Partners in Care

Nurse practitioners work tirelessly to improve quality of life for seniors with dementia and their families.

For Julie Bertram, a nurse practitioner at Sage Hill Retirement Residence (an integrative supportive living facility in Calgary’s northwest), learning the stories and personalities of her patients is one of the most rewarding — and important — aspects of her job. It’s by being present and getting to know a patient on a daily basis, she says, that rapport and trust are built.

“I have one patient, Mrs. D, who has dementia, and she is quite dear to me,” says Bertram. “She is a lady of few words, but she gets very agitated with change or with a lot of commotion.”

Bertram says that, over time, Mrs. D has come to engage with her in a familiar way, like someone would with a close friend. But, one day, while Bertram was in her office at Sage Hill, she heard a commotion at the nurses’ desk. She went out to find Mrs. D upset and anxious, pointing at another Sage Hill resident who was holding one of the unit’s new therapy dolls.

Bertram tried to explain that the dolls belonged to everyone, but Mrs. D was still angry.

So, Bertram took her for a walk to calm her. They headed down a corridor with pictures on the wall, where Mrs. D usually liked to point out things in the images with a word or two. This time, however, when they stopped to rest, Bertram got a surprise. Mrs. D turned to her and said, “Standing with the baby is dangerous.”

“I was shocked, I had never heard her say so many words,” recalls Bertram. “I reassured her that, from then on, I would have people sit when holding the baby, and she smiled, happy.”

Bertram is one of only 16 nurse practitioners that work in Integrated Supportive and Facility Living (ISFL) in the Calgary zone, and she has certification and extensive specialization in geriatrics. A nurse practitioner (NP) is a registered nurse who holds a master’s degree in nursing, has additional intensive clinical training, and has the ability to assess, diagnose and prescribe both medication and non-pharmacological treatments. Because of these enhanced nursing duties and responsibilities, NPs can act as the primary care provider in their specialized scope of practice, such as geriatrics.

ISFL is a relatively recent, collaborative effort between Alberta Health Services and the private care industry to use on-site NPs at seniors’ residences in order to reduce hospitalization, reduce or manage medication, and provide more proactive care for residents.

The ISFL environment and mission is one that Bertram embraces. “Personally, I’m not the kind of person who wants to work in the ICU or the ER,” she says. “In those situations, you’re dealing with acute, stressful issues, and you don’t always see the outcomes. I like to see the outcomes, and I like to experience them with my patients and their families.”

An Escalating Need

The use of geriatric NPs in Calgary has grown as the demand for elder care has grown — considering dementia cases alone, there are at least 13,000 people in the Calgary area living with dementia, and that number is expected to double by 2030, according to the Alzheimer Society of Calgary. NPs have become an important part of a large team of seniors’ care providers to address the resulting strain on the healthcare system. In their roles, NPs can work with and coordinate multidisciplinary teams (registered nurses, licensed practical nurses, health-care aides, pharmacists, physicians, and allied health professionals such as recreational therapists and dieticians).

Like Bertram, Debra Vermunt is an NP within ISFL. She balances her time between two supportive living facilities in Okotoks and High River and believes that one of the key necessities of her role is being accessible — it’s important to build trusting relationships with residents and their families, caregivers and physicians.

“[NPs] work autonomously,” she says, “but we also work with a great group of physicians who are very open-minded about what a nurse practitioner can do.”

Another key necessity for NPs to be able to do their jobs well is peer support and collaboration. “The NP group we have developed within ISFL has been extremely supportive of each other,” says Vermunt, who goes on to explain that most of the 16 NPs throughout the Calgary zone meet formally every month, and also hold frequent education sessions. “That peer support has made a huge difference working in this environment. You can phone up a colleague [in the ISFL group] and say, ‘I have this situation, what do you think?’”

According to Vermunt, among the most frequent situations or challenges that arise for NPs is managing patient medication in such a medically complex population. Clients can have not just one chronic disease, such as Alzheimer’s, but often multiple conditions.

“Medications are not the same for someone who is 40, as someone who is 80 or 90,” she says. “Metabolism is different, the doses are different.”

As such, Vermunt performs a med review for all incoming clients and works closely with the geriatric pharmacist and physicians to reduce unnecessary prescriptions. Patients with dementia can exhibit aggression, irritation and disorientation, but wherever possible, Vermunt uses non-pharmacological treatments to manage these behaviours. In the secured unit just outside her office door at the Okotoks facility — the unit where patients with the most complex cases of dementia reside — the atmosphere is calm and quiet.

“It’s not because they’re sedated. We have recreational therapy, we have staff that know what they’re doing, and we try everything before we would ever, ever sedate,” says Vermunt. “One of our goals when people get into supportive living is to support them, rather than use medication.”

Measuring Success

Behaviour management can be a challenge for NPs in a hospital setting, as well. Rishma Rhemtulla is one of just two NPs in Calgary who work in acute care in geriatric services. In her role at South Health Campus, Rhemtulla consults on cases ranging from early signs of dementia to palliative care. She receives referrals from physicians or emergency admissions, and works with geriatricians to thoroughly diagnose, treat and transition her clients.

Rhemtulla sees a significant number of cases with complex behaviours. Her team uses preventative strategies to try to understand what might be triggering the behaviours, and then provides music that may be therapeutic for the client.

“I had an individual who was getting increasingly agitated, and he threw a glass of water at me,” recalls Rhemtulla, without judgment or alarm. “That’s not to say [the non-drug strategies] didn’t work, it was just not the right time for him. He just needed time.”

Rhemtulla works closely with health-care providers and family members to provide quality — not just quantity — support, and to reduce harm to both the patient and staff. NPs take the time to understand who the individual is, their medical and biopsychosocial history

“There is always possibility of things improving,” she says. “You always want to pursue a good outcome.”

Measuring outcomes and success for NPs in a geriatric role can be difficult — it’s all about building relationships with clients and caregivers, gaining the trust of physicians, communicating with and supporting nurses or solving an urgent matter on a busy day.

Rhemtulla says one of her biggest rewards as an NP is improving a patient’s quality of life, whether that’s by mitigating complex behaviour, providing a seamless transition back to that patient’s community, or helping family members understand and cope with their loved one’s journey. It’s because of the complexities, not despite them, that Rhemtulla has always gravitated toward working with seniors.

“I’ve always loved it,” she says. “I can’t think of working anywhere else.” [ ]

Defining Nursing Roles

Nurse Practitioner (NP)

NPs are registered nurses with advanced education and training. NPs assess, diagnose and prescribe medications or therapeutic interventions. Nurse practitioners can act as a primary care provider in their stream of practice.

Minimum requirements:

• 4,500 hours of experience as a Registered Nurse
• Master’s degree in advanced nursing practice
• National Nurse Practitioner Exam in stream of practice

Registered Nurse (RN)

RNs coordinate, implement and evaluate patient care as part of a health care team. RNs may specialize in a particular type of care (i.e. emergency) or in a type of patient. RNs also develop and deliver health education programs.

Minimum requirements:

• Baccalaureate degree in nursing
• Canadian Registered Nurse Exam

Licensed Practical Nurse (LPN)

LPNs care directly for patients and their families in collaboration with other members of a health care team. They offer practical care, record vital signs, collect blood or urine samples, assess needs, and provide treatment.

Minimum requirements:

• Approved Practical Nursing Program
• Canadian Practical Nurse Registration Exam (CPNRE)

Health Care Aide (HCA)

HCAs provide direct support to patients who are ill, elderly or disabled. They assist patients with bathing, grooming, dressing and toileting. They may also help with feeding, exercise and helping patients take medications.

Minimum requirements:

• Recognized Health
• Care Aide program

Sources: Alberta Health Services, College and Association of Registered Nurses of Alberta (CARNA), College of Licensed Practical Nurses of Alberta (CLPNA), alis Alberta