Improving the quality of geriatric nursing care: enduring outcomes from the geriatric nursing education consortium.

The nation's aging demography, few nursing faculty with gerontological nursing expertise, and insufficient geriatric content in nursing programs have created a national imperative to increase the supply of nurses qualified to provide care for older adults. Geriatric Nursing Education Consortium (GNEC), a collaborative program of the John A. Hartford Foundation, the American Association of Colleges of Nursing, and the New York University (NYU) Nursing Hartford Institute for Geriatric Nursing, was initiated to provide faculty with the necessary skills, knowledge, and competency to implement sustainable curricular innovations in care of older adults. This article describes the background, step-by-step process approach to the development of GNEC evidence-based curricular materials, and the dissemination of these materials through 6-, 2-, and a half-day national Faculty Development Institutes (FDIs). Eight hundred eight faculty, representing 418 schools of nursing, attended. A total of 479 individuals responded to an evaluation conducted by Baruch College that showed faculty feasibility to incorporate GNEC content into courses, confidence in teaching and incorporating content, and overall high rating of the GNEC materials. The impact of GNEC is discussed along with effects on faculty participants over 2 years. Administrative- and faculty-level recommendations to sustain and expand GNEC are highlighted.

Ensuring specialty nurse competence to care for older adults: reflections on a decade of collaboration between specialty nursing associations and the Hartford Institute for Geriatric Nursing.

Geriatric preparation of specialty nurses is critical because their direct care and administrative responsibilities profoundly impact the care of countless older patients in all settings. For a decade, the Hartford Institute for Geriatric Nursing, NYU College of Nursing, has worked with 54 national specialty nursing associations, and intensely with 14, to develop strategies for new standards for quality care for older patients. A successful blueprint for specialty associations to sustain and enhance these outcomes will be presented.

Ensuring a nurse practitioner workforce prepared to care for older adults: findings from a national survey of adult and geriatric nurse practitioner programs.

PURPOSE: To present the findings from a needs assessment of adult primary care (ANP), gerontological (GNP), and adult acute care (ACNP) nurse practitioner faculty regarding the transition to adult-gerontology NP (A-GNP) programs. DATA SOURCES: Data were obtained from two sources: (a) an online survey to identify the faculty's primary needs in order to facilitate success in this transition and (b) telephone focus groups to explore survey responses in greater depth. CONCLUSIONS: The survey and the focus group findings indicate that there is a strong need for (a) access to a set of nationally recognized competencies for A-GNPs; (b) teaching/learning resources to support faculty in implementation of A-GNP programs; and (c) formal faculty development opportunities to facilitate faculty efforts to engage in curricular redesign and innovations and assure that NP students acquire strong competence in gerontology content. IMPLICATIONS FOR PRACTICE: The transition to A-GNP has implications not only for NP faculty but also for practicing NPs. Almost all NPs care for older adults in a variety of settings. However, most of these NPs are not specialists in geriatrics. This article provides a context for self-assessment by these NPs of their own needs related to this transition.

The Hartford Geriatric Nursing Initiative experience in geriatric nursing education: looking back, looking forward.

This article traces the impact of the John A. Hartford Foundation's (JAHF) Hartford Geriatric Nursing Initiative (HGNI) on the geriatric preparation of nursing students. With over 2.6 million practitioners, nurses play a critical role in assuring the health care of older adults. Older adults make up the majority of patient days in hospitals, home care, and nursing homes. Yet, when the JAHF began its investment in geriatric nursing, specific content on care of older adults was woefully absent in academic programs preparing entry- and graduate-level nurses. Clearly, the JAHF HGNI investment in nursing education has paid huge dividends. Baccalaureate nursing students are now likely to graduate with competencies in care of older adults. In the next 5 years, ongoing JAHF HGNI initiatives should yield similar outcomes in associate degree-prepared graduates and in advanced practice registered nurse graduates. This article traces the impact of the JAHF HGNI on nursing education.

A Bill of Rights for Hospitalized Older Adults.

Acute-care hospitals have few structures, programs, or staff prepared to address the special needs of older adults. To address this issue, the Hartford Institute for Geriatric Nursing [including the Nurses Improving Care for Hospitalized Elders (NICHE) program] and the Coalition of Geriatric Nursing Organizations proposed language for a Bill of Rights for Hospitalized Older Adults. The Bill of Rights moves from general value statements to the specific knowledge, skills, and actions necessary to provide quality of care to older adults. The authors describe the development and testing of the Bill of Rights and suggest steps for its adoption and dissemination.

Teaching strategies for atypical presentation of illness in older adults.

Atypical presentation of illness is a phenomenon where "seeing is believing." Expert geriatric nurses and clinicians know all too well the early signs and symptoms of this phenomenon, which frequently masquerades bacterial infections, pain, acute myocardial infarction, heart failure, or other serious medical ailments in older adults. Students, however, as novices to clinical practice, require interactive learning approaches to reflect on the patient's illness presentations, help with developing the necessary skills to analyze and synthesize clinically relevant data, and witness resolution of an atypical presentation when found and treated. Use of a case study as an educational tool can facilitate critical thinking about a clinical problem, such as atypical presentation of illness, for students within a problem-based learning format. Furthermore, we highlight strategies for teaching students atypical presentation of illness with consideration of student learning preferences, which include visual, auditory, reading, and kinesthetic modes of learning.

Nursing delegation and medication administration in assisted living.

Assisted living (AL) residences are residential long-term care settings that provide housing, 24-hour oversight, personal care services, health-related services, or a combination of these on an as-needed basis. Most residents require some assistance with activities of daily living and instrumental activities of daily living, such as medication management. A resident plan of care (ie, service agreement) is developed to address the health and psychosocial needs of the resident. The amount and type of care provided, and the individual who provides that care, vary on the basis of state regulations and what services are provided within the facility. Some states require that an RN hold a leadership position to oversee medication management and other aspects of care within the facility. A licensed practical nurse/licensed vocational nurse can supervise the day-to-day direct care within the facility. The majority of direct care in AL settings is provided by direct care workers (DCWs), including certified nursing assistants or unlicensed providers. The scope of practice of a DCW varies by state and the legal structure within that state. In some states, the DCW is exempt from the nurse practice act, and in some states, the DCW may practice within a specific scope such as being a medication aide. In most states, however, the DCW scope of practice is conscribed, in part, by the delegation of responsibilities (such as medication administration) by a supervising RN. The issue of RN delegation has become the subject of ongoing discussion for AL residents, facilities, and regulators and for the nursing profession. The purpose of this article is to review delegation in AL and to provide recommendations for future practice and research in this area.

Expanding the knowledge base of resident and facility outcomes of care delivered by advanced practice nurses in long-term care: expert panel recommendations.

In 2003, a panel of nationally recognized experts in geriatric practice, education, research, public policy, and long-term care convened to examine and make recommendations about care quality and safety issues related to advanced practice nurses (APNs) in nursing home practice. This article reports on the panel recommendation that addressed expanding the evidence base of resident and facility outcomes of APN nursing home practice. A review of the small but important body of research related to nursing home APN practice suggests a positive impact on resident care and facility outcomes. Recommendations are made for critically needed research in four key areas: (a) APN nursing home practice, (b) relative value unit coding, (c) outcomes related to geropsychiatric and mental health nursing services, and (d) outcomes related to geriatric specialization. The APN role could be significantly enhanced and executed if its specific contribution to resident and facility outcomes was more clearly delineated through the recommended rigorous research.

A panel data analysis of the relationships of nursing home staffing levels and standards to regulatory deficiencies.

OBJECTIVE: To examine the relationships between nursing staffing levels and nursing home deficiencies. METHODS: This panel data analysis employed random-effect models that adjusted for unobserved, nursing home-specific heterogeneity over time. Data were obtained from California's long-term care annual cost report data and the Automated Certification and Licensing Administrative Information and Management Systems data from 1999 to 2003, linked with other secondary data sources. RESULTS: Both total nursing staffing and registered nurse (RN) staffing levels were negatively related to total deficiencies, quality of care deficiencies, and serious deficiencies that may cause harm or jeopardy to nursing home residents. Nursing homes that met the state staffing standard received fewer total deficiencies and quality of care deficiencies than nursing homes that failed to meet the standard. Meeting the state staffing standard was not related to receiving serious deficiencies. CONCLUSIONS: Total nursing staffing and RN staffing levels were predictors of nursing home quality. Further research is needed on the effectiveness of state minimum staffing standards.

Nursing homes as a clinical site for training geriatric health care professionals.

Nursing homes can be ideal clinical teaching and learning environments for acquiring geriatric specialty and interdisciplinary team skills, particularly those regarding assessment, care planning, management, monitoring, and collaborating in an interdisciplinary milieu. Little is known as to how geriatric specialty training programs use nursing homes to meet expected specialty competencies, or the types of clinical experiences in nursing homes required by academic geriatric training programs. This article describes the expectations of 5 clinical health care disciplines (dentistry, medicine, nursing, pharmacy, and social work) and nursing home administration regarding desirable nursing home characteristics that support gaining geriatric competencies. The issues involved in using nursing homes as supportive educational environments in geriatric education are discussed.

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.

Healthcare professional training: a comparison of geriatric competencies.

Health professionals specializing in geriatrics are a unique but scarce resource who nevertheless play a critical role in shaping the care of older adults. An interdisciplinary didactic and clinical training milieu would have the potential to maximize training opportunities for geriatric healthcare professionals. The fact that little is known about the concordance between discipline-specific geriatric competencies hampers the creation of interdisciplinary geriatric training opportunities. Discipline-specific geriatric experts compared the geriatric competencies specified by geriatric-certifying bodies of five healthcare professions: dentistry, medicine, nursing, pharmacy, and social work. Overlap and differences in geriatric competencies across disciplines are presented, and opportunities and barriers to interdisciplinary geriatric education are discussed.

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.

Rethinking teaching nursing homes: potential for improving long-term care.

To meet the special needs of and provide quality health care to nursing home residents, the health care workforce must be knowledgeable about the aging process. Health professionals are minimally prepared in their academic programs to care for older adults, and few programs have required rotations in geriatrics. Teaching nursing homes (TNHs) have shown promise as sites for the preparation of a health workforce to care for older adults in nursing homes as well as improvement of quality outcomes. This article reports on the process and recommendations of a TNH summit of experts in geriatric education and practice as to the feasibility of developing a sustainable and replicable TNH model that would prepare a professional workforce knowledgeable about and prepared to work in long-term care. The TNH summit identified characteristics of partnerships between academia, nursing home(s), and other stakeholders that would constitute a successful TNH collaboration. Goals of a TNH partnership between service and academia include interdisciplinary education and practice, research and dissemination of evidence-based practices, and benchmarks of a nursing home professional learning environment.

Recognition of dementia in hospitalized older adults.

Many hospital patients with dementia have no documented dementia diagnosis. In some cases, this is because they have never been diagnosed. Recognition of Dementia in Hospitalized Older Adults proposes several approaches that hospital nurses can use to increase recognition of dementia. This article describes the Try This approaches, how to implement them, and how to incorporate them into a hospital's current admission procedures. For a free online video demonstrating the use of these approaches, go to http://links.lww.com/A216.

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.