A Canberra-based nurse practitioner (NP) who developed an innovative model integrating specialist palliative care into residential aged care in a bid to give people more dignity and choice at the end of life was recently named the inaugural Health Minister’s Nursing Trailblazer following Australia’s launch of the global Nursing Now campaign in Sydney.
Established by the Australian College of Nursing (ACN), the new award acknowledges the vital role nurses play in improving the country’s health and aged care system.
Following an introduction from Federal Health Minister Greg Hunt, via video link, Lord Nigel Crisp, Co-Chair Nursing Now, presented the award to Nikki Johnston, a Palliative Care Nurse Practitioner from Canberra who works for Calvary Health Care’s Clare Holland House.
It includes a specialist palliative care service with a 19-bed inpatient unit, community outreach looking after some 200 people in their home, and Ms Johnston’s arm integrating specialist palliative care into 29 residential aged care facilities.
“I think it’s the highlight of my career,” Ms Johnston said of the award.
“It was amazing and I’m very grateful because there’s a lot of talented people out there. I feel like winning the award will help us improve care and that’s the biggest part of this for me.”
Ms Johnston has worked in palliative care for two decades and found people’s experience with death wasn’t always as good as it could be.
“When I was working in acute care I just noticed a lot that death and dying wasn’t recognised and wasn’t talked about and people were dying without having said their goodbyes or without planning,” she recalls.
“They had unfinished business and they were often dying in hospital with a lot of intervention and so they weren’t really given an opportunity to say what was important to them or where they wanted to die. So because it wasn’t talked about there were no plans and people were dying badly.”
The gap in choice at end of life led Ms Johnston to develop the INSPRED: Integrating specialist palliative care into residential care for older people project in 2014.
“I noticed there was definitely no consistency about how people were dying and I really only had enough time to put out spot fires,” she says.
“I also thought the staff working in residential aged care needed mentoring and support to understand how to do this work.”
The team then developed a pilot program titled Palliative Care Needs Rounds in 2015, starting at four nursing homes, with Ms Johnston undertaking hour-long monthly education sessions with staff to enhance their knowledge about what dying looks like and identifying residents at the greatest risk of dying to ensure they had proper plans in place.
The intervention, which included involvement from residents and family, also involved mentoring staff to enable them to facilitate end of life decision making and develop advance care plans specific to resident needs.
Ms Johnston says the pilot successfully reduced hospital stay by 67% and people died in their preferred place 100% of the time.
After the pilot, the team began a randomised controlled trial in 2017 integrating the Palliative Care Needs Rounds model across 12 residential aged care facilities in Canberra caring for 1,700 residents.
The study ended six months ago with similar results.
“So far the results mirror the pilot and we’ve also improved the quality of dying. People are dying with less pain. Other symptoms like breathlessness are managed a lot better. They’re dying in the place they want with the people around them and families have better connectivity to them and better spiritual care.
“It’s been incredibly uplifting and when we did the pilot and when we did the trial you really feel the change within the residential aged care facilities. The confidence of all the staff lifts and they feel much more able to do this work, they feel better about their job and turnover is less. They also get less complaints because the family is involved in the decision making so we all become one team.”
Ms Johnston says one of the most significant findings to emerge from the implementation of the model was the impact of registered nurses.
“Just having some senior nurses in there supporting has really improved the care for people as one of the biggest challenges is that the majority of the workforce are unregulated, either carers or assistants in nursing. They’re not regulated and they’re not remunerated very well or overly valued.
“So I think we could do a lot better with the workforce if we regulated it [more] and then we could value it more. That’s why I think we really need to put more registered nurses in residential aged care. So definitely more registered nurses and like in hospitals, where we have staff to patient ratios. I think that would really improve care.”
Ms Johnston is now hopeful the program can be rolled out nationally to improve care for older people in residential aged care across the country.
She says the costs of implementing the program would be offset by reductions in hospitalisations.
“I’ve worked out that if we had 200 nurse practitioners in palliative care that would cover Australia but we’d need to train them first and create positions and then fund them. But if we looked at a cost benefit analysis, we’d save so much more money than that.
“Nursing is really well placed to innovate and change the health system so that it fits people instead of people having to fit the system.”