Esterson, Jessica MPH; Bazile, Yamilee BA; Mezey, Mathy EdD, RN, FAAN; Cortes, Tara A. PhD, RN, FAAN; Huba, George J. PhD
Responding to the special needs of a patient is a hallmark to delivering high-quality nursing care. Regulatory and health facility–specific guidelines require that nurses demonstrate competence to care for patients with specialized needs, for example in pediatrics, critical care, oncology, and cardiology. Older adults (>65 years) represent the largest consumers of patient care in hospitals, home care, and institutional long-term care.1 The Centers for Medicare and Medicaid new criteria for readmissions and reimbursement are driving hospitals to achieve improved patient outcomes, use evidence-based interventions, and promote nurses’ competence to care for complex patients.2 Although the Joint Commission addresses the need for age-specific care, only a very small percentage of the registered nurse (RN) work force has been certified in gerontology: 3% of RNs and 1.9% of advanced practice RNs.3
An RN workforce capable of caring for older adults is critical given that these patients are expected to consume a disproportionately high percentage of future healthcare and nursing resources. People 65 years or older currently account for 13% of the total population and by 2030 will represent 20% of the total population.4 Already, people 65 years or older account for 48% of nonobstetrical days of care5 in most hospitals. United States healthcare costs for patients 65 years or older are 3 to 5 times higher than those for patients younger than 65 years and are projected to increase by 25% by 2030.6
Many older adults require care in areas of specialty practice. Older adults comprise 43% of adults with heart disease, 46% of adults with cancer, 39% of adults with diabetes,7 and 25% of people with musculoskeletal diseases.8 More than 1.5 million nurses practice in specialty areas in hospitals, representing approximately 50% of the RN workforce.3 However, despite the high caseload of older patients, nurses in specialty practice have little or no formal education in or workplace exposure to even the basic concepts of geriatric nursing practice, such as knowledge of medications known to adversely affect older adults, how to prevent functional declines, or ways to prevent or treat delirium.
Specialty nursing associations underpin the role of specialty nurses in hospitals. Associations offer continuing education and credentialing. They create scope and standards that serve as the basis for the specialty certification examinations, offered either by associations or in conjunction with the American Nurses Credentialing Center. Associations use multiple vehicles, for example, white papers, protocols, Web sites, eLearning opportunities, e-newsletters, journals, and conferences that communicate best practices, support nurses’ clinical decision-making ability, and encourage a spirit of inquiry, which are crucial components for achieving quality benchmarks.
Drawing on a singular mission to shape the quality of healthcare for older adults through excellence in nursing practice, the Hartford Institute for Geriatric Nursing (HIGN), NYU College of Nursing (www.HartfordIGN.org), saw an opportunity for specialty nursing associations to help hospitals and other clinical sites meet expanded quality outcomes. In 1999, the HIGN began to work with specialty associations to prepare their members to better care for older patients. Initially, the HIGN introduced geriatric best practices through a booth that travelled to association meetings. The HIGN next engaged 54 of approximately 78 existing national nursing specialty associations in strengthening their geriatric content. In 2007, 14 of the associations whose nurses primarily worked in acute care received enhanced funding to develop enduring infrastructures and resources for geriatric initiatives. This article summarizes more than 10 years of collaboration between specialty nursing associations and the HIGN and presents outcomes specific to 54 associations and the 14 associations that received enhanced funding.
Assessing the Need and Creating the Coalition for Change
From 1999 to 2002, the HIGN committed modest resources to build relationships with specialty nursing associations through a partnership program. Funding from the Avon Foundation supported a double-sized exhibit booth that created a “geriatric presence” at specialty nursing conferences. The goals for the booth were to (1) increase specialty nurses’ awareness of the number of older patients they cared for, (2) encourage specialty nurses to use best practices in addressing the unique needs of both their specialty (eg, oncology) and of geriatrics, and (3) increase awareness of geriatric care resources relevant to areas of specialization. The booth distributed HIGN geriatric best-practice resources and other authoritative agencies such as the National Institute on Aging. The conferences allowed HIGN staff to better understand the challenges of members seeking to address the needs of older patients. The HIGN booth, which exhibited at 30 conferences, was extremely popular and was invited to make repeat exhibits by several associations.
In conjunction with the booth, the HIGN completed an environmental scan of 55 nursing specialty associations, identifying membership, staff, and communication strategies, for example, conferences, journals, newsletters, special interest groups (SIGs), and position papers. This gave the HIGN an appreciation of the unique capacity of each association and the ability for geriatrics to fit within identified association priorities and structures and be congruent with association goals. Few associations had competencies or resources related to older patients, nor did they have the financial capacity to commit to geriatric resource development. By 2002, the HIGN discerned that specialty associations were receptive to enhancing their members’ competence in aging. However, the booth alone clearly could not address these needs, and the HIGN sought other avenues to mount a more concentrated and comprehensive approach.
In 2002, with partial funding from The Atlantic Philanthropies (USA) Inc, the HIGN and the American Nurses Association (ANA) initiated a competitive process whereby 54 nursing specialty associations representing more than 420 000 nurses were awarded 3-year implementation grants to create geriatric activities to enhance member competence in aging.9 In 2007, the HIGN received a 2nd wave of funding from Atlantic Philanthropies that allowed 14 associations with an acute care focus to receive 3 years of funding to create sustainable geriatric infrastructures and resources.
HIGN Strategies to Help Specialty Associations Incorporate Geriatric Best Practices
Beginning with the process of applying for funding, the HIGN incorporated 2 overall strategies to help ensure comprehensive incorporation of geriatrics within the specialty associations (Table 1).
Developing a Geriatric Value in Specialty Nursing Organizations
Involvement of Leadership and Designating Champions
From the application process forward, the HIGN saw commitment of association leadership as key to the project’s success. Applications for funding required letters of support from both the association board chair and executive director. Communications from the HIGN to the associations were routinely copied to the association project director, the chief executive officer (CEO), and the board chair. Staff of the HIGN encouraged the formation or strengthening of geriatric SIGs and provided technical assistance to help SIGS champion project goals. The SIGS were coached to send regular written reports on project outcomes to the board. Board chairs and CEOs were invited to HIGN-sponsored annual face-to-face meetings, providing a vehicle to update new association board members and staff.
Creating a Vision
The HIGN envisioned that specialty practice nurses would layer on knowledge on the unique care needs of older adults to their specialty practice skills. The grant application required specialty associations to provide statistics on older adults served by their members and how incorporating geriatric language and resources into association materials and activities would enhance nursing practice and patient outcomes. Identifying areas for practice improvements helped associations clearly articulate a vision for their members’ role in care of older adults. The grant application process asked associations to identify barriers as well as facilitators to achieving successful outcomes.
Support/Coaching to Ensure and Celebrate Enduring Change
In addition to funding, the HIGN provided associations with coaching and technical assistance to help ensure that their geriatric initiatives would be self-sustaining, enduring, and embedded in the infrastructure. Because specialty associations retained ownership of new resources, they had a stake in creating a strong geriatric infrastructure. A listserv fostered exchange of information, successes, and consultation on key strategies. Associations were encouraged to establish awards to be presented at national meetings as a way to recognize accomplishments.
Building Geriatric Capacity
Strengthening Scope and Standards
Because of the importance of scope and standards documents in establishing and defining a specialty, the HIGN initiated a process to support incorporation of language about care of older adults in these documents.
Most specialty associations publish a scope and standards of practice document specific to their area of specialty practice that describes the knowledge, skills, and abilities that hospitals and other healthcare agencies can expect from the nurses they hire. In 2005, the ANA10 included formal language addressing care of older adults in its document Recognition of a Nursing Specialty, Approval of a Specialty Nursing Scope of Practice Statement and Acknowledgement of Specialty Nursing Standards of Practice. Since 2005, all new or revised specialty nursing scope and standards submitted through the process of the ANA Congress of Nursing Practice must specifically address issues related to care of older adults.
The HIGN tracked when each of the specialty associations with scope and standards (n = 12) were due to update their documents and provided consultation to encourage associations to incorporate language about care of older adults in their updated documents. A guideline, “Professional Nursing Associations Creating &/or Revising Professional Scope and Standards: Guidelines for Addressing Issues Related to Care of Older Adults,” provided draft language for associations to consider in revising their opening scope statement and in the standards of practice. Associations could access further consultation through an arrangement with the National Gerontological Nursing Association.
To ensure knowledge transfer, specialty associations were directed to undertake 2 major activities: (1) create and disseminate new, sustainable geriatric resources specific to their specialty, with an emphasis on Web-based resources and (2) link to existing evidence-based general resources in geriatric nursing.
The HIGN helped associations conceptualize and implement their new geriatric resources. Web-based resources were encouraged as a means of reaching all members, with preconferences and workshops at national meetings as means to introduce members to these new resources. The HIGN offered to review drafts and identify geriatric expert consultants in new resource development, broker collaborations between associations to develop and disseminate resources, and propose speakers and consultants for conferences and geriatric articles to include in association publications.
For existing, evidence-based clinical protocols, assessment instruments, and other geriatric nursing resources, associations were directed to the HIGN clinical Web site (www.ConsultGeriRN.org), which has served as a virtual comprehensive geriatric nursing resource since 2006. To promote widespread dissemination, the HIGN Web site was expanded to accommodate links to the specialty associations and display new resources as they were posted on the specialty association Web sites. The HIGN created the Specialty Nursing Assessment Series as an expansion of its evidenced-based Try This® Assessment Series and invited associations to post specialty-specific instruments.
Enhancing Web Capacity
The HIGN encouraged associations to maximize their use of electronic outlets to disseminate new geriatric resources to members. Associations were provided with a small amount of funding to appoint “Web fellows” responsible for posting association and other aging content on their Web sites. To help Web fellows conceptualize and implement changes to their sites, HIGN Web experts held webinars and individual telephone calls with Web fellows. Where associations lacked capacity, the HIGN offered to host association Web-based resources on HIGN’s Web site.
Anchoring the Value of Care for Older Adults: Tangible Outcomes
All of the 54 specialty associations participating in this project enhanced their resources for members related to care of older adults.11 More detailed outcomes from the 14 specialty associations that received enhanced funding support are shown are summarized in Table, Supplemental Digital Content 1, http://links.lww.com/JONA/A249.
All 14 associations created or strengthened their geriatric SIGs as a way to ensure continued association commitment to geriatric goals. Often, SIGs are the structure that associations use to ensure continued commitment to care of special populations, for example, older adults. For geriatrics, SIGs act as the champions and internal expert consultants to the association on geriatric initiatives.
Enhanced Scopes and Standards
All 6 associations with scope and standards that came up for review during the course of the project modified their documents to include specific language on care of older adults and specific competencies related to their care. As an example, the Hospice and Palliative Nurses Association (HPNA) modified their scope document to include the developmental needs of all patient age groups, ensure that members provided age-appropriate care, and address care of patients with noncancer diagnoses, including dementia. To the diagnosis standard, the association added that nurses need to recognize the influence of age on the patient’s condition and when formulating nursing diagnoses. To the outcomes identification standard, the association has added that general and advance practice nurses should know that outcomes often differ in older adults.
Associations created a large number of sustainable products (Table 2) to meet the growing need of hospitals and individual nurses for geriatric content and resources. Associations use revenue generated through charging for resources (webinars, online modules, contact hours, etc) to update and enhance information on a 2- to 3-year cycle. Three examples for sustainable resources are below:
American Academy of Nursing (AAN) and the American Association of Critical Care Nurses (AACN): One of the earliest associations to participate in this project, AACN became involved following a 2002 survey of its 66 000 members which showed that 70% did not identify geriatric patients in their population group even though, when asked about their patient’s actual ages, most members acknowledged taking care of many very old patients (J. Medina, personal communication, 2002).
Subsequently, AACN began an all-out effort to embed content on how age-related changes affect nursing care to critically and acutely ill patients, including launching monthly newsletter articles on geriatric issues in critical care. The association examined whether questions on the critical care nurse examination adequately addressed age-related competency and hired experts to write new questions for its certification examination to reflect older adult issues. In 2009, AACN and AAN collaborated to develop and release a free online, self-paced program, “Best Practices for Elder Care.”12 As of 2012, more than 4 000 individuals have completed the course for continuing education.
Emergency Nurses Association (ENA): At the project outset, ENA had no advanced level and sustainable specialty-specific geriatric resources and the web site had no links to geriatric resources. A geriatric work group existed but was not strongly embedded in the association infrastructure. However, the HIGN booth had been well received at 2 national conferences.
With leadership from a geriatric champion, ENA created a geriatric workgroup that evolved into a standing geriatric committee. A “geriatric emergency care” button was added to the Web site, as well as links created from the “Practice Focal Points” to association and other geriatric resources. With HIGN funding, ENA developed the Geriatric Emergency Nursing Education (GENE) program, which was launched in 200413 and became 1 of their most popular resources. The GENE program has been updated (2013) to include ENA’s Practical Guide to Safer Handoff of Older Adults Patients Between Long-term Care Facilities and Emergency Department.14 With more than 32 000 members, ENA leads the field in offering specialty specific geriatric resources for its members.
American Organization of Nurse Executives (AONE): In 1999, AONE (4 000 members) lacked a geriatric focus at annual meetings, in publications, on their web site, and had no organizational structure (special interest group or committee) for members interested in issues of aging.
Building on member interest in the HIGN geriatric exhibit booth, AONE formed a geriatric task force that became a permanent geriatric committee. With HIGN funding, AONE convened 2 Days of Dialogue that resulted in the document “Guiding Principles for the Elder Friendly Hospital/Facility” that now resides on AONE’s Web site, as well as an accompanying toolkit.15 In 2011, AONE hosted a geriatric preconference on this initiative at its annual meeting. A geriatric resource page on the AONE Web site updates the latest geriatric resources for nurse executives.
Associations made substantial changes to enhance visibility and access to Web-based geriatric resources. Included in the HIGN technical support were content, news items, and links for associations to include on their pages. Associations were encouraged to provide geriatric content in 2 to 3 clicks from the homepage. For example, the National Association of Clinical Nurse Specialists added a gerontology page under their resource section, and the Association for Nursing Professional Development (formerly known as NNSDO) added a geriatric resource page under the “resources for educators” section.
Several categories of awards were established to recognize project success. The National Organization Liaison Forum (NOLF) offered competitive awards to associations. Each specialty association was encouraged to create awards for their members or for hospitals. In addition, the HIGN offered a Web award for associations who enhanced their Web sites to include content on care of older adults based on criteria of visibility, content, and relevance.
Global Vision Statement
The specialty nursing associations spearheaded a collaborative effort to leverage their individual voices to influence care of older adults nationally. In 2006, associations requested the HIGN to draft a global vision statement for them to speak with 1 voice on issues that impact care of older adults. The resulting “Specialty Nursing Association Global Vision Statement on Care of Older Adults” was endorsed by 43 national nursing organizations and published in 2009 in Geriatric Nursing.16
The past 10 years has seen a substantial move forward on the part of specialty nursing associations in their commitment and involvement in enhancing care of older adults of their members. This has resulted in increased awareness of associations as to the importance of training of specialty practice nurses in geriatric care and the development of permanent organizational structures and enduring resources to meet the growing needs of their members, hospitals, and other health delivery settings for authoritative geriatric clinical nursing materials and resources.
Outcome data from the initial 54 participating associations show a range of enhanced geriatric initiatives and products. Building on their initial efforts, the 14 specialty nursing associations that received enhanced funding created enduring structures and are well positioned to provide their members with authoritative content and resources on care of older adults. By strengthening the breadth, scope, and specificity of geriatric content and geriatric SIGs and creating sustainable clinical products and Web vehicles for their dissemination, these specialty associations have attained new standards for geriatric care among their specialty nurse members. The blueprint for specialty associations to sustain and enhance these outcomes is now clear, and many are well along this journey. Older adult patients and their families will be the appreciative beneficiaries of these efforts.