Nursing Practice Gerontological Practices
Gerontological Advanced Practice Nursing,Advancement in Nursing,Literature Review in Nursing and Outcomes, GAPN Role and Quality of Nursing Care,How ANPs Evaluate Nursing Success,How GAPN Evaluate Nursing Issues,All-inclusive Care for the Elderly (PACE),Benefits of GPNs, Needs of APN.
Gerontological Advanced Practice Nursing
Over
the last 3 decades, research examining the proliferation of Advanced Practice
Nurses (APNs) has demonstrated that APNs improve quality of care, increase
patient and staff satisfaction, while being cost effective across health care
settings (Feldman, Ventura, Crosby, 1987; Master et al., 1987; Miller, SK,
1997; Naylor, Brooten, et al., 1999; Ramsay, McKenzie, & Fish, 1982; Sox,
1979; Spitzer et al., 1974).
Advancement in Nursing
During
the late 1960s to 1970s graduate nursing programs began developing specialties
in gerontological nursing. GAPN is an umbrella term referring to Geriatric
Nurse Practitioner (GNP) or Gerontological Clinical Nurse Specialist (GCNS).
Currently there are nearly 4,000 certified GNPs and over 1,000 certified GCNSS
(American Association of Colleges of Nursing, 2004). GAPN subgroups presently
require gerontological-focused graduate education. Traditionally, GCNS roles
include educator, researcher, practitioner, manager, and consultant.
In
addition to the GCNS roles, GNPs have the ability to conduct advanced health
histories and physical assessments make diagnosis, and prescribe appropriate
medical treatments-including pharmaceuticals within a collaborative agreement
with a physician. Scopes of practice for both vary between states.
Literature
demonstrates more similarities between nurse practitioners (NPs) and clinical
nurse specialists (CNSS) than differences. Nursing leaders are currently
debating role integration (Fenton & Brykczynski , 1993; Soehren &
Schumann, 1994, Lincoln, PE, 2000).
Literature Review in Nursing and Outcomes
The
literature reported APNs favorably influence health care outcomes such as:
mortality, morbidity, length of stay, functional status, mental status, stress
level, and patient satisfaction, burden of care, and cost of care.
Overall,
studies demonstrated consumer acceptance and satisfaction with NPs, physician
comparative quality of care, increased productivity, cost savings, saved
physician time, effective management of both preventive and chronically ill
care, and improved patient education (Feldman et al., 1987; Naylor , Munro,
& Brooten, 1991).
GAPN Role and Quality of Nursing Care
The
GAPN role impacts the quality of care in long-term care (LTC) populations by
decreasing hospitalizations, reducing pharmaceutical usage, and improving
patient-family-staff satisfaction. GAPNs hold an essential role in reducing
restraints in the nursing home population (Evans, LK, et al., 1997).
Most
notably, the GAPNs provide cost-effective quality care. Using a
quasi experimental design, Kane and colleagues (1989) compared data of pre- and
post-GNP time periods in 60 nursing homes (30-GNP; 30-control) dispersed
throughout eight western states and discovered that GNP provided cost effective care to residents primarily by reducing hospital utilization.
Another study, a 1-year retrospective data analysis for 1,077 LTC res idents,
compared 414 residents followed by GNP/MD teams and 663 residents followed by
MDs alone. Patients of the /MD teams yielded a $72 per resident per month
savings (Burl, Bonner, Rao, & Khan, 1998).
How ANPs Evaluate Nursing Success
GNPs
may succeed in nursing home management. Grzeczkowski and Knapp (1988) evaluated
a 120-bed nursing home after a GNP became the Director of Nursing.
Their
findings demonstrated decreased medication usage, lower rates of
urinary/respiratory tract infections, decreased utilization of indwelling
urinary catheters, and less decubiti. GNPs extensive geriatric education and
ability to work well within interdisciplinary teams yielded effective patient
care.
How GAPN Evaluate Nursing Issues
GAPN
education, focused on geriatric issues such as falls, restraint usage,
delirium, polypharmacy, and normal versus abnormal physical changes, carves a
vital role in acute care management of frail older adults. Often GAPNs
anticipate these conditions and provide early intervention.
Models of care that
have improved hospital care to the elderly include geriatric evaluation teams,
Nurses Improving Care to the Hospitalized Elderly (NICHE), Geriatric Resource
Nurse (GRN), Case Management (CM), Geriatric Evaluation and Management (GEM)
units and Acute Care of the Elderly (ACE) units. GAPNs have been integral
members of these models of care.
A
retrospective analysis of nursing home patients admitted to an acute care
facility demonstrated a mean decrease of 2.78 (p < 0.05) days in length of
stay when care involved a GNP (Miller, SK, 1997). Naylor and colleagues (1999)
went further than evaluating “in-house” statistics.
Their randomized
clinical trial included 363 patients (186 control; 177 intervention) with
follow-up data collection up to 24 weeks posthospital discharge. In the
intervention group, GAPNS were responsible for comprehensive discharge planning
and maintaining a home follow-up protocol.
Examples of the outcome measures
were hospital readmission, recurrence or exacerbation of the index
hospitalization diagnostic-related groups (DRG), comorbidity, cumulative days
of rehospitalization, functional status, depression, and patient satisfaction.
The findings at 24 weeks posthospital discharge demonstrated that GAPN patients
experienced fewer hospitalization days, yielding a Medicare savings of almost
$600,000. Other findings: functional status, depression scores, and patient
satisfaction, were similar in both study groups.
Case studies of older adults
living at home describe the accessible, comprehensive, accountable, continual,
and collaborative care delivered by GNPs (Burns- Tisdal & Goff, 1989).
Alessi and colleagues (1997) studied 414 home care clients (215-intervention
and 199-control).
The intervention group had GNP-performed geriatric
assessments (CGAs) annually for 3 years, along with quarterly follow-up visits.
The authors examined the GNP’s health care recommendations given to clients and
proposed that repetitive reinforcement and the GNP-patient relationship
contributed to achieving patient adherence to therapies. This warrants further
investigation.
All-inclusive Care for the Elderly (PACE)
The
Program of All-inclusive Care for the Elderly (PACE), developed in San
Francisco known as On Lok in 1971, focuses on health and social day services to
enable frail older adults to remain in the community. PACE’s model requires
GAPNs in the interdisciplinary team. PACE programs now exist in nine states
providing cost effective quality care with a reduction in institutional care
use (Eng. Pedulla , Eleazer, McCann, & Fox, 1997).
Benefits of GPNs
GNPs
provide effective ambulatory care. McDowell, Martin, Snustad , and Flynn (1986)
performed a retrospective review of 800 patients comparing GNPs’ care to two
internal medicine board-certified physicians with geriatric experience using
polypharmacy and functional status as comparison measurements. GNPs provided
high-quality, cost-effective care.
Another study (Mahoney, DF, 1994) compared
medication usage of NPs and MDs; Three geriatric vignettes designed by GNPs,
geriatricians, and geriatric pharmacists were presented to 373 MDs and 118 NPs.
Analysis of the MDs and NPs was discussed and it was discovered that NPs used
fewer drugs.
The NP sample was not specifically limited to GNPs; family and
adult nurse practitioners were included in the sample. Geriatric experience and
prescribing experience proved to be significant factors affecting appropriate
prescribing. Mahoney proposed that gerontological education for APNs and Family
Nurse Practitioners (FNPs) would ensure proper pharmaceutical usage for the
elderly.
Needs of APN
Meta analysis
methods have allowed researchers to examine conflicts in the data and deduce
clearer and more conclusive findings. Often lacking in the literature is a
clear presentation of APN preparation and specialty. Future research needs to
be rigorous with attention to:
(a)conceptual definitions sensitivity of
outcome measures, study of care delivery processes not solely on the provider,
relationship between the process and outcomes of care.
(b) measurement of
variables.
(c) APN educational backgrounds.
(d) methodology-more blind
randomized trials with attention to internal and external validity (Brown, SA,
& Grimes, 1995).