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Using a Nursing Salon to Identify and Develop an Initiative for Family Caregivers of Older Adults

Sullivan-Bolyai, Susan DNSc, RN, CNS, FAAN; Pellegrini, Linda MS, GNP-BC, RN; Boucher, Jean PhD, RN; Gravlin, Gayle EdD, RN, NEA-BC; O'Neil, William NP, RN; Coco, Angelina MSN, RN; Vitello, Joan PhD, RN

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JONA: The Journal of Nursing Administration: January 2020 - Volume 50 - Issue 1 - p 40-44
doi: 10.1097/NNA.0000000000000837
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Abstract

In a time when interprofessional collaboration is a mainstay for improving clinical outcomes, nursing salons that are interprofessional in nature are a unique and effective way to identify older adult care needs from multiple perspectives and to create corresponding strategies that will better support older adults in a community. We were inspired to hold a salon with community geriatric thought leaders including nurses, physicians, bioengineers, psychologists, social workers, and PhD and doctorate of nursing practice (DNP) students. The salon's purpose was to explore what the current community healthcare issues are for older adults living in Central Massachusetts and to develop innovative strategies that support and enhance the health of our aging population.

By 2030, the baby boomer generation in the United States will have reached the age of 70 years or older. The older adult (>65 years) population will have grown to 76 million, a 55% increase from their number in 2015. In addition, the number of older adults aged 85 years or older will have doubled by 2035, and those who are 100 years of age will have tripled by 2045.1 Because of advancements in life-prolonging treatments, including a focus on disease prevention, healthy lifestyles, and lower smoking rates, we are all living longer. No better illustration of this frontier longevity exists than observing in big cities such as New York or Chicago the large numbers of the oldest of the old living among us—shopping, walking, and inspiring us about life after retirement. That said, nurses must consider developing resources and strategies to help our aging population and their families navigate their living communities.

Aging in place in an individual's residential community is becoming quite commonplace. This situation, however, sometimes burdens the family caring for the loved one. Many of our older adult population will require hospitalization from time to time, but the ideal is to keep them in their home as much as possible, avoiding rehospitalization and emergency department (ED) visits.

Our academic health center has been planning to initiate the NICHE (Nurses Improving Care for HealthSystem Elders) program to facilitate better clinical outcomes and fewer hospitalizations and ED visits for this population.2 The plan has been that selected hospital units and geriatric nurse resource leaders will be educated on the evidence-based practice protocols provided by the NICHE program, which hopefully will result in increased knowledge when caring for patients older than 65 years, thereby improving clinical outcomes. It seemed timely to link this institutional initiative to an overall dialogue with geriatric community leaders on what we are presently doing in our community to engage older adults and their families in aging well.

We chose the salon strategy to facilitate this process. Our salon was well aligned with the report of the National Academies of Sciences, Engineering, and Medicine entitled Families Caring for an Aging America,3 which calls for immediate action to better support the essential role of family caregivers in order that they can maintain their own health, financial security, and well-being. Specific recommendations of the report include ensuring that family caregivers are identified in delivery of healthcare services to older adults who rely on help. The report motivated us to find strategies to better identify and support those family caregivers caring in our community. Thus, a salon was developed and implemented to explore areas of need.

Salons

Salons, gatherings to share knowledge and exchange ideas through conversations, started in Italy during the 16th century and were adopted by the French in the 17th and 18th centuries,4 especially during the enlightenment period. When one thinks of salons, Gertrude Stein's salons in Paris come to mind during the 1920s, with Hemingway, Matisse, and Picasso attending weekly conversations; and in New York City, prominent female artists such as Fleurine Stettheimer held similar salons, all to enlighten, expand perspectives of current artistic issues, and to amuse. Because nursing is both a science and an art, a natural connection exists for using salons to explore the art of nursing, especially because art can be defined as something that “does things to or for you that makes things happen.”5 With that perspective of art in mind, Marie Mathey (https://mariesnursingsalon.wordpress.com/), a living legend in the American Academy of Nursing (AAN), has developed and facilitated nursing salons to encourage thoughtful conversations about our dynamic nursing profession and the common issues we encounter.6 A nursing salon is an opportunity to reflect, listen, contemplate, and hear varying perspectives on who we are, how we are perceived, and what we do as a profession. It is an experience in what a thoughtful colleague of ours says we do not do enough of: focus on think time. Because we are living presently in a very challenging time in our nation, having thoughtful and reflective conversations about current healthcare issues seemed quite appropriate.

Thinking of the NICHE program about to be initiated at our medical center, we thought focusing on aging in our local community with an introduction to NICHE as well as other older adult care resources might be a good place to begin our 1st salon. It would be an opportunity to bring together like-minded and passionate interprofessional geriatric healthcare leaders from our community to introduce NICHE and discuss what we already have in place for our community older adults, as well as what we could creatively develop for the future to augment existing resources.

Implementing the Salon

Our Aging Well Salon, held on September 19, 2018, was partially funded by a small conference grant through our Center for Clinical and Translational Science. Our dean also financially supported the event. The framework from which the salon emerged is based on Grace and colleagues' unifying focus of nursing7: that we facilitate (with patients and families) humanization, meaning, choice, quality of life, and healing, and especially in the case of aging adults, we would add habilitation, across living and dying. We invited key informants with varied perspectives (hospital, clinic, community resources, homecare) to participate in the 3-hour salon to discuss how we provide care for older adults and what we need in our community to maximize resources for aging in place. All of the 37 health professionals we had carefully chosen, with a snowball approach from the 1st set of contacts, agreed enthusiastically to join us for the dialogue. They included thought leaders from nursing, medicine, and early adapters from the medical center who would be involved in the NICHE program, engineering and technology professionals, social work leaders from our local elder services, and family caregiver experts of older adults living in the local community. Dr Alice Bonner, a graduate of our PhD program and a geriatric nurse practitioner, policy expert, and, until recently, Secretary for Elder Affairs in Massachusetts, agreed to join us to set the stage for collaboration and networking. Two bioengineers from New York University also joined us and shared their creative “dresser” that they have developed for people with mild Alzheimer's disease. The robot dresser gives these individuals messages on dressing themselves.8 Participating also were a PhD and 2 DNP nursing students who plan to focus their graduate research and clinical projects on healthcare needs of the elderly and caregiving—adding to the intellectual merit of the proposal. Prereading materials were sent to the participants 3 weeks prior to the salon to generate dialogue.

The 1st hour introduced participants to the goal and objectives of the salon: To increase collaboration between our academic health science center, the medical center, and community resources to facilitate aging in place for seniors living in our area. Dr Bonner opened the session with a brief historical overview and current state of health affairs for older adults living in the Commonwealth. From the Massachusetts State government level, Dr Bonner shared the focus of the governor's task force for improving elder care. She also shared personal experiences in how she had navigated local aging-in-place resources with her mother. The bioengineers gave a video demonstration of the dresser, inspiring us and underscoring the importance of having bioengineering technology involved in any future projects we develop. After we provided a tea, the next hour was devoted to small-group dialogue sessions with facilitators focusing on the following topics listed in Table 1. The small-group facilitators had open-ended questions to generate dialogue for each small group (Table 2).

Table 1
Table 1:
Topics for Each Small-Group Discussion
Table 2
Table 2:
Dialogue Questions for Break-out Small Groups

During the final hour, each group reported back with a summary and recommendations for possible future collaborative projects, education, implementation, research, and/or policy implications. We also discussed possible funding options for future projects, education, and/or potential research studies to support and disseminate new knowledge that emerged from the salon to facilitate future growth opportunity as an outcome. We ended our salon with a gift for each participant: The Longevity Economy by Joseph Coughlin,9 a compelling book on longer lifespans and how we need to adapt to and celebrate older people.

Outcomes

From within the small-group discussions with varying topics (Table 1), the theme that focused on family caregiving kept reoccurring in the group reports. A recent position statement from the AAN10 concisely summarizes the demographic including the definition of “family,” complexity of care, economics, and competing work demands that must be considered for future family caregiving policy initiatives. Presently, several policy initiatives at the state and federal levels have been developed. These include paid leave; CARE act, which ensures caregivers receive adequate training and education upon their loved one's discharge from hospital; and RAISE Family Caregivers Act, which will establish an advisory board to work with the US Department of Health and Human Services.

The Massachusetts Department of Public Health and the Executive Office of Elder Affairs recently published recommendations from the Alzheimer's and Related Dementias Acute Care Advisory Committee on how to provide optimal acute care to persons with dementia.11 The recommendations are designed to improve acute care experiences for both patients and their caregivers as well as care quality and cost-effectiveness. The committee proposed that the recommendations become the standard of care for all Massachusetts hospitals, especially for those patients with dementia. Identification and inclusion of the caregiver and their role were also targeted as a priority. The Massachusetts Health and Hospital Association issued a report “Guidance for Developing an Operational Plan to Address Diagnosis and Care for Patients With Alzheimer's Disease and Related Dementias in Hospital Settings.”12 Not surprising, these reports ensure that family and caregivers are an integral part of the care planning and transitions from admission through discharge for their older loved ones. Once again, our salon aligns well with these state and national recommendations for addressing the needs of caregivers.

As a consensus, following the salon, we decided our practical and achievable focus should be to explore the development of a query that could be asked of everyone during clinic, hospital admission, and/or emergency room visits to get at the important question of “Are you a caregiver?” or “Who helps you at home?”3 How often is someone seen during a clinic visit without an awareness of competing demands at home besides their own healthcare management? We determined that this would be an attainable goal to 1st establish a small group of us to further explore how to develop this initiative locally and then to implement this question in a manageable healthcare-related setting as a pilot study that both our PhD and DNP students could facilitate with our guidance.

We established a small working group of healthcare professionals: 3 doctorally prepared faculty, our coauthor L.P. (the gerontology clinical expert who initially brought to our attention the needs of older adults in our community associated with NICHE), and a PhD and DNP student to start the initiative process. The plan is to add more members as we move forward. For instance, the executive director of our local elder services has been incredibly receptive to working with us collaboratively as we build this initiative. We have done an initial review of the literature and found several caregiving advocacy websites that ask this simple question and then give resource and education guidance. However, we have not found other initiatives that encourage the asking and exploration of the caregiver question as a standard of care for healthcare professionals. The “caregiver” definition is another area we will be making more explicit to ensure potential caregivers truly understand what the definition entails. Many individuals exist in our community who would qualify for caregiver resources who do not perceive themselves as a caregiver, such as someone who helps with errands, takes patients to doctor appointments, cooks, and so on.

The policy initiative entitled “Have You Ever Served in the Military?”13 has been our group's initial framework to guide us in the development of our caregiver initiative. Our 1st author has been in communication with Dr Schwartz, who readily gave us a step-by-step description of the process they used. Their group, like ours, views nurses as pivotal to their cause. The military outcome included pocket guides with appropriate questions to ask and resources available for referrals. Our goal is to develop something similar.

Discussion and Future Ideas

We actually have many well-regarded older adult service resources in our local community, yet they are not fully utilized by family caregivers because either they are unaware of them or the referral process is cumbersome. The question we are in the process of developing will hopefully make the resources known with information about how to efficiently navigate the intake process. We also plan after the pilot stage of our initiative to move it beyond our local area and, with the help of our state's elder affairs officials, expand it to a statewide initiative and beyond. We will explore organizations where we might be able to extend our efforts via interprofessional collaboration through a follow-up salon in the fall of 2019.

It also should be noted that despite this salon being focused on care for older adults and caregiving, the Are you a caregiver? question needs to be considered across the lifespan. Many children in our country are providing care to their parents who have a chronic condition or disability, to siblings, and/or other relatives.14 We would be remiss not to ask this simple question to everyone who is seeking healthcare.

Another area to explore regarding caregiving and future development of resources is through the Edge Runner programs awarded through the AAN each year.15 A myriad of incredibly creative ideas have been developed such as several aging-in-place projects, caregiving skills intervention, SeniorWISE, and SeniorASSIST. In addition, community grassroots programs such as On Lok Senior Health Services16 serve as exemplars. Looking at all these existing programs and seeing if we have similar capabilities in our community will help us avoid reinventing the wheel.

Our salon approach was also an excellent opportunity to allow both of our doctoral-level students to work interprofessionally and intraprofessionally. Our PhD student coauthor will use this experience for his research practicum. His dissertation, focused on caregiving and caregivers, may emerge from this initiative as well. Our DNP student coauthor also plans to develop her clinical DNP scholarly project within this initiative. The other DNP student who attended the salon used this opportunity as part of his leadership practicum and, in collaboration with the lead nurse educator at University of Massachusetts Memorial Hospital and Medical Center for the NICHE program, conducted a survey of other NICHE-designated organizations in Massachusetts. Similarly, although not part of the salon, 1 of our DNP students worked with nurse leaders at the Massachusetts Health and Hospital Association and was part of the workgroup that developed the “Guidance for Developing an Operational Plan to Address Diagnosis and Care for Patients With Alzheimer's Disease and Related Dementias in Hospital Settings.”12 In all 4 examples, our DNP/PhD learners witnessed leadership in action by observing and engaging with faculty mentors, organizational leaders, and other team members. This collaborative endeavor intraprofessionally and with other disciplines is most meaningful when experienced firsthand. The Aging Well Salon served as an example of recognizing value in all our perspectives; respect, and collaboration at its best.

Conclusions

Using a salon to generate new ideas, inspire, and challenge perspectives is an effective way to identify and build healthcare initiatives. We hope this will be the 1st of many interprofessional salons targeting common issues we encounter in nursing and healthcare. A salon should be seen as a starting point and can provide a wonderful venue for collaboration and deliverables that are realistic, doable, and useful.

References

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