All Nurse Practitioners and Student Nurse Practitioners, participating in the national project, were asked to identify the core intervention of each client consultation. This was then entered into the JBI database. The possible interventions are listed in the table below.
It is essential to note that, as reported by JBI in the site specific report, “In the final six months of the project (from October 2006), an additional field ‘not a core intervention’ was added to the MDS because data had not been entered into this field in a large number of cases previously”.41
During the review process of this data, clarification from JBI regarding this anomaly, revealed that across all sites there had been a significant lack of data entry into this particular field and that in total there was ‘insufficient data to provide adequate information for the final analysis.41
The addition of this new category, three-quarters of the way through the two-year study and more importantly, the inclusion of it in analysis of the final data set, has potentially skewed the data.
Core Intervention Table40
Core Interventions
— Complex Wound Management including ordering investigations and treatment/ medications
— Coordination of a winter flu strategy within the facilities eg initiating fluvax
— Engaging in a collaborative review of resident pharmacotherapy on admission to the trial in consultation with a General Practitioner
— Identification and treatment of a symptomatic urinary tract infections including the ordering of investigations and administering of antibiotics according to identified sensitivity
— Implement anxiolytics in emergency situations
— Implementing complementary therapies and managing their therapeutic benefits — Implementing treatment/medications for acute conditions (eg antiemetics,
antidiarrhoea, aperients, medicated creams — Managing physical restraint authorisation
— Managing other infections including ordering tests and medications (eg diarrhoea, upper respiratory tract infections
— Not a core intervention *
— Ordering medical imaging for suspected fractures — Pain Management
— Referring to specialists – eg speech pathology, ophthalmology, dental, palliative care, wound specialists, continence advisors
— Unknown
If the Nurse Practitioners had had this option available to them throughout the project it would have undoubtedly revealed a significantly larger number of occasions of service where ‘not a core intervention’ was chosen as the best available descriptor of the consultation.
Final Report Implementing the Nurse Practitioner Role in Aged Care
Australian Capital Territory, November 2007
It would have been preferable to have several other category options listed, to accurately reflect advanced nursing practice. For example, ‘management of multifaceted complex clinical issue’, ‘planning and implementation of specialist clinical education’, ‘provision of education and support’ may have been more appropriately included as core interventions.
Further, the core interventions are descriptive of tasks and associated costs but do not reflect the depth and breadth of the Nurse Practitioner role. Thus they are limiting and by being task and cost oriented they grossly undervalue the role and its potential in terms of advanced nursing practice.
In terms of the future development of Nurse Practitioner roles it is disingenuous to imply that advanced practice nursing is primarily concerned with tasks and clinical interventions, rather than acknowledging the broad range of critical analysis and assessment, advanced and problem-based interventions that may not involve a direct action to or on a person but rather contribute to the overall positive therapeutic outcome by implementing a holistic approach to a range of therapeutic interventions.
Research conducted by Naylor et al (2000) demonstrated that in advanced practice nursing the most frequent core interventions were related to three major categories being ‘surveillance, teaching/guidance/ counselling and case management’.42 These interventions were by far, more frequent than those related to
treatment and procedures.42
In an attempt to compensate, for the lack of intervention options, both Nurse Practitioners entered a free text comment describing the main intervention or activity of consultations. This information has not been included in the JBI data set nor mentioned in the discussion section of the report to ACT Health. Prior to commencement of the data collection period, the Nurse Practitioners were required to attend an education and training session with the principle researchers from JBI. Both Nurse Practitioners considered this session inadequate because at the time of the education they were informed that the research database was incomplete and therefore unavailable for any data entry training and simulation.
Discussion was held around the core intervention categories and both Nurse Practitioners expressed their concern, particularly regarding the number of interventions that were not available as data fields. There was lengthy discussion regarding this but no changes were made as a result.
Comment, from one of the Nurse Practitioners, was that as none of the other participants, at that time, were authorised but were in fact continuing with their studies, it may be that they did not have the same concerns, because at that time they lacked the practice experience that would enable a deeper understanding of relevant intervention categories. This may explain the lack of significant support from the other participants regarding potential changes in the core intervention categories at the commencement of the project.
From the perspective of quality research it is noteworthy that at no time throughout the course of data collection were either of the Nurse Practitioners contacted to clarify the reasons for lack of data entry in the core interventions field, or in fact to verify if there was a problem with the database maintaining recorded entries.
It is reasonable to assume that monitoring of the database would be carried out efficiently and effectively and identification of anomalies and inconsistencies would occur early in the process.