Nurses Improving Care for Healthsystem Elders - a model for optimising the geriatric nursing practice environment

The clinical advantages of making our hospitals older adult friendly

Older adults (≥65 years old), now comprise half of the inpatient population. Catering for the needs of this group requires consideration of the processes of care, the inpatient environment and care practices operating in our hospitals. Older adults are often multimorbid, more likely than older adults in the community to be malnourished and have coexistent physical and cognitive impairments. These older adults are at great risk of suffering hospital associated harms or being designated as "bed blockers", partly due to inadequate understanding of their needs, a failure of recognition or an unwillingness to address them. The adoption of older adult friendly care presents considerable opportunity to transform the manner in which care is delivered in order to mitigate avoidable harms and optimize outcomes for older adults. This review explores the nature of our older adult inpatients, the implications of older adult friendly care, the requirement for true interprofessional care, the advantages of systematic assessment which spans pre-hospital to post-hospital care and highlights specific interventions to deal with in hospital problems which differentially impair health related outcomes for older adults. As such it raises awareness of the needs of older adults under cardiological to improve outcomes for hospitalized older adults.

Experiential learning via a tour on the history of public health in Jerusalem in an epidemiology course for master of science in nursing students: A cross-sectional study

AIM

The aim of this study was to evaluate the incorporation of an educational tour into the curriculum for master's nursing students.

BACKGROUND

Experiential learning is an educational approach that emphasizes hands-on experiences outside the classroom. In a two-kilometer radius in Jerusalem are historical health institutions, established beginning in the 1830s through the British Mandate, from which much can be learned about the state of public health then and how it shaped modern institutions.

DESIGN

This was a cross-sectional study.

METHODS

This study utilized the feedback received by students through an evaluation survey sent out after the tour. The survey had questions on overall satisfaction, how the tour contributed to their knowledge, and the appropriateness of the tour as part of the course. Additionally, students were asked if the tour added to their experience and how in an open-ended question.

RESULTS

High scores were given for overall satisfaction, contribution to knowledge and the appropriateness of the tour. Additionally, four points were raised in the open-ended question: national pride in healthcare leadership, socio-political aspects and conflicts, the role of funding, and personal inspiration and professional development.

CONCLUSIONS

The tour evaluation emphasized the advantages of experiential learning, enabling a deep understanding of the healthcare system's historical development in a multicultural city, as well as lessons for the future.

Transition of Care for Older Adults Undergoing General Surgery

The demand for surgical intervention and hospitalization is expected to increase with the growth of the older adult population. Despite advances in technology and minimally invasive surgical procedures, the needs of the older adult in the perioperative period are unique. Transitions of care from the decision to support surgery through surgical intervention, subsequent hospitalization, and postacute discharge must be supported to achieve optimal patient outcomes. The clinical nurse specialist is well suited to address care delivery and assure implementation of best practices across the continuum.

Evaluation of Nurses’ Knowledge and Attitudes towards Older Adults and Associated Factors

Background:

Due to the increased risk of developing chronic diseases among older adults, their demand for health care has increased. Preparing nurses to care for the older adults is one of the most difficult challenges in nursing education.

Objective:

This study investigated nurses’ knowledge and attitudes towards older adults and demographic and occupational features that affect them.

Methods:

This cross-sectional study was conducted on 412 participants from July to October 2020. Patients were selected using a random sampling method. Three questionnaires were used: a socio-demographic form, an Older Patient in Acute Care Survey, and a Knowledge about Older Patients-Quiz.

Results:

According to the Pearson correlation test, there is a statistically significant and positive correlation between knowledge and general opinion (P = 0.000), (r = 0.271) as well as between practice experiences and general opinion (P = 0.000), (r = 0.205) of nurses about older adult’s care. There was no statistically significant relationship between knowledge and practice experiences (P = 0.857), (r = -. 009).

Conclusion:

Having a better understanding of the needs of the older adults would improve the quality of care that nurses provide to them.

A Scoping Review of the Evidence About the Nurses Improving Care for Healthsystem Elders (NICHE) Program

BACKGROUND AND OBJECTIVES

The Nurses Improving Care for Healthsystem Elders (NICHE) is a nurse-led education and consultation program designed to help health care organizations improve the quality of care for older adults. To conduct a scoping review of the evidence associated with the NICHE program to (a) understand how it influences patient outcomes through specialized care of the older adult and (b) provide an overview of implementation of the NICHE program across organizations as well as its impact on nursing professionals and the work environment.

RESEARCH DESIGN AND METHODS

Six databases were searched to identify NICHE-related articles between January 1992 and April 2019. After critical appraisal, 43 articles were included.

RESULTS

Four thematic categories were identified including specialized older adult care, geriatric resource nurse (GRN) model, work environment, and NICHE program adoption and refinement. Specialized older adult care, a key feature of NICHE programs, resulted in improved quality of care, patient safety, lower complications, and decreased length of stay. The GRN model emphasizes specialized geriatric care education and consultation. Improvements in the geriatric nurse work environment as measured by perceptions of the practice environment, quality of care, and aging-sensitive care delivery have been reported. NICHE program adoption and refinement focuses on the methods used to improve care, implementation and adoption of the NICHE program, and measuring its impact.

DISCUSSION AND IMPLICATIONS

The evidence about the NICHE program in caring for older adults is promising but more studies examining patient outcomes and the impact on health care professionals are needed.

Translation and content validation of the Geriatric Institutional Assessment Profile for Brazil

OBJECTIVE

to describe the process of content adaptation and validation of the Geriatric Institutional Assessment Profile (GIAP) for nurses working in the health care for older adults in Brazilian hospitals.

METHOD

methodological study conducted in five stages: initial translation, synthesis of initial translation, back translation, evaluation by committee of judges, and pre-test for cultural adaptation of the instrument.

RESULTS

the instrument evaluation had good agreement between the judges, with general content validity of 0.94. The items of the translated version evaluated as unsatisfactory by the judges were reformulated from the professionals' considerations in each group. Thirty-one subjects participated in the study. They considered the instrument easy-to-understand and suggested minor adjustments in some items.

CONCLUSION

the content of the Brazilian version of the GIAP is considered adapted and validated, with potential use in hospital institutions. The next stage will be to submit the instrument to the evaluation process of its psychometric properties for use in Brazilian populations.

Using a Nursing Salon to Identify and Develop an Initiative for Family Caregivers of Older Adults

The purpose of the Aging Well Nursing-Interprofessional Salon was to explore current local community healthcare issues for older adults and to develop innovative strategies that support and enhance their health. An initiative emerged from the salon that focuses on identifying caregivers to ensure their awareness of available support resources. We are in the process of developing a pilot plan that includes collaboration of PhD and doctorate of nursing practice students, nursing faculty, and community agencies that support older adults.

Geriatric nurse involvement during intra-hospital transitions

Geriatric nurses are skilled in the special needs of hospitalized older adults. While significant focus has been placed on improving care transitions upon discharge, less attention has been placed on intra-hospital transitions. Intra-hospital transitions represent transfers occurring between hospital units or rooms. Intra-hospital transitions challenge normal nursing workflow and require careful consideration of care coordination to prevent adverse events for older adults. Frequent changes in environment and a lack of consistency in care may support the development or prolongation of delirium as older adults are transferred between units and rooms. Additional adverse event risks include infections and falls, which also increases with each transfer. Geriatric nurse involvement can enhance communication between units as well as ensuring appropriate geriatric assessments occur. Geriatric nurses are thus well positioned to act as leaders during intra-hospital transitions, potentially reducing these and adverse events.

The feasibility of implementing education on older person care to practice on medical units: Nurses' perceptions and the influence of practice context

AIM

As part of a larger primary study on evidence-informed practice with hospitalised older people, we aimed to (a) examine nursing staffs' perceptions of the interactive geriatric educational intervention and to explore how perceptions of their work context may influence their ability to enact the evidence-informed assessment and care approaches discussed during the educational sessions and (b) compare differences in perceptions of context between RNs, LPNs and HCAs.

METHOD

A survey-based evaluation that used both closed and open-ended questions was conducted as part of an interactive educational intervention on cognitive impairment and managing responsive behaviours. Data were gathered on participants' perceptions of the education intervention and organisational context.

RESULTS

Findings from this study suggest when education is tailored to nurses' articulated educational needs, it is well received; however, barriers to implementation exist. Assessment of the context by using a standardised survey tool to get the nursing staffs' perceptions of organisational context revealed strengths in leadership support and day-to-day interactions with other nurses and healthcare professionals, but potential barriers related to lack of facilitation to transfer new knowledge into practice existed.

CONCLUSION

Providing evidence-based education related to care of older patients and evaluating nursing staffs' perceptions of the education and their context has laid the groundwork for a long-term relationship with the managers and nursing staff on the participating medical units. Further investigation about how best to incorporate the facilitator role into the medical units to support evidence-based practices with older patients is warranted.  IMPLICATIONS FOR PRACTICE: While nurses are receptive to new knowledge, the unpredictable workload of acute care creates challenges to implementing this new knowledge. Assessment of contextual factors that influence evidence-informed practice facilitates planning for implementation of new knowledge and support practice change.

Frailty Identification and Care Pathway: An Interdisciplinary Approach to Care for Older Trauma Patients

BACKGROUND

Frailty is a well-established marker of poor outcomes in geriatric trauma patients. There are few interventions to improve outcomes in this growing population. Our goal was to determine if an interdisciplinary care pathway for frail trauma patients improved in-hospital mortality, complications, and 30-day readmissions.

STUDY DESIGN

This was a retrospective cohort study of frail patients ≥65 years old, admitted to the trauma service at an academic, urban level I trauma center between 2015 and 2017. Patients transferred to other services and those who died within the first 24 hours were excluded. An interdisciplinary protocol for frail trauma patients, including early ambulation, bowel/pain regimens, nonpharmacologic delirium prevention, nutrition/physical therapy consults, and geriatrics assessments, was implemented in 2016. Our main outcomes were delirium, complications, in-hospital mortality, and 30-day readmission, which were compared with these outcomes in patients treated the year before the pathway was implemented. Multivariate logistic regression was used to determine the association of being on the pathway with outcomes.

RESULTS

There were 125 and 144 frail patients in the pre- and post-intervention cohorts, respectively. There were no significant demographic differences between the 2 groups. Among both groups, the mean age was 83.51 years (SD 7.11 years), 60.59% were female, and median Injury Severity Score was 10 (interquartile range 9 to 14). In univariate analysis, there were no significant differences in complications (28.0% vs 28.5%, respectively, p = 0.93); however, there was a significant decrease in delirium (21.6% to 12.5%, respectively, p = 0.04) and 30-day readmission (9.6% to 2.7%, respectively, p = 0.01). After adjusting for patient characteristics, patients on the pathway had lower delirium (odds ratio [OR] 0.44, 95% CI 0.22 to 0.88, p = 0.02) and 30-day readmission rates (OR 0.25, 95% CI 0.07 to 0.84, p = 0.02), than pre-pathway patients.

CONCLUSIONS

An interdisciplinary care protocol for frail geriatric trauma patients significantly decreases their delirium and 30-day readmission risk. Implementing pathways standardizing care for these vulnerable patients could improve their outcomes after trauma.

Development of a Comprehensive Geriatric Assessment Led by Geriatric Nurse Consultants: A Feasibility Study

Hospitalized older adults are at high risk for complications, leading to negative outcomes such as longer lengths of stay, hospital readmissions, and functional and cognitive decline. Comprehensive Geriatric Assessment (CGA) models are effective in mitigating these syndromes but are not widespread. Nurses with expertise in gerontology who can provide consultation and care coordination can improve care processes and clinical outcomes. This pilot study capitalized on the role of the geriatric nurse consultant (GNC) to develop, implement, and test the feasibility, acceptability, and utility of a GNC-led CGA. Through repeated applications with hospitalized patients, this study demonstrated that GNCs could complete a CGA and identify clinically actionable findings. This study also uncovered clinical geriatric concerns that would not have otherwise been identified via traditional nursing assessments. The results highlight contribution of a GNC-led CGA as a mechanism to support care process improvements to address common geriatric concerns in the acute care setting. [Journal of Gerontological Nursing, 44(12), 25-34.].

An Interdisciplinary Clinical Approach for Workplace Violence Prevention and Injury Reduction in the General Hospital Setting: S.A.F.E. Response

BACKGROUND: Workplace violence is a major public health concern. According to the U.S. Bureau of Labor Statistics, from 2002 to 2013, incidents of serious workplace violence (those requiring days off) were four times more common in health care than in private industry. AIMS: An interprofessional committee developed, implemented, and evaluated a quality improvement project from 2012 to 2016 to reduce workplace violence and prevent staff injury. The initiative termed S.A.F.E. Response stands for Spot a threat, Assess the risk, Formulate a safe response, Evaluate the outcome. METHOD: An institutional review board-approved quality improvement survey was implemented and evaluated. The data were analyzed using descriptive statistics. An interprofessional committee developed and implemented a comprehensive program to prevent injury, which included (a) a mandatory eLearning educational training, (b) a S.A.F.E. Response with standardized interventions for the clinical conditions affecting safety, and (c) a clinical debriefing process. A reduction in nursing staff assault incidence rates was identified as a success. RESULTS: Nursing staff injury rates decreased an average of 40%. CONCLUSIONS: A reduction in nursing staff assault incidence rates was notable. Clinicians equipped with knowledge, skills, and resources can identify and defuse unsafe situations to prevent violence. This clinical approach shifts the focus from crisis intervention to crisis prevention, which reduces injury.

Mortality and associated risk factors for older adults admitted to the emergency department: a hospital cohort

Background

Older emergency department patients are more vulnerable than younger patients, yet many risk factors that contribute to the mortality of older patients remain unclear and under investigation. This study endeavored to determine mortality and factors associated with mortality in patients over 60 years of age who were admitted to the emergency departments of two general hospitals in Mexico City.

Methods

This is a hospital cohort study involving adults over 60 years of age admitted to the emergency department and who are beneficiaries of the Mexican Institute of Social Security and residents of Mexico City.

All causes of mortality from the time of emergency department admission until a follow-up home visit after discharge were measured. Included risk factors were: socio-demographic, health-care related, mental and physical variables, and in-hospital care-related. Survival functions were estimated using Kaplan-Meier curves. Hazard ratios (HR) were derived from Cox regression models in a multivariate analysis.

Results

From the 1406 older adults who participated in this study, 306 (21.8%) did not survive. Independent mortality risk factors found in the last Cox model were age (HR = 1.02, 95% CI, 1.005–1.04; p = 0.01), length of stay in the ED (HR = 1.003, 95% CI = 0.99, 1.04; p = 0.006), geriatric care trained residents model in Hospital A (protective factor) (HR = 0.66, 95% CI = 0.46, 0.96; p = 0.031), and the FRAIL scale (HR of 1.34 95% CI, 1.02–1.76; p = 0.033).

Conclusions

Risk factors for mortality in patients treated at Mexican emergency departments are length of stay and variables related to frailty status.

Factors That Contribute to Recovery of Community Mobility After Hospitalization Among Community-Dwelling Older Adults

This study aimed to determine the proportion of older adults who recovered community mobility after hospitalization and identify factors associated with recovery. Using a random sample of 1,000 Medicare beneficiaries ≥65 years of age, we identified individuals with at least one hospitalization over 8.5 years of follow-up. Data were collected at baseline and every 6 months, including demographics, function, social support, community mobility measured by the UAB Life-Space Assessment (LSA), and overnight hospital admissions. Recovery was defined as a LSA score no more than five points lower than the prehospitalization LSA score at last follow-up. Overall, 339 participants (M age = 75.4 [SD = 6.6] years, 44% African American, 48% female) had at least one hospitalization. In the full logistic regression model, younger age (p = .007) and religious service attendance (p = .001) remained independently associated with recovery. An understanding of factors associated with recovery after hospitalization may provide a target for future interventions.

The Experience of Paid Family-Care Workers of People with Dementia in South Korea

PURPOSE

The South Korean government introduced the universal long-term care insurance program in 2008 that created a new employment category of "paid family-care worker" to assist the elderly with chronic illnesses including dementia. The aim of this study was to understand the lived experience of paid family-care workers of people with dementia in South Korea.

METHODS

The study was a qualitative research design underpinned by interpretive description principles involving eight paid family-care workers. The participants were recruited by attaching the advertisement flyer in a notice board of an educational facility for paid family-care workers.

RESULTS

Paid family-care workers struggled to manage the behavioral and psychological symptoms of their care recipients. Their workloads created physical, emotional, social, and financial burdens. However, the care-giving activities were encouraged through their sense of responsibility, filial piety, and personal religious beliefs. Financial subsidies from the government and help received from others were also identified as encouragements. The education course provided to them assisted them to improve their dementia-care capabilities.

CONCLUSION

Understanding paid family-care workers' lived experience in dementia care in South Korea assists with the identification of their educational needs and level of support they require to improve dementia care in the home care environment. A number of suggestions are made to increase paid family-care workers' knowledge, clinical skills, and job satisfaction to reduce their burdens and work-related incidents, such as challenging behaviors from those being cared for.

Nurse perception of care of hospitalized older adults - a comparative study between northern and central regions of Portugal

Objective:

to analyze the relationship between the perceptions of nurses about geriatric care (GC) environment and geriatric nurses’ knowledge and attitudes according to unit type considering the northern and central regions of Portugal.

Method:

a cross-sectional study was developed among 1068 Portuguese’s nurses in five hospitals. The instrument was Geriatric Institutional Assessment Profile - Portuguese version. The independent samples t-test was when the assumption of normality was verified, otherwise, the Mann-Whitney U test was used. The level of significance was 5%.

Results:

the profile of perceptions of GC showed a relatively homogeneous pattern (no statistically significant results were found). For the geriatric care environment scale, only the CC/ED units presented significant differences in all considered subscales (resource availability; aging-sensitive care; institutional values; and continuity of care), with more positive perceptions among nurses in the northern region. In Professional Issues scales, only the scale perception of burden related with upsetting behaviors revealed significant differences between regions in all specialties.

Conclusion:

the findings suggest the need for increased investment by hospital leaders to promote a geriatric nursing practice environment that supports the specialized needs of hospitalized older adults.

Nurses' attitudes towards older people care: An integrative review

AIMS AND OBJECTIVES

To examine hospital nurses' attitudes towards caring for older adults and delineate associated factors contributing to their attitudes.

BACKGROUND

Population ageing is of international significance. A nursing workforce able to care for the ageing population is critical for ensuring quality older adult care. A synthesis of research related to nurses' attitudes towards older adult care is important for informing care quality and the nursing workforce issues.

METHODS

A systematic integrative review process guided the review. Cumulative Index of Nursing and Allied Health Literature and Medline databases were searched for primary research published between 2005-2017. A total of 1,690 papers were screened with 67 papers read in-depth and eight selected for this review that met the inclusion/exclusion criteria.

RESULTS

Nurses' held coexisting positive and negative attitudes towards generic and specific aspects of older adult care. Negative attitudes, in particular, were directed at the characteristics of older adults, their care demands or reflected in nurses' approaches to care. Across jurisdictions, work environment, education, experience and demographics emerged as influences on nurses' attitudes.

CONCLUSION

There is a paucity of research examining nurses' attitudes towards older adult care. The limited evidence indicates that attitudes towards older people care are complex and contradictory. Influences on nurses' attitudes need further study individually and collectively to build a strong evidence base. Interventional studies are needed as are the development of valid and reliable instruments for measuring nurses' attitudes towards older adult care.

RELEVANCE TO CLINICAL PRACTICE

Bolstering postgraduate gerontological preparation is critical for promoting nurses' attitudes towards older adult care. Creating age-friendly work environments, including appropriate resource allocation, is important to support older people care and facilitate positive nursing attitudes.

Workplace continuing education for nurses caring for hospitalised older people

AIMS AND OBJECTIVES

To develop, implement and evaluate a workplace continuing education programme about nursing care of hospitalised older people.

BACKGROUND

The healthcare system cannot rely solely upon nurses' prelicensure education to prepare them to meet the evolving needs of hospitalised older patients. Over the past decade, there has been a dramatic rise in the proportion of older people in hospitals, yet many nurses do not have specialised knowledge about the unique care needs of this population.

DESIGN

A multimethod pre-to post-design was employed.

METHODS

Between September 2013 and April 2014, data were collected via surveys, focus groups and interviews. Thirty-two Registered Nurses initially enrolled in the programme of which 22 completed all data points. Three managers also participated in interviews. One-way repeated-measures ANOVAs were conducted to evaluate the effect of the programme and change over time. Qualitative data were analysed using thematic analysis.

RESULTS

Survey results indicated improvements in perceptions about nursing care of older people but no changes in knowledge. Themes generated from the qualitative data focused on participants' experiences of taking part in the programme and included: (i) relevance of content and delivery mode, (ii) value of participating in the programme and (iii) continuing education in the context of acute care.

CONCLUSIONS

This study illustrated the potential role of workplace continuing education in improving care for hospitalised older people, particularly the potential to change nurses' perceptions about this population. Nurses prefer learning opportunities that are varied in delivery of educational elder-focused content and accessible at work. Organisational leaders need to consider strategies that minimise potential barriers to workplace continuing education.

IMPLICATIONS FOR PRACTICE

Workplace continuing education can play a key role in improving quality of care for hospitalized older adults and ought to be a priority for employers planning education for nurses.

Creating a Geriatric-Focused Model of Care in Trauma With Geriatric Education

The literature suggests that by 2050, about 40% of all trauma patients will be over age 65 years. We already exceeded this prediction at Lehigh Valley Health Network in 2013, with 46.6% of the Pennsylvania trauma registry qualifiers being age 65 or greater, and 17.7% age 85 and greater. Currently, only 8.8% of trauma centers incorporate Geriatric Resource Programs into trauma care. Our trauma team has incorporated geriatric education for nurses by incorporating an educational nursing program called Nurses Improving Care for Healthsystem Elders, to improve outcomes, reduce hospital complications, and reduce health care costs for this high-risk population. The older adult population is on the rise and trauma nurses must be provided the tools to care for this high-risk patient group.

The extended palliative phase of dementia – An integrative literature review

This article presents an integrative literature review of the experience of dementia care associated with the extended palliative phase of dementia. The aim was to highlight how dementia is defined in the literature and describe what is known about the symptomatology and management of advanced dementia regarding the needs and preferences of the person with dementia and their family carer/s. There was no consistent definition of advanced dementia. The extended palliative phase was generally synonymous with end-of-life care. Advanced care planning is purported to enable professionals to work together with people with dementia and their families. A lack of understanding of palliative care among frontline practitioners was related to a dearth of educational opportunities in advanced dementia care. There are few robust concepts and theories that embrace living the best life possible during the later stages of dementia. These findings informed our subsequent work around the concept, ‘Dementia Palliare’.

Changing negative stereotypes regarding aging in undergraduate nursing students

OBJECTIVE

The aim of this study was to explore the modification of stereotypes and myths regarding aging among third-year nursing students before and after undergoing an Aging Nursing course.

METHOD

A within-subject repeated-measures descriptive study was conducted. The Negative Stereotypes Questionnaire about Aging (CENVE) was used.

RESULTS

The overall prevalence of negative stereotypes was 62.0% pre-intervention (P1) and 12.3% post-intervention (P2) measured; these values were 63.5% (P1) and 9.2% (P2) for the health factor, 43.1% (P1) and 4.9% (P2) for the motivation and social factors and 58.3% (P1) and 3.8% (P2) for the character-personality factor. Paired Student's t tests confirmed that the differences were statistically significant.

CONCLUSIONS

There was a high prevalence of negative stereotypes toward aging among the nursing students, even though they had conducted clinical practice and were in their third year. The course was demonstrated to be effective in modifying these stereotypes. The proper training of future professionals markedly contributes the dispensation of proper care and the eradication of ageism, which remains prevalent in the healthcare system.

Nurses' perspectives: hospitalized older patients and end-of-life decision-making

AIMS

To explore pressing issues identified by nurses caring for older patients in US NICHE (Nurses Improving Care for the Healthsystem Elders) hospitals, regarding palliative care and end-of-life (EOL) decision-making. Objectives are to (1) identify the most pressing palliative care and EOL decision-making issues and strategies to address them and (2) identify the association of nursing demographics (age, gender, race, education and experience), institutional/unit characteristics and these issues.

BACKGROUND

Critical care nurses have an integral role in supporting older patients and families faced with palliative care and EOL decision-making issues. Despite national imperatives to improve the quality of palliative care, patients continue to experience uncontrolled pain, inadequate communication, disregard of their wishes and life prolonging interventions. These contribute to increased hospitalizations and costs. Understanding the prevalent issues is needed to address patient needs at the end-of-life.

DESIGN

It is a mixed method study.

METHODS

A secondary analysis of the NICHE Geriatric Institutional Assessment Profile (GIAP) database (collected 1/08-9/13) was conducted using the sample of Critical Care RNs who provided comments regarding palliative care and EOL decision-making. Qualitative data were analyzed using Dedoose software. Data clusters and patterns of co-occurring codes were explored through an iterative analysis process. Themes were examined across nurse demographics, institutional and unit characteristics.

RESULTS

Comments specifically addressing issues regarding EOL decision-making were provided by 393 critical care nurses from 156 hospitals (x‾ age = 42·3 years, 51% BSN degree). Overarching theme was discordance in goals of care (prolonging life versus quality of life), ineffective physician-patient-family communication, lack of time and unrealistic expectations.

CONCLUSIONS

Nurses' descriptions highlight the need for increased communication, staff education and availability of palliative care services.

RELEVANCE TO PRACTICE

Palliative care and EOL decision-making will remain a nursing priority as people age and require increased care.

From research to reality: minimizing the effects of hospitalization on older adults

This review examines ways to decrease preventable effects of hospitalization on older adults in acute care medical (non-geriatric) units, with a focus on the Israeli experience at the Rambam Health Care Campus, a large tertiary care hospital in northern Israel. Hospitalization of older adults is often followed by an irreversible decline in functional status affecting their quality of life and well-being after discharge. Functional decline is often related to avoidable effects of in-hospital procedures not caused by the patient's acute disease. In this article we review the literature relating to the recognized effects of hospitalization on older adults, pre-hospitalization risk factors, and intervention models for hospitalized older adults. In addition, this article describes an Israeli comprehensive research study, the Hospitalization Process Effects on Functional Outcomes and Recovery (HoPE-FOR), and outlines the design of a combined intervention model being implemented at the Rambam Health Care Campus. The majority of the reviewed studies identified preadmission personal risk factors and psychosocial risk factors. In-hospital restricted mobility, under-nutrition care, over-use of continence devices, polypharmacy, and environmental factors were also identified as avoidable processes. Israeli research supported the findings that preadmission risk factors together with in-hospital processes account for functional decline. Different models of care have been developed to maintain functional status. Much can be achieved by interdisciplinary teams oriented to the needs of hospitalized elderly in making an impact on hospital processes and continuity of care. It is the responsibility of health care policy-makers, managers, clinicians, and researchers to pursue effective interventions to reduce preventable hospitalization-associated disability.

Portuguese nurses' knowledge of and attitudes toward hospitalized older adults

Portugal is impacted by the rapid growth of the aging population, which has significant implications for its health care system. However, nurses have received little education focusing on the unique and complex care needs of older adults. This gap in the nurses' education has an enormous impact in their knowledge and attitudes and affects the quality of nursing care provided to older adults. A cross-sectional study was conducted among 1068 Portuguese nurses in five hospitals (northern and central region) with the following purposes: (i) explore the knowledge and attitudes of nurses about four common geriatric syndromes (pressure ulcer, incontinence, restraint use and sleep disturbance) in Portuguese hospitals; and (ii) evaluate the influence of demographic, professional and nurses' perception about hospital educational support, geriatric knowledge, and burden of caring for older adults upon geriatric nursing knowledge and attitudes. The mean knowledge and attitudes scores were 0.41 ± 0.15 and 0.40 ± 0.21, respectively (the maximum score was 1). Knowledge of nurses in Portuguese hospitals about the four geriatric syndromes (pressure ulcers, sleep disturbance, urinary incontinence and restraint use) was found inadequate. The nurses' attitudes towards caring for hospitalized older adults were generally negative. Nurses who work in academic hospitals demonstrated significantly more knowledge than nurses in hospital centers. The attitudes of nurses were significantly associated with the hospital and unit type, region, hospital educational support, staff knowledge, and perceived burden of caring for older adults. The study findings support the need for improving nurses' knowledge and attitudes towards hospitalized older adults and implementing evidence-based guidelines in their practice.

Factors Influencing RNs’ Perceptions of Quality Geriatric Care in Rural Hospitals

The rapidly aging population and their frequent use of hospital services will create substantial quality challenges in the near future. Redesigning rural hospital work environments is the key to improving the quality of care for older adults. This study explored how the work environment influences registered nurses’ (RNs’) perceived quality of geriatric care in rural hospitals. We used an exploratory mixed-methods research design emphasizing the qualitative data (in-depth, semi-structured interviews). Quantitative data (questionnaire) measuring the RN work environment were also collected to augment qualitative data. Four themes emerged: (a) collegial RN relationships, (b) poor staffing/utilization, (c) technology benefits/challenges, and (d) RN–physician interactions, which were identified as key factors influencing the quality of geriatric care. We concluded that rural hospital work environments may not be optimized to facilitate the delivery of quality geriatric care. Targeted interventions are needed to improve overall quality of care for hospitalized older adults in rural settings.

Implementation of geriatric acute care best practices: initial results of the NICHE SITE self-evaluation

Nurses Improving Care of Healthsystem Elders (NICHE) provides hospitals with tools and resources to implement an initiative to improve health outcomes in older adults and their families. Beginning in 2011, members have engaged in a process of program self-evaluation, designed to evaluate internal progress toward developing, sustaining, and disseminating NICHE. This manuscript describes the NICHE Site Self-evaluation and reports the inaugural self-evaluation data in 180 North American hospitals. NICHE members evaluate their program utilizing the following dimensions of a geriatric acute care program: guiding principles, organizational structures, leadership, geriatric staff competence, interdisciplinary resources and processes, patient- and family-centered approaches, environment of care, and quality metrics. The majority of NICHE sites were at the progressive implementation level (n = 100, 55.6%), having implemented interdisciplinary geriatric education and the geriatric resource nurse (GRN) model on at least one unit; 29% have implemented the GRN model on multiple units, including specialty areas. Bed size, teaching status, and Magnet status were not associated with level of implementation, suggesting that NICHE implementation can be successful in a variety of settings and communities.

Ageism in nursing

AIM

Ageism in health care delivery and nursing poses a fundamental threat to health and society. In this commentary, implications of age discrimination are presented to generate an agenda for action in nursing management.

BACKGROUND

In nations like the United States and the United Kingdom, nursing is an ageing profession caring for an ageing society where age discrimination takes many forms and has broad impact.

EVALUATION

This commentary critically synthesizes the literature on ageism and relevant data on ageing societies for nurse managers and other leaders.

KEY ISSUES

Investigations of ageism suggest that discrimination negatively affects health and results in poor health care experiences. Age discrimination is present in nursing, exacerbating workforce shortages and limiting the use of expertise within the profession.

CONCLUSION

Nursing faces a future for which understanding ageing societies and ageism is essential. An agenda for the future is proposed.

IMPLICATIONS FOR NURSING MANAGEMENT

Nurse managers possess the power to enact an agenda for combating ageism in health care and nursing.

Research priorities in geriatric palliative care: policy initiatives

Coordinated palliative care matched to patient needs improves quality of care for vulnerable patients with serious illness and reduces costly use of hospitals and emergency departments. Unfortunately, there is a disconnect in translating geriatric palliative care models and principles into policy and widespread practice. Gaps in policy-relevant research are addressed, including implementation strategies to scale up existing care models, the role of palliative care and geriatrics in health care payment reform efforts, development of quality measures for complex patients, strategies to address workforce shortages, and an approach to hospice reform.

Validation of geriatric care environment scale in portuguese nurses

The number of hospitalized older adults in Portugal necessitates a better understanding of the acute care environment for older adults. This study translated and examined the psychometric qualities of the Geriatric Care Environment Scale (GCES) among 1,068 Portuguese registered nurses (RNs). Four factors emerged from the exploratory factor analyses: resource availability, aging-sensitive care delivery, institutional values regarding older adults and staff, and continuity of care. The internal consistency of the GCES was α = .919. The GCES was significantly associated with the variables of region, hospital type, unit type, and RNs perception of hospital educational, staff knowledge, difficulty, rewarding, and burdensome in caring for older adults. Nurses who worked in hospitals centers in the northern region and medical and surgery units had more positive perceptions of the geriatric care environment. More positive perception was also found among RNs that reported more educational support, had more knowledge, and felt more rewarding and less difficulty and burden in caring older adults. This process resulted in a valid and reliable measurement of the geriatric care environment Portuguese version which provides hospital leadership with an instrument to evaluate organizational support for geriatric nursing practice and target specific areas that support or hinder care delivery.