Reflection & Dialogue #5 - Care of Older Adults, March 2010

ACES Project (Advancing Care Excellence for Seniors)

Care of Older Adults
March 2010 

Introduction

The National League for Nursings mission is to advance excellence in nursing education to build a strong and diverse nursing workforce. It is essential to that mission that we lead in setting standards for teaching students how to manage the complexity of care for multi-ethnic older adults. The focus must be on health promotion in a wide variety of environments, such as independent living, rehabilitation and home settings, and acute care facilities. Since new graduates of nursing programs must be competent in caring for older adults across multiple health settings (Institute of Medicine, 2008), it is crucial that nursing students understand how coordinating care during significant life transitions for older adults is fundamental to ensuring culturally competent, individualized, holistic care for older adults and their care-givers. Yet this focus may not be sufficiently emphasized in todays nursing curricula. 

During the past 20 years, the integration and strengthening of learning experiences about nursing care for older adults has been advocated by national funders. For example, the Robert Wood Johnson Foundation funded the Teaching Nursing Home Project (1982-1987) to improve the quality of nursing home care and the clinical education of nurses by linking nursing schools with nursing homes. And the W.K. Kellogg Foundation funded the Community College Nursing Home Partnership grant (1986-1993) to enhance gerontological nursing education in two-year associate degree programs. 

Since 1996, the John A. Hartford Foundation has authorized more than $70 million for programs related to gerontological nursing at the baccalaureate, masters, and doctoral levels. Extensive funding to the American Academy of Nursing (AAN) and to the American Association of Colleges of Nursing (AACN) has fostered increased doctoral preparation of gerontological nurse researchers, the development of a wide range of comprehensive, up-to-date on-line resources through the Hartford Institute for Geriatric Nursing at New York University, and faculty development and leadership initiatives. More recently, the Hartford Foundation expanded its focus to all pre-licensure nursing programs. 

All these initiatives aim to raise the visibility of gerontological nursing, improve gerontological nursing education practice and research, address the critical shortage of nursing leaders in gerontological nursing research and education, and create centers of gerontological nursing excellence. The NLNs ACES (Advancing Care Excellence for Seniors) project, a partnership of the National League for Nursing and Community College of Philadelphia, funded by the John A. Hartford Foundation, Laerdal Medical, and the Independence Foundation, is the latest effort to foster gerontological integration in all pre-licensure nursing programs nationally. NLNs ACES will build upon existing Hartford Foundation-funded resources and competencies, as well as new resources and strategies developed by the National League for Nursing and Community College of Philadelphia.

These philanthropic efforts have been designed to increase the nations capacity to provide high quality, affordable care to our rapidly growing older adult population. But despite these concerted efforts to bring care of this group to the forefront of nursing education, a major gap continues to exist in knowledge and experience related to care of older adults. How will nurse faculty substantively change pre-licensure nursing curricula to teach students to manage the complexity of care for older adults in emerging environments?

Considerations/Concerns

• The need for health care professionals educated in geriatric principles escalates every year. Approximately 50 percent of patients in hospital and ambulatory care settings are over 65 years of age and more than 90 percent of residents in nursing homes are older adults. Health care utilization models developed to project future demands for health care predict a 30 percent increase in hospital inpatient days, a 20 percent increase in outpatient visits, and a 17 percent increase in emergency department visits by 2020 (HRSA, Physician supply and demand: projections to 2020, 2006). "Much of this demand will be driven by the growth in the absolute number of older Americans, which will result in a greater total volume of illness and disability and a greater collective need for services from the health care system" (Institute of Medicine, 2008, p. 2-21).
  
  
• The 2008 Institute of Medicine report, Retooling for an Aging America: Building the Health Care Workforce, calls for fundamental reform in the way the workforce is educated and used to care for older adults. The report advocates an increase in both the size and the capabilities of the existing workforce to care effectively and efficiently for older adults with diverse needs and to account for the uniqueness of their background, personal preferences, culture, values, traditions, and family preferences. The situation forecasts a health care crisis as the number of older patients, with more complex health needs increasingly outpaces the number of health care providers with the knowledge and skills to adequately care for them. 
  
  
• A 2009 AARP report, Chronic Care: A Call to Action for Health Reform, emphasizes the staggering care needs that result from transitions among home, hospital, and other care settings. Overall, the report suggests, transitions are stressful for patients and care-givers and often precipitate communication, psychological, financial, and quality of care issues. The need to improve coordination of care and improve communication among health care providers in multiple settings through adoption of health information technology and better tools for people to manage chronic illnesses through transitions is critical to providing high quality, safe care and to support human flourishing in a wide variety of settings. 
  
  
• American 21st-century changing demographics, such as the dramatic growth in identified minorities (e.g. the Hispanic community), has made it essential to have a diverse ethnic racial nursing workforce. An important variable in preparing this workforce is the nurse educator from an ethnic racial background. Without a culture of caring built on the diversity of providers and educators, the nursing profession is short sighted in its vision to work successfully with the older adult population. 
  
  
• Older adults are among the nurses most complex clients. They represent a broad spectrum of strengths, needs, and expectations and come into contact with health professionals in a wide variety of settings. Major life transitions such as hospitalizations and other changes in living environments threaten quality of life and call for new approaches to individualized care such as interventions for health promotion, nutrition, function, safety, and social interactions. Unfortunately, the complexities of care for the older adult have not always been addressed in nursing education or in the learning experiences faculty create for students. To a great extent, nursing curricula today focus primarily on acute care needs.

Recommendations

• Faculty need to evaluate how their students learn about decision making by older adults and their families or caregivers about care before, during and following life transitions.



• The rapid changing field of gerontology requires that faculty update their knowledge in geriatric nursing through participation in local and national development programs.



• Innovative models for teaching holistic care of older adults must be developed and should include curricular and instructional resources for classroom, clinical, and simulation experiences.



• Make the older adult the prototype client in nursing curricula textbooks and software and technology resources in order to best teach complex care management within the context of multiple health care settings.



• Design intentional encounters with older adults during the program of learning is essential so that students learn how to 1) assess an older adults aging pattern, including the complex interplay of multiple chronic conditions and treatments, as well as individualized preferences, values, and cultural traditions; 2) evaluate clinical situations where standard treatment recommendations require modification to accommodate the older adults needs, wishes, and life transitions; and 3) promote improved functional status, quality of life, and maintenance of chronic conditions and end-of-life care in ways that are efficient, safer, higher quality, and effective.



• The NLN must reinforce its promotion of academic progression for all nurses. Because it is critical that nurses at every point on the continuum of entry into the profession become more prepared to work with the older adult, this progression would include strong gerontology content using multiple learning strategies such as simulations and other new technology to advance the knowledge and the practice of caring for our older adults.

Colleagues, these are our thoughts at this point. Please join us in the dialogue and of course, the reflection: 

1. As the number of older adults continues to increase, management of acute and chronic conditions, as well as implementation of interventions to promote health, function, quality of life, and end-of-life care converge in complex ways. Is this not a mandate to refocus and emphasize evidence-based care for older adults in nursing education curricula?



2. What essential experiences to promote health, function, and well-being and provide holistic, culturally competent, individualized care to older adults need to be incorporated into nursing curricula?



3. How can faculty more effectively teach students how to manage the complexity of care for older adults?

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References

AARP. (2009). Chronic care: A call to action for health care reform.
Washington, DC: AARP. 

HRSA. (2006). Physician supply and demand: Projections to 2020.
Rockville, MD: HRSA. 

Retooling for an aging America. Building the health care workforce. Washington, DC: The National Academies Press.