This discursive paper presents a selective critical analysis of the descriptive and empirical literature addressing the implementation of geriatric models in relation to the NPE. A summary of the major geriatric practice models is presented; although all models require significant nursing input, only NICHE promotes a significant role for nursing to address geriatric hospital practice. The general NPE is described as the organisational characteristics of a work setting that facilitate or constrain professional nursing practice Lake Current evidence indicates the significant influence of the NPE, at both the hospital and unit levels, on nurse, patient and organisational outcomes Aiken et al.
Evidence-Based Geriatric Nursing Protocols for Best Practice
Thus, models that promote a positive NPE have become regarded as a potential system-level intervention for promoting quality and patient safety Kim et al. Organisational interventions to improve the professional practice environment include supporting nurses to perform at the highest level of practice, to function successfully within an interdisciplinary team and to mobilise resources quickly Friese et al.
Cline, E. Capezuti, V. It is not clear, however, whether these factors are effective in all settings. Testing of geriatric acute care models has shown that complications common to hospitalised older adults can be prevented. Kim et al.
Evidence-Based Geriatric Nursing Protocols for Best Practice
The general NPE was negatively related to nurse-perceived quality of geriatric care, but total geriatric-specific NPE was positively related to nurse-perceived quality of geriatric care after adjusting for nurse and hospital covariates. Consistent with previous studies Boltz et al. Structure and processes of hospital nursing services also need to focus on specific patient care needs. Organisational support should address nurse competencies related to the complex interdisciplinary care management of older adults and the resources needed to improve the safety and outcomes of hospitalised older adults Kim et al.
In general, these models target the prevention of complications that occur more commonly in older adults and the hospital factors that contribute to complications by employing evidence-based, ageing-sensitive interventions, promoting interdisciplinary communication and emphasising discharge planning Steele Despite the fact that these models are empirically driven and clinically successful, hospitals are reluctant to adopt them Jayadevappa et al.
Although geriatric models of care differ in their approach, all require significant nursing input; however, only NICHE aligns its approach to nurse involvement in hospital decision-making regarding care of older adults. NICHE is evidence-based programme that has been evolving through research conducted over the last 20 years. The core components of a system-wide, acute care programme designed to meet the needs of older adults are grouped into eight categories guiding principles, leadership, organisational structures, the physical environment, patient- and family-centred approaches, ageing-sensitive practices, geriatric staff competence, and interdisciplinary resources and processes Boltz et al.
Each category is viewed as an important element and, when combined, represents a unified system-wide approach to improving geriatric acute care. These elements, in addition to associated resources, programmes and activities, provide a framework for a hospital to use in the planning, implementation and evaluation of an acute care model for older adults.
NICHE functions similar to a not-for-profit professional membership organisation in that health facilities pay an initiation and annual membership fee; however, it is also a professional collaborative as membership requires organisational commitment including participation of senior personnel in a NICHE leadership training programme and ongoing demonstration of active geriatric programming.
NICHE coordinators at each site guide the core steering committee to implement and sustain the NICHE programme such as influencing the incorporation of geriatric-specific protocols and staff education programmes. Nurses Improving Care for Healthsystem Elders site designation is determined by both internal and external indicators.
Internally, each site must demonstrate administrative commitment, active geriatric programming, defined NICHE leadership, active provider involvement and an action plan that includes clear measurable outcomes for evaluation.
The national office at New York University College of Nursing supports a centralised, web-based portal for educational, clinical and operational tools as well as the web-based survey, the GIAP. Collaboration is emphasised at the unit, interdisciplinary, organisational and the NICHE membership levels. The GRN model provides staff nurses, via education and modelling by a geriatric advanced practice nurse, with explicit content to identify and address specific geriatric syndromes, such as falls and confusion, and to implement care strategies that discourage the use of restrictive devices and promote patient mobility Boltz et al.
GRNs function in all types of units that serve older adults, including specialty units, critical care areas Boltz et al. The GRN model is considered the foundation for improving geriatric care. The underlying goal of the GRN model is to improve the geriatric knowledge and expertise of the bedside nurse, which is essential to implementing system-wide improvement in the care of older adult patients.
Nurses are supported by a NICHE coordinator and in those hospitals with the resources, a geriatric advanced practice nurse, geriatrician and other geriatric health specialists. The goal is to promote nurses as leaders who use patient rounds, bedside teaching, geriatric interest groups, hospital committees and geriatric initiatives to increase geriatric knowledge and maximise the coordination of care across disciplines Fletcher et al. The care of older adults requires an interdisciplinary approach. The NICHE coordinator at each site functions in a leadership role facilitating a hospital-wide steering committee, teaching and mentoring others and changing systems of care to promote a geriatric-responsive practice environment for all disciplines.
This introductory series provides a foundation for developing geriatric sensitive care across all hospital departments Stevenson et al. A second feature, evidence-based clinical protocols, provides the structured interdisciplinary processes for an effective application of a team approach to common geriatric issues such as pressure ulcers, catheter-associated urinary tract infections CAUTIs , delirium and falls Capezuti et al. Without institutional-level support, unit-level interdisciplinary and individual clinician efforts are unlikely to be sustained. Hospitals using this approach are more likely to improve the experience and outcomes of hospitalisation for older adults Boltz et al.
Some NICHE hospitals have entered into partnerships with schools of nursing to educate frontline staff and support the implementation and evaluation of geriatric quality initiatives Hendrix et al. Finally, an annual conference provides another venue for sites to describe and disseminate their innovative approaches and measurable outcomes through poster presentations and oral paper presentations.
In addition to their role of translating research to the bedside, NICHE sites can also participate in a network of study sites for research. The latter is also responsible for the analyses of de-identified benchmarking data from the GIAP Kim et al. NICHE sites thus contribute to a growing body of knowledge of effective mechanisms to improve care processes Boltz et al.
Improved geriatric outcomes at the nurse, patient and organisational levels include both single-site and multisite studies of NICHE hospitals. Units that have implemented the GRN model have demonstrated significantly improved nurse knowledge and attitudes related to incontinence Pfaff , improved nurse knowledge related to pressure ulcers, restraint use, incontinence and sleep Fitzpatrick et al.
Decreased incidence of patient complications include new onset of confusion or delirium Guthrie et al. Reported improved organisational outcomes are decreased length of stay Turner et al. The GIAP is a psychometrically validated instrument used by NICHE hospitals to evaluate staff knowledge as well as perceptions of the care environment specific to care of older adults and the quality of geriatric care delivered Fulmer et al.
These study findings indicate that organisational support for geriatric nursing exerts an important influence upon perceptions of quality of geriatric care Boltz et al. Although these outcomes are encouraging, this study did not use direct measures of patient outcomes. Currently, Dr Marie-Claire Rosenberg at NYU College of Nursing is evaluating three years of Medicare claims data of older patients hospitalised for a hip fracture or acute myocardial infarction to compare NICHE with non-NICHE hospitals on both nurse-sensitive patient pressure ulcers, postoperative infection, failure-to-rescue and organisational in-hospital mortality and length of stay outcomes.
Nurses Improving Care for Healthsystem Elders sites influence the development of elder-responsive programmes and models. For example, NICHE health systems that include rural hospitals have had difficulty broadening their geriatric initiatives to these sites because their location or size precludes employing geriatric specialists. We are exploring how an e-GAPN can promote the geriatric expertise of direct care nurses as well as mentor hospital administrators and unit managers within an online learning community.
Long-distance communication strategies e. Nurses Improving Care for Healthsystem Elders is also working with researchers to improve processes of care. Dr Marie Boltz of NYU and Dr Barbara Resnick of the University of Maryland are testing the feasibility of a system-level intervention designed to optimise functional performance throughout the hospital stay and facilitate carryover of that care to the postacute setting e.
They aim to improve patient outcomes, specifically physical function, physical activity, self-efficacy and outcome expectations for function, while lowering the incidence of adverse events falls, pressure ulcers, infections at discharge Boltz et al. The CAUTI intervention consists of a electronic audit and feedback reports to hospitals on unit-specific, patient-level urinary catheter duration and CAUTI rates and b an educational session on CAUTI prevention and evidence-based best practices for urinary catheter management Wald et al.
Finally, NICHE is collaborating with other professional organisations to develop and test the effectiveness of new resources to improve the patient and family experience of hospitalisation. NICHE, in partnership with the American Association of Retired Persons AARP and the American Journal of Nursing, will create educational materials and toolkits to help nurses and social workers support family caregivers with a particular focus on the needs of diverse communities.
She has served as the first nurse on the board of the American Geriatrics Society and as the first nurse to serve as president of the Gerontological Society of America. For 15 years, Dr. She is currently working as an independent geriatric consultant. She completed her doctor of nursing practice degree in with a primary focus as a clinical scientist and secondary in nursing education at Drexel University in Philadelphia.
She has been a registered nurse for 32 years with clinical practice experience as a geriatric nurse practitioner since in primary care, subacute, long-term care, and recently palliative care and a clinical expert consultant in many domains in geriatrics. Her areas of interest in geriatrics include proactive intervention in older adults to prevent adverse drug events, pain control to aid in maintaining function and quality of life, and preventing hospital iatrogenesis particularly in persons with dementia.
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Research, Theory, and Measurement. Undergraduate Nursing. Watson Caring Science Institute. Browse All. Social Work. Healthcare Administration. Public Health. Other Specialties. Assessment Diagnosis and Clinical Skills. Administration Management and Leadership. Ear, Nose, and Throat. Usually delivered in days? The new fifth edition of one of the premier references for geriatric nurses in hospital, long-term, and community settings, delivers current guidelines, real-life case studies, and evidence-based protocols developed by master educators and practitioners.
With a focus on improving quality of care, cost-effectiveness, and outcome, the fifth edition is updated to provide the most current information about care of common clinical conditions and issues in older adults. Several new expert contributors present current guidelines about hip fractures, frailty, perioperative and postoperative care, palliative care, and senior-friendly emergency departments.
Additionally, chapters have been reorganized to enhance logical flow of content and easy information retrieval. Protocols are organized in a consistent format and include an overview, evidence-based assessment and intervention strategies, and an illustrative case study with discussion.
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