Advanced Practice Nursing for vulnerable populations

Richard Newman became an advanced practice nurse in Australia after working as a cardiology and emergency department nurse. As he advanced to more senior roles, he found that he had a passion for clinical assessment of patients and for providing great care every time.

“I’ve always only focused on one patient at a time,” he says. “Each patient I treat I think how would I want them to be treated if they were my relative, my mum, my dad. Is that my daughter in that bed? How would I like them to be cared for, and how much knowledge would I want that treating clinician to have? You could never guarantee what level of care someone would get when it wasn’t you being able to provide it, so that’s why I went to study because I wanted to make sure my patients got the very best care that they possibly could.”

Once he qualified as a nurse practitioner (NP), Richard went to work at Justice Health, which provides health services to those in the criminal justice and forensic mental health systems. “If you look at the standards of practice of a nurse practitioner, it matches very well with supporting vulnerable populations,” says Richard, “and the Justice Health population is very vulnerable. They have a very limited access to healthcare so they need people who can provide a lot of care in one interaction. A lot of them also have very low levels of health literacy so they may come in with one problem and through a series of conversations they realise that there are quite a number of problems.”

Working inside the custodial framework has been very challenging and difficult. Each jail has its own health centre with nurses providing day to day operational needs, such as blood tests, delivering medicines, monitoring patients’ weight and other primary care interventions. There is also a mental health nurse; nurses who deal with drug and alcohol issues; population health nurses who look after the general health of the custodial patients, as well as communicable diseases nurses who provide infectious disease management such as hepatitis and COVID-19.

During COVID-19, patients were screened daily, and a quarantine process was set up for patients who had to leave the jail for court or hospitalisation, so they would not have to serve a mandatory amount of time before re-entering the general population of the jail. Richard’s job is to assess the primary care of the patients, such as acute care, chronic care and complex care needs. On a daily basis, he will assess patients, managing a variety of disease from cardiovascular disease, diabetes, pneumonia, liver disease or wound care.

Richard says, “I have had a lot of support from our directorate. Most days I will be talking to the other two NPs in the primary care team with whom I work very closely as well as the custodial mental health care team, the dental team, population health team for patients that might have hepatitis.”

Richard believes that “When you partner with your patients, you get a handle on improving their whole health”. Many of the custodial patients have very fractured health histories; have been in jail multiple times; and have seen a variety of healthcare practitioners. “Being able to sit down and talk openly and honestly with patients has been invaluable in improving their healthcare and maybe moving them from treatments they were currently on to treatment that might help them achieve their health goals more effectively and sustainably.”

Richard stresses the importance of access to culturally sensitive healthcare. Justice Health has a number of Aboriginal healthcare workers and chronic care nurses who partner with Aboriginal patients. “Knowing where a patient is going to get their best of value healthcare can sometimes not be with me,” he says. Richard talks about the importance of making sure you are effectively partnered with your patient, to advocate for them and, if you think they are missing out on something important through your conversations, to make sure you explain to them why it is important. “You need to use language that people can understand, so using words like ‘You seem agitated’ isn’t helpful if people don’t understand what ’agitated’ means.”

Richard thinks that, in the future, there will be a great need for reinvestment in chronic care within the custodial environment and helping people re-enter the community with good health.

This year, Richard has also supported Australian national and international COVID responses. He worked at Howard Springs quarantine facility in Australia’s Northern Territory to help with people returning from overseas, and in Papua New Guinea, where he worked to develop the response to COVID-19 and a sustainable development programme in partnership with the Australian volunteers programme through the Department of Foreign Affairs and Trade.