workforce
Nikki Johnston receiving
the Nursing Trailblazer
award. Photo: supplied
which was sort of over and above what
my daily clinical work was. Then ACT
Health funded the project. Without both
of those, INSPIRED definitely wouldn’t
have happened.
How long has INSPIRED been up and
running? Are you getting feedback or
seeing some of the effects?
then the pharmacy has to deliver it. Lastly,
it has to be given.
That whole process can take a week,
just because of the system. We thought we
could do better than that, which is where
the nurse practitioner side of things comes
in with increasing access to medicine.
We need to improve capacity for the
workforce. We need to improve the
experience of living and dying in the last
months of life. And we need to finetune the
referrals we get to specialist palliative care
– they need to be for the most complex
people, those with the most complex
needs. How could we put all of that
together with the resources we had?
That’s where we came up with
integration between specialist palliative
care and residential aged care. This hasn’t
been done anywhere else in the world.
By joining specialist palliative care into
residential aged care, we became a team,
and together we can do anything – it’s
really worked.
How much scope is there normally for
nurse practitioners to come up with ideas
like this in the workplace?
I must say that I’m incredibly grateful,
because I did come up with an idea, but
it wouldn’t have happened if it wasn’t
supported by my employer and the
government.
My employer, Calvary, gave me the
greenlight and the support to do research,
We’re getting a lot of feedback. In 2014
we did the pilot study, and that involved
integrating into four residential aged care
facilities. From that, we decreased hospital
stays by 67 per cent, we increased the
chance of dying in your preferred place,
and we increased the capacity of the staff.
We did all of the things we wanted to do.
What we needed to know was, were
the effects clinician specific, or was the
model working?
So we did a randomised controlled trial,
a stepped-wedge methodology over 18
months, with 1700 participants.
The intervention takes the form of
palliative care needs rounds. What
that means is, the palliative care nurse
practitioner goes into each facility, one
hour per month, and sits down with all the
staff – not just the registered nurses – all
the staff, and I get the staff to bring 10
residents who are likely to die in the next
six months without a plan in place.
There’s already teaching there because
I’m getting them to recognise dying. For
them to be able to bring the right people,
they’ve got to know, “Well, what does
dying look like? What do the last months
of life look like? What does deterioration,
rather than being sick, look like?” That’s the
first part.
Then we sit down and discuss those 10
people. We see if they have an alternate
decision-maker, we talk about the law
around the decision-making at end of
life, we see if they’ve got an advanced
care plan. If the answer’s no, we do a case
conference. That’s the next step.
Back in that palliative care needs round,
I teach the staff how to talk to relatives and
patients about death and dying, and help
them to understand how to assess and
treat pain. It’s an hour of intense education
and it’s case-based, but what I teach them
about Mary, they can put into practice
with Bill.
The first step is only with staff. The
second step is multidisciplinary end-of-life
case conferencing, where I’m mentoring
the staff in the residential aged care facility
to run these case conferences. We fill out
an advanced care plan, we do anticipatory
planning, which includes prescribing
anticipatory injectable medications for
that specific person. We think about what
they are at risk of dying of, or what could
happen to this person. We put a plan in
place and write up those meds.
At that stage, I still haven’t had a
specialist palliative care referral, so these
people aren’t on our books, per se. If they
have complex needs, then I will get a
referral and go and do a clinical visit, and
go in and assess and plan.
Having GPs in the case conference is
vital. We all just need to be on the same
page and work together. The nurse
practitioner works with the GP and the
staff in the facility.
At the case conferencing we do
education for staff and the community
around the benefits and burdens of
hospitalisation when you’re older. That’s
often a big discussion around, “Well, you
know, if I have pneumonia, do I want to go
to hospital, or I could have it treated here?”
Lots of people start by saying, “Of
course, if they’re sick they go to hospital,”
but then once they realise that there’s
actually quite big risks of going to hospital,
particularly if you’ve got dementia, they
then decide, “Well, if comfort is the goal of
care, we’re going to keep them home.”
Out of all that, what we managed to do
was drastically reduce avoidable hospital
transfers, saving the government quite a lot
of money.
We increased, for the first time
internationally, the quality of dying. What
that means is people had better pain relief,
people died without restlessness, people
died with their family around, people died
with better spiritual care, and the staff had
It’s quite a simple,
effective idea that doesn’t
cost that much money.
the capacity to care for them. People died
in their preferred place, and they were able
to do that because we’d asked them where
that was. Everybody’s a winner.
You’re based in the ACT, but is there
any talk about it being rolled out in any
other states or territories?
I’d like to see it go across Australia. It’s quite
a simple, effective idea that doesn’t cost
that much money. We’ll be lobbying to take
it across the country. n
agedcareinsite.com.au 35