Nurse clinics - Improving the quality of life for people with palliative care needs

By Margaret Dempsey, APNA Project Officer, Building Nurse Capacity Nurse Clinic Project 2021–2022 

Source: APNA Primary Times Winter 2022 (Volume 22, Issue 1)

The Acacia Ridge and Thornlands general practices in Brisbane participated in APNA’s Building Nurse Capacity Nurse Clinic Project 2020–2021. Lead nurses Isabella Zhao and Georgina Tsang were involved in the project, which established new Supportive Care Nurse Clinics to provide improved symptom management and to support quality of life for people with palliative care needs. 

 
APNA describes a nurse clinic as a nurse-delivered, team-based model of care where the nurse is the primary coordinator of care and partners with other health professionals to meet individuals’ holistic health-care needs. Nurses working within a nurse clinic model of care undertake assessments and provide education, support, treatment, monitoring and referrals to other health professionals. Nurse clinic models are underpinned by high levels of autonomy and advanced decision-making, providing the opportunity for nurses to optimise their scope of practice.  

There are demonstrated benefits of nurse-delivered models of care, focusing on promotion of early palliative care interventions that positively impact patient outcomes, such as psychological function, health-related quality of life, and survival. Other outcomes positively impacted by comprehensive care delivery include end-of-life planning, emotional function, and satisfaction with care.1 Many patients requiring palliative care support have health-care needs that can be easily managed in the primary care setting with additional support provided from the specialist sector as required. 
 

Initial planning saw Isabella and Georgina undertake a review of their respective practice’s active patient database, identifying those patients with palliative care needs. They found that less than 10% of identified patients had their palliative care needs managed in the general practice. 

Establishment of the nurse clinics has expanded the roles of Isabella and Georgina in their respective practices. They work closely with GPs and allied health professionals, including pharmacists and psychologists, along with the practice team to improve palliative care support for patients in the primary care setting. They have responsibility for an allocated patient caseload and coordinate various health services in order to deliver efficient and effective clinical care based on current palliative care guidelines, advance care planning and symptom management. 

The initiative has facilitated the implementation of a planned, systematic approach to palliative care for patients with at least nine appointments scheduled over a 12-month period. These appointments involve various Medicare-funded initiatives, including care planning, health assessments, medication management, case conferencing and nurse-related care-plan monitoring items. Eligible patients receive regular assessments and follow-up care to meet their individual needs, including timely interventions and referrals to other providers, as appropriate. This systematic approach also aims to reduce duplication of services, and avoid unnecessary hospital admissions and the associated economic health system burden. 

A key factor in supporting patients with palliative care needs was the initiation of discussions with patients about advance care planning and assisting with the development of advance care directives to document the wishes and values of the individual and ensure that appropriate care will be provided in the future. Interestingly, both nurses reviewed the terminology they used when addressing patients with palliative care needs. The nurses identified a level of disengagement when using the term ‘palliative care’ for patients, especially those with non-malignant life-limiting health conditions. Subsequently, a change of name from the ‘Palliative Care Clinic’ to ‘Supportive Care Nurse Clinic’ enabled conversations to progress and supported an associated increase in patient uptake to participate in the nurse clinic.  

“This initiative is very good! Keep it up!” 

- Patient feedback after attending the Supportive Care Nurse Clinic, Acacia Ridge 

Supportive Care Nurse Clinic initiatives were discussed and agreed upon at regular practice team meetings and brochures were developed to promote this new service, ensuring a whole-of-team approach to patient care was implemented within the practices. There was minimal disruption for existing nurse clinic patients during periods of mandated pandemic-related lockdown as the practices shifted to providing telehealth consultations. It was, however, identified that recruitment of new patients into the Supportive Care Nurse Clinic program was better achieved during face-to-face interactions.   

Both practices used the Patient Enablement and Satisfaction Survey (PESS)2 to gauge the success of their Supportive Care Nurse Clinic. Designed for the Australian general practice nurse context, the PESS is a validated and reliable patient-reported experience measure developed through a collaboration between the Australian Primary Health Care Research Institute, Australian National University and the Australian Medicare Local Alliance 2012. The Supportive Care Nurse Clinics used the first version of this tool,2 although a second version has recently been released.3  

The PESS can be used after each visit to the nurse clinic. Questions are answered using a 5-point Likert scale and are divided and scored across two domains: patient experience and patient enablement. Fifteen patient-experience questions measure satisfaction with the quality and timeliness of the nursing interaction and the extent to which the patient felt involved in their care. The patient's perceived capacity to manage their health-care conditions are assessed with six patient-enablement questions. 

Both the Acacia Ridge and Thornlands Supportive Care Nurse Clinics scored consistently high for patient satisfaction with an average of 66 and 65 points, respectively, out of a possible 75. However, average patient-enablement scores were lower, at 5.9 and 5.1 points, respectively, from a maximum of 10, which may reflect the declining overall health and complex needs of the palliative care population. The opportunity for patients to include comments when completing the PESS is another important component to evaluating the effectiveness of a nurse clinic. 

For more information about nurse clinics, visit APNA’s dedicated Nurse Clinic website: nurseclinics.apna.asn.au. 

Building Nurse Capacity is part of the Nursing in Primary Health Care Program, supported by funding from the Australian Government Department of Health and Aged Care.

References 

1 Australian College of Nursing, ‘Achieving quality palliative care for all: the essential role of nurses’, 2019, accessed 14 April 2022.  www.acn.edu.au 

2 J Desborough, M Banfield and R Parker, ‘A tool to evaluate patients’ experiences of nursing care in Australian general practice: development of the Patient Enablement and Satisfaction Survey’, Aust J Prim Health, 2013, 20(2), 209–215. 

3 J Desborough, C Phillips, M Banfield, N Bagheri and J Mills, ‘Impact of nursing care in Australian general practice on the quality of care: a pilot of the Patient Enablement and Satisfaction Survey (PESS)’, Collegian, 2014, 22(2), 207–214.