Since introducing the nurse practitioner role into older people’s mental health in Otago in 2006, the Southern District Health Board’s hospital admissions have decreased, resulting in a reduction of six hospital beds and staffing. This has allowed funding to be reallocated into alternative community-based options and provided a more responsive service to older people with mental health issues.
In 2012, of the 101 registered nurse practitioners (NPs) in New Zealand, only six are registered to work with people experiencing mental health and/or addiction problems. Nationally services have been slow to realise the cost effectiveness of the NPs scope of practice which can work across primary, secondary health, including provider arm and non-government organisations (NGOs). NPs also have the ability to work independently in rural settings where the need is great and where it is harder to attract staff.
The Southern District Health Board began developing the role of nurse practitioner in 2002 by ensuring everyone in the service understood the role. They then completed a gap analysis process on how nurse practitioners could make a difference to health outcomes in Otago. This new role had to be funded from the existing budget which meant reprioritising funding allocations.
Heather Casey, nursing director, Mental Health and Intellectual Disability Services, has been leading the development of the nurse practitioner role in Otago (Southern District Health Board). It became evident that a role with a broader scope of practice than that of a registered nurse, which provided greater assessment and treatment options, was needed. “Nurse practitioners have the ability to undertake some of the tasks normally carried out by psychiatrists, such as complex assessments, ordering diagnostic tests and prescribing”, says Heather.
Two nurse practitioners and authorised prescribers working in Otago are Liz Langer and Bernadette Paus.
Bernadette Paus (Forde) – Nurse practitioner
Mental health and intellectual disabilities (ID)
Bernadette registered as a nurse practitioner in 2004 and has worked for the Southern DHB as a nurse practitioner since 2006. She was a member of the Ministry of Health working group to develop the role and has also served on the Nurse Practitioners Advisory Committee. Bernadette has two roles: 0.5 FTE dual diagnosis role – clinical responsibility for people being treated by the adult community mental health teams with a dual diagnosis of intellectual disability and mental health issues which spans primary, secondary and NGO services within the ID/mental health diagnosis area; and 0.5 FTE role in adult mental health within the Clutha Community Mental Health team (CCMH).
Bernadette’s first role
In the first role she works with people who have a dual diagnosis of mental health problems and a developmental disability. Bernadette is also responsible for dual diagnosis education within the wider DHB and with NGOs, which includes trusts such as Idea Services (formerly IHC). Bernadette provides a lot of education with NGOs, to increase their ability to meet the mental health needs of the clients they support and to increase their understanding and awareness.
“The needs of people with dual diagnosis can be complex, incorporating elements of behavioural problems, psychosocial issues and often medical concerns,” says Bernadette. “There is a very small pool of clinicians with the skills to work in this area. That’s why it was logical for my role to develop into a nurse practitioner – because there weren’t enough psychiatrists to do this work.”
Bernadette runs an outpatient clinic three days a week working with local community mental health teams. She sees three-quarters of the people she works with at the clinic and the remainder at their homes.
“It’s not uncommon for me to see people who have been living an unnecessarily miserable and unhappy life because of unrecognised mental illness. Those around them may have decided that this mood state was normal for this person. To be able to turn that around is satisfying.”
In this dual diagnosis role Bernadette works with around 100 people, spending up to an hour on each appointment.
“I work autonomously, conduct assessments, order laboratory tests, make diagnoses, and prescribe and manage medication. The ability to do this allows me to provide a one-stop shop so people don’t need to see a number of different mental health professionals. I work collaboratively with a psychiatrist whom I meet with weekly to discuss complex cases.”
Trish Pain, Pact South Otago area manager, sees first-hand the benefits of the nurse practitioner role.
“Getting wellness plans and early intervention strategies from Bernadette has been a positive step for our staff, enabling them to seek clinical support earlier to avoid admissions of people. She has been able to help staff to better understand and support our clients living with Aspergers.”
Pact offers support for people with intellectual or other disabilities or those recovering from mental health problems, providing services in the West Coast, Otago and Southland.
“Working in a small rural town we’re very isolated,” says Trish. “Previously the clinical on-call staff had to travel from Dunedin. Our work with Bernadette is a good example of cross-agency collaboration. She shares information about common clients. We receive her review and progress notes. If we have any doubts or questions we email or phone her and get an immediate response.”
Bernadette’s second 0.5 role
This is spent with Balclutha’s Clutha Community Mental Health team (CCMH), one of the Otago rural teams working with NGOs and Public Health Organisations (PHOs) providing input into mental health plans for rural communities. Bernadette’s role in the CCMH team was a new initiative. It was implemented to explore how the NP role could complement the consultant psychiatrist’s limited time (0.2 FTE position) within the team. The aim was also to assess if the introduction of the NP role would reduce EPS (Emergency Psychiatric Service) assessments, crisis hospital admissions and the length of stay of admissions.
- some new assessments go directly to the nurse practitioner clinic, resulting in reduced waiting time for people needing psychiatric assessments
- the consultant psychiatrist has more time to keep clinical notes up-to-date
- significantly reduced need for out-of-hours contact with the consultant psychiatrist.
Team member’s perspective
“In rural situations, with limited access to a psychiatrist, a nurse practitioner is the ideal solution,” says Lyn Latta, charge nurse manager, Clutha Community Mental Health (CCMH), Balclutha.
“Bernadette’s ability to prescribe has enabled us to provide more timely medication adjustments, resulting in faster stabilisation for people. They can see Bernadette during her Balclutha visits rather than waiting up to a fortnight to see a psychiatrist. This means we can resolve acute patient situations faster. We can be more proactive and use medications more efficiently. Bernadette’s expertise has prevented some people from requiring hospital admissions.”
Liz Langer – Nurse practitioner
Older People’s Mental Health Service
Liz worked as a nurse practitioner in the USA since 1986. She immigrated to New Zealand in 2003 and became a registered nurse practitioner here in 2006. She works with the Older People’s Mental Health Service (OPMH) across primary, secondary and NGO services to ensure that people receive adequate mental health care. Supporting other health professionals is a key aspect of her role. She deals directly with the person being treated and also supports rest home staff and general practitioners (GPs) to provide mental health service to older people. Liz provides management advice and also prescribes.
There was a clearly identified need for the establishment of the NP role within the Older People’s Mental Health Service (OPMH) in Otago2, due to:
- gaps in service provision
- long-term unfilled psychogeriatrician position
- people being admitted when in crisis
- the need for better links with residential aged-care facilities.
“When I started here, no one knew what a nurse practitioner was,” says Liz. “I’ve earned my credibility. I make everybody aware that I’m not a doctor. I have daily contact with psychiatrists. We discuss the people I’ve seen or am about to see and clarify medications. I also consult with registrars every day and receive direct referrals from GPs as well as from the rest homes.”
Liz makes rounds of all 24 rest homes in Dunedin and Mosgiel as needed, visiting each rest home at least once a fortnight. She has clinical responsibility for assessment and treatment of dementia and behaviour issues and sees 50 people on average per week. On a typical day she sees 10 clients and at the end of each day writes her reports.
“There are people I write reports about, and others who I see briefly and may make adjustments to their medication,” says Liz. “I do a lot of medication management. I try to manage my people so that they don’t reach the stage where they need to be admitted to hospital.”
Liz also sees people in their own homes, but primarily she works within rest homes and at the Dunedin Hospital.
“The most rewarding aspect of the job is helping older people who may be agitated and angry, seeing them settle down and become happier. To work in aged care you have to love old people. I think they’re really wonderful. I hope my role helps rest home staff to enjoy their work more and to value the elderly,” says Liz, “in the six years since I’ve been in my role, hospital admissions for older people have decreased. Six acute in-patient bed closed since the establishment of this role. This means an improved quality of life for rest home residents, and fewer older people being moved away from their familiar environments.”
- improved health/mental health as a result of early intervention and by improving capacity for complex nursing interventions in community
- decreased preventable geriatric mental health exacerbations
- reduced disruption in care for clients and transfers between settings
- reduced length of stay for unavoidable admissions.
“When Liz’s role was created she filled a significant gap in the service. She has subsequently developed the role far beyond assessment and support by providing education to the support workers and trained nurses in these facilities,” says Dr Anna Lise Seifert, psychiatrist, Mental Health Older People’s Health Service (MHOPH).
Liz also provides advice to the District Health Board planners, liaises with all of the GPs and meets with Anna Lise Seifert twice a day. “Liz has taken a burden off my shoulders. Being out on the road every day she is able to visit the huge group of referrals in the community, adjust medication and offer advice on the spot”, says Anna Lise.
“The down-to-earth explanations Liz gives to staff and to the families gives them confidence that someone is looking at the issues. We have fewer hospital admissions because Liz has been able to adjust medications on an as-required basis. Her assessment skills have enabled this to be done here, rather than disturbing residents by moving them to another environment,” says Margaret Stevenson, nurse manager of a 23-bed dementia unit at Birchleigh Residential Care Centre, Mosgiel.
Planning for the future
The Southern DHB wanted to ensure succession planning and has developed a nurse practitioner candidacy programme to ensure that the benefits gained from creating NP roles were sustained. The first nurse practitioner candidate, Jo Russell, has been appointed and is receiving up to two years’ mentoring and supervision from an experienced nurse practitioner, as she prepares her portfolio for the Nursing Council.
Australian-born Jo is a registered nurse with a NP master’s from the University of Newcastle, New South Wales. She is currently completing pharmacology and NP portfolio papers at the University of Otago. She works alongside Liz Langer and Dr Anna Lise Seifert, as part of a two-year candidacy programme to become a registered NP, hopefully in 2013.
In her daily work as candidate NP ‘shadowing’ Liz Langer, Jo is given opportunities to enhance her skills working with older people who are have behavioural symptoms of dementia, depression, anxiety and other mental health problems (see PDF on nurse practitioner candidacy role development and framework). Together Liz and Jo gather information from staff, create a care plan and prepare reports. “I’m doing one-third of these, which Liz then counter signs. I’m learning a huge amount about the mental health assessment of people, as well as improving my interview skills” says Jo.
A DHB can provide mentoring and a pathway to the role. People may have requisite qualifications, but until they gain the practical experience and mentoring that enables them to prepare a portfolio, they may experience a delay in being able to apply for the nurse practitioner scope.
“Championing the nurse practitioner role requires people to do things differently. People may have difficulties imagining how a new role can make a difference” says Heather, Nursing Director, Mental Health and Intellectual Disability Services, Southern DHB. “In order for aspiring nurse practitioners to gain the support of a DHB it is necessary that health leaders and managers understand the role and the difference it can make to the outcomes and health needs of a community. Once they understand they will be more committed to developing the role.”