How nurse practitioners enhance family communications: families' complex information needs are best met by someone with centralized expertise.

As professions go, the role of nurse practitioner (NP) is relatively new. Developed 40 years ago to compensate for a shortage of pediatricians, NPs have since assumed a position of central responsibility in healthcare delivery, and their role continues to evolve in long-term care settings. In most states, they can write prescriptions, make independent treatment decisions, and coordinate medical services for those in their care.

I have worked at Evercare, a health plan provider, for many years and know firsthand that NPs are a key force in healthcare today and are among healthcare's most valued players. Evercare was founded in 1987 by two NPs who recognized that there was not only an urgent, growing demand for eldercare in general, but also a pressing need for greater coordination of care for frail, elderly individuals, especially in long-term care settings.

NPs are equipped to play a central role in the delivery of long-term care for a number of reasons. Because the frail elderly often have multiple, complex chronic illnesses; take several medications daily; and are under the care of an array of healthcare professionals, NPs help overcome the fragmentation of services that often results and "pull it all together." Through focused communication, they keep families informed of and involved in all critical decisions and ensure that they understand all aspects of care surrounding their loved ones.

Particularly in the nursing home setting, the role of the NP encompasses more than just the clinical aspects of resident care. As the nature of care delivery becomes increasingly complex and multidisciplinary, NPs have incorporated additional roles into their daily rounds: clinician, collaborator, care manager, coordinator, coach/educator, counselor, communicator, and even cheerleader. On any given day an NP may do a comprehensive health history for a new resident, attend a family meeting, present an in-service to nursing staff, see residents for routine follow-up, and evaluate residents for changes in condition.

Working with residents and families, NPs are a source of support and a vital communications link in connecting with healthcare providers and other involved parties, such as social workers. This process begins by formulating a health and care plan (formally known as the advance directive, which the NP develops within 30 days of a resident's nursing home admission). The plan establishes a protocol of care to be followed should the resident's condition require medical intervention. A well-designed plan provides peace of mind for the resident, as well as family members and loved ones, that his or her wishes dictate how care is delivered. Because they see the people under their care frequently, NPs can quickly determine the need for preventive or diagnostic healthcare services, coordinate those services, and communicate with the appropriate parties.

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As I have shown, NPs' skill sets align with the needs of nursing home residents and their families. Perhaps most importantly, the NPs' clinical skills enable them to provide direct care that complements and supplements regular nursing home care. Their medical knowledge encompasses a broad understanding of disease management and advanced drugs. This knowledge is indispensable. Their in-depth understanding of how both multiple diseases and multiple drugs interact helps ensure that a resident's plan of care is best suited to his or her needs.

Because NPs are skilled at bonding with residents and their families, they function as a critical hub in care planning. Families see NPs as medically knowledgeable, approachable, and more readily accessible than physicians. The bonds formed between NPs and the residents' families instill a willingness to confide, which eases the families' burden of coming to grips with some of the most difficult decisions they will ever make.

As figures who inspire trust, NPs also assist families in working together to resolve the increased decision-making responsibilities with--or for--their loved ones. The latter is a frequent reality since more than 50% of nursing home residents suffer some degree of dementia. The secret to good resident/family relationships is staying in touch, frequently meeting with each resident to monitor for the slightest change in condition, and providing the family an in-depth monthly update.

Keys to Building Strong Relationships

True partnerships between NPs and families can significantly increase the likelihood of achieving the ultimate goal: optimal care and the fullest degree of functionality possible. To put this relationship on a firm foundation, the following are some recommendations for NPs--or, for that matter, any staff member--dealing with families:

* Be clear about expectations. A high degree of clinical skill does not make a caregiver a miracle worker. Dealing with family members who are in denial about their loved one's failing health and helping them come to grips with poor prognoses are key tasks for NPs.

* Outline care options in an easy-to-understand approach, and communicate them to all involved parties. The advance directive serves as the foundation for decisions about care options. Make sure that the family understands the diagnoses and care options available. Ask decision makers to restate what they heard in their own words to confirm their understanding of the information.

* Listen carefully to everyone involved in the care plan. Often the NP must act as a bridge of understanding between different points of view. To help form consensus, the NP must have a clear understanding of every party's viewpoint.

* Consider both medical history and present conditions when making decisions about treatment. There is no substitute for forming an up-to-date diagnosis, plan of care, and prognosis than having an in-depth knowledge of the medical history of the residents under the NPs' care.

* If a major change in health status (e.g., a new illness, the advance of an existing one, or incapacitation) occurs, refer to the advance directive when making all decisions. A well-designed advance directive covers a wide range of contingency situations specifying what medical interventions should or should not be made and what the resident's wishes are in the event of incapacitation. If there is any doubt of what action to take, the NP should consult the advance directive and contact the family or other responsible party immediately. Remember, the advance directive is a "living document" that requires frequent updating.

The sidebar offers advice that might be passed along to families to help maximize their communications with staff.

Conclusion

Viewed in total, NPs' greatest value is the focus, continuity, and clarity they bring to healthcare delivery, especially in the nursing home setting. NPs provide an extra layer of care that has been documented to improve residents' health and quality of life. A study published in the October 2003 Journal of the American Geriatrics Society showed that the Evercare approach reduced emergency room visits by half and hospitalizations by 45%. It also significantly reduced the incidence of acute episodes in nursing facilities. The same study showed that the use of NPs reduced average individual resident care by approximately $103,000 a year.

Over the past 40 years, N Ps have emerged and matured as a profession during a time when healthcare and the family institution itself have undergone profound change. In most states, NPs can now deliver care in an autonomous manner, write prescriptions, and make independent treatment decisions. Today, NPs serve an invaluable function as a central provider and coordinator of medical services. Managing the communications among all parties is a key ingredient in this equation. By building trust as a source of clinical knowledge and personal concern and support, NPs create a solid foundation for dealing with all phases of long-term care.

Patricia A. Kappas-Larson, MPH, APRN, BCBSN, RN, is Senior Vice-President, Professional Relations and Development, at Evercare, a UnitedHealth Group company that serves the frail elderly, chronically ill, and disabled. For more information, call [phone] or visit www.evercareonline.com. To send your comments to the author and editors, please e-mail [e-mail].

BY PATRICIA A. KAPPAS-LARSON, MPH, APRN, BCBSN, RN

RELATED ARTICLE: Tips for Successful Relationships

The following suggestions can enhance the communications of families and staff:

* Meet regularly to discuss the resident's needs and work out differences among family members about care options. Making care decisions collectively and routinely, rather than in response to a sudden medical emergency, ensures better care.

* Have the family appoint one member as a spokesperson who can be the regular contact for the NP. It is easier for an NP to form a strong relationship with one individual than with many family members.

* Create a journal that is accessible to all family members so everyone can make entries. The journal should include medical data and treatment sequences; physicians' names, phone numbers, and visiting schedules; meeting and appointment summaries; medications and dosages, including side effects and conflicts; and emotional and physical baselines. The journal should document changes in body language and nonverbal behavior, emotion or spirit, physical symptoms, and transitional needs.

* Use the Internet to enhance medical knowledge. While the Internet contains much authoritative information, in healthcare matters it is often a more reliable source of good medical questions rather than answers. Nevertheless, families will find the Internet a valuable tool to aid them in asking key questions and gaining familiarity with the latest therapeutic options.

--Patricia A. Kappas-Larson, MPH, APRN, BCBSN, RN