24
NURSING RESEARCH
A Value-Added Benefit of Nurse
Practitioners in Long-Term Care
Settings: Increased Nursing Staff’s
Ability to Care for Residents
Esther Sangster-Gormley, RN, PhD
Associate Professor,
University of Victoria School of Nursing
Victoria, BC
Nancy Carter, RN, PhD
Assistant Professor,
School of Nursing and Canadian Centre for
Advanced Practice Nursing Research (CCAPNR),
McMaster University
Hamilton, ON
Faith Donald, NP-PHC, PhD
Associate Professor, Daphne Cockwell School
of Nursing, Ryerson University
Toronto, ON
Canadian Centre for Advanced Practice
Nursing Research (CCAPNR),
McMaster University
Hamilton, ON
Ruth Martin Misener, RN-NP, PhD
Associate Professor
School of Nursing
Dalhousie University
Halifax, NS
Jenny Ploeg, RN, PhD
Professor, School of Nursing,
Faculty of Health Sciences and
Department of Health, Aging and Society,
McMaster University
Hamilton, ON
Sharon Kaasalainen, RN, PhD
Associate Professor, School of Nursing and
Research Fellow, HSFO/Michael G. Degroote
Chair in Cardiovascular Nursing Research
Faculty of Health Sciences,
McMaster University
Hamilton, ON
Carrie McAiney, PhD
Associate Professor
Department of Psychiatry &
Behavioural Neurosciences
McMaster University
Hamilton, ON
Lori Schindel Martin, RN, PhD
Associate Professor and Associate Director –
Scholarship, Research and Creativity,
Daphne Cockwell School of Nursing,
Ryerson University
Toronto, ON
Alan Taniguchi, MD
Assistant Clinical Professor (PT) Department
of Family Medicine and Education Director
Division of Palliative Care,
McMaster University Medical Centre
Hamilton, ON
Noori Akhtar-Danesh, PhD
Associate Professor of Biostatistics,
School of Nursing,
McMaster University
Hamilton, ON
Abigail Wickson-Griffiths, RN, MN
PhD Student, School of Nursing,
McMaster University
Hamilton, ON
A Value-Added Benefit of Nurse Practitioners in Long-Term Care Settings
Abstract
The number of people living longer is increasing, and those with physical or cognitive impairments may need admission into long-term care settings. In long-term care
there is a need to increase nursing staff’s capacity to meet the care needs of residents, develop a team approach to providing care and provide opportunities for staff
to improve their knowledge and skills. One approach to meet these needs has been
to employ a nurse practitioner (NP). The purpose of this paper is to examine nursing
staff’s perceptions of how working with an NP affected their ability to provide care,
function as a team and increase their knowledge and skill. Data used in this paper
were obtained from nursing staff and managers who participated in focus groups
that were part of case studies conducted in the second phase of a larger sequential,
two-phase mixed-methods study. NPs used multiple approaches to increase staff
knowledge and skills and improve quality of care. These findings describe the benefits of employing NPs in long-term care settings.
Introduction
In today’s long-term care (LTC) settings the majority of healthcare is provided
by nurses (Kaasalainen et al. 2010a; Meijer et al. 2000) with an increased use of
licensed practical nurses (LPNs) and unregulated caregivers, and fewer registered
nurses (RNs) providing direct patient care (Abdallah 2005; Lyon et al. 2008). In a
review of staffing in LTC in Ontario, Canada, Sharkey (2008) identified the need
to increase nursing staff ’s capacity to meet the care needs of residents, develop a
team approach to providing care and provide opportunities for staff to improve
their skills and acquire the specialized knowledge required to care for residents
(Lyon et al. 2008; Silversides 2011). One approach to meeting these needs has been
to add a nurse practitioner (NP) to the care team (Bakerjian 2008). In this paper,
we use data obtained from Phase Two of a larger mixed-methods study to describe
managers’ and nursing staff ’s perceptions of how working with an NP affected
their ability to care for residents.
Background
In Canada, NPs are defined as RNs with additional education and experience
“who possess and demonstrate the competencies to autonomously diagnose,
order, and interpret diagnostic tests, prescribe pharmaceuticals, and perform
specific procedures within their legislated scope of practice” (Canadian Nurse
Practitioner Initiative 2006: 26). NPs have provided services in LTC in the United
States for several decades (Abdallah et al. 2005). Researchers have found that NPs
in LTC improve access to primary care and reduce hospital admissions, emergency
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Nursing Leadership Volume 26 Number 3 • 2013
department use and costs (Intrator et al. 2004; Kane et al. 1991, 2003). Abdallah
(2005) found that in addition to providing direct clinical care, NPs spent much of
their indirect care time consulting and collaborating with nursing staff. As a result
of staff–NP interactions, nursing staff increased their ability to care for wounds
(McAiney et al. 2008) and manage challenging behaviours exhibited by some
residents (Borbasi et al. 2010; Stolee et al. 2006). These studies have limitations
including small sample size, no comparator groups (Intrator et al. 2004; McAiney
et al. 2008; Stoley et al. 2006) and the inability to isolate the data to the NP role
(Kane et al. 1991, 2003). In spite of these limitations, they provide evidence of
NPs’ contributions in LTC.
NPs were introduced into Canadian LTC settings in the late 1990s to support the
increasingly complex care needs of residents (Kaasalainen et al. 2010b; Stolee
et al. 2006). With legislation now in place for the role in all Canadian provinces
and territories (Kaasalainen et al. 2010b), NPs are well positioned to become
members of collaborative healthcare delivery models in LTC (Donald et al. 2009).
Describing nursing staff ’s perceptions of how working with an NP affected their
ability to care for residents will add to our understanding of changes that occur
when an NP is added in LTC.
Method
Data used for this paper were obtained from a larger sequential, two-phase mixedmethods study of the integration of NPs in LTC (Donald et al. 2011; Tashakkori
and Teddlie 2003). In Phase One, a survey of NPs working in Canadian LTC
settings and their managers was used to collect demographics, characteristics
of the settings, role definition, NP job satisfaction, practice patterns and factors
influencing role integration. Phase Two was a qualitative study of four LTC
settings where NPs were employed and included individual interviews and focus
group discussions with NPs, managers, healthcare providers, physicians, family
members and residents, document analysis and field observations.
Design
In Phase Two, we conducted an explorative qualitative study of four LTC settings
representing western, central and eastern Canada. We purposefully selected LTC
settings with diverse characteristics, including location and bed capacity (Table 1).
Participants
For the purpose of this paper, we used data obtained through focus groups with
licensed nurses (RNs and LPNs; n=35), unregulated employees referred to as
personal support workers (PSWs; n=15) and in-depth, face-to-face, individual
interviews with managers (n=18), which included administrators, directors of
care (DOCs) and assistant DOCs, for a total of 68 participants. The majority of
participants were female (94.3%). Licensed nurses, on average, had worked in
A Value-Added Benefit of Nurse Practitioners in Long-Term Care Settings
their settings for 10.65 years and PSWs 16.26 years. Ethics approval was obtained
from all necessary universities, health authorities and institutions participating in
the study.
Table 1.
Characteristics of LTC settings
Characteristics
Setting 1
Setting 2
Setting 3
Setting 4
Funding model
for LTC setting
For-profit
Not-for-profit
For-profit
Not-for-profit
Funding source
for NP role
Government
Mixed
government/LTC
setting
LTC setting
Mixed
government/LTC
setting
Location
Rural/suburban
Urban
Suburban
Urban
Number of sites
in setting
Multiple
Single
Single
Single
Setting’s bed
capacity
200 plus
200 plus
200 plus
200 plus
Years NP in
position
>5 years
2–5 years
>5 years
<2 years
Average number
of hours NP on
site/week
39 (among all
sites)
40
37.5
40
LTC = long-term care; NP = nurse practitioner.
Recruitment
The administrator of each setting distributed a letter describing the study and
inviting employees to attend the focus groups. Focus groups with nursing staff
were scheduled during regular working hours and in the afternoon to accommodate participation at the end or the beginning of their work hours. Interviews with
managers were scheduled at times convenient for them. Participation was voluntary, and participants signed an informed consent prior to data collection.
Data Collection
Data were collected from October to December 2010. Focus groups were led by
two researchers. Interview questions were used to guide the discussion and elicit
participants’ perceptions of their experiences working with NPs, their expectations of the NP role and examples of how they work with NPs (available upon
request). Participants were asked to complete a short demographic questionnaire
and describe the reasons for which they contacted the NP. All interviews and focus
group discussions were audio-recorded.
Data Analysis
Data from focus groups and interviews were transcribed verbatim and analyzed
using NVivo 9.0 (QSR International 2009). Concepts from the data were coded
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and categorized using conventional content analysis methods (Boyatzis 1998;
Richards and Morse 2007). First, three research team members independently
hand-coded three transcripts and discussed a preliminary coding framework.
Next, the emergent framework was discussed in a research team meeting. The
remaining transcripts from each setting were independently coded by three or
four researchers who identified themes and subthemes. NPs enhancing nursing
staff ’s ability to care for residents was one of the major themes originally identified. One researcher (ESG) subsequently completed an in-depth analysis of
transcripts from nursing staff focus groups and manager interviews to better
understand their perceptions of how NPs affected nursing staff ’s ability to care
for residents.
A number of strategies were used to promote qualitative rigour, specifically credibility, dependability, confirmability and transferability (Duggleby 2005). To
promote credibility, triangulation of data sources (inclusion of four different
settings, and interviews and focus groups) and investigator triangulation were
used. Results of data analyses led by three research team members were reviewed
and discussed by six additional research team members, who confirmed interpretation of most findings and refined others, an approach that enabled data to
be interpreted in a non-biased manner. Dependability was promoted through
the provision of an in-depth description of the study methods. Study confirmability was promoted through the use of an audit trail including notes on analytic
decisions, and investigator triangulation. Finally, transferability was promoted
through a thick description of the settings, sample and methods. We used several
member-checking strategies, including checking with participants to clarify
concepts and ideas that emerged during the interviews, and interweaving emerging ideas from previous interviews with participants in subsequent interviews
(Krefting 1991).
Results
On average, licensed nurses reported working directly with the NP for 4.14 years,
and PSWs reported 5.41 years. When asked how often they were in direct contact
with the NP, licensed nurses indicated they had 15.47 direct contacts with the NP
per month; PSWs reported 3.75 contacts. Both licensed nurses and PSWs indicated they most often contacted the NP to assist with managing and monitoring
residents’ chronic conditions, providing episodic care and answering questions.
Licensed nurses also contacted the NP to review medications and complete admission assessments. PSWs contacted the NP for support with palliative care, to
manage and monitor mental health concerns and for wound care management.
A Value-Added Benefit of Nurse Practitioners in Long-Term Care Settings
Reasons for introduction of the NP role
We asked managers to describe their reason for hiring an NP. The primary reason
was to address concerns about the quality and accessibility of primary healthcare
for an increasingly complex resident population, as one manager expressed:
“It’s their (NP) expertise. You don’t always have a physician, and the
physician is not going to be in any setting all the time. You have a person
with that kind of expertise, it’s absolutely perfect. The average resident
has many symptoms or diseases. Care is more complicated, residents
are older. We need help to look after these people; [the NP] is a perfect
avenue.”
In addition to providing clinical care, NPs were expected to collaborate and
consult with nursing staff. A manager described how NPs were expected to
increase the nursing staff ’s ability to care for residents:
“We were hoping that the NP would build capacity for the LPNs because
you have an opportunity for mentoring, coaching and clinical support. If
we build nursing staff ’s capacity, they are able to provide better day-today care and … to see issues more quickly and refer more appropriately.”
At the time of this study, much of the care was provided by LPNs and PSWs,
with RNs providing supervisory support. By consulting, collaborating with and
mentoring the nursing staff, NPs were expected to increase the capacity of staff to
care for residents.
NP contributions to the abilities of nursing staff
Our findings identified two approaches that NPs used to enhance staff ’s abilities. One approach was to assume a leadership role when working with staff, and
the second was to consult and collaborate in a variety of ways. As leaders, NPs
mentored and coached staff, helped them to identify their learning needs and
developed and implemented educational programs. NPs consulted and collaborated with the nursing staff to improve quality of care and to help them fully enact
their scope of practice.
Leadership
NPs helped nursing staff identify their learning needs and helped them develop
new clinical skills. Participants indicated that the NPs often used a train-thetrainer approach to teach them new clinical skills. Once staff acquired a new
skill, the responsibility for carrying it out was transferred to them. A participant
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related: “In the beginning [the NP] did those clinics, and then she taught us how
to collect the information ... and let us fly on our own.” Staff stated that they were
more confident and that their skill development had broadened, as exemplified by
one LPN’s comment:
“As for teaching, she will teach you new skills and expect you to use them.
As dependent as we are on her, she’s also making us independent in our
thinking and skills. The NP would say, ‘Okay, now you know how to do
this, go ahead and do it.’ This is unique for her to do that, it shows a level
of trust in us.”
NPs taught nursing staff new skills, such as syringing ears to remove impacted
cerumen. Equally important, NPs taught them to replace feeding tubes and helped
increase their knowledge of and skill with wound care. An LPN remarked:
“She showed us how to look after certain types of wounds, for example,
if it is draining, you don’t use this, you use that. I didn’t really know too
much about wounds before.”
In addition to these clinical skills, NPs helped staff more effectively manage residents with behavioural issues, as related by another LPN:
“We had a difficult resident, and we thought we needed to get some expertise. [The NP] sat down with PSWs and discussed what helps and what
doesn’t. They were able to voice their concerns and opinions. She recommended good care; she was good with them [PSWs].”
One approach to mentoring and coaching staff was to provide short discussions
or “mini workshops.” These provided opportunities for NPs to discuss issues of
wound care, medication use or other topics, as described by one PSW:
“She had these little mini workshops with staff to come and listen. A halfhour discussion where she would discuss medication or wound care or
whatever we wanted.”
Participants describe the NP as providing “informal,” “on the spot” teaching and
being a “good teacher … providing little teaching tidbits … teaching the patient
and me at the same time.” Another participant said: “She is an educator; when
she goes on the floor, many people learn from the visit.” For nursing staff, having
timely responses and ongoing teaching from the NP assisted them with their
increasingly complex work. As a result of NP coaching and mentoring, staff felt
the quality of care they provided was improved, and this was “a big asset.”
A Value-Added Benefit of Nurse Practitioners in Long-Term Care Settings
Another program developed by the NP was a “lunch and learn” speaker series
within the setting. This is how one LPN described the series:
“The continuing education programs she pioneered are amazing. We
have 50, 70 people at some of those sessions. And it wasn’t just for lunch,
because sometimes lunch wasn’t that good. They came in for the speakers.”
Nurse managers related that NPs helped them develop their clinical skills. For
example, one manager related that the NP helped her to learn to “give residents
intramuscular injections.” Another manager, new to LTC, indicated that she anticipated the NP would assist her:
“I think that she will have a great impact on my learning. She said she
would show me anything, answer any questions I have.”
Participants spoke of mentoring occurring on a day-by-day basis, with all nursing staff. As well, participants believed the NPs “boosted their morale” by being
supportive and continuously offering encouragement. Participants related that at
times their work was stressful, and they could call on the NP to help them cope.
They liked how the NP was aware of circumstances occurring in the LTC setting
that were upsetting, such as when a resident died. Participants related that the NP
would say to them, “You’re doing a good job. You could do this now … take a deep
breath, and tell me what is going on today.”
In summary, as supportive leaders, NPs contributed to the nursing staff ’s ability
to provide better wound care and treatment; they also helped managers and staff
to learn to administer injections, which facilitated residents’ receiving flu vaccines,
and to replace feeding tubes so that residents did not have to go to the hospital
for the procedure. As a result of the nursing staff ’s having better assessment skills,
changes in residents’ health status were identified more quickly. NPs helped nurse
managers to increase their knowledge and skills in residential care by being available to answer questions and provide support.
Consultation and collaboration
NPs consulted and collaborated with nursing staff to improve quality of care and
build effective teams by asking for their input and involving them in care planning. The NP asked all of the nursing staff for their opinion of residents’ health
status. This approach resulted in staff ’s perceiving they were more involved in
care decisions. Staff liked being involved, because they worked closely with
residents and could identify changes in residents more quickly. As a result of
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collaborating with the NP, participants related that their confidence in providing
care grew. They liked the ability to consult with the NP and ask questions, as this
RN expressed:
“It is a comfort to know I have somebody I can go to, to assist me. When
you are trying to make a decision about a situation, you need somebody
with a higher skill level to help. It’s so good to have her available.”
A PSW related that NPs worked with all members of the nursing staff, not just the
RN or LPN:
“She says, ‘Okay, how is [resident] today?’ We can say, ‘She is feeling this
way or that.’ Having that kind of interaction is how it should be. We are
the front-line workers. We see residents on a daily basis. It makes sense to
ask us, and we feel validated.”
The PSWs felt validated because the NP “involved everyone, not just the charge
people.” One PSW said, “All those people who couldn’t act before are free to act in
the moment and exercise their skills and knowledge.” Interactions between the NP
and the nursing staff were described as open. NPs were aware the nursing staff had
more daily contact with residents and because of this, asked for staff ’s opinions of
residents’ health status. Staff members were comfortable providing their opinions
because they felt the NP listened to what they had to say, as one LPN related:
“We’ve had clients where we worked closely with [the NP] on issues. Over
a period of a few weeks, we talked every day or every other day … to make
sure we were working together until we saw resolution.”
Participants felt valued and heard
Participants said the NP was approachable and respectful of everyone, regardless of their credentials: “It doesn’t matter if you are high up or down low [in the
organization]; she treats you all the same.” Staff appreciated that the NP asked for
their opinion and recognized their experience and their “feelings and emotions
towards residents.”
Participants related that NPs expected them to enact their scope of practice to
improve quality of care. For example, before bringing a care issue to the NP, staff
knew they needed to complete a patient assessment. The information from the
assessment was then reported to the NP. An RN described this process:
“Having [the NP] on board has forced us to do better assessments. The
amount of review of systems, etc., done by the nurses in conjunction with
A Value-Added Benefit of Nurse Practitioners in Long-Term Care Settings
working with the NP is greater. Her standards for assessment are higher
than what the physician would ask of us. Even though the physician
would be happy to get those things, they would not say, ‘Well, the minimum assessment I need is a pain assessment, a depression scale and vital
signs.’ The physician may not ask, whereas the NP would ask for these
prior to her visiting so that she has something to work on.”
Staff perceived the NP to be supportive, as one LPN expressed: “[The NP]’s
been there for me, and I’ve learned a lot,” resulting in better care for residents.
A manager related:
“We don’t shy away from accepting [complex] residents because we have
the NP as a resource, and she will help us and teach us how to handle
them on our own.”
Participants related that they liked the NP’s approach to working with them.
They described the NP as approachable and respectful of staff. Many spoke of
her “having good rapport” and making people feel comfortable. One participant
identified how the NP “almost walks side by side with you through lots of difficult stuff ” and linked the perceived support from the NP to their job satisfaction,
attendance and retention. An LPN described this:
“It gives you a good feeling because [the NP is] building staff morale. She
is giving you that confidence to continue. She has given me confidence to
continue to provide palliative care.”
In summary, as a result of consultation and collaboration with NPs, nursing
staff perceived that they were able to practise to their full scope; care of residents
was timely, staff functioned more efficiently as a team and the quality of care
improved. They indicated that morale improved, and the settings could admit
residents with more complex care needs.
Discussion
This study makes an important contribution to understanding the processes
by which NPs assume a leadership role to educate and collaborate with nursing staff in LTC. We learned from participants that NPs assisted them to expand
their clinical skills, provide better care to residents, increase confidence and feel
more valued. Although researchers have found that NPs improve access to care
and reduce hospital admissions, emergency department use and costs (Intrator et
al. 2004; Kane et al. 1991, 2003; Rosenfeld et al. 2004), less is known of how NPs
influence care provided by nursing staff. In a recent systematic review Donald and
colleagues (2013) found few studies that evaluated the impact of NPs and clinical
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Nursing Leadership Volume 26 Number 3 • 2013
nurse specialists (CNSs) in LTC on nursing staff. Of those included, the majority
evaluated the CNS role. As advanced practice nurses, CNSs and NPs are expected
to use their knowledge and skills to improve patient care (CNA 2008). These
findings are similar to those of Kane and colleagues (2001), who found that in
addition to providing direct care, NPs spent most of the remainder of their time
consulting with staff. Consultation occurred through formal inservice education
and informal on-the-job training, with the aim to increase staff ’s capacity to care
for residents (Abdallah et al. 2005; Kane et al. 2001). Stolee and colleagues (2006)
also found that working with an NP boosted staff ’s morale and helped them to
improve their nursing skills and problem-solving abilities.
Similar to the findings of Borbasi and colleagues (2011), participants in our study
trusted the NPs and valued their knowledge. They indicated that NPs mentored
them, provided support and helped them to increase their capacity to care for residents. Nursing staff look to leaders to provide support and direction. They want
to be engaged in decision-making and appreciated (Simpson et al. 2002). NPs in
our study were leaders who worked closely with staff. According to Havens and
colleagues (2006), increased involvement and communication with nursing staff
have a positive impact on recruitment and retention and patient care. We found
staff were more involved in patient care, a finding that could potentially improve
future recruitment and retention.
This study adds to the body of knowledge of NP role effectiveness. To the best of
our knowledge, no previous study has explored in depth nursing staff ’s perceptions of how the NP role influenced their ability to improve quality at the point of
care. Therefore, this study adds insight into how NPs improve quality and address
complex care issues by working directly with nursing staff.
Implications
Knowledge of this value-added benefit of the NP role has implications for policy
makers who are responsible for allocating scarce financial resources. Our findings
provide support that hiring NPs in LTC settings is a sound financial investment
that benefits nursing staff and could indirectly benefit residents. These findings
have implications for practice, and are of importance to administrators of LTC
settings who want to increase their staff ’s capacity to address complex care issues.
Administrators can use these findings to justify hiring an NP. As well, these findings have implications for NP educators who can build in opportunities for NP
students to spend time in LTC. Finally, there is a need for additional research to
build and expand upon these findings. Comparing the knowledge, skills and abilities of nursing staff before and after an NP was hired would be valuable.
A Value-Added Benefit of Nurse Practitioners in Long-Term Care Settings
Limitations
A number of issues limit credibility and transferability of study results. It is possible that only participants with positive views of the NP role participated. In relation to transferability, there were a limited number of participants at each site, but
we found consistency of themes across settings. Only English-speaking participants were included, so we did not capture the perspectives of people from different backgrounds. Our findings relate only to nursing, and we cannot relate them
to outcomes of care of residents.
Conclusions
The NP role in LTC is relatively new in Canada. With the number of people residing in LTC expected to increase in coming years, NPs’ capability to provide direct
care and enhance nursing staff ’s knowledge and ability is a valuable benefit. In this
study, we were able to explore nursing staff ’s perceptions of how NPs increased
their capacity to care for residents. NPs assumed a leadership role in assessing
staff ’s abilities and went about helping them to increase their knowledge and
skills. Additionally, NPs collaborated and consulted directly with nursing staff to
care for residents. Staff perceived they were more involved in care decisions and
could provide better care to residents. Currently, there is only a small number
of NPs in LTC settings. This represents an opportunity for policy and decisionmakers in the healthcare system to improve the provision of care through the
employment of additional NPs.
Correspondence may be directed to: Dr. Esther Sangster-Gormley, University of
Victoria, School of Nursing, PO Box 1700 STN CSC, Victoria, BC CA V8W 2Y2;
email: egorm@uvic.ca.
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