Specialty nurses constitute an important

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1 Ensuring Competence of Specialty Nurses in Care of Older Adults Mathy Mezey, EdD, RN, FAAN, Linda J. Stierle, MSN, RN, CNAA, BC, G. J. Huba, PhD, and Jessica Esterson, MPH Overview Specialty nurses constitute an important component of the nurse workforce in ambulatory settings, hospitals, home care, and long-term care. The direct care and administrative responsibilities of specialty nurses profoundly affect the care of countless older patients and their families. The volume of direct care provided by specialty nurses to older adults is evident in many specialties. Given that 63% of patients with cancer are over the age of 65, much of the practice of members of the Oncology Nurses Society focuses on older adults. Similarly, with 60% of visits to cardiologists and 52% of visits to urologists made by patients 65 and older, older adults represent a large portion of the work of nurse members of the cardiovascular nursing and urological nursing associations. In hospitals, older adults make up 60% of medical-surgical patients and 46% of critical care patients, and they account for 50% of intensive days. Thus much of the care provided by medical-surgical, coronary care, and critical care specialty nurses revolves around older adults. Outside of hospitals, 80% of patients in home care and 85% of residents of institutional long-term care settings 1,2 are aged 65 and over. In addition to providing direct care, specialty nurses often administer specialty units within their institutions. In these positions, specialty nurses are responsible for, among other areas, the purchase of equipment for the unit, continuing education and development of staff, and decisions as to which indicators to track through quality-improvement initiatives. Specialty nurses also help set institutional policies and procedures, educate nurses who are new to the facility, and serve as clinical faculty for nursing students. The decisions that specialty nurses make in all of these areas have profound consequences for older patients. Yet despite their responsibilities related to care of older adults, few specialty nurses have received information about such care either in school or in their practice settings. Even today, only one-third of nurses graduating from baccalaureate nursing programs have had a standalone, required course in s. Most staff 3 development and in-service education programs in hospitals and home care do not include even basic information about the principles of care of older adults, such as assessment and prevention, or recognition and management of syndromes such as delirium, falls, and urinary incontinence. Findings from a survey of hospital nurses (unpublished data, the Measurement Group, 2007) found that only 37% of respondents had participated in a hospital in-service training on the care of older adults. Lack of knowledge on the part of specialty nurses is particularly worrisome given that the care of older adults improves when nurses have been educated about principles of care, either in academic programs or through on-the-job training. Applying principles has been shown, to name only a few examples, to reduce the use of physical restraints 4 and side rails, 5 decrease the prevalence of delirium, 6 improve end-of-life care, 7 and improve quality of life for residents of nursing homes. 8 The implementation of models of care, such as Acute Care of the Elderly units 9 10 or the Geriatric Resource Nurse model, 11 and the use of volunteers as in the HELP model have been shown to improve outcomes for older 12 adults. Moreover, models of transitional care improve adherence to management regimens and patient and family satisfaction and are associated with longer time from discharge to readmission for medical patients. Thus investing in programs to ensure specialty nurse competency in care of older adults is highly likely to yield substantial improvements in care. The scope of practice of specialty nurses derives from specialty associations. establish the scope and standards for the specialty, disseminate best practices, and develop and often administer the certification examination. Approximately 440,000 nurses, or 17%, of the 2.6 million practicing nurses, belong to 55 Geriatric Nursing, Volume 28, Number 6S 9

2 specialty associations whose members are likely to care for large numbers of older adults. In 1998, to disseminate information about best practice in care of older adults to these specialty nurses, the Hartford Institute for Geriatric Nursing at New York University College of Nursing developed the Specialty Nursing Activities Partnership Program (SNAPP). The SNAPP program featured a booth that traveled to specialty association annual meetings to create a presence and to acquaint members with readily accessible resources to improve the care they provide to older adults. Created in 2002, Nurse Competence in Aging was a 5-year initiative funded by the Atlantic Philanthropies (USA), which was awarded to the American Nurses Association (ANA) through the American Nurses Foundation (ANF) and represented a strategic alliance between ANA, the American Nurses Credentialing Center (ANCC), and The Hartford Institute for Geriatric Nursing to help associations expand their offerings to members. The project had 3 major goals: 1. Enhance of national specialty nursing associations 2. Promote gerontological nursing certification 3. Provide a Web-based comprehensive nursing resource center. This special issue of Geriatric Nursing reports on outcomes achieved by the project in relation to efforts of the specialty associations to gerontologize their members and create permanent organizational structures to ensure the associations ongoing commitment to s. This article summarizes the major outcomes of the specialty associations. Other articles highlight specific of associations, including the implementation of the Web Fellows program and efforts of associations to infuse care of older adults into their scope and standards documents. The Specialty Nursing Project (Nurse Competence in Aging) Specialty Nursing Fifty-four specialty nursing associations received a total of 60 grants from the project. These were to be used for planning or implementation of designed to increase the nursing skills of their members and enhance the infrastructure necessary to ensure that members were given opportunities to learn about practicing their nursing specialty with elderly patients. were invited to apply through a request-for-proposal process, and 54 associations were funded in 5 cohorts over 4 years. first embarking on initiatives applied for 1-year Planning Grants of approximately $1000, and associations ready to expand initiatives applied for 2-year Implementation Grants of up to $13,000 each. Given that the specialty associations varied in size, membership composition, administrative structure, and existing commitment to care of older adults, each participating association was given substantial leeway in defining its. As is shown in Table 1, associations could select the types of to pursue, including developing and/or enhancing a special interest group or other sustained structure; conducting plenary sessions or preconference workshops at national meetings; developing enduring educational materials either in print or online, including those with continuingeducation unit credits; creating white papers or position statements; designating Web Fellows; infusing s into new or revised scope and standards documents; including s in specialty certification examinations; and creating new, -related award programs. Technical assistance and support to the 54 participating Specialty Nursing Association Partners in Geriatrics was provided by the Hartford Institute and ANA on an extensive and as-needed basis throughout the duration of the program. In addition, 2 national meetings were held for the funded associations to share information on their programs and innovations and to identify needs for further consultation and support. Web-Based Information and Decision- Making Support To address the need for nurses of all specialties to obtain accurate and clinically useful information that would permit them to make immediate decisions about the course of treatment, as well as to access more in-depth discussions of key topics, a Web site was developed www. ( GeroNurseOnline.org). The clinical content for the site consisted of existing and newly developed material from the Hartford Institute, with links to existing and newly developed content from participating specialty asso- 10 Geriatric Nursing, Volume 28, Number 6S

3 Table 1. Scope of Geriatric Activities of Participating Specialty (n 54) Area of Activity N % Exemplars and Typical Stage of Work in the 2-Year Implementation Period administrative infrastructure awards and recognitions competencies in s for members Infusing content into specialty exams Attempting to leverage SNAPG award into another grant significant linkages with other associations in the area of s Conducting a needs assessment Working on policy issues Educating board members about priorities Establishing a staff champion, putting a section on s into the new board briefing book Having the board pass a resolution that s are a formal priority of the association Establishing an annual research award Establishing an annual award for best publication in the area of s Establishing an annual award for outstanding clinical practice or program development related to s formal statements of the competencies in s expected of a specialty nurse Circulating materials on identified competencies Incorporating statements about competencies to board members and having them endorse such statements Establishing a process with the association board to make it a priority to include content in the specialty exam Working with test developers to include items measuring knowledge of issues Formally instituting tests including content 5 9 Submission of further grants to support infrastructure for the development of interest in the association Establishing one or more linkages with other nursing associations to share materials and expertise about issues Cross-linkages to other nursing Web sites with content Information exchange with other associations Conducting limited or large-scale assessments of member knowledge Conducting limited or large-scale assessments of member need for training Conducting limited assessments of board knowledge about issues statements of the importance of s in the policies of the association statements to be used in the development of public policy Geriatric Nursing, Volume 28, Number 6S 11

4 Table 1. Continued Area of Activity N % Exemplars and Typical Stage of Work in the 2- Year Implementation Period a position paper Promoting dual certification in the specialty and s methods for promoting CEUs Promoting s at the association conference Working toward including s in scope and standards Working on developing or enhancing a s special interest group Using Web technologies to promote issues 3 6 Formally writing a position paper on the importance of s in the of the association Actively promoting dual certification in the association s specialty and gerontological nursing through information dissemination, articles in the association newsletter, training sessions ways of contracting with relevant experts to provide CEUs Formally developing an association-sponsored CEU course or opportunity Putting CEU courses into the association s preconference sessions at its annual meeting Allocating space in the annual meeting agenda to issues Ensuring that sessions are a continuing formal priority of the annual meeting paper-selection committee Circulation of memoranda on issues related to the association s scope and standards document Development of a new special interest group (SIG) Recruitment for SIG members Reenergizing an existing SIG Providing materials and support to an existing SIG Development of a Web-based training course on s Putting formal content on the association s Web site Linking to other associations and sources of content Linking to GeroNurseOnline CEU continuing-education unit; SNAPG Specialty Nursing Association Partners in Geriatrics. ciations. Clinical content previously found on can now be found at Web Fellow Project Every association involved in the NCA project had a Web site, but at the onset of the project, few even mentioned s or had resources available on their sites. To assist associations in building access to resources on their Web sites, the Hartford Institute implemented the Web Fellow project. The project was designed to help the associations enhance specialty nursing content on their Web sites and create portals to other Web sites. (Please see pages in this 12 Geriatric Nursing, Volume 28, Number 6S

5 supplement for a more in-depth look at the Web Fellow project.) Overall Outcomes Achieved by Specialty Nursing During the course of this project, participating associations conducted a number of designed to change their associations permanently, in 1 or more ways, so that they would be more focused on issues. The scope of of the participating specialty associations is shown in Table 1, along with some exemplars of each activity. One major goal of this project was to create an infrastructure within associations that would support ongoing. Several outcomes support achievement of this goal (Table 1). Seventy-four percent of the 54 participating specialty nursing associations worked on developing an administrative infrastructure for s, and 76% worked on developing or strengthening the association s special interest group. Evidence of embedding s and enduring is reflected among the 52% of associations that worked on including s in their scope and standards of practice documents and among the 41% that worked to infuse content into their specialty examinations. Most (80%) associations used Web technologies as part of their project. A second major goal of the project was for associations to develop resources for members. Measures taken in meeting this goal are reflected by the fact that 100% of associations disseminated information about s, 91% promoted s at association conferences, 80% worked on developing competencies in s for their members, 67% developed methods for promoting continuingeducation units, and 76% worked on methods of research or evaluation. Other association addressed project goals of recognition for nursing within and outside the association. Sixty-five percent of associations developed awards and recognitions, 83% worked on forming significant linkages with other associations around the area of s, and 31% worked on policy issues. A small number of associations (9%) were able to leverage their award into another grant. Other included conducting a needs assessment (57%) and working to promote dual certification in both the given specialty and s (33%). An index of the robustness of association, in terms of their potential for affecting long-term change, was developed by determining the number of listed above conducted by the 54 associations.* On average, associations conducted in 8.4 areas (SD 3.0). In terms of robustness, of participating associations: 9% (n 5) worked on 13 or more types of 26% (n 14) worked on at least 11 types of 55% (n 28) worked on at least 9 types of 83% (n 45) worked on at least 6 types of 95% (n 52) worked on at least 4 types of Discussion The overall outcomes achieved by the specialty associations that participated in this project speak to their capacity to take on an issue and disseminate relevant information to members. In relation to s, associations clearly evidenced a readiness to ensure that their members had the knowledge to care for older adults. At the time they came into the project, associations varied as to their expertise in developing and disseminating best practices in care of older adults to their members. What is impressive is that all associations achieved substantive outcomes. One important focus of the project was to help associations create infrastructures that would sustain going forward. That 74% of associations did indeed work on developing infrastructure, 76% worked to develop or enhance a special interest group, and 52% worked to modify their scope and standards documents to include care of * A factor analysis suggests that these 15 activity areas can be conceptually reduced to 5 correlated major themes: 1) building association infrastructure including specialty exams, 2) promoting continuing interest through the development of formal documents, 3) using annual association meetings to promote issues, 4) using Web technologies for linkages and needs assessments, and 5) developing policy and seeking future grants. Geriatric Nursing, Volume 28, Number 6S 13

6 older adults reflects a strong step in creating an enduring presence within these associations. Efforts by associations to create a strong presence for at the board level are particularly impressive. The fact that each association conducted, on average, more than 8 types of speaks to the interest and involvement of associations in care of older adults. The 14 associations that worked on at least 11 types of had a total membership of more than 94,700. They ranged in size from associations with 29,000 members to those with as few as 200 members. Four associations had at least 10,000 members, and 6 had 2000 members or fewer. Although it can be assumed that associations with large memberships have paid staff, our data suggest that substantive and significant outcomes were achieved by associations with primarily volunteer staff and small memberships. It is likely that associations that made robust efforts to implement multiple are better positioned to sustain their once funding ceases than are those with fewer. Especially impressive were the structural changes made to ensure that association boards were informed about ; associations investment in organizational infrastructure, such as special interest groups; and the changes associations made to their scope and standards documents. These changes are likely to leave in place a strong footprint that will continue despite turnover of elected and administrative personnel. Similarly, the ability of some associations to implement enduring educational materials, fully detailed in subsequent articles, should also help sustain after the project ends. In summary, specialty associations have proved to be successful vehicles to provide ongoing education to thousands of practicing nurses who may not have received prior education to prepare them for the reality that a large portion of patients are older adults. Continued efforts on behalf of specialty associations to provide educational opportunities to members will benefit both nurses and the patients they care for. References 1. Health Care Financing Administration. National health expenditure projections Med Care Res Rev 1998;55: National Center for Health Statistics. Health care in America, trends in utilization. (DHHS Publication No : ). Hyattsville, MD; Berman A, Mezey M, Kobayashi M, et al. Gerontology nursing content in baccalaureate nursing programs: comparison of findings from J Prof Nurs 2005;21: Evans L, Strumpf N, Allen-Taylor S, et al. A clinical trial to reduce restraints in nursing homes. J Am Geriatr Soc 1997;45: Capezuti E, Maislin G, Strumpf N, et al. Siderail use and bed-related fall outcomes among nursing home residents. J Am Geriatr Soc 2002;50: Wanich C, Sullivan-Marx E, Gottlieb GL, et al. Functional status outcomes of a nursing intervention in hospitalized elderly. Image J Nurs Scholarship 1992; 24: Happ MB, Capezuti E, Strumpf N, et al. Advance care planning and end-of-life care for hospitalized nursing home residents. J Am Geriatr Soc 2002;50: Rantz MJ, Popejoy L, Petroski FG, et al. Randomized clinical trial of a quality improvement intervention in nursing homes. Gerontologist 2001;41: Landfield CS, Palmer RM, Kresevic DM, et al. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. New Engl J Med 1995;32: Lopez M, Delmore B, Ake, JM, et al. Implementing a resource nurse model. J Nurs Admin 2002;32: Rubin FH, Williams BS, Lescisin DA, et al. Replicating the Hospital Elder Life Program in a community hospital and demonstrating effectiveness using quality improvement methodology. J Am Geriatr Soc 2006;54: Naylor M, Brooten DA, Campbell RL, et al. Transitional care of older adults hospitalized with heart failure: a randomized clinical trial. J Am Geriatr Soc 2004;52: MATHY MEZEY, EdD, RN, FAAN, is professor and director at The Hartford Institute for Geriatric Nursing, New York University College of Nursing, New York. LINDA J. STIERLE, MSN, RN, CNAA, BC, is chief executive officer of the American Nurses Association, Silver Spring, Maryland. G. J. HUBA, PhD, is president of The Measurement Group, Culver City, California. JESSICA ESTERSON, MPH, is a program director at The Hartford Institute for Geriatric Nursing, New York University College of Nursing, New York /08/$ - see front matter 2008 Mosby, Inc. All rights reserved. doi: /j.gerinurse Geriatric Nursing, Volume 28, Number 6S