Advanced practice nursing in the care of frail older adults

Characterizing the high-risk homebound patients in need of nurse practitioner co-management

By providing more frequent provider visits, prompt responses to acute issues, and care coordination, nurse practitioner (NP) co-management has been beneficial for the care of chronically ill older adults. This paper describes the homebound patients with high symptom burden and healthcare utilization who were referred to an NP co-management intervention and outlines key features of the intervention. We compared demographic, clinical, and healthcare utilization data of patients referred for NP co-management within a large home-based primary care (HBPC) program (n = 87) to patients in the HBPC program not referred for co-management (n = 1027). A physician survey found recurrent hospitalizations to be the top reason for co-management referral and a focus group with nurses and social workers noted that co-management patients are typically those with active medical issues more so than psychosocial needs. Co-management patients are younger than non-co-management patients (72.31 vs. 80.30 years old, P < 0.001), with a higher mean Charlson comorbidity score (3.53 vs. 2.47, P = 0.0001). They have higher baseline annual hospitalization rates (2.27 vs. 0.61, P = 0.0005) and total annual home visit rates (13.1 vs. 6.60, P = 0.0001). NP co-management can be utilized in HBPC to provide intensive medical management to high-risk homebound patients.

The Role of the Advanced Practice Nurse in Geriatric Oncology Care

OBJECTIVES

To describe how the Advanced Practice Nurse (APN) is uniquely suited to meet the needs of older adults throughout the continuum of cancer, to explore the progress that APNs have made in gero-oncology care, and make suggestions for future directions.

DATA SOURCE

Google Scholar, PubMed, and CINAHL. Search terms included: "gero-oncology," "geriatric oncology," "Advanced Practice Nurse," "Nurse Practitioner," "older adult," "elderly," and "cancer."

CONCLUSION

Over the last decade, APNs have made advances in caring for older adults with cancer by playing a role in prevention, screening, and diagnosis; through evidence-based gero-oncology care during cancer treatment; and in designing tailored survivorship care models. APNs must combat ageism in treatment choice for older adults, standardize comprehensive geriatric assessments, and focus on providing person-centered care, specifically during care transitions.

IMPLICATIONS FOR NURSING PRACTICE

APNs are well-positioned to help understand the complex relationship between risk factors, geriatric syndromes, and frailty and translate research into practice. Palliative care must expand beyond specialty providers and shift toward APNs with a focus on early advanced care planning. Finally, APNs should continue to establish multidisciplinary survivorship models across care settings, with a focus on primary care.

Design of a Predictive Scheduling System to Improve Assisted Living Services for Elders

As the number of older adults increases, and with it the demand for dedicated care, geriatric residences face a shortage of caregivers, who themselves experience work overload, stress, and burden. We conducted a long-term field study in three geriatric residences to understand the work conditions of caregivers with the aim of developing technologies to assist them in their work and help them deal with their burdens. From this study, we obtained relevant requirements and insights to design, implement, and evaluate two prototypes for supporting caregivers’ tasks (e.g., electronic recording and automatic notifications) in order to validate the feasibility of their implementation in situ and their technical requirements. The evaluation in situ of the prototypes was conducted for a period of 4 weeks. The results of the evaluation, together with the data collected from 6 months of use, motivated the design of a predictive schedule, which was iteratively improved and evaluated in participative sessions with caregivers. PRESENCE, the predictive schedule we propose, triggers real-time alerts of risky situations (e.g., falls, entering off-limits areas such as the infirmary or the kitchen) and informs caregivers of routine tasks that need to be performed (e.g., medication administration, diaper change, etc.). Moreover, PRESENCE helps caregivers to record caring tasks (such as diaper changes or medication) and well-being assessments (such as the mood) that are difficult to automate. This facilitates caregiver's shift handover and can help to train new caregivers by suggesting routine tasks and by sending reminders and timely information about residents. It can be seen as a tool to reduce the workload of caregivers and medical staff. Instead of trying to substitute the caregiver with an automatic caring system, as proposed by others, we propose our predictive schedule system that blends caregiver assessments and measurements from sensors. We show the feasibility of predicting caregiver tasks and a formative evaluation with caregivers that provides preliminary evidence of its utility.

Internal consistency and construct validity assessment of a revised Facts on Aging Quiz for Flemish nursing students: an exploratory study

BACKGROUND

Since more people are reaching older and older ages, healthcare systems are becoming in need of more and more knowledgeable nurses to meet the specific health care needs of older persons. Several instruments exist to measure and evaluate students' knowledge of older persons, ageing, and gerontological care; however, unequivocal evidence on their use and psychometric properties is scarce. The aim of the study was to validate a revised version of Palmore's Facts on Aging Quiz (FAQ).

METHODS

A cross-sectional, exploratory study was conducted. Palmore's FAQ version 1 and Facts on Aging Mental Health Quiz were used as bases for the development of a revised FAQ instrument. Three researchers translated these instruments into Dutch. A panel of nine experts in geriatric research and gerontological care evaluated the translation and the face and content validity of the instrument. We used a cross-sectional, exploratory design to assess its internal consistency and construct validity. Cronbach's alpha coefficients, exploratory factor analysis, and the known-groups technique were used for these analyses.

RESULTS

Based on the experts' consensus, a revised version of the FAQ, consisting of 36 items, was produced. Exploratory factor analysis did not reveal underlying constructs suggesting that the revised version encloses a more general concept of knowledge (e.g. about older persons, aging, gerontological care). Using the known-groups technique, we validated the instrument, showing that it discriminates between the knowledge of first- and third-year nursing students. The overall Cronbach's coefficient of 0.723 was acceptable and changed minimally (from 0.708 to 0.724) when items were removed.

CONCLUSION

We conclude that the revised version of the FAQ can be used to properly evaluate nursing students' knowledge about older persons and gerontological care, as reasonable reliability and validity were established for this revised version of the FAQ.

Provider staffing effect on a decision aid intervention

This study examined the association between Nurse Practitioner (NP) and Physician Assistant (PA) staffing in nursing homes and the effect of a decision aid regarding feeding options in dementia on the frequency of surrogate-provider discussions and on surrogates' decisional conflict. We compared these outcomes for facilities that had no NPs/PAs, part-time-only NP/PA staffing, and full-time NP/PA staffing. The sample included 256 surrogate decision makers from 24 nursing homes. The decision aid was associated with significant increases in discussion rates in facilities with part-time or no NP/PA staffing (26% vs. 51%, p < .001, and 13% vs. 41%, p < .001, respectively) and decreases in decisional conflict scores (-0.08 vs. -0.047, p = .008, and -0.30 vs. -0.68, p = .014, respectively). Sites with full-time NP/PA staffing had high baseline rates of discussions (41%). These findings suggest that the decision aid and full-time NP/PA staffing can enhance surrogate decision making in nursing homes.

Effects of an advanced practice nurse in-home health consultation program for community-dwelling persons aged 80 and older

Objectives

To evaluate the effects of an advanced practice nurse (APN) in-home health consultation program (HCP) on quality of life, health indicators (falls, acute events), and healthcare utilization.

Design

Randomized clinical trial.

Setting

One urban area in the German-speaking part of Switzerland.

Participants

Four hundred sixty-one community-dwelling individuals aged 80 and older (mean age 85, 72.7% female, all Caucasian) participated in the intervention (n = 231) and control (n = 230) groups.

Intervention

After a comprehensive geriatric assessment, participants were randomly assigned to the 9-month HCP with four in-home visits and three phone calls from APNs or to a control group with standard care with no intervention.

Measurements

The primary outcome was quality of life at 3, 6, and 9 months. Secondary outcomes were incidence of falls, acute events due to health problems, and healthcare utilization measured for 3-month periods at 3, 6, and 9 months.

Results

The intervention and control groups did not differ significantly on any dimension of the World Health Organization Quality of Life questionnaire but differed significantly over 9 months in self-reported acute events (116 vs 168, relative risk (RR) = 0.70, P = .001), falls (74 vs 101, RR = 0.71, P = .003), consequences of falls (63.1% vs 78.7%, chi-square = 7.39, P = .007), and hospitalizations (47 vs 68, RR = .70, P = .03).

Conclusion

The in-home HCP provided by APNs and guided by the principles of health promotion, empowerment, partnership, and family-centeredness, can be effective in reducing adverse health outcomes such as falls, acute events, and hospitalizations.

A qualitative analysis of an advanced practice nurse-directed transitional care model intervention

PURPOSE

The purpose of this study was to describe barriers and facilitators to implementing a transitional care intervention for cognitively impaired older adults and their caregivers lead by advanced practice nurses (APNs).

DESIGN AND METHODS

APNs implemented an evidence-based protocol to optimize transitions from hospital to home. An exploratory, qualitative directed content analysis examined 15 narrative case summaries written by APNs and fieldnotes from biweekly case conferences.

RESULTS

Three central themes emerged: patients and caregivers having the necessary information and knowledge, care coordination, and the caregiver experience. An additional category was also identified, APNs going above and beyond.

IMPLICATIONS

APNs implemented individualized approaches and provided care that exceeds the type of care typically staffed and reimbursed in the American health care system by applying a Transitional Care Model, advanced clinical judgment, and doing whatever was necessary to prevent negative outcomes. Reimbursement reform as well as more formalized support systems and resources are necessary for APNs to consistently provide such care to patients and their caregivers during this vulnerable time of transition.

A structure and process evaluation of an Australian hospital admission avoidance programme for aged care facility residents

AIM

To describe and evaluate the structures and processes involved in a hospital in the Nursing Home programme.

BACKGROUND

Older Australians are the largest consumers of healthcare, and as a result of the ageing process are at risk of developing hospital acquired iatrogenic complications. Hospital admission avoidance programmes that aim to provide care for patients in their own environment include Hospital in the Home and, more recently, Hospital in the Nursing Home.

METHODS

In 2006, a qualitative evaluation of a nurse-led Hospital in the Nursing Home programme using semi-structured interviews with 19 stakeholders was undertaken. Data analysis involved using start codes and content analysis.

FINDINGS

Effective referral and communication strategies were important for Hospital in the Nursing Home implementation. Furthermore, the Hospital in the Nursing Home programme manager had acute care and community experience and worked in an advanced practice role. These elements were integral to the programme's operation.

CONCLUSION

As the population ages, reducing hospital admissions for aged-care facility residents has the potential to improve patient outcomes. A structurally and procedurally sound programme is a key element in achieving this aim.

Fewer hospitalizations result when primary care is highly integrated into a continuing care retirement community

Meeting the medical and social needs of elderly people is likely to be costly, disruptive, and at odds with personal preferences if efforts to do so are not well coordinated. We compared two different models of primary care in four different continuing care retirement communities. In the first model, used in one community, the physicians and two part-time nurse practitioners delivered clinical care only at that site, covered all settings within it, and provided all after-hours coverage. In the second model, used in three communities, on-site primary care physician hours were limited; the same physicians also had independent practices outside the retirement community; and after-hours calls were covered by all members of the practices, including physicians who did not practice on site. We found that residents in the first model had two to three times fewer hospitalizations and emergency department visits. Only 5 percent of those who died did so in a hospital, compared to 15 percent at the other sites and 27 percent nationally. These findings provide insight into what is possible when medical care is highly integrated into a residential retirement setting.

Care coordination: a priority for health reform

Care coordination is one of the priorities to transform the health care system (Institute of Medicine). Nurses have taken on the central role in care coordination for decades, and are now being recognized for expertise in care coordination. Attention has focused on nursing models that use care coordination and report outcomes. Nursing care coordination models emphasize patient education, engagement of patients and families in prevention, self-care, and adoption of health information technology to improve access to information. Policy recommendations needed to enhance care coordination include the following: (a) facilitate better information transfer with wider use of information technology, (b) include Nurse Practitioners (NPs) as equal practitioners in reimbursement, (c) create incentives to improve coordination of care, (d) reward the use of evidence-based practices, and (e) advocate for better care coordination models that include interdisciplinary teams and greater health system integration.

Expanding the knowledge base of resident and facility outcomes of care delivered by advanced practice nurses in long-term care: expert panel recommendations

In 2003, a panel of nationally recognized experts in geriatric practice, education, research, public policy, and long-term care convened to examine and make recommendations about care quality and safety issues related to advanced practice nurses (APNs) in nursing home practice. This article reports on the panel recommendation that addressed expanding the evidence base of resident and facility outcomes of APN nursing home practice. A review of the small but important body of research related to nursing home APN practice suggests a positive impact on resident care and facility outcomes. Recommendations are made for critically needed research in four key areas: (a) APN nursing home practice, (b) relative value unit coding, (c) outcomes related to geropsychiatric and mental health nursing services, and (d) outcomes related to geriatric specialization. The APN role could be significantly enhanced and executed if its specific contribution to resident and facility outcomes was more clearly delineated through the recommended rigorous research.

Describing gerontological nursing: an academic exercise or prerequisite for progress?

AIMS AND OBJECTIVES

To develop a practitioner-led description of gerontological nursing and articulate the principles which underpin its practice.

BACKGROUND

As the population ages expertise in gerontological nursing will become increasingly important. However, a complete and widely accepted delineation of the rationale, philosophy, knowledge base and special skills for gerontological nursing is yet to be developed.

METHODS

As one cycle of a larger action research project informed by realistic evaluation, a representative sample of 30 Scottish nurses worked together as a Community of Practice to develop a description of gerontological nursing that would have utility in their practice and in the development of best practice care guidance. Data collection involved group interviews and records of on-line discussions. Data were analysed using content analysis. The emerging description was verified through external consultation with other nursing colleagues and older people.

RESULTS

Nursing older people within Scotland was perceived as low status and participants reported that a positive reframing of gerontological nursing was needed. A description and underlying principles were developed by nurses and used as a lens to shape best practice statements. The description embraces a person-centred and enabling approach to evidenced-based gerontological nursing.

CONCLUSIONS

Gerontological practice requires an accessible consensus view and description to support its development. Practising nurses developed such a view and its utility has been seen in the development of best practice statements. Relevance to clinical practice. The description and principles of gerontological nursing can be used to guide nursing practice, practice development and research.

Working with older adults: a nurse practitioner's experience from a humanbecoming perspective

Although nurse practitioners use medical knowledge and skills for diagnosing and treating various diseases, the approach to care for their patients should be firmly grounded in nursing science from a nursing theoretical perspective. This column explicates a nurse practitioner's experiences working with community-dwelling older persons in a house-call program and using the theory of humanbecoming as a guide for practice. Three practice situations are described to illustrate the humanbecoming approach to nurse practitioner practice.

Mealtime care on a geriatric- psychiatric ward from the perspective of the caregivers: a qualitative case study design

This study aims to obtain insight into the care process surrounding mealtimes within a geriatric-psychiatric ward from the perspective of the caregivers. A qualitative study was carried out in accordance with the case study method. Data was generated by participant observation, semi-structured interviews, and focus groups. A mealtime turned out to be a much more complex event than it appears to be, looking at it superficially. The caregivers recognize the valuable therapeutic meaning of the mealtime. Nevertheless, they experience internal conflict when it comes to certain significant problem areas in their search for a balance between the functional-organizational approach and the patient-oriented approach.

Critical thinking: what does it mean in the care of elderly hospitalized patients?

In today's complex healthcare environment, it is more important than ever that nurses possess critical thinking skills to provide optimal care for their patients. This article offers a definition of critical thinking for nurses and describes the importance of critical thinking in the care of our growing elderly patient population. Examples related to geriatric nursing care, including acute care, dementia care, and end-of-life care, are provided to reinforce the importance of critical thinking and its benefits to our elderly patient population.

Optimizing reserve in hospitalized elderly

Aging is a multidimensional process that involves the physical, psychosocial, and spiritual domains. The reserves in each of these areas are challenged during the stressful experience of acute and critical care illness and hospitalization. It is imperative that hospital nursing staff recognize the vulnerability of the elderly and take appropriate evidence-based interventions to prevent avoidable decline and deterioration. There are opportunities for nurses to strengthen reserve in the elderly in the areas of practice, research, education, and policy.

Continuity of care for acutely unwell older adults from nursing homes

BACKGROUND

Continuity of care (COC) for acutely unwell older adults, particularly those who are nursing home residents, who present to hospital, is complicated by the presence of co-morbid conditions, long waiting times, both for the ambulance and in the department, and poor after-hours general practitioner access.

AIM

To present a critical review of the literature on COC for older adults from nursing homes who present to hospital and who are acutely unwell. The review will answer the following questions: (i) What is the contemporary meaning of the construct continuity of care? (ii) What is the relevance of continuity of care to the population of older adults who reside in nursing homes and present to hospital? and (iii) What models exist for promoting continuity of care to older adults who present to hospital?

METHOD

Guided by the conceptual analysis process a database search of CINAHL and MEDLINE was carried out utilizing the search terms 'continuity of care', 'older adults', 'nursing homes', 'emergency department' and 'acute illness'. A hand-search of additional references was also conducted. Retrieved articles were critically reviewed if they focused on older adult patients, the acute care/community settings and COC.

FINDINGS

The contemporary meaning of the COC is that it incorporates care of an individual patient over time by bridging discrete elements in the care pathway. Four distinct models of COC were identified. These were Primary Health Care; General Practice and Primary Medical Care; Consumers; and Health Policy and Systems. All are based on the proviso that the individual is sufficiently independent to be able to coordinate their own care and to take overall responsibility.

CONCLUSIONS

The connection between COC and acutely unwell older adults who present to hospital is a prolific area for further research. In particular, the effectiveness of programmes aimed at enhancing the advanced nursing practice role and the COC process for older adults, needs investigation.

Communication enhancement: nurse and patient satisfaction outcomes in a complex continuing care facility

AIMS

This paper presents an evaluation of a communication enhancement intervention on staff and patients in a complex continuing care facility.

BACKGROUND

The importance of effective communication as a fundamental element of nursing has been emphasized and is regarded as integral to the provision of quality patient care. For people residing in complex continuing care (similar to long-term care facilities), opportunities for socialization occur primarily during interactions or communication with staff, and these interactions have been found to be limited. One way to improve nursing staff communication is through a communication enhancement intervention.

METHODS

Twenty-one nursing staff members (Registered Nurses, Registered Practical Nurses and healthcare aides) working in a complex continuing care environment and 16 patients participated in this study, conducted in the summer of 2003. A repeated measures design was used to evaluate the effects of the communication enhancement intervention on outcomes. Data were collected from patients and nurses at baseline, 5 weeks into the intervention and at 10 weeks after the intervention. Nurse outcome variables included nurses' job satisfaction and their relationships with patients; patient outcome variables included two measures of patient satisfaction with care.

RESULTS

Nursing staff felt closer to their patients (F(2,40) = 3.0, P = 0.045) following the intervention and reported higher levels of job satisfaction (F(2,40) = 4.1, P = 0.02). No changes were found in the level of patient satisfaction with care.

CONCLUSIONS

Our results suggest that nursing staff can feel better about their job and about their patients as they enhance their communication skills. Understanding the barriers to finding time to talk with patients for a few minutes a day, outside of direct hands-on caregiving, requires further exploration.

An exploration of nurse practitioner care to homebound frail elders

PURPOSE

To identify and classify care activities of nurse practitioners (NPs) providing primary care for frail homebound elders and to describe NPs' perceptions of the outcomes of their care activities.

DATA SOURCES

Three focus groups were held with 24 NPs with at least 1-year experience in caring for frail homebound elders to elicit NPs' descriptions of their practice. In addition, individual interviews with 10 NPs and participant observation of 2 NPs visiting elders in their homes validated the data. The total sample size was 36 NPs. Field notes and audiotapes were transcribed for analysis and coded using Brykczynski's existing domains and competencies of NP practice.

CONCLUSIONS

Most of the care activities of NPs providing primary care to frail elders in their home involve management of patient health and illness, case management, and the teaching-coaching function. The NP informants believe that they prevent medication errors, falls, emergency room visits, hospitalizations, and even death. They reported that they improve their patients' quality of life and help to provide a peaceful death when death is imminent.

IMPLICATIONS FOR RESEARCH

Further refinement of the proposed model is needed in order to examine the effectiveness of NP care on clinically relevant patient outcomes.

Hospitalizations during the last months of life of nursing home residents: a retrospective cohort study from Germany

Background

To describe hospitalisations of nursing home (NH) residents in Germany during their last months of life.

Methods

Retrospective cohort study on 792 NH residents in the Rhine-Neckar region in South-West Germany, newly institutionalized in the year 2000, who died until the study end (December 2001). Baseline variables were derived from a standardized medical examination routinely conducted by the medical service of the health care insurance plans in Germany. Information on hospitalisations and deaths was extracted form records of the pertinent health insurance plans.

Results

NH residents who died after NH stay of more than 1 year spent 5.8% of their last year of life in hospitals. Relative time spent in hospitals increased from 5.2% twelve months before death (N = 139 persons) to 24.1% in their last week of life (N = 769 persons). No major differences could be observed concerning age, gender or duration of stay in NH. Overall, 229 persons (28.9%) died in hospital. Among these, the last hospital stay lasted less than 3 days for 76 persons (31.9%). Another 25 persons (3.2%) died within three days after hospital discharge.

Conclusion

Our study indicates that proximity of death is the most important driver of health care utilization among NH residents. The relation of age or gender to health care expenditures seem to be weak once time to death is controlled for. Duration of NH stay does not markedly change rates of hospitalisation during the last months of life.

Strategies to Increase Research-based Practice

PURPOSE

A major focus of clinical nurse specialist nursing practice is the integration of research findings into practice. The purpose of this study was to describe strategies used to facilitate research utilization (RU) by nurses in a practice setting.

DESIGN

This multiple-case study identified the strategies that clinical nurse specialists and master's degree-prepared nurse educators, working collaboratively, used to facilitate RU.

SETTING/SAMPLE

The setting included 8 units in 4 sites of a university hospital with all willing nurses participating.

METHODS

Open-ended focus groups and individual interviews and observational sessions were conducted using investigator-designed interview guides. Comprehensive qualitative analysis led to identification of categories and themes related to RU and the unit culture that supported it.

FINDINGS

Findings demonstrated that strategies to facilitate RU by staff at the unit level included conducting original research, supporting nurses participating in research, assessing and meeting staff learning needs, promoting staff attendance at conferences, stimulating goal-setting for presentations and publications, encouraging and responding to new ideas, questioning practice and stimulating inquiry, capitalizing on expertise in research knowledge and skills, and generating information and material resources. Characteristics of unit culture were linked to varying degrees of success with these strategies. The interplay of strategies with unit culture and research-based practice is described.

CONCLUSION

A wide repertoire of strategies is needed to facilitate RU, and the outcome of these strategies is influenced by the unit culture.

IMPLICATIONS FOR PRACTICE

Consideration of the findings and the scope of the strategies used by nurses in the study can help clinical nurse specialist and other nursing leaders facilitate the building of practice on research.

The Employment of Nurse Practitioners and Physician Assistants in U.S. Nursing Homes

PURPOSE

Nursing facilities with nurse practitioners or physician assistants (NPs or PAs) have been reported to provide better care to residents. Assuming that freestanding nursing homes in urban areas that employ these professionals are making an investment in medical infrastructure, we test the hypotheses that facilities in states with higher Medicaid rates, and those in more competitive markets and markets with higher managed care penetration, are more likely to employ NPs or PAs.

DESIGN AND METHODS

The Online Survey Certification and Reporting System (OSCAR) database, Area Resource File, and information from surveys of state policies from 1993 to 2002 are used to study the employment of NPs or PAs, using a cross-sectional time-series generalized estimating equation model with surveys nested within facilities, testing several market and state-policy effects while controlling for facility and market characteristics.

RESULTS

Throughout the 1990s the proportion of nursing facilities with NPs or PAs doubled, from less than 10% to over 20%. Facilities in states in the upper quartile of Medicaid reimbursement rates were 10% more likely to employ NPs or PAs. Facilities in more competitive markets, and in markets with higher managed care penetration, were more likely to employ NPs or PAs (adjusted odds ratio = 1.27, 1.20 respectively).

IMPLICATIONS

More generous state Medicaid nursing home reimbursement and higher competition may advance the investment in medical infrastructure, which in turn may positively affect the quality of care provided to nursing home residents.

Development and psychometric testing of the EverCare Nurse Practitioner Role and Activity Scale (ENPRAS)

PURPOSE

To develop and test an instrument measuring the frequency of the performance of role activities by EverCare nurse practitioners (NPs), who provide primary care to nursing home residents.

DATA SOURCES

One hundred thirty-one EverCare Nurse Practitioner Role and Activity Scale (ENPRAS) activities were identified through telephone interviews (n= 11), participant observation (n= 5), and a focus group (n= 4).

CONCLUSIONS

Two content validity tests (n= 11; n= 15) (Content Validity Index > or = .78 for all retained items) and internal consistency reliability testing (n= 127; Cronbach's alpha = .78-.96) yielded 99 activities arranged in six role subscales-Collaborator, Clinician, Care Manager/Coordinator, Counselor, Communicator/Cheerleader, and Coach/Educator.

IMPLICATIONS FOR PRACTICE

The ENPRAS can be used to measure similarities and differences in NP practice activities performed by EverCare NPs working at different EverCare program sites and to compare practice activities performed by EverCare NPs and other NPs. The EverCare program is sponsored by United Health Care, which leads the field in collaborative NP/MD primary care in nursing homes. Future studies should be directed toward testing the generalizability of the ENPRAS with NPs working in other collaborative models, as well as NPs in noncollaborative models of care delivery in the long-term care setting.

Minimizing the use of restrictive devices in dementia patients at risk for falling

The accumulating empirical evidence demonstrates that restrictive devices can be removed without negative consequences. Most importantly, use of nonrestrictive measures has been correlated with positive patient outcomes and represents care that is dignified and safe for confused elders. Most of these nonrestrictive approaches promote mobility and functional recovery; however, testing of individual interventions is needed to further the science. As the research regarding restrictive devices has been translated into professional guidelines and regulatory standards, the prevalence of usage has declined dramatically. New institutional models of care discouraging routine use of restrictive devices also will foster innovative solutions to clinical problems associated with dementia.

Care of the elderly as a global nursing issue

The size of the world's elderly population is growing at a rapid rate, with the 60 and older population of Europe and North America outpacing total population growth in recent decades. As life expectancy lengthens, the quality of that life becomes an issue of importance to nursing practitioners and nursing educators. Developed countries and developing countries will be faced with different challenges when determining service delivery models for their aging populations. Innovation in delivery models and comprehensive and longitudinal data are needed if the goal of aging in place is to be achieved.