NIKKI JOHNSTON - PALLIATIVE CARE NP

The experience of dying improves if it is recognised and planned for. Nikki works with a  research team who have been recognised internationally for their approach that improves outcomes for older people living in residential aged care through integrating specialist palliative care. Older Australians deserve the best care at end of life regardless of where they live.

What influenced your decision to become a nurse, and eventually a Palliative Care Nurse Practitioner?

I began nursing over 30 years ago, I wanted to be a nurse for as long as I can remember and I still love it. Nursing has given me enormous opportunity and sometimes its been challenging. I moved to Sydney from Orange at age 18 to study nursing. I was one of the first to be educated as a registered nurse at UTS, I studied to become a nurse practitioner as a single mum with three kids, and I was the first palliative care nurse practitioner in Canberra.

My experience for the first ten years involved working in bone marrow transplant, oncology, and HIV AIDS at Royal North Shore Hospital and ST Vincent’s Public Hospital in Darlinghurst Sydney. I have a lot of fond memories of this time as I had fantastic mentors and experiences. I completed a graduate certificate in oncology and found myself drawn towards palliative care. I began to think that there must be a better way of managing the suffering that many of these patients endured at end of life. People were dying in hospital having intensive and burdensome treatments. Dying wasn’t recognised or talked about and people died without saying goodbye and with unfinished business.

When I moved to Canberra in 1998 with my family I started a job at ACT Hospice (as it was called back then). I worked in the research centre for nursing practice and was very fortunate to work with Professor Glenn Gardner and Professor Anne Gardner, who I will be forever grateful to for teaching me that through education and research nurses can change health care for the better. At the research centre my first project was to investigate the process of dying in the acute care setting. From there I worked in the specialist palliative care consulting service at Canberra Hospital and again learned from great mentors and commenced a masters in palliative care at Flinders University.

My interest in Palliative Care, research and furthering my education increased. It was clear to me that palliative care in Australia was evolving and changing and that there was a great need for specialist palliative care clinicians to be trail blazers and contribute to the changing landscape. Through medical science people live longer often with multi-morbid conditions and reduced quality of life. I wanted to help people live better in their last months and to improve their experience of dying.

Becoming a nurse practitioner gave me the opportunity to do this as I could still do the hands on care, do research and help to improve dying in the community.

Like many nurses, I have to say that nothing beats the feeling of competence and confidence. Confidence about skills, confidence about what is the latest evidence and trends in practice, a confidence that builds over time with experience and with reflection and by the gracious feedback from peers, mentors and good managers. I like that I now feel confident to walk into an emergent clinical mess - either poorly controlled symptoms, or a profoundly complex family crisis where others feel overwhelmed. I and can move quickly and judiciously through careful assessment to a plan or a strategy that helps patients, families and their care providers feel that someone knows what they are going through; someone knows what to do, has seen this before and knows what steps or strategies will work.

I love learning with others, especially those who really and truly appreciate that no matter how much experience and how many qualifications they have they can always learn more and that just as importantly everyone has something to learn and everyone has something to teach. Through his or her approach or life long journey the cleaner may have something to teach the professor, the child has something to teach the parent, the student has something to teach their mentor and patients have something to teach nurses. It is that spirit of humility and shared endeavour that I look for in others which makes health care and palliative care in particular such a compelling and exciting field to work and learn in.

Tell us about your current role.

At the end of 2014, I started my current role, which is working as a Palliative Care nurse practitioner providing care to older people living in residential aged care facilities. While my role is now permanent, at that time I only had a 1-year contract and knew that I had to do something to prove my worth. Our research team came up with an idea to integrate a proactive rather than reactive model of palliative care into residential aged care. The model is called Palliative Care Needs Rounds.In 2015, we piloted Palliative Care Needs Rounds model in four sites in Canberra, with positive results. We increased the capability of staff providing care to the people at end of life, people died at their preferred place, and we reduced avoidable hospital stays by 67%. Our results have been published in peer review articles. Due to the success of the pilot, my role was funded for another two years. In 2017 we commenced a randomised controlled trial of the model across 12 out of 28 residential aged care facility sites in Canberra.

The success of our research resulted in our service employing two Palliative Care Nurse Practitioners working across 28 facilities. We have completed our randomised controlled trial in July 2018, which included 1,700 residents over 18 months. It is the largest trial of its type. We are the first to develop a nurse led model which integrates palliative care into residential aged care, nationally and internationally. Our results will be published in the near future.

It is really rewarding for me to be able to improve the lives and deaths of older Australians living in residential aged care. As a nurse practitioner, improving access to end-of-life medicines is now something that I can do, which is great. It improves the ability to provide care in a timely manner, which leads to people living with less pain and suffering. Furthermore, developing a model that works is very rewarding to me.

What are you hoping to achieve in your current role as a NP?

I know it’s going to require a lot of work,

but I’d really like to see our model rolled out across Canberra, and eventually across Australia.

I also want to do more research that explores “Does the experience of trauma affect the way we die?” I plan on having 10 years of my career left and would really like to research this before I retire.

What advice do you have for anyone wanting to become a NP?

The first thing I’d say is that it’s definitely worth doing. It was challenging to be one of the first NPs in Canberra, but I am hoping the pathway will be a little bit easier as the profession develops in Australia. Even though there are negative sides of it, just like any other job, the positives outweigh them. Nurse practitioners can make a real difference, and it is a very worthwhile job to have.

If you want to become a nurse practitioner, surround yourself with people who believe in you. I suggest you reach out to your local nurse practitioner and partner with a mentor, because it really helps. And you must believe in yourself, believe that you can do it. I wasn’t the brightest student who received gold medals for my achievements, but I really wanted to do this, and I was determined to make it. I think determination and persistence are the biggest things you need to become a nurse practitioner.