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U n i t O n e

Core Knowledge

• Continuing care retirement community
• Core competencies
• Financial gerontology
• Geriatrics
• Gerontological nursing
• Gerontological rehabilitation nursing
• Gerontology
• Geropharmacology
• Geropsychology
• Hospice
• Independent living
• Middle old
• Old old
• Rehabilitation
• Skilled care
• Social gerontology
• Subacute care
• Unlicensed assistive personnel (UAP)
• Young old

Introduction to

Gerontological Nursing

Jeanne St. Pierre, MN, RN, GCNS-BC

Deborah Conley, MSN, APRN-CNS-BC, FNGNA

L E A R N I N G O B J E C T I V E S

At the end of this chapter, the reader will be able to:

• Define important terms related to nursing and the aging process.
• Outline significant landmarks that have influenced the development of geronto- logical nursing as a specialty.
• Identify several subfields of gerontologi- cal nursing.
• Develop the beginnings of a personal phi- losophy of aging.
• Describe the unique roles of the geronto- logical nurse.
• Discuss the scope and standards of prac- tice in gerontological nursing.
• Examine core competencies in geronto- logical nursing.
• Contrast various settings in which nurses care for older adults.
• Distinguish the educational preparation, practice roles, and certification require- ments of the various levels of gerontolog- ical nursing practice.

K E Y T E R M S

• Activities of daily living (ADLs)
• Ageism
• Assisted living facility
• Certification

C H A P T E R 1

THE HISTORY OF GERONTOLOGICAL NURSING The history and development of gerontological nursing is rich in diversity and experiences, as is the population it serves. There has never been a more opportune time than now to be a gerontological nurse. No matter where nurses practice, they will at some time in their career care for older adults. The health care movement is constantly increasing life expectancy; therefore, nurses must expect to care

The History of Gerontological Nursing 5

for relatively larger numbers of older people over the next decades. With the increasing numbers of acute and chronic health conditions experienced by elders, nurses are in key positions to provide dis- ease prevention and health promotion, and to pro- mote positive aging. The American Journal of Nursing, the American Nurses Association (ANA), and the John A. Hartford Foundation Institute for Geriatric Nursing at New York University contributed significantly to the development of the specialty of gerontological nurs- ing. The specialty was formally recognized in the early 1960s when the ANA recommended a spe- cialty group for geriatric nurses and the formation of a geriatric nursing division, and convened the first national nursing meeting on geriatric nursing prac- tice. The growth of the specialty soared over the next three decades. In the early 1970s, the ANA Standards for Geriatric Practice and the Journal of Gerontological Nursing were first published (in 1970 and 1975, respectively). Following the enactment of federal programs such as Medicare and Medicaid, rapid growth in the health care industry for elders occurred. In the 1970s, the Veterans Administration funded a number of Geriatric Research Education and Clinical Centers (GRECCs) at VA medical centers across the United States. Nurses were provided sub- stantial educational opportunities to learn about the care of older veterans through the development of GRECCs. The Kellogg Foundation also funded numerous certificate nurse practitioner programs at colleges of nursing for nurses to become geriatric nurse practitioners. These were not master’s in nursing–level programs, but provided needed nurses who were trained in geriatrics to meet the growing needs of an aging population. Terminology used to describe nurses caring for elders has included geriatric nurses, gerontic nurses, and gerontological nurses. These terms all have various meanings; however, gerontological nursing provides an encompassing view of the care of older adults. In 1976, the ANA Geriatric Nursing Division changed its name to Gerontological Nurs- ing Division and published the Standards of Geron- tological Nursing (Ebersole & Touhy, 2006; Meiner & Lueckenotte, 2006). The decade of the 1980s saw a substantial growth in gerontological nursing when the National Gerontological Nursing Association was estab-

lished, along with the ANA statement on the Scope and Standards of Gerontological Nursing Practice. Increased numbers of nurses began to obtain mas- ter’s and doctoral preparation in gerontology, and higher education established programs to prepare nurses as advanced practice nurses in the field (geriatric nurse practitioners and gerontological clinical nurse specialists). Thus, interest in theory to build nursing as a science grew and nurses were beginning to consider gerontological nursing research as an area of study. Implementation of five Robert Wood Johnson (RWJ) Foundation Teaching- Nursing Homes provided the opportunity for nurs- ing faculty and nursing homes to collaborate to enhance care to institutionalized elders. An addi- tional eight community-based RWJ grant–funded demonstration projects enabled older adults to remain in their homes and fostered cooperation between social service and health care agencies to partner in providing in-home care. In the 1990s, the John A. Hartford Foundation Institute for Geriatric Nursing was established at the NYU Division of Nursing. It provided unprecedented momentum to improve nursing education and practice and increase nursing research in the care of older adults. In addition, it focused on geriatric public policy and consumer education. The Nurses Improving Care for Healthsystem Elders (NICHE) program gained a national reputation as the model of acute care for older adults. The 21st century has provided a resurgency in gerontological care, as older adults are gaining full status and recognition by society. As the baby boomers enter the older age group in 2011, this cadre of individuals will not only expect but demand excellence in geriatric care. In 2003, the collaborative efforts of the John A. Hartford Institute for Geriatric Nursing, the American Academy of Nursing, and the American Association of Colleges of Nursing (AACN) led to the development of the Hartford Geriatric Nursing Initiative (HGNI). This ini- tiative substantially increased the number of geron- tological nurse scientists and the development of evidence-based gerontological nursing practice. Today, there are multiple professional journals, books, Web sites, and organizations dedicated to the nursing care of older adults. One of the newest journals to emerge in 2008 was the Journal of Gerontological Nursing Research.

Attitudes Towards Aging and Older Adults 7

1980 AJN publishes Geriatric Nursing journal

Education for Gerontic Nurses by Gunter and Estes suggests curricula for all levels of nursing education

ANA establishes Council of Long Term Care Nurses

1980 First Robert Wood Johnson (RWJ) Foundation grants for health-impaired elders given (eight in the United States)

1981 First International Conference on Geronto- logical Nursing sponsored by the International Council of Nursing (Los Angeles, California)

ANA Division of Gerontological Nursing publishes statement on scope of practice

John A. Hartford Foundation’s Hospital Outcomes Program for the Elderly (HOPE) using a geriatric resource nurse (GRN) model developed at Yale Uni- versity under the direction of Terry Fulmer

1982 Development of RWJF Teaching-Nursing Home Program (five programs in the United States)

1983 First endowed university chair in geronto- logical nursing (Florence Cellar Endowed Geronto- logical Nursing Chair) established at Case Western Reserve University

1984 National Gerontological Nursing Association (NGNA) established

ANA Division on Gerontological Nursing Practice becomes Council on Gerontological Nursing

1986 National Association for Directors of Nurs- ing Administration in Long Term Care established

ANA publishes Survey of Gerontological Nurses in Clinical Practice

1987 ANA revises Standards and Scope of Geron- tological Nursing Practice

1988 First PhD program in gerontological nursing established (Case Western Reserve University)

1989 ANA certification established for Clinical Specialist in Gerontological Nursing

1990 ANA establishes Division of Long Term Care within the Council of Gerontological Nursing

1992 Nurses Improving Care for Healthsystem Elders (NICHE) established at New York University (NYU) Division of Nursing based on the HOPE programs

1996 John A. Hartford Foundation Institute for Geriatric Nursing established at NYU Division of Nursing

NICHE administered through the John A. Hartford Foundation Institute for Geriatric Nursing 1998 ANA certification available for geriatric advanced practice nurses as geriatric nurse practi- tioners or gerontological clinical nurse specialists 2000 American Academy of Nursing, the John A. Hartford Foundation, and the NYU Division of Nurs- ing develop the Building Academic Geriatric Nurs- ing Capacity (BAGNC) program 2002 American Nurses Foundation (ANF) and ANA fund the Nurse Competence in Aging (NCA) joint venture with the John A. Hartford Foundation Institute for Geriatric Nursing 2003 The John A. Hartford Foundation Institute for Geriatric Nursing, the American Academy of Nurs- ing, and the American Association of Colleges of Nursing (AACN) combine efforts to develop the Hartford Geriatric Nursing Initiative (HGNI) John A. Hartford Foundation Institute for Geriatric Nursing at NYU awards Specialty Nursing Associa- tion Programs-in Geriatrics (SNAP - G) grants 2004 American Nurses Credentialing Center’s first computerized generalist certification exam is for the gerontological nurse 2005 Journal of Gerontological Nursing celebrates 30 years 2007 NICHE program at John A. Hartford Founda- tion Institute for Geriatric Nursing at NYU receives additional funding from the Atlantic Philanthropies and U.S. Aging Program 2008 Geriatric Nursing journal celebrates 30 years Journal of Gerontological Nursing Research emerges

ATTITUDES TOWARD AGING AND OLDER ADULTS As a nursing student, you may have preconceived ideas about caring for older adults. Such ideas are influenced by your observations of family members, friends, neighbors, and the media, and your own experience with older adults. Perhaps you have a close relationship with your grandparents or you have noticed the aging of your own parents. For some of you, the aging process may have become noticeable when you look at yourself in the mirror. But for all of us, this universal phenomenon we call

8 Chapter 1: Introduction to Gerontological Nursing

aging has some type of meaning, whether or not we have taken the time to consciously think about it. The way you view aging and older adults is often a product of your environment and the experiences to which you have been exposed. Negative attitudes toward aging or older adults ( ageism ) often arise in the same way—from negative past experiences. Many of our attitudes and ideas about older adults may not be grounded in fact. Some of you may have already been exposed to ageism, which is often displayed in much the same way as sexism or racism—via attitudes and actions. This is one rea- son for studying the aging process—to examine the myths and realities, to separate fact from fiction, and to gain an appreciation for what older adults have to offer. Population statistics show that the majority of your careers as nurses will include caring for older adults. As Mathy Mezey, director of the John A. Hartford Foundation Institute for Geriatric Nursing at NYU, stated, “The population of older Americans is exploding. Geriatric patients are not one sub- group of patients but rather the core business of health systems” (Mezey, 2005). Providing high- quality care to elders requires knowledge of the intricacies of the aging process as well as the unique syndromes and disease conditions that can accompany growing older. As you read and study this book, you are encouraged to examine your own thoughts, values, feelings, and attitudes about growing older. Per- haps you already have a positive attitude toward caring for older adults. Build on that value, and con- sider devoting your time and efforts to the practice of gerontological nursing. If, however, you are reading this chapter with the idea that gerontolog- ical nursing is a less desirable field of nursing, or that only those nurses who cannot find jobs else- where work in nursing homes, or that working with older people would be an option of last resort, then you may need to re-examine these feelings. Armed with the facts and some positive experiences with older adults, you may change your mind. Advocates for older adults, such as Nobel lau- reate Elie Wiesel, feel that older adults, as reposito- ries of our collective memories, should be appreciated and respected. As the 1997 American Psychological Association’s keynote convention speaker, Wiesel said, “... an old person represents

wisdom and the promise of living a full life... the worst curse is to make him or her feel worthless” (American Psychological Association, 2008). The older population is changing dramatically as the baby boomers (those born from 1946–1964) reach retirement age (as of 2011). Because this phe- nomenon is happening in many places around the globe (see Chapters 2 and 23), gerontology is the place to be! Caring for the largest number of older adults in history will present enormous opportuni- ties. With the over-85 age group being the fastest growing, the complexity of caring for so many peo- ple with multiple physical and psychosocial changes will present a challenge for the most dar- ing of nurses. Will you be ready? The purpose of this book is to provide the essen- tial information needed by students of gerontolog- ical nursing to provide quality care to older adults. In your study of this text, you will be presented with knowledge and insights from experienced profes- sionals with expertise in various areas of geronto- logical nursing and geriatrics. Each chapter contains thought-provoking activities and questions for per- sonal reflection. Case studies will help you to think about and apply the information. A glossary is included at the end of the chapter to help you mas- ter key terms, and plenty of tables and figures sum- marize key information. Web sites are included as a means of expanding your knowledge. Use this text as a guidebook for your study. Use all the resources available, including your instructors, to immerse yourself in the study of the aging process. By the end of this book, you will have learned about the essential competencies needed to provide excellent care to older adults.

DEFINITIONS Gerontology is the broad term used to define the study of aging and/or the aged. This includes the biopsychosocial aspects of aging. Under the umbrella of gerontology are several subfields including geriatrics, social gerontology, geropsy- chology, geropharmacology, financial gerontology, gerontological nursing, and gerontological rehabil- itation nursing, to name a few. What is old and who defines old age? Interest- ingly, although “old” is often defined as over 65 years of age, this is an arbitrary number set by the

10 Chapter 1: Introduction to Gerontological Nursing

modifications such as a healthy diet, smoking ces- sation, appropriate weight maintenance, increased physical activity, and stress management. Nurses have a responsibility to educate the older adult pop- ulation about ways to decrease the risk of certain disorders such as heart disease, cancer, and stroke, the leading causes of death for this group. Nurses also may develop expertise in specialized areas and teach skills to other nurses in order to promote quality patient care among older adults.

Manager

Gerontological nurses act as managers during everyday practice as they balance the concerns of the patient, family, nursing, and the rest of the inter- disciplinary team. Nurse managers must be skilled in leadership, time management, building relation- ships, communication, and managing change. Nurse managers may supervise other nursing per- sonnel including licensed practical nurses (LPNs), certified nursing assistants (CNAs), technicians, nursing students, and other unlicensed assistive personnel (UAP). The role of the gerontological nurse as manager and leader is further discussed in Chapter 23.

Advocate

As an advocate, the gerontological nurse acts on behalf of older adults to promote their best interests and strengthen their autonomy and decision mak- ing. Advocacy may take many forms, including active involvement at the political level or helping to explain medical or nursing procedures to family members on a unit level. Nurses may also advocate for patients through other activities such as helping family members choose the best nursing home for their loved one or listening to family members vent their frustrations about health problems encoun- tered. Whatever the situation, gerontological nurses must remember that being an advocate does not mean making decisions for older adults, but empowering them to remain independent and retain dignity, even in difficult situations.

Research Consumer

The appropriate level of involvement for nurses at the baccalaureate level is that of research con- sumer. Gerontological nurses must remain abreast of current research literature, reading and put-

ting into practice the results of reliable and valid studies. Using evidence-based practice, gerontol- ogical nurses can improve the quality of patient care in all settings. Although nurses with under- graduate degrees may be involved in research in some facilities, such as assisting with data collec-

Case Study 1-

Rose is a 52-year-old nursing student who has returned to school for her BSN after raising a fam- ily. She is the divorced mother of two grown chil- dren and has one young grandson. In addition to being a full-time student in an accelerated program, Rose also cares for her 85-year-old mother in her own home and occasionally helps provide childcare for her grandson while his parents work. Rose’s mother has diabetes and is legally blind. Rose is tak- ing a gerontology course this semester and finds herself going home quite upset after the first week of classes when attitudes toward aging were dis- cussed. While sharing with the course instructor her feelings and surprising emotional discomfort, Rose is helped to identify that she is afraid of getting older and being unable to care for her ailing mother and herself. As a single woman, she is unsure that she can handle what lies ahead for her as she is begin- ning to feel the effects of aging herself.

Questions:

1. What can Rose do to become more comfort- able with facing her own advancing age?
2. What factors may have influenced her discom- fort with the course material?
3. Is there anything the instructor of the course might do to help Rose cope with the feelings she is having as she completes the required coursework?
4. There may be some activities that Rose can do in order to understand her feelings about aging better. Can you think of some such activities?
5. What is Rose’s role as the caregiver in this sit- uation? How may the role change over time?
6. How much does Rose’s present home and liv- ing situation contribute to her fears and per- ceptions of aging?

Certification 11

tion or providing research ideas inspired by clinical problems, their basic preparation is aimed prima- rily at using research in practice. All nurses should read professional journals specific to their specialty and continue their education by attending seminars and workshops, participating in professional orga- nizations, pursuing additional formal education or degrees, and obtaining certification. In being a research consumer, gerontological nurses can improve the quality of patient care in all settings. Expanded roles of the gerontological nurse may also include counselor, case manager, coordinator of services, collaborator, geriatric care manager, and others. Several of these roles are discussed in Chapters 20, 23, and 25.

CERTIFICATION

To provide competent, current care to elders, nurses need to have gerontological nursing content in their basic undergraduate nursing curricula and are encouraged to become certified in gerontological nursing. Less than 1% of nurses in the United States are certified in gerontological nursing; however, more than 50% of the patients cared for are elders. Adults age 65 or older utilize 48–50% of the nation’s total health care resources and represent approxi- mately 38% of all admissions to hospitals (Stierle et al., 2006). Patients and their families are knowl- edgeable about quality health care and patient safety and want the most expert clinicians at the bedside. Certification provides reassurance to patients and their families that the nurses caring for them are highly skilled and possess expert knowledge in pro- viding excellence in gerontological nursing care (Hartford Institute for Geriatric Nursing, 2008). Nurse certification is a formal process by which a certifying agency validates a nurse’s knowledge, skills, and competencies through a written exami- nation in a specialty area of practice. There are two levels of certification: generalist and advanced practice level. Each has different eligibility stan- dards. The American Nurses Credentialing Center (ANCC) is the certifying body for both levels of gerontological nursing practice.

Generalist Certification

The generalist in gerontological nursing has com- pleted a basic entry-level program in nursing, which

can be a diploma in nursing, or an associate or bach- elor of science degree in nursing. Before meeting additional eligibility requirements to become certified in gerontological nursing, the applicant must be a licensed registered nurse for at least 2 years. ANCC offers the generalist computerized exam in geronto- logical nursing at over 300 computer-based testing sites across the country. This exam was the first one to become computerized, increasing the convenience of sitting for gerontological nursing certification. Certified gerontological nurses utilize principles of gerontological nursing and gerontological com- petencies as they implement the nursing process with patients. Gerontological certified nurses:

• Assess, manage, and deliver health care that meets the needs of older adults
• Evaluate the effectiveness of their care
• Identify the strengths and limitations of their patients
• Maximize patient independence
• Involve patients and family members (Ameri- can Nurses Credentialing Center [ANCC], 2008) There are a number of compelling reasons for nurses to pursue gerontological nurse certification. Certified gerontological nurses:
• Experience a high degree of professional accomplishment and satisfaction
• Demonstrate a commitment to their profession
• Provide higher quality of care to older adults
• Act as resources for other nurses and interdis- ciplinary team members
• Demonstrate evidence-based gerontological nursing care
• Are recognized as national leaders in geronto- logical nursing care
• Create the potential for higher salaries and benefits
• Are actively recruited for employment at nurs- ing faculty, in Magnet and NICHE designated hospitals, in long-term care facilities, in acute rehab, and in community health agencies (ANCC, 2008; Hartford Institute for Geriatric Nursing, 2008)

See the ANCC Web site (http://www.nursecredential ing.org) for eligibility requirements and informa- tion about gerontological nurse certification and recertification.

Scope and Standards of Practice 13

physicians, managing caseloads, and diagnosing and treating geriatric syndromes. The ANCC describes the role of the gerontological nurse prac- titioner as follows:

The Gerontological Nurse Practitioner (GNP) is a registered nurse prepared in a graduate level gerontological nurse practitioner program to provide a full range of health care services on the wellness-illness health care continuum at an advanced level to older adults. The GNP practice includes independent and interdepend- ent decision making, and is directly account- able for clinical judgments. The graduate level preparation expands the GNP’s role to include differential diagnosis and disease management, participation in and use of research, develop- ment and implementation of health policy,

leadership, education, case management, and consultation. (ANCC, 2008, p. 1)

SCOPE AND STANDARDS OF PRACTICE The scope of nursing practice is defined by state regulation, but is also influenced by the unique needs of the population being served in a given set- ting. The needs of older adults are complex and multifaceted, and the focus of nursing care depends on the setting in which the nurse practices. Gerontological nursing is practiced in accordance with standards developed by the profession of nurs- ing. In 2001, the ANA Division of Gerontological Nursing Practice developed the second edition of the Scope and Standards of Gerontological Nursing

BOX 1-1 Web Exploration

Explore the following Web sites for further

information on certification and geronto-

logical associations of interest to nurses.

Educational Web Sites

Hartford Geriatric Nursing Initiative, About

HGNI

www.gerontologicalnursing.info

Hartford Geriatric Nursing Initiative, Consult-

GeriRN.org

www.consultgeriRN.com

American Nurses Association (ANA)

www.nursingworld.org

Associations

U.S. Administration on Aging

www.aoa.dhhs.gov

American Geriatrics Society

www.americangeriatrics.org

American Nurses Credentialing Center (ANCC)

www.nursecredentialing.org

Gerontological Society of America

www.geron.org

Hospice and Palliative Nurses Association

(HPNA)

www.hpna.org

John A. Hartford Foundation Institute for Geri-

atric Nursing

www.hartfordign.org

National Adult Day Services Association

www.nadsa.org

National Association of Geriatric Nursing

Assistants (NAGNA)

www.culturechangenow.com/

stories/nagna.html

National Association of Professional Geriatric

Care Managers

www.caremanager.org

National Council on the Aging

www.ncoa.org/

National Gerontological Nursing Association

www.ngna.org

National Institute on Aging

www.nia.nih.gov

14 Chapter 1: Introduction to Gerontological Nursing

Practice , in collaboration with the National Geron- tological Nursing Association, the National Asso- ciation of Directors of Nursing Administrators in Long Term Care, and the National Conference of Gerontological Nurse Practitioners. Standards are provided both for clinical care and for the profes- sional role of the nurse. These standards include assessment, diagnosis, outcome identification, planning, implementation, and evaluation. The standards of professional gerontological nursing performance include quality of care, performance appraisals, education, collegiality, ethics, collabo- ration, research, and research utilization. Students should note that these are the basic standards for professional nursing, but here they are applied to the care of the older adult. Core competencies, discussed in the next section, provide specific guidelines for gerontological nursing care. A full description and

copy of the scope and standards is available at www.nursingworld.org or www.ngna.org.

CORE COMPETENCIES Specific core competencies have been identified for gerontological nursing in addition to general professional nursing preparation. These competen- cies are influenced by the level at which the nurse will function and the role expectations of the nurse. Core competencies provide a foundation of added knowledge and skills necessary for the nurse to implement in daily practice. For example, the gerontological nurse in advanced practice has expanded expertise and skills to fulfill specialized roles. Common bodies of assumptions, knowledge, skills, and attitudes that are essential for excellent clinical nursing practice with older adults have been developed and provide the basic foundation for all levels of gerontological nursing practice. The American Association of Colleges of Nursing (AACN) and the John A. Hartford Foundation Institute for Geriatric Nursing gathered input from qualified gerontological nursing experts to publish Older Adults: Recommended Baccalaureate Competencies and Curricular Guidelines for Geriatric Nursing Care (2000). This document also provided the framework for this text. The core competencies set forth for gerontological nursing appear in Table 1-2. The purpose of this document specific to gerontological nursing was to use the AACN’s Essentials of Baccalau- reate Education for Professional Nursing Practice (1998) as a framework to help nurse educators inte- grate specific nursing content into their programs. The original AACN document suggested core com- petencies, knowledge, and role development for pro- fessional nurses. These appear in Table 1-3. The geriatric competencies in Table 1-2 correlate with and were derived from the suggestions in the more general AACN document in Table 1-3. By using these published documents as guides, nursing professors and others who educate in the area of gerontologi- cal nursing should be able to prepare students to be competent to provide excellent care to older adults.

CONTINUUM OF CARE Gerontological nurses practice in a multitude of set- tings. Adults over age 65 comprise 48% of patients

BOX 1-2 Additional Resources

American Nurses Credentialing Center (ANCC)

P.O. Box 791333

Baltimore, MD 21279-

www.nursecredentialing.com

John A. Hartford Foundation

55 East 59th Street

16th Floor

New York, NY 10022-

E-mail: [email protected]

www.hartfordign.org

www.jhartfound.org

Geriatric Nursing Review Syllabus: A Core

Curriculum in Advanced Practice Geriatric

Nursing (GNRS) (2003–2005)

Available from the American Geriatrics

Society

1-800-334-1429 ext. 2529

16 Chapter 1: Introduction to Gerontological Nursing

seen in the hospital, 80% of home care patients, and 90% of those in nursing homes (Mezey, 2005). A few of these settings will be discussed here. Some addi- tional unique areas of employment are suggested in Chapter 23. Because of the nature of the aging process, it is likely that older adults will enter and exit the health care system at many different points throughout old age. Figure 1-1 presents the web of health care that often occurs when older adults enter the sys- tem due to illness or accident. Settings of care can be described and titled in a variety of ways. Following is a brief description of some of the most common settings of care, employ- ing commonly used nomenclature.

Acute Care Hospital

The acute care hospital is often the point of entry into the health care system for older adults. Nurses working in hospitals are likely to care for older adults even if they do not specialize in geriatrics, because about half of all patients in this setting are 65 years of age or older. In this setting, gerontolog- ical nurses focus on nursing care of acute problems, often involving exacerbations of cardiopulmonary conditions, cancer treatment, and orthopedic prob- lems. All nursing units (with the exception of labor and delivery, postpartum, and pediatrics) in acute care hospitals admit older adults, so nurses may encounter elderly patients in critical care or reha- bilitative services or anywhere in between. The goal of inpatient care will be to promote recovery and prevent complications.

Acute Rehabilitation Rehabilitation may be found in various degrees in several settings, including the acute care hospital,

TABLE 1-3 AACN Essentials (1998)

Core Competencies Critical thinking Communication Assessment Technical skills

Core Knowledge Health promotion, risk reduction, and disease prevention Illness and disease management Information and health care technologies Ethics Human diversity Global health care Health care systems and policy

Role Development Provider of care Designer/manager/coordinator of care Member of a profession

SOURCE: American Association of Colleges of Nursing. (1998). Essentials of baccalaureate education for profes- sional nursing practice. Washington, DC: Author.

28. Involve, educate, and when appropriate, supervise family, friends, and assistive personnel in imple- menting best practices for older adults.
29. Ensure quality of care commensurate with older adults’ vulnerability and frequency and intensity of care needs.
30. Promote the desirability of quality end-of-life care for older adults, including pain and symptom management, as essential, desirable, and integral components of nursing practice.

SOURCE: American Association of Colleges of Nursing and the John A. Hartford Institute for Geriatric Nursing. (2000). Older adults: Recommended baccalaureate competencies and curricular guidelines for geriatric nursing care. Washington, DC: Author.

TABLE 1-2 (continued)

Continuum of Care 17

subacute care or transitional care, and long-term care facilities (LTCFs). Regardless of the setting, rehabilitation is accomplished through the work of an interdisciplinary team that includes nurses, ther- apists, and physicians as well as other professional staff. The goals of rehabilitation are to maximize independence, promote maximal function, prevent complications, and promote quality of life within each person’s strengths and limitations. The level of intensity of acute rehabilitation is greater than for subacute or long-term care. For older adults to qualify for rehabilitation in the acute care hospital, they must be able to tolerate at least 3 hours of therapy per day. The interdisciplinary team will work together to set up mutually estab- lished goals with the patient. Inpatient rehabilitation in the acute setting is beneficial to help persons

recovering from or adapting to such conditions as stroke, head trauma, neurological diseases, ampu- tation, orthopedic surgery, and spinal cord injury.

Home Health Care Independent-living older adults requiring a longer period of observation or care from nurses may be candidates for home health care services. Home health care is designed for those who are home- bound due to severity of illness or immobility. Vis- iting nurse associations (VNAs) have long been known for their positive reputation in providing home health care. For reimbursement of allowable expenses, home health care services must be ordered by a physician and the person must be con- sidered homebound. There has been record growth in the number of home health agencies in the past

FIGURE 1-1 The “web” of health care for older adults.

Inpatient subacute
unit

Home

Inpatient rehabilitation
unit

Long-term care facility
(Nursing home)

ACUTE CARE HOSPITAL

–Long-term transitional
–General
–Chronic
–Transitional

–PT

–OT

–Speech therapy
–Social services
–Nursing care
–Ancillary services

–OP therapies
–Home health care
–Adult day care
–Vocational rehab
–Hospice

–Skilled
–Intermediate
–Assisted living
–Residential
–Group homes
–Hospice
–Subacute

SOURCE: Easton, K. L., 1999, Gerontological Rehabilitation Nursing, p. 14. Philadelphia: W.B. Saunders. Used with permission.

Continuum of Care 19

Hospice

Gerontological nurses may also choose to work in hospice , caring for dying persons and their fami- lies. Although many patients in hospice are not eld- erly, the majority of the dying are older. The concept of hospice is centered on holistic, interdisciplinary care that helps the dying person “live until they die.” (See Chapter 24 for further discussion.) A number of team members who specialize in thanatology and palliative care work together to provide quality care for patients in their last months, weeks, days, and hours of life. Pain management and comfort care are the standards upon which treatment is based. Nurses and physicians work closely with social workers, chaplains, psychologists, and other hospice professionals to make death as comfort- able and as easy a transition as possible. Hospice care is found in a variety of facilities. Some hospices are stand-alone organizations with their own building. Home care often offers hospice, and certain nursing homes will offer a hospice unit or care within the skilled unit or from an outside hospice nurse. Clinical nurse special- ists provide a great service as expert clinicians and consultants to the hospice team. Whatever the setting, hospice requires a great deal of patience, expertise, understanding, interdisciplinary com- munication, and compassion on the part of the gerontological nurse.

Respite Care

Caregiving for a dependent older adult can be a demanding task. Caregivers often need a break from caregiving to relieve stress and prevent burnout. Respite care provides time off for family members who care for someone who is ill, injured, frail, or demented. Respite care can be provided in an adult daycare center, in the home of the person being cared for, or in an assisted living facility or long-term care facility. Although there are different approaches to respite care, all have the same basic objective: to provide caregivers with temporary, intermittent, substitute care, allowing for relief from the daily responsibilities of caregiving. Respite care is not covered by Medicaid or Medicare, but may be covered by long-term care insurance policies or by local social service agencies, with fees based on a sliding scale of financial need.

Continuing Care Retirement Community (CCRC) Also referred to as a life care community, a con- tinuing care retirement community (CCRC) provides a continuum of care from independent living to skilled care (the latter consisting of care typically provided by traditional nursing homes), all within a single campus, with levels of care adjusted to individual needs. Depending on the facility’s contract, additional services are provided for an additional fee or are included in a lump-sum upfront payment. Older adults can move seam- lessly among independent living, assisted living, skilled care, or long-term care as their conditions warrant. Some CCRCs include independent and assisted living, but provide home health services within the facility instead of moving the resident to a skilled unit. Nurses play a role in the care of CCRC residents as they progress from independent living to requiring skilled nursing care, but geron- tological nurses may also function in the area of health promotion to help older adults maintain independence for as long as possible.

Assisted Living As older persons continue to age, it is likely that common disorders associated with the aging process may interfere with their ability to care for themselves. Assisted living facilities (ALFs), a bur- geoning option for older adults, provide an alterna- tive for those older adults who do not feel safe living alone, who wish to live in a community setting, or who need some additional help with activities of daily living (ADLs). The ALF may be connected with a long-term facility or care network, or may be free-standing. For those units that are part of a larger facility, residents who find themselves in need of greater assistance may then progress to the next level of care. The drawback of a free-standing facil- ity is that older adults whose condition worsens and who need greater assistance may need to pay extra for that assistance, depending on the terms of their contract. Some may even need to find an alternate facility that provides a higher level of care than that provided by their ALF. The typical resident in an assisted living facility has a private room or apartment (with a variety of designs available for different costs). All rooms will

FIGURE 1-2 Assisted living facilities aid older people with activities of daily living.

SOURCE: © Comstock Images/Alamy Images.

20 Chapter 1: Introduction to Gerontological Nursing

have some type of kitchen or kitchenette and pri- vate bathroom with shower. The rest of the space includes a bed or bedroom, living area, and closet space. Older adults who enter an ALF often sell their homes and plan to spend as long as possible living with minimal assistance. Assisted living facilities generally provide healthy meals, planned activities, places to walk and exercise, and pleasant surroundings where adults can socialize with others in a safe and pro- tected environment. Walking paths, aviaries, work- out rooms, beauty salons, community gathering rooms, chapels, and game rooms are part of many assisted living facilities.

Foster Care or Group Homes Foster care and/or group homes are for those older adults who can do most of their ADLs, but may have safety issues and require supervision with some activities such as dressing or taking medica- tions. Foster or group homes generally offer more personalized supervision in a smaller, more family- like environment than a traditional nursing home and, depending on state regulations, may be licensed to provide such services. Some persons offering this service have a small number of elders inside their existing home, whereas others have purchased a larger dwelling for this purpose (see