700 STN CSC, Victoria, BC, V8W 2Y2, Canada.
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Niezen MG, Mathijssen JJ. Reframing professional boundaries in healthcare: A systematic review of facilitators and barriers to task reallocation from the domain of medicine to the nursing domain. Health Policy 2014; 117:151-69. [DOI: 10.1016/j.healthpol.2014.04.016] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 03/24/2014] [Accepted: 04/22/2014] [Indexed: 11/30/2022]
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Smith M, Stolder ME, Jaggers B, Liu MF, Haedtke C. Depression training in nursing homes: lessons learned from a pilot study. Issues Ment Health Nurs 2013; 34:90-102. [PMID: 23369120 PMCID: PMC4108158 DOI: 10.3109/01612840.2012.723798] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Late-life depression is common among nursing home residents, but often is not addressed by nurses. Using a self-directed CD-based depression training program, this pilot study used mixed methods to assess feasibility issues, determine nurse perceptions of training, and evaluate depression-related outcomes among residents in usual care and training conditions. Of 58 nurses enrolled, 24 completed the training and gave it high ratings. Outcomes for 50 residents include statistically significant reductions in depression severity over time (p < 0.001) among all groups. Depression training is an important vehicle to improve depression recognition and daily nursing care, but diverse factors must be addressed to assure optimal outcomes.
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Affiliation(s)
- Marianne Smith
- University of Iowa, College of Nursing, Iowa City, IA 52242, USA.
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Bakerjian D, Harrington C. Factors associated with the use of advanced practice nurses/physician assistants in a fee-for-service nursing home practice: a comparison with primary care physicians. Res Gerontol Nurs 2012; 5:163-73. [PMID: 22716651 DOI: 10.3928/19404921-20120605-01] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Accepted: 08/01/2011] [Indexed: 11/20/2022]
Abstract
The purpose of this research was to examine factors associated with the use of advanced practice nurse and physician assistant (APN/PA) visits to nursing home (NH) patients compared with those by primary care physicians (PCPs). This was a secondary analysis using Medicare claims data. General estimation equations were used to determine the odds of NH residents receiving APN/PA visits. Ordinary least squares analyses were used to examine factors associated with these visits. A total of 5,436 APN/PAs provided care to 27% of 129,812 residents and were responsible for 16% of the 1.1 million Medicare NH fee-for-service visits in 2004. APN/PAs made an average of 33 visits annually compared with PCPs (21 visits). Neuropsychiatric and acute diagnoses and patients with a long-stay status were associated with more APN/PA visits. APN/PAs provide a substantial amount of care, but regional variations occur, and Medicare regulations constrain the ability of APN/PAs to substitute for physician visits.
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Affiliation(s)
- Debra Bakerjian
- Betty Irene Moore School of Nursing, University of California, Davis, Sacramento, CA, USA.
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Wagner LM, Damianakis T, Mafrici N, Robinson-Holt K. Falls Communication Patterns Among Nursing Staff Working in Long-Term Care Settings. Clin Nurs Res 2010; 19:311-26. [DOI: 10.1177/1054773810370995] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Effective fall-risk communication both among staff and between staff and family members is vital for ensuring the safety of residents in long-term care (LTC) settings. This study uses focus group methodology to investigate how information about falls is identified, communicated, and responded to by licensed staff (registered nurses/registered practical nurses) and unlicensed staff (personal support workers) in four LTC facilities. The authors report on the major themes that emerged throughout the focus groups relating to falls management and report on similarities and differences in the communication processes between the two sampled groups. Results highlight communication of the resident’s fall risk, reporting procedures to staff and family members, care plan communication and adherence information, a falls quality improvement knowledge deficit, and barriers to falls quality improvement. Recommendations toward improved communication networks among diverse LTC staff to enhance fall-reduction efforts in LTC settings are provided.
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Affiliation(s)
- Laura M. Wagner
- Baycrest Geriatric Health Care System, Toronto, Ontario, Canada, , University of Toronto, Toronto, Ontario, Canada
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Bakerjian D. Care of nursing home residents by advanced practice nurses. A review of the literature. Res Gerontol Nurs 2010; 1:177-85. [PMID: 20077962 DOI: 10.3928/19404921-20080701-04] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The complexity of care in nursing homes has steadily increased during the past several years. Many nursing homes now provide care for both short-stay and long-stay patients who range in age from young to very old. At the same time, there has been a shortage of primary care physicians to provide care while nursing homes have been under intense scrutiny and pressure to improve the quality of care provided. Advanced practice nurses (APNs) are increasingly evident members of the nursing home workforce, providing both primary care to individual residents in collaboration with physicians and consultative services to nursing homes. This article reviews the research that documents the relationship between APNs and improved quality of care and begins a discussion of what constitutes APN best practices in the nursing home setting.
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Affiliation(s)
- Debra Bakerjian
- University of California-San Francisco, 3333 California Street, San Francisco, CA 94118, USA.
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Advanced practice nurses core competencies: a framework for developing and testing an advanced practice nurse discharge intervention. CLIN NURSE SPEC 2008; 22:218-25. [PMID: 18753879 DOI: 10.1097/01.nur.0000325366.15927.2d] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The purpose of this paper was to describe evidenced-based interventions as implemented by advanced practice nurses (APNs) conducting intervention research with a vulnerable population of blood and marrow transplant patients. In addition, each of the 6 core competencies of the APN role identified by Hamric are outlined and applied using a patient case study. These competencies are the following: direct clinical practice, expert coaching and advice, consultation, research skills, clinical and professional leadership, collaboration, and ethical decision making. This article chronicles a typical patient's journey through a post-hospital discharge nursing research study involving APNs as "intervention nurses" and discusses the various aspects of the APN core competencies throughout the process.
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McAiney CA, Haughton D, Jennings J, Farr D, Hillier L, Morden P. A unique practice model for Nurse Practitioners in long-term care homes. J Adv Nurs 2008; 62:562-71. [DOI: 10.1111/j.1365-2648.2008.04628.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Wagner LM, Capezuti E, Brush B, Boltz M, Renz S, Talerico KA. Description of an advanced practice nursing consultative model to reduce restrictive siderail use in nursing homes. Res Nurs Health 2007; 30:131-40. [PMID: 17380514 DOI: 10.1002/nur.20185] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Researchers have demonstrated that the use of physical restraints in nursing homes can be reduced, particularly where advanced practice nurses (APNs) are utilized. We examined the link between APN practice, siderail reduction, and the costs of siderail alternatives in 273 residents in four Philadelphia nursing homes. The majority of participants were cognitively and physically impaired with multiple co-morbidities. APNs recommended a total of 1,275 siderail-alternative interventions aimed at reducing fall risk. The median cost of siderail alternatives to prevent falls per resident was $135. Residents with a fall history experienced a significantly higher cost of recommendation compared to non-fallers. Findings suggest that an APN consultation model can effectively be implemented through comprehensive, individualized assessment without incurring substantial costs to the nursing home.
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Affiliation(s)
- Laura M Wagner
- Baycrest Centre for Geriatric Care, Kunin-Lunenfeld Applied Research Unit, 3560 Bathurst Street, Toronto, Ontario, Canada M6A 2E1.
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Capezuti E, Wagner LM, Brush BL, Boltz M, Renz S, Talerico KA. Consequences of an intervention to reduce restrictive side rail use in nursing homes. J Am Geriatr Soc 2007; 55:334-41. [PMID: 17341234 DOI: 10.1111/j.1532-5415.2007.01082.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To examine the effect of an advanced practice nurse (APN) intervention on restrictive side rail usage in four nursing homes and with a sample of 251 residents. A secondary question explored the association between restrictive side rail reduction and bed-related falls. DESIGN Pre- and posttest design. SETTING Four urban nursing homes. PARTICIPANTS All nursing home residents present in the nursing home at three time points (n=710, 719, and 707) and a subset of residents (n=251) with restrictive side rail use at baseline. INTERVENTION APN consultation with individual residents and facility-wide education and consultation. MEASUREMENTS Direct observation of side rail status, resident and nurse interview for functional status, mobility, cognition, behavioral symptoms, medical record review for demographics and treatment information, and incident reports for fall data. RESULTS At the institutional level, one of the four nursing homes significantly reduced restrictive side rail use (P=.01). At the individual participant level, 51.4% (n=130) reduced restrictive side rail use. For the group that reduced restrictive side rails, there was a significantly (P<.001) reduced fall rate (-0.053; 95% confidence interval (CI)=-0.083 to -0.024), whereas the group that continued restrictive side rail did not demonstrate a significantly (P=.17) reduced fall rate (-0.013; 95% CI=-0.056-0.030). CONCLUSION An APN consultation model can safely reduce side rail use. Restrictive side rail reduction does not lead to an increase in bed-related falls. Although side rails serve many purposes, routine use of these devices to restrict voluntary movement and prevent falls is not supported.
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Affiliation(s)
- Elizabeth Capezuti
- John A. Hartford Foundation Institute for Geriatric Nursing, New York University College of Nursing, New York, New York 10003, USA.
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Stolee P, Hillier LM, Esbaugh J, Griffiths N, Borrie MJ. Examining The Nurse Practitioner Role in Long-Term Care: Evaluation of a Pilot Project in Canada. J Gerontol Nurs 2006; 32:28-36. [PMID: 17048754 DOI: 10.3928/00989134-20061001-05] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This study examined the nurse practitioner (NP) role in three long-term care facilities in Ontario, Canada, to identify factors that facilitate or impede the implementation of this role. Facility staff were surveyed about their perceptions of the NP role, and the NP assigned to the facilities was interviewed. Findings indicated the NP had a positive impact on practice activities and staff assessment skills. Ratings of effectiveness and satisfaction with the role were high, although they varied by facility and the frequency of staff interaction with the NP. This study indicated NPs can significantly impact the primary care of residents in long-term care facilities. The NP role can be facilitated by clear delineation of the scope of practice, optimal NP to resident ratios, and organizational support.
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Affiliation(s)
- Paul Stolee
- School of Optometry, University of Waterloo, Ontario, Canada
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Cacchione PZ, Decker SA. Caring for the incontinent elder: advanced practice nursing concepts. Clin Geriatr Med 2004; 20:489-97, vii. [PMID: 15341810 DOI: 10.1016/j.cger.2004.04.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Urinary incontinence (UI) in the older adult is a multisystem health problem that has an impact on the lives of millions of older adults. Advanced practice nurses (APNs) specializing in gerontology,family, and adult practice are equipped educationally with the expertise to prevent, assess, and manage this health problem. The emerging emphasis on UI prevention will help guide the practice of APNs in the future. APNs will serve older adults well in prevention and management of UI by capitalizing on their roles as expert clinicians, researchers, consultants, educators, and collaborators with the interdisciplinary teams.
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Affiliation(s)
- Pamela Z Cacchione
- Saint Louis University, School of Nursing, 3525 Caroline Mall, St. Louis, MO 63104, USA.
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Abstract
Clinical nurse specialists (CNSs) are enjoying a rebirth. As health science and healthcare increase in complexity, it is critical that nurse experts provide leadership to improve patient care, advance nursing practice, and strengthen healthcare delivery systems. CNSs with specialty expertise combined with competencies in patient care, nursing practice, and healthcare delivery systems are essential to translating the products of our vast research enterprise into policies and practices that serve the patient. Many challenges loom. New diseases have emerged; treatments change constantly. We are newly aware of the gravity of the perils posed by natural and man-made disasters. Patients use complimentary and alternative health practices but we do not understand the power and risks of these approaches. Information technology makes possible new approaches to educating nurses and patients and tracking clinical outcomes. CNSs are vital to building a healthcare system that is evidence based, patient centered, outcome effective, safe, ethical, interdisciplinary, and cost-effective.
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Affiliation(s)
- Margaret M Heitkemper
- Department of Biobehavioral Nursing and Health Systems, University of Washington School of Nursing, Seattle, Wash 98195, USA.
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