The Residential Aged Care Nurse-Led After-Hours Initiative, Enhancing nurse assessment and decision making.

Background Current staffing levels and current care standards have been linked to negative clinical outcomes for Residents in living in Residential aged care. Low levels of confidence have impounded a Registered Nurses ability to meet many acute challenges found in this environment. The utilisation of Emergency Department transfers for acute ill residents is an increasing epidemic. This research project aimed to contemporise, adapt, implement and evaluate a set of Clinical Practice Guidelines (CPGs) and a Nurse Practitioner Role in Residential Aged Care adapted with permission from Waitemata District Health Board New Zealand [1, 2]. The purpose of the CPGs was to empower clinical staff in Residential Aged Care Facilities (RACFs), to recognise early clinical deterioration, provide safe evidence based care to residents, and prevent unnecessary transfers of residents to an acute hospital emergency departments. Methods Action research was chosen for this research because it was not only cyclic/participative in nature, but it provided a progressive evaluation of the CPGs implementation and the current context as it related to past, progressive, and post implementation nurse decision making practices. A total of 4 Focus groups with an average of eight respondents were recruited to this study (Total participants, 16 RNs and 16 PCWs). Results Focus group data showed unequivocal evidence of increased confidence among staff in implementing the care guidelines, communicating with fellow professionals, and assessing incidents. The CPGs and NP intervention was successful in engaging staff and developing their confidence with assessment of acute resident issues. Additional longitudinal research is required to better understand the influences of these interventions on ED presentations. Conclusions Research needs to better explore the direct correlation between PCW knowledge, skills, and training, and a failure to rescue residents experiencing an adverse event. This should also encompass more research scrutiny on the impact of poor communication practices between PCWs and the RN. The role NPs play in reducing ED utilisation needs greater long term evaluation to better ascertain clinical care and economic benefits.

budget and availability [1]. Minimal publications have addressed the importance of clinical confidence in this cohort of RNs. The lack of these clinical attributes greatly affects capacity and capability with assessment and care planning thereby leading to failures in individualized care, continuity of care, rescue from deterioration and gaps in essential health care information [1,8].
This gap between planning and delivery also appears to have its origins within the role that PCWs play in assessment and communication of resident issues [9]. These researchers suggest that the growing neglect regarding the value of early clinical cue recognition by PCWs is an unrecognised contributor to adverse events for residents. In fact they suggest this continued neglect is undermining quality care and leading to a failure to rescue [9]. Consequently Kontos et al. [9], recommend greater exploration of PCWs' core skill and practice within the context of appropriate guideline integration into care delivery by PCW's. Current knowledge and skill within PCWs may impact on the ability of these staff to better assess and report issues to RN's for intervention.
The voices stemming from current evidence clearly highlights the importance of the Nurse Practitioner (NP) role in supporting the growth of clinical confidence for RACF staff [10]. Arendts et al. [10] focuses on the value proposition in capacity building through the NP role for the aged care clinical workforce. These researchers believe that NPs can offer growth in essential knowledge, specifically -what to report, why, and when? A review by Dwyer et al. (11) acknowledges several latent patient and organizational factors that are potentially modifiable through the introduction of a specialist clinician like an NP. They suggest a possible correlation with the reduction of ED transfers as well as improved care standards. Other researchers also listed recommendations regarding facility staffing, and improving advance directives [11]. Additional research supports Dwyer et al. (11) outlining that the nurse practitioner role has real potential to function in an inter-professional manner, thus addressing the missing link manifesting in gaps in care across registered nurse and care worker roles [10].
What is abundantly clear is that the lack of knowledge and skill mix [3], poor clarity or availability of clinical guidelines [6] the neglect towards the value of early cue recognition, care pathways for the PCWs discussed by Kontos et al. [9], and the lack of a NP role as recommended by Arendis et al. [10] are all leading to an over utilisation of emergency rooms and hospitals [12]. Amadoru et al. [12] through qualitative enquiry suggest a stipulation of appropriately skilled nursing care for all residents as per accreditation requirements. They summate that growing RN to resident ratios within an environment of declining clinical skill sets have led to an increased reliance on acute emergency services. They recommend the availability of timely and appropriate medical and nursing care in RACFs as they are viewed as influential to the hospital transfers.
This Nurse-Led After-Hours Initiative adopted a triple strategy of Aged Care Guides provision, provision of contemporary education and Nurse Practitioner support for Residential Aged Care Facilities (RACFs). Interventions were implemented with an aim to evaluate the impact of these interventions on preventable hospital transfers and enhanced clinical confidence of RACF staff. The foundation of this study was based on the success of New Zealand models which improved outcomes for residents through systemic initiatives and access to clinical support [2,13].
This research project aimed to contemporise, adapt, implement and evaluate a set of Clinical Practice Guidelines (CPGs) in Residential Aged Care adapted with permission from Waitemata District Health Board New Zealand [1,2]. The purpose of the Aged Care Guide was to empower clinical staff in Residential Aged Care Facilities (RACFs), to recognise early clinical deterioration, provide safe evidence based care to residents, and prevent unnecessary transfers of residents to an acute hospital emergency departments. The intervention was implemented in two Residential Aged Care Facilities across Ipswich, Queensland. The primary objective was to ascertain an improved experience for RNs and PCWs in assessing, reporting, and managing resident clinical care issues.A secondary objective was to ascertain if there was perceived reduction in the need for resident transfers to the acute hospital emergency department.

Methods
Action research was chosen for this research for its responsiveness and because not only was the cyclic/participative nature appropriate to the study design but it provided a progressive evaluation of the CPGs implementation and the current context as it related to past, progressive, and post implementation nurse decision making practices [14][15][16]. It is the cyclic quality of action research that was most appealing as the review cycle allows responsiveness to the dynamic of participants needs.
This form of research method provided flexibility for vague beginnings while progressing towards appropriate endings [14,16,17].
Two private aged care facilities in the Ipswich region of Queensland were chosen as the sites for the triple strategy of Aged Care Guides, education and Nurse Practitioner support for Residential Aged Care Facilities (RACFs).
A total of 4 Focus groups with an average of eight respondents were recruited to this study (Total participants, 16 RNs and 16 PCWs). These were separated into homogeneous groups to foster equal participation so that each group contained staff equal in status, and grade [18]. There were two RN groups, one at each facility, and two PCW groups, also one at each facility.
Groups were moderated (facilitated) by an experienced qualitative researcher. They acted as group facilitator with the purpose of introducing topics (see table 1) and to guiding discussion around the agreed area of interest [18,19]. The focus group facilitators always brought the discussion back to the agreed area of interest if discussions between group members went off-track.
Exclusion criteria: Senior supervisors were excluded from focus groups so that participants felt safe to express their honest perceptions, feelings, and any concerns [18].
Recruitment: Convenience sampling was used to recruit participants who are easily accessible to the study and met the inclusion criteria. Organizational permissions were sought, and flyers were distributed to seek participation in this study. Thematic analysis made use of a manual categorization process to refine down meaningful themes resulting in distinct concepts where there was evidence of some saturation to the data.
Data analysis occurred after each cycle of the action research implementation over a time period of six months i.e. a three intervals, preliminary/ intermediate/ and post implementation. All manual thematic analysis was confirmed using Leximancer Software an analytics technology and text-mining software to automatically analyze the content of collections of textual documents and display the extracted information [20].

Results
Impact of the CPGs on the level of confidence RNs and PCWs have in providing high standards of care (Pre-implementation phase) Early pre-intervention concept generation from preliminary focus group data revealed a distinct lack of confidence with the treatment being provided to residents within these facilities. Examples included lack of confidence in provision of effective pain management, and dealing with family if staff were unable to offer contemporary and effective clinical care. Issues surrounding pain management related to a delayed response in obtaining pain relief, the ongoing management of break through pain, or ongoing pain assessment. As one of the PCWs outlined a resident had 'been in pain for two months and its getting worse.' They further alluded to the fact they had contacted the RN on Prior to the intervention of the CPGs there appeared to be a culture enabling distrust and lack of confidence by PCW's in timely RN assessment of residents. This was demonstrated when some PCWs engaged the family as a means to facilitate action from the RN or Doctor in response to resident care issues. This type of behaviour had the potential for damaging the clinical reputation of the organisation. PCW staff were acutely aware of this strategy to engage family to catalyse visibility of care need as noted in the following statement by a PCW 'it wasn't until the family member got involved that they got attention.' One PCW admitted to using the family to enable action saying, 'I can't do it,' dealing with 'what pain she must be going through. I can't let her suffer like that.' This then led them to inform the family as a mechanism to enabling action. Clearly linked to the emerging concept of low confidence in the clinical capability was the perception of RN's as noted in the following statement, 'I guess some family have a lack of confidence in the nursing care, aged care.
News, Four Corners, you know?' Additional evidence indicating a lack of confidence from the family in the ability of the facility to offer adequate treatment and care also included family insisting on hospital transfer. As one RN outlined, 'the family will ask the question, if my mum or dad will get better treatment than here, and can you send them to hospital.' The tendency to use hospital transfers rather than identify deterioration early and manage care in the RACF also demonstrated there was a lack of confidence from RNs that they could facilitate appropriate care. Evident from pre-intervention participant feedback was the notion that a lack of familiarity with the resident may also be a contributing factor to increased numbers of hospital transfers. Where there was no continuity of care or understanding of what is "normal" or baseline biometrics for the resident, a risk mitigation approach in transferring this resident to hospital was an end result. This correlated with a lack of confidence to continue to care for the resident. A team of PCWs expressed their frustration on how they were not involved in handover for resident care. One PCW says, 'I can't remember here, but a few of -there's no handover for carers. They don't do a handover between the RNs -the RNs don't gather them'. 'It varies, which side, and it's all different.
So they're not getting information, they're just taking handover from the outgoing staff in, which is carer to carer.' In that facility RN to RN handed over was practiced and PCW's often did not know changes from previous shifts or post hospitalisation episodes.
There also appeared to be inconsistencies in decision making around whether hospital transfer was necessary. As one RN stated in relation to the afterhours doctor, 'once it gets to afterhours, if we haven't heard back from them, you're not able to get that high level intervention. '

Final Phase
Saturation of positive comment related to the impact and utilisation of the care guidelines could be articulated as unequivocal evidence. High-quality, evidence-based CPGs offered a way of bridging the gap between RACF policy, standards for care, and staff knowledge. These care guidelines have been upheld by participants as an essential part of quality care supporting clinical reasoning and impacting patient/resident care and ongoing management.
The CPGs offered a series of goals namely the intent to improve effectiveness of resident quality of care, to mitigate variations in clinical practice, to enhance clinical assessment and early deterioration and to reduce costly preventable hospital admissions. There is clear evidence stemming from this data that staff feel they have intervened in patient care earlier than otherwise anticipated as a result of using these care guidelines. These CPGs have improved clinical reasoning skills confidence and had a major impact in reducing failure to rescue.
Barriers to effective shared decision-making between the RNs and PCWs included lack of time, skills, knowledge, mutual respect and effective communication processes. This research found that the CPGs as a decision making tool positively aided communication process between PCW and RN by legitimising the PCW assessment of residents and being able to translate this into information for RN decision-making.
Clearly visible from this research is the need for ongoing education and training such as an annual refresher and new staff orientation training within and across RACF and the development of an app to improve access to the CPGs. As one PCW advocated, 'the care guidelines should become part of mandatory training.' Their rationale for this was that 'It means that every year we get reminded that there is a guideline'.. This staff member also referred to the benefit of an electronic "app" for the care guides stating, this could be 'brief information [

PCW Care Team Experience
The PCWs as core members of the care team expressed frustration about not be able to say something when they were confident there was a clinical issue with the resident. This is an interesting concept as the PCW plays an integral role in identify early clinical cues that something is not right with the resident. Proportionally there are more PCWs than RNs in RACF meaning that the PCWs are better positioned to detect early clinical signs and symptoms regarding clinical changes in the health status of the resident. Recognising that as unregulated health care workers, PCWs do not have a set of governing care standards, many of them still refer to working within the parameters of their role which is dictated by their employer. As one PCW noted, 'well we deal with dementia, but delirium and depression is not really our section. We look for the signs but if somethings out of the ordinary with a resident, we're not going to say, oh that's delirium, because we don't diagnose it.' Another PCWoutlined their views regarding pain by stating, 'so you know their grimacing signs but you're not going to ask a resident who's not going to talk and say they are in pain. Because some will say no; you can see it in their face and it's like hang on, this residents in pain so you'll get the RN before you actually tend to their care.' This demonstrates critical thinking by the PCW in noting that there is pain management strategies and medication in place prior to commencing activities of daily living.
What is clear is that the new CPGs have assisted the PCWs in helping to define their role within the care team. PCWs later in the cycle of data collection referred to identifying symptoms such as 'When There was a general acceptance that participation in ongoing education was an indication not only for the acceptance of these CPGs, but also for the presence of a NP. One RN stated, 'I think moving forward and now that the nurse practitioner is going to be coming in providing good support that we can look at some of the modules and she can keep elaborating on it.' Another RN explained, 'Continuous education gives us more understanding, with being able to identify the different things.' When staff were engaging in clinical solution generation regarding the medical (GP) response time for clinical issues in the facility one RN asked the question, 'What about Nurse Practitioner?' Another RN responded, 'Yeah, a nurse practitioner with a prescription on site will solve a lot of issues', implying residents would get the assessment and intervention or medication they require for treatment more quickly. Another RN agreed with this assertion stating, 'antibiotic orders in the afterhours with a GP or next day clearly delays the decision making'.

Discussion
Analysis of the pre-implementation phase reflected that post hospitalization support was often not forthcoming with poor communication between the health service and many RACFs a contributing factor. Good communication is central to quality healthcare and early findings from this research required by the resident placing the PCW in a prime position to detect changes in a resident's health status to identify and communicate information to enable early assessment and prevention of deterioration. With little formal training, extremely high workload expectations, and frequent exposure to behaviours from residents, PCW's are under pressure but ideally placed to ensure patient safety and care.
The workload of PCW's in contemporary RACF services is such that it places this cohort at high risk for burnout. This is known to affect the quality of resident care, including the quality of response for emergent health care needs. [23] Poor quality of health care delivery in nursing homes has severe consequences for residents and the health care system. Many of the early perceptions articulated by the PCWs in this study reflected high levels of stressors such as feeling overworked, uncertain, undervalued and unsupported. Many expressed concern around the standard of care and response being provided to meet resident's needs.
What is clear from this research supported by Arendts et al [10] is that a Nurse Practitioner does offer increased support for the PCW care staff and RNs. This coupled with the care guidelines has shown a change in PCW perceptions who indicated that they were now feeling supported and more certain in their role assessing and communicating resident issues.
The goal of this research was to achieve the triple aim of CPG provision, provision of contemporary education, and Nurse Practitioner support for RACFs. As noted these CPGs were based on the Boyd, Armstrong [1] New Zealand model, and adapted to the Australian context in collaboration with RACFs, nursing and medical gerontology experts.
As evidenced in the literature the use of clinical guides in RACFs can provide staff with additional resources to support clinical judgment and strategies for nursing led care management of residents [9]. This research has highlighted support for the research recommendations from Kontos [9] which advocated for integrating PCW knowledge in assessment and care planning, and examining occupational identity for the PCW role as inter-professional stakeholders in long-term care [9]. Early research data from this study has supported earlier findings that PCWs are infrequently consulted when care direction is being decided or implemented [9]. What is clear from the PCWs participating in this research is that lack of professional respect, communication, and collaboration among PCWs and RNs was at an all-time low.
Interim and post qualitative findings though have shown that the care guidelines have improved professional communication and collaboration resulting in earlier response times due to enhanced assessments preventing exacerbation of clinical deterioration for residents. Registered nurses felt safer about their practice when they transferred patients to the hospitals rather waiting for the after hour's doctor's review. Implementation of guidelines has enhanced confidence among registered nurses and a mutual understanding of expected outcomes within the organisation staff, stakeholders and primary health care providers. A combination of the CPGs intervention with that of the availability of a NP has indicated progress in improving the team work of the PCWs and RNs which is anticipated to improve the quality of care for older adults residing in RACF. This research also supported the notion that NP adds significant value clinically in RACF settings as access to Medical Support is often limited to GP availability or after hours services.
The CPGs hanwere also a valuable asset in providing a platform for PCWs to raise concerns to RNs early using structured evidence. The impact found regarding the confidence of PCWs to escalate early deterioration to RNs was also evident throughout the course of the focus group interviews.

Conclusions
The results of this research provide the potential opportunity for future research on a number of concepts occurring in RACF clinical environments. Further research needs to better explore the direct correlation between PCW knowledge, skills, and training, and a failure to rescue through an inability or unwillingness to advocate legitimately on behalf of RACF residents. This should also encompass more research scrutiny on the impact of poor communication practices between PCWs and the RN.
Longitudinal research is required to better explore the levels of complex care these organisations could accommodate if factors like staff to resident ratios and improved clinical knowledge were further addressed. Future studies examining the direct impact of NP roles on reducing the inappropriate utilisation of EDs should be explored in more depth. The role NPs play in reducing ED utilisation needs greater long term evaluation to better ascertain clinical care and economic benefits.