Gerontological and geriatric nursing
Brenda L. Hage
Introduction
The nursing profession has a long history of providing healthcare to sick older people. Initially, geriatric nursing focused on physical care, comfort measures and palliation. The care was often given almost entirely by nurses and their assistants in nursing homes or in people’s own homes. As knowledge, technology, public policy and societal expectations changed, the scope, types of geriatric services and quality of nursing care also changed. The establishment of the first formal standards for nursing care for older adults, adopted in 1970 by the American Nurses Association (ANA), was a landmark initiative for nurses in geriatrics. It provided a link to nursing science, which is defined by the ANA as the deliberate problem-solving process, grounded in the biopsychosocial sciences, of diagnosing and treating actual or potential health problems (American Nurses Association, 1970).
As these practice standards were reviewed and modified over time, patient-centered care, family participation and nursing services related to the prevention of disease and disability and the promotion of good health for older adults were articulated more explicitly as major components of geriatric nursing practice. This paved the way for the use of the term ‘gerontological nursing’ to refer to a domain in the continuum of the science and practice of nursing that is devoted to the complex care of older people and their families and to balancing the effects of normal aging and pathology. Today, the term ‘geriatric nursing’ indicates specialized clinical care for the health problems of the elderly in various interdisciplinary patient-care settings. Nurses with advanced training who practice in this area are known as primary care or acute care adult/gerontologic nurse practitioners or gerontologic clinical nurse specialists.
An overall goal for gerontological and geriatric nursing is to provide humanistic healthcare to older adults and their families by paying careful attention to individual circumstances, needs and goals. Preventing impairment, restoring function and maintaining an enduring state of health and wellbeing are embedded in these goals. A key strategy that is used to meet these goals is the application of the nursing process that consists of assessment, planning, intervention and evaluation within the context of healthcare issues presented by the elder and their family.
Gerontological and geriatric nurses have critical roles in the collaboration of the healthcare team, as they must be involved in planning, implementing and evaluating patient care. The nurses’ roles and functions include nursing management and other therapeutic activities for direct patient care, case management, patient and family health education and counseling, administration, advocacy, public policy development and education and research.
Direct patient care
To ensure seamless care, continuous leadership and accountability are necessary. Professional nurses act on these responsibilities in acute care units, ambulatory care clinics, long-term care facilities, homecare agencies and other sites where the need for geriatric care can be fulfilled.
At least three different types of nursing expertise, using different levels of critical thinking and clinical decision-making skills, are available to older patients to assist them in meeting their healthcare needs:
2. Advanced practice nursing roles in gerontological nursing primarily include clinical specialists and nurse practitioners. These master’s degree or doctorally prepared nurses function in a variety of roles to support this challenging patient population:
B. Gerontologic nurse practitioners have expertise in performing comprehensive physical examination and assessments, ordering and interpreting laboratory and diagnostic testing, differential medical diagnosis, and developing pharmacologic and non-pharmacologic management plans, and outcome evaluations for medical problems, in partnership with other team members. Primary care nurse practitioners provide services in ambulatory clinics, long-term care facilities, and adult day health programs while acute care nurse practitioners see patients in mostly inpatient settings. Crossover may occur between these settings and the primary care and acute nurse practitioner roles (National Organization of Nurse Practitioner Faculties, 2012).
The nursing process
The nursing process guides the registered nurse to individualize, contextualize and prioritize problem areas. The steps consist of assessment, nursing diagnosis, planning, intervention and evaluation.
Step 1: Assessment
Biopsychosocial data about geriatric patients is collected by means of interviews, record reviews, direct observations and other approaches, as time allows, building a composite picture of the multiple and often competing needs of the geriatric patient and the informal caregiver. For example, the federally mandated multidisciplinary assessment called the Minimum Data Set is used in nursing homes by long-term care nurses to record assessment data as part of the team approach to care planning and treatment (Burke & Walsh, 1997). The Care Dependency Scale offers a framework for assessing the care needs of institutionalized patients for nursing care (Dijkstra et al., 2012).
Step 2: Diagnosis
Data from nursing assessments are necessary to identify problems in the order of clinical significance at a specific time and according to the urgent need for nursing interventions. The information may include general and specific data on the presenting problems as defined by the patient and the caregiver, medical diagnoses, prescribed medical treatments, status of physical and mental functions, alternate healthcare resources, patient goals and expectations, safety risks, self-care abilities for recovery, including the ability to perform activities of daily living, and other information that a nurse considers clinically relevant to the case or situation. Identifying nursing diagnoses and prioritizing these problem areas are the major intended process outcomes.
Since 1973, the North American Nursing Diagnosis Association (NANDA) has continued to develop a taxonomy of nursing diagnoses, and currently there are approximately 130 approved classifications of patient care problems in nine categories. In 1987, the Center for Nursing Classification and Clinical Effectiveness at the College of Nursing, University of Iowa (USA) developed taxonomies for classifying and organizing nursing interventions and nursing outcomes through the use of the Nursing Intervention Classification (NIC) (McCloskey Dochterman & Bulacheck, 2004). This was followed by the development of Nursing Outcomes Classification (NOC) coding systems in 1992 (Moorhead et al., 2004). The NIC/NOC codes are linked to the NANDA diagnoses and serve to document the effectiveness of nursing interventions and outcomes. Refinement of the NIC/NOC classification systems has been ongoing. The use of nursing taxonomies facilitates the capture of nursing data useful for evaluation, quality improvement and research activities.
Step 3: Planning
The nursing care plan incorporates specific nursing interventions and activities to treat specific nursing diagnoses or deal with problem areas such as changes in food intake, impaired capacity for personal care, risk for accidental injuries due to general weakness and mild dementia, grief unrelated to the health problem and other needs of the geriatric patient and the caregiver. Included in the plan are nursing actions to ensure the continuity of all prescribed medical treatments and other intervention modalities for the geriatric patient. Clinical judgment is an important nursing skill in this process because it enables an accurate identification of the nursing diagnosis.
Step 4: Implementation
The process of implementation utilizes the collective efforts of members of the nursing staff, including auxiliary nursing personnel, and directs them so that the nursing care plan can be carried out. Safe and compassionate approaches that are clinically and technically appropriate are used to achieve the desired clinical outcomes. Nursing actions may include activities such as checking vital signs, changing the position of an immobilized elderly patient, orienting an elder with a memory deficit to time, place and activity, interviewing a family caregiver prior to home care, consulting other healthcare professionals, advocating for an elder to obtain a local community resource, and other actions aimed at resolving a nursing problem or reducing the impact of a nursing diagnosis.
Step 5: Evaluation
A patient’s physical, verbal and behavioral responses, informal caregivers’ reports, and observations by healthcare providers from other disciplines are important aspects of the feedback mechanism that helps the nursing staff to maintain a dynamic, flexible care plan. Critical analysis of information obtained while nursing interventions are in progress may be used to modify nursing interventions, redirect patient and family participation in the overall treatment and management plan, reexamine the healthcare team’s understanding of the clinical problem, determine cost benefits, realign leadership and support the standards of quality patient care.
Case management
The nurse case manager follows a group of elderly patients and informal caregivers. As a rule, frailty, multiple chronic illnesses, unstable functional status, complex psychosocial and financial situations, and other multilayered clinical issues trigger the need for this type of professional nurse. Advanced skills in clinical decision-making, communication, resource identification, referral, management, systems analysis, and cost analysis are essential for effective case management. The role of a nurse case manager involves consulting with healthcare providers; meeting with patients, family members and other support systems; advocating for need-specific health and social services; planning for discharge; ensuring safe termination of services; facilitating shared decision-making; and recording appropriate documentation. Case managers may also negotiate a change of health benefit with third party payers to ensure that the older patient’s needs are being optimally addressed. As healthcare delivery systems change, the number of nurse case managers for older people is expected to increase, particularly in community-based programs such as home-based services, adult day health programs, and respite and hospice services. For example, in the home health arena, the nurse is the ideal team leader; in that role, the nurse can coordinate the case and facilitate the completion of required documentation by interdisciplinary care providers, institutions, physicians in group or private practice, and payers. With the growing trend toward managed care, the nurse in such a role might be called a case manager. Other administrative functions may also be a part of the geriatric nurse case manager’s responsibility in the practice sites mentioned earlier.
Health education and counseling for patients and families
A major focus of the teaching and counseling done by gerontological and geriatric nurses relates to the implementation of treatment and management prescribed by healthcare providers in acute care, home care, or community care. Teaching patients before they are discharged to home or another site of care helps to prepare the patient and the family. Education in ways of preventing disease, disability and complications of existing chronic health conditions becomes increasingly necessary as the shift to community care expands. Teaching and counseling by these nurses take place across the continuum of care of the elderly. This function may be combined with direct patient care and case management functions.
Administration
Professional roles for administrative nurses include director of nursing services in a skilled-nursing facility and administrator in a variety of settings, such as home care, adult day health, respite care, hospice and other community care programs for older adults. Some nurse entrepreneurs take on the challenge of administering small board-and-care (i.e. personal care) homes. The legislative mandates of Medicare and Medicaid, regulations, and the standards of care, to name a few, are complex bodies of information that the geriatric nurse administrator is able to translate into practice in order to support quality standards of care and ensure fiscal responsibility.
Advocacy and public policy development
Although nurse activism is found among all types of practitioners of nursing, some nurses in gerontology and geriatrics build careers in advocacy dedicated to shaping and changing public policy. Their expertise in the legislative process and their analyses of public policies may be applied to issues related to healthcare access for the aging population and other relevant concerns. They find employment in governmental agencies, in the offices of public officials, with advocacy organizations, or with other entities oriented toward public policy issues and aging.
Education and research
With the increasing number of education programs in gerontological and geriatric nursing being taught in colleges and universities, the need for faculty members with doctoral and master’s degrees in gerontology and geriatrics will continue to grow. Clinical nurse specialists, nurse practitioners and nursing educators predominate in the faculties of many nursing schools across the country. Gerontological and geriatric nurses with doctoral degrees typically have teaching and research responsibilities. Advanced practice nurse faculty members who are clinical nurse specialists or nurse practitioners are also required to maintain clinical practice in order to maintain role competency. Faculty members with research doctorates are prepared to function as principal investigators in research projects and clinical trials and to establish research programs in gerontological and geriatric nursing science. Knowledge generation is an important commitment of these nurse researchers. Some of the domains of nursing research are sleep disturbances, agitation, family caregiving, falling behavior, sensory disabilities, use of technology to support aging in place and self-care deficits. The body of knowledge produced by their studies contributes to improving healthcare for older people and to advancing the science of aging. In addition, these researchers create opportunities for other nurses to experience the research process as assistants, graduate students or participants in the study. Nurses with the practice doctorate (DNP) use this evidence-based nursing knowledge in practice change projects to improve nursing practice (American Association of Colleges of Nursing, 2006).
Conclusion
Gerontological and geriatric nurses have a variety of roles and functions. With the trend toward downsizing and the shift to managed care programs, these roles and functions are being fused and structured in different ways. New personnel who deliver direct bedside care but have limited formal education and training are being introduced into the clinical arena. The challenge to nursing, in particular to nurses in gerontology and geriatrics, is to maintain the standards of healthcare for older adults, especially those who are disempowered by chronic disability, socioeconomic status, racial or cultural factors, environmental situations, low health literacy or technological illiteracy and lack of technology access. Also, the aging of the baby boomers, a social and historical phenomenon, is already shifting the focus of healthcare from the curative model to the chronic care model. The high incidence of chronic disease in this population requires new approaches to assisting older adults in the development of self-management skills needed to effectively deal with these problems. It is clear that new expertise and more advance-practice nurses will be needed in this specialty.
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