Utilization of a benchmarking database to inform NICHE implementation.

An integral part of NICHE (Nurses Improving Care for Healthsystem Elders) is a benchmarking service that provides member sites with the ability to evaluate staff perceptions of the care environment compared with other NICHE sites. The NICHE Database includes more than 100,000 surveys (Geriatric Institutional Assessment Profile). This study aimed to explain how secondary analyses of this aggregate database can inform effective geriatric programming in hospitals. We found that nurse age and experience influence nurse perceptions of organizational alignment to NICHE guiding principles and that those perceptions improve following NICHE implementation. The NICHE Database addresses knowledge generation in key areas of geriatric nursing practice and assists hospitals' systemic capacity to effectively embed NICHE Guiding Principles: evidence-based geriatric knowledge, patient-family centered care, healthy and productive practice environment, and multidimensional metrics of quality. It contributes to the growing field of implementation science that seeks to promote the uptake of research findings into clinical practice.

New nurses' views of quality improvement education.

BACKGROUND: Quality improvement (QI) is a focus of hospital managers and policymakers. The role of registered nurses (RNs) in QI in hospitals is vital because most hospital-based RNs provide direct care to patients. QI skills are necessary to identify gaps between current care and best practice and to design, implement, test, and evaluate changes and are essential for R.N.s to participate effectively in QI. Newly licensed registered nurses' (new nurses') positions as direct caregivers could have an impact on QI if nurses lack sufficient knowledge, concepts, and tools required for QI. METHODS: Data came from the 436 respondents (69.4% response rate) to a 2008 eight-page mailed survey to participants in a nationally representative panel survey of new nurses who graduated between August 1, 2004, and July 31, 2005. RESULTS: Overall, 159 (38.6%) of new nurses thought that they were "poorly" or "very poorly" prepared about or had never heard of" QI. Their perceptions of preparation varied widely by the specific topic. Baccalaureate (B.S.) graduates reported significantly higher levels of preparation than associate degree (A.D.) graduates in evidence-based practice; assessing gaps in practice, teamwork, and collaboration; and many of the research-type skills such as data collection, analysis, measurement, and measuring resulting changes. DISCUSSION: Registered-nurse educational programs need to improve education about and application of QI concepts and to consider focusing QI content into a separate course to have some confidence that faculty will teach it. Despite the strong focus on QI in hospitals, new nurses do not see the connection between QI education and successfully performing their hospital jobs. Both nursing programs and hospitals should help new nurses make the connection.

Factor structure of the geriatric institutional assessment profile's professional issues scales.

The Geriatric Institutional Assessment Profile (GIAP) is a self-administered survey of hospital nurses, designed to assess a hospital's readiness to implement geriatric programs. A sample of 2,211 direct care RNs in 24 hospitals was randomly split in half to analyze the Geriatric Professional Issues scales of the GIAP, using one sample for exploratory factor analysis and one for confirmatory factor analysis. An exploratory factor analysis of the six Geriatric Professional Issue scales (staff disagreement, staff/family/patient disagreement, use of geriatric services, perceived legal vulnerability, perceived upsetting behaviors, and burden of upsetting behaviors) demonstrated very good internal consistency both as a whole (Cronbach's alpha coefficient = 0.90) and as individual factors (0.94, 0.91, 0.92, 0.89, 0.85, and 0.81, respectively). The six factors were validated in a half randomly selected sample, with a root-mean-square error of approximation fit index of 0.07 and the normed and non-normed fit indices both 0.8, all indicating adequate fit of the six-factor model.

Test--retest reliability of the Geriatric Institutional Assessment Profile.

The Geriatric Institutional Assessment Profile (GIAP) is a self-administered survey of hospital nurses designed to assess a hospital's readiness to implement geriatric programs. The GIAP measures nurses' knowledge and attitudes toward older adults as well as the organizational attributes that support or constrain geriatric best practices. Test-retest reliability estimates of the GIAP were conducted with a sample of 166 direct care nurses in three urban, university-affiliated hospitals over a 3-week time period. Intraclass correlation coefficients of GIAP scales and subscales ranged between .82 and .92, demonstrating good to very good reliability. The GIAP is a reliable measure of organizational attributes of the hospital relevant to geriatric care.

Understanding new registered nurses' intent to stay at their jobs.

Nursing turnover is costly for health care organizations. Newly licensed registered nurses work behavior is a complex process, influenced by their attitudes toward their work, personal characteristics, job opportunities, and workplace attributes. Several characteristics are significant in predicting satisfaction (ethnicity, gender) and organizational commitment (patient load, mandatory overtime, shift, and unit type) and intent to stay (income, age) over and above work attitudes. Among the most important implications are how the findings can inform management and policy. Findings from this study provide information that may be useful for those organizations that want to decrease their turnover rates.

The nursing practice environment and nurse-perceived quality of geriatric care in hospitals.

The relationships between general and geriatric-specific nursing practice environments (NPEs) and nurse-perceived quality of geriatric care in hospitals were examined using the Nurses Improving Care for Healthsystems Elders benchmarking database. The overall general NPE was negatively related, but the overall geriatric-specific NPE was positively related to quality of geriatric care. Among five subdomains of the general NPE measured by the Practice Environment Scale of the Nursing Work Index, Nurse Participation in Hospital Affairs was positively related to quality of geriatric care, whereas two subdomains were not significant, and another two were negatively related to quality of geriatric care. All three subdomains of the geriatric-specific NPE measured by the Geriatric Nursing Practice Environment scale were positively related to quality of geriatric care when adjusting for general NPE. These findings suggest geriatric-specific organizational support combined with nurse involvement in hospital decision making is critical for delivering quality geriatric care.

A comparison of second-degree baccalaureate and traditional-baccalaureate new graduate RNs: implications for the workforce.

The purpose of this study was to describe the differences between traditional-baccalaureate graduates (TBGs) who had a baccalaureate degree in nursing and no other academic degree or diploma and second-degree baccalaureate graduates (SDGs) who had both a baccalaureate degree in nursing and a baccalaureate or higher degree in a field other than nursing. Using a sample of 953 newly licensed registered nurses (NLRNs), we compared SDGs and TBGs on demographic and work characteristics, including attitudes toward work, intent to stay in their current job, and whether they are searching for a job. TBGs worked slightly more hours per week and were more likely to provide direct care. SDGs were more likely to plan to stay indefinitely in their first job and were less uncertain of plans to stay. SDGs experienced higher family-work conflict and lower workgroup cohesion. Full-time SDGs earn over $2,700 more income per year. Potential explanations for the salary difference are the greater human capital that SDGs bring to the job and their older age. Understanding the workforce productivity of these two groups is important for both organizational planning and policy for recruitment and retention.

Hospital nurses' perception of the geriatric nurse practice environment.

PURPOSE: To test the relationship between nurses' perceptions of the geriatric nurse practice environment (GNPE) and perceptions of geriatric-care delivery, and geriatric nursing knowledge. DESIGN: A secondary analysis of data collected by the New York University Hartford Institute Benchmarking Service staff using a retrospective, cross-sectional, design. METHODS: Responses of 9,802 direct-care registered nurses from 75 acute-care hospitals in the US that administered the GIAP (Geriatric Institutional Assessment Profile) from January 1997 to December 2005 were analyzed using linear mixed effects modeling to explore associations between variables while controlling for potential covariates. FINDINGS: Controlling for hospital and nurse characteristics, a positive geriatric nurse practice environment was associated with positive geriatric care delivery (F=4,686, p<.0001) but not geriatric nursing knowledge. The independent contribution of all three dimensions of the geriatric nurse practice environment (resource availability, institutional values, and capacity for collaboration) influences care delivery for hospitalized older-adult patients. CONCLUSIONS: Organizational support for geriatric nursing is an important influence upon quality of geriatric care. CLINICAL RELEVANCE: Hospitals that utilize an organizational approach addressing the multifaceted nature of the GNPE are more likely to improve the hospital experience of older adults.

Changes in the Geriatric Care Environment Associated with NICHE (Nurses Improving Care for HealthSystem Elders).

The aging of the U.S. population has profound implications for acute care nursing practice. NICHE (Nurses Improving Care for HealthSystem Elders) is the only national nursing program that addresses the needs of the hospitalized older adult. This secondary analysis examines the influence of the NICHE program on nurse perceptions of the geriatric nursing practice environment and quality of geriatric care, as well as geriatric nursing knowledge in a sample comprising 8 acute care hospitals in the United States that administered the Geriatric Institutional Assessment Profile before and after NICHE implementation. Results were compared in a sample of 821 and 942 direct care nurses, respectively. Controlling for hospital and nurse characteristics, both nurse perceptions of the geriatric nursing practice environment (P < .0001) and quality of geriatric care (P =.0004) increased, but not geriatric nursing knowledge (P =.1462), following NICHE implementation. NICHE tools and principles can exert an important influence over the care provided to older adult patients by increasing the organizational support for geriatric nursing.

Factor structure of the geriatric care environment scale.

BACKGROUND: Older adults comprise approximately 60% of all adult, nonobstetric hospital admissions. Nurses Improving Care for Health System Elders (NICHE) is a national program aimed at system improvement to achieve patient-centered care for older adults. The NICHE hospitals use the Geriatric Institutional Assessment Profile (GIAP) to assess their institutional readiness to provide quality care to older adults and to document improvement in geriatric care delivery. OBJECTIVE: To explore the factorial structure of the 28-item Geriatric Care Environment Scale (GCES) of the GIAP, test its validity with a sample of staff registered nurses (RNs), and evaluate its invariance across 4 groups of RNs who worked at 4 different types of hospitals. METHODS: Staff RNs (N = 9,400) at 71 acute hospitals, who responded to the GIAP from 1999 to 2004, were split randomly into 2 groups for cross-validation. A 3-step data analysis was completed. The a priori factor structure was developed using exploratory factor analysis. The obtained factor model was validated, and its invariance by types of hospitals was examined by confirmatory factor analyses. RESULTS: The GCES is internally consistent (Cronbach's alpha = .93) and accounts for approximately 55% of the total variance. The 4 factors extracted from the exploratory factor analysis are Aging-Sensitive Care Delivery, Resource Availability, Institutional Values Regarding Older Adults and Staff, and Capacity for Collaboration. The 4-factor structured model is validated in a half-randomly selected sample (normed fit index [NFI] = .931, nonnormed fit index [NNFI] = .933, comparative fit index [CFI] = .939, root-mean-square error of approximation [RMSEA] = .058) and does not vary significantly across the 4 groups of RNs who worked at the 4 different types of hospitals (NFI = .969, NNFI = .975, CFI = .976, RMSEA = .027). CONCLUSIONS: The GCES is a reliable measure of RN perception of how care provided to older adults reflects age-sensitive principles and the organizational practice environment that supports or hinders care delivery.

Portrayal of nursing to incoming students: results of a national survey of geriatric and pediatric web images on baccalaureate nursing program web sites.

In the face of a rapidly aging America and given that older adults are the population that avail health care services the most, there is a clear mandate to stimulate nursing student interest in care of older adults. The purpose of this study was to determine if web sites of baccalaureate nursing (BSN) programs stimulate interest in care of older adults by quantifying and comparing images of older adults and children on baccalaureate nursing program web sites and examining the characteristics of these images. The reality that nurses primarily care for older adults is not reflected in images on BSN program web sites. This creates both a skewed perception of the nursing profession and a lost opportunity to stimulate interest in geriatric nursing.

Newly licensed RNs' characteristics, work attitudes, and intentions to work.

OBJECTIVE: In an effort to better understand turnover rates in hospitals and the effect of new nurses on them, this study sought to describe the characteristics and attitudes toward work of newly licensed RNs, a population important to both the nursing profession and the health care system. METHODS: A survey was mailed to a random sample of new RNs in 35 states and the District of Columbia. A total of 3,266 returned surveys met the inclusion criteria, for a response rate of 56%. RNs who qualified had completed the licensing examination and obtained a first license between August 1, 2004, and July 31, 2005. Data pertaining to four areas were collected: respondent characteristics, work-setting characteristics, respondents' attitudes toward work, and job opportunities. Respondents who were not working were asked to specify why. RESULTS: Of the eligible newly licensed RNs, 58.1% had an associate's degree, 37.6% had a bachelor's degree, and 4.3% had a diploma or a master's or higher degree as their first professional degree. They were generally pleased with their work groups but felt they had only moderate support from supervisors. About 13% had changed principal jobs after one year, and 37% reported that they felt ready to change jobs. More than half of the respondents (51%) worked voluntary overtime, and almost 13% worked mandatory overtime. Also, 25% reported at least one on-the-job needlestick in a year; 39%, at least one strain or sprain; 21%, a cut or laceration; and 46%, a bruise or contusion; 62% reported experiencing verbal abuse. A quarter of them found it "difficult or impossible" to do their jobs at least once per week because of inadequate supplies. CONCLUSIONS: This study provides descriptive evidence that a majority of newly licensed RNs are reasonably satisfied and have no plans to change jobs, but the group is not homogeneous. The negative attitudes expressed in response to some survey questions suggest that newly licensed RNs may not remain in the acute care settings where they start out. Investing in better orientation and management may be the key to retaining them in hospitals. The authors will be following these RNs for two years and will develop predictive models of turnover rates.

Geriatric competencies for RNs in hospitals.

Nurses in staff development are responsible for assuring nurses' competence in the delivery of care. Older patients are the predominant population in hospitals, yet there are no instruments that specifically assess the competency of nurses to deliver care to older patients. This article reports on the development and testing of an instrument, Geriatric Competencies for RNs in Hospitals, and makes recommendations as to how staff development educators can use the geriatric competency instrument with staff nurses.

Neglect assessment in urban emergency departments and confirmation by an expert clinical team.

BACKGROUND: Elder neglect accounts for over 70% of all adult protective services reports in the nation annually, and it has been estimated that there are over 70,000 new cases each year. The purpose of this study was to conduct elder neglect research in the emergency department (ED), using a dyadic vulnerability/risk-profiling framework for elder neglect. METHODS: Patients were recruited through four EDs in New York and Tampa from the beginning of February 2001 through the end of September 2003. Demographics, a Mini-Mental Status Examination score, and an initial elder assessment screen were collected. The diagnosis of neglect was then made by a Neglect Assessment Team (NAT) comprising a nurse, physician, and social worker, with extensive clinical experience in elder neglect. RESULTS: Of the 3664 ED screens of adults 70 years and older, 405 (11%) met the inclusion criteria and agreed to participate. Neglect was diagnosed by the NAT in 86 of the 405 cases reviewed. Demographic differences between neglect versus no neglect cases were examined using Fisher's exact test, and differences emerged between the 2 groups. CONCLUSION: This study documents the underreporting of cases of neglect as evidenced by differences in diagnoses by screeners versus experts. The research assistants screened positive for neglect in 5% (N=22) of the 405 cases. The NAT made the diagnosis of neglect in 22% (86/389) of the cases. This markedly different rate of neglect may mean that ED screens are important but may underestimate the true number of cases. Conversely, an NAT may make the diagnosis of neglect in an older adult more often given a higher sensitivity and a more robust knowledge base of the problem.

Dyadic vulnerability and risk profiling for elder neglect.

PURPOSE: Neglect of older adults accounts for 60% to 70% of all elder-mistreatment reports made to adult protective services. The purpose of this article is to report data from research, using a risk-and-vulnerability model, that captures the independent contributions of both the elder and the caregiver as they relate to the outcome of neglect. METHODS: Between February 2001 and September 2003, older adults were screened and recruited through four emergency departments in New York and Tampa. The diagnosis of neglect was made by an expert neglect-assessment team. Elders and their caregivers were then scheduled for separate face-to-face interviews after discharge. RESULTS: Constructs within the risk-and-vulnerability model were examined for scale-score significance based on the outcome diagnosis of neglect. In the risk domain, caregivers' functional status, childhood trauma, and personality were statistically significant. In the vulnerability domain, the elders' cognitive status, functional status, depression, social support, childhood trauma, and personality were significant. IMPLICATIONS: Findings from this study underscore the value of interdisciplinary assessment teams in emergency departments for screening elder neglect, with attention given to risk factors related to the caregiver and elder vulnerability factors, including reports of childhood trauma. The risk-and-vulnerability model may provide a link between the caregiving and neglect research. Data should be collected independently from both members of the elder-caregiver dyad in order for clinicians to understand factors related to elders who receive the diagnosis of neglect from interdisciplinary teams.

Attitudes toward working on interdisciplinary healthcare teams: a comparison by discipline.

Interdisciplinary teams are important in providing care for older patients, but interdisciplinary teamwork is rarely a teaching focus, and little is known about trainees' attitudes towards it. To determine the attitudes of second-year post-graduate (PGY-2) internal medicine or family practice residents, advanced practice nursing (NP), and masters-level social work (MSW) students toward the value and efficiency of interdisciplinary teamwork and the physician's role on the team, a baseline survey was administered to 591 Geriatrics Interdisciplinary Team Training participants at eight U.S. academic medical centers from January 1997 to July 1999. Most students in each profession agreed that the interdisciplinary team approach benefits patients and is a productive use of time, but PGY-2s consistently rated their agreement lower than NP or MSW students. Interprofessional differences were greatest for beliefs about the physician's role; 73% of PGY-2s but only 44% to 47% of MSW and NP trainees agreed that a team's primary purpose was to assist physicians in achieving treatment goals for patients. Approximately 80% of PGY-2s but only 35% to 40% of MSW or NP trainees agreed that physicians have the right to alter patient care plans developed by the team. Although students from all three disciplines were positively inclined toward medical interdisciplinary teamwork, medical residents were the least so. Exposure to interdisciplinary teamwork may need to occur at an earlier point in medical training than residency. The question of who is ultimately responsible for the decisions of the team may be an "Achilles heel," interfering with shared decision-making.