Gerontological nursing history, education, and roles

Theris A. Touhy

THE LIVED EXPERIENCE

I don’t think I will work in gerontological nursing; it seems depressing. I don’t know many older people, but they are all sick without much hope to get better. I’ll probably go into labor and delivery or the emergency room where I can really make a difference.

Student nurse, age 24

To know that I have made them feel they are human, that they’re loved…that someone still cares about them. I believe that lots of times they feel ignored and as if they have no value. It’s very important to me that they feel valued and they know that they still contribute not only to society but to the personal growth of everyone who comes into interaction with them.

Gerontological nurse, age 35, working in a nursing home

Learning objectives

Upon completion of this chapter, the reader will be able to:

• Discuss the implications of a growing older adult population on nursing education, practice, and research.

• Identify several factors that have influenced the development of gerontological nursing as a specialty practice.

• Examine the American Nurses Association Scope and Standards of Gerontological Nursing Practice and the recommended competencies for gerontological nursing practice.

• Recognize and discuss the importance of certification.

• Compare various gerontological nursing roles and requirements.

• Discuss formal gerontological organizations and their significance to the gerontological nurse.

evolve.elsevier.com/Ebersole/gerontological

Care of older adults: A nursing imperative

The world population is aging. By 2050, one in five Americans will be over 65 years of age, with those over 85 showing the greatest increase in numbers. The number of people living to 100 years of age is projected to grow at more than 20 times the rate of the total population by 2050. Older people today are healthier, better educated, and expect a much higher quality of life as they age than did their elders. Healthy aging is now an achievable goal for many and it is essential that we have the knowledge and skills to help people of all ages, races, and cultures achieve this goal.

The developmental period of elderhood is an essential part of a healthy society and as important as childhood or adulthood (Thomas, 2004). We can expect to spend 40 or more years as older adults and our preparation for this time in our lives certainly demands attention as well as expert care from nurses. How does one maximize the experience of aging and enrich the years of elderhood despite the physical and psychological changes that may occur?

Most nurses care for older people during the course of their careers. In addition, the public looks to nurses to have knowledge and skills to assist people to age in health. Every older person should expect to receive care provided by nurses with competence in gerontological nursing. Gerontological nursing is not only for a specialty group of nurses. Knowledge of aging and gerontological nursing is core knowledge for the profession of nursing (Young, 2003).

Eldercare is projected to be the fastest growing employment sector in the health care industry. Older adults are the core consumers of health care, with higher rates of outpatient provider visits, hospitalizations, home care, and long-term care service use than other age groups. Despite demand, the number of health care workers who are interested in and prepared to care for older people remains low. America’s eldercare workforce is dangerously understaffed and unprepared to care for the growing numbers of older adults (Institute of Medicine, 2008). Less than 1% of registered nurses (RNs) and only 3% of advanced practice registered nurses (APRNs) are certified in gerontology (Institute of Medicine, 2008; Stierle et al., 2006).

Geriatric medicine faces similar challenges with just 7,128 geriatricians, one for every 2,546 older Americans. By 2030, it is estimated that this number will increase to only 7,750, one for every 4,254 older Americans, far short of the predicted need for 36,000 geriatricians (Institute of Medicine, 2008). Other professions such as social work have similar shortages. These issues are critical not only in the United States but across the globe. “If these issues remain unresolved, the cumulative impact for our aging population and our overall health care system will be significant. Projected consequences include, but are not limited to extremely high nurse-patient ratios; proliferation of high-tech, low-touch care systems; and a decline in public trust for nursing” (American Nurses Association, 2010, p. 23). Healthy People 2020 includes goals related to geriatric education (see the Healthy People box).

Enhancing interest, recruitment, and preparation of students and practicing nurses in care of older adults across the continuum is essential. Positive role models, a deep commitment to caring, and an appreciation of the significant contribution of a nursing model of care to the well-being of older people, are often the motivating factors that draw nurses to the specialty. Box 2-1 presents the views of some of the geriatric nursing pioneers, as well as current leaders, on the practice of gerontological nursing and what draws them to care of older adults.

HEALTHY PEOPLE 2020

Older adults

• Increase the proportion of the health care workforce with geriatric certification (physicians, geriatric psychiatrists, registered nurses, dentists, physical therapists, dietitians)

From U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion: Healthy people 2020 (2012). Available at http://www.healthypeople.gov/2020.

BOX 2-1

Reflections on Gerontological Nursing from Gerontological Nursing Pioneers and Current Leaders in the Field

Doris schwartz, gerontological nursing pioneer

“We need to remind ourselves constantly that the purpose of gerontic nursing is to prevent untimely death and needless suffering, always with the focus of doing with as well as doing for, and in every instance to attempt to preserve personhood as long as life continues.” (From interview data collected by Priscilla Ebersole between 1990 and 2001.)

Mary opal wolanin, gerontological nursing pioneer

“I believe that one of the most valuable lessons I have learned from those who are older is that I must start with looking inside at my own thinking. I was very guilty of ageism. I believed every myth in the book, was sure that I would never live past my seventieth birthday, and made no plan for my seventies. Probably the most productive years of my career have been since that dreaded birthday and I now realize that it is very difficult, if not impossible, to think of our own aging.” (From interview data collected by Priscilla Ebersole between 1990 and 2001.)

Terry fulmer, dean, college of nursing, new york university and co-director, john a. hartford institute for geriatric nursing

“I soon realized that in the arena of caring for the aged, I could have an autonomous nursing practice that would make a real difference in medical outcomes. I could practice the full scope of nursing. It gave me a sense of freedom and accomplishment. With older patients, the most important component of care, by far, is nursing care. It’s very motivating.” (From Ebersole P, Touhy T: Geriatric nursing: growth of a specialty, New York, 2006, Springer, p. 129.)

Neville strumpf, edith clement chair in gerontological nursing, university of pennsylvania, director of the hartford center of geriatric nursing excellence and center for gerontological nursing science

“My philosophy remains deeply rooted in individual choice, comfort, and dignity, especially for frail, older adults. I fervently hope that the future will be characterized by a health care system capable of supporting these values throughout a person’s life, and that we shall someday see the routine application of evidence based practice to the care of all older adults, whether they are in the community, a hospital, or the nursing home. We have not yet achieved that dream.” (From Ebersole P, Touhy T: Geriatric nursing: growth of a specialty, New York, 2006, Springer, p. 145.)

Mathy mezey, professor emeritus and associate director, the hartford institute for geriatric nursing, New York university college of nursing

“Because geriatric nursing especially offers nurses the unique opportunity to dramatically impact people’s lives for the better and for the worst, it demands the best that you have to offer. I am very optimistic about the future of geriatric nursing. Increasing numbers of older adults are interested in marching into old age as healthy and involved. Geriatric nursing offers a unique opportunity to help older adults meet these aspirations while at the same time maintaining a commitment to the oldest and frailest in our society.” (From Ebersole P, Touhy T: Geriatric nursing: growth of a specialty, New York, 2006, Springer, p. 142.)

Jennifer lingler, PHD, FNP

“When I was in high school, a nurse I knew helped me find a nursing assistant position at the residential care facility where she worked. That experience sparked my interest in older adults that continues today. I realized that caring for frail elders could be incredibly gratifying, and I felt privileged to play a role, however small, in people’s lives. At the same time, I became increasingly curious about what it means to age successfully. I questioned why some people seemed to age so gracefully, while others succumbed to physical illness, mental decline, or both. As a Building Academic Geriatric Nursing Capacity (BAGNC) alumnus, I now divide my time serving as a nurse practitioner at a memory disorders clinic, teaching an ethics course in a gerontology program, and conducting research on family caregiving. I am encouraged by the realization that as current students contemplate the array of opportunities before them, seek counsel from trusted mentors, and gain exposure to various clinical populations, the next generation of geriatric nurses will emerge. And, I am confident that in doing so, they will set their own course for affecting change in the lives of society’s most vulnerable members.” (Jennifer Lingler as cited in Fagin C, Franklin P: Why choose geriatric nursing? Six nursing scholars tell their stories, Imprint, September/October, 2005, p. 74.)

History of gerontological nursing

Historically, nurses have always been in the frontlines of caring for older people. They have provided hands-on care, supervision, administration, program development, teaching, and research and are, to a great extent, responsible for the rapid advance of gerontology as a profession. Nurses have been, and continue to be, the mainstay of care of older adults (Mezey & Fulmer, 2002). Gerontological nurses have made substantial contributions to the body of knowledge guiding best practice in care of older people. In examining the history of gerontological nursing, one must marvel at the advocacy and perseverance of nurses who have remained deeply committed to the care of older adults despite struggling against insurmountable odds over the years. We are proud to be the standard-bearers of excellence in care of older people. Table 2-1 presents a timeline of significant accomplishments in the history of gerontological nursing.

TABLE 2-1

Professionalization of Gerontological Nursing

1906	First article is published in American Journal of Nursing (AJN) on care of the elderly.
1925	AJN considers geriatric nursing as a possible specialty in nursing.
1950	Newton and Anderson publish first geriatric nursing textbook. Geriatrics becomes a specialization in nursing.
1962	American Nurses Association (ANA) forms a national geriatric nursing group.
1966	ANA creates the Division of Geriatric Nursing. First master’s program for clinical nurse specialists in geriatric nursing developed by Virginia Stone at Duke University.
1970	ANA establishes Standards of Practice for Geriatric Nursing.
1974	Certification in geriatric nursing practice offered through ANA; process implemented by Laurie Gunter and Virginia Stone.
1975	Journal of Gerontological Nursing published by Slack; first editor, Edna Stilwell.
1976	ANA renames Geriatric Division “Gerontological” to reflect a health promotion emphasis. ANA publishes Standards for Gerontological Nursing Practice; committee chaired by Barbara Allen Davis. ANA begins certifying geriatric nurse practitioners. Nursing and the Aged edited by Burnside and published by McGraw-Hill.
1977	First gerontological nursing track funded by Division of Nursing and established by Sr. Rose Therese Bahr at University of Kansas School of Nursing.
1979	Education for Gerontic Nursing written by Gunter and Estes; suggested curricula for all levels of nursing education.
1980	Geriatric Nursing first published by AJN; Cynthia Kelly, editor.
1983	Florence Cellar Endowed Gerontological Nursing Chair established at Case Western Reserve University, first in the nation; Doreen Norton, first scholar to occupy chair. National Conference of Gerontological Nurse Practitioners is established.
1984	National Gerontological Nurses Association is established. Division of Gerontological Nursing Practice becomes Council on Gerontological Nursing (councils established for all practice specialties).
1989	ANA certifies gerontological clinical nurse specialists.
1992	John A. Hartford Foundation funds a major initiative to improve care of hospitalized older patients: Nurses Improving Care for Healthsystem Elders (NICHE).
1996	John A. Hartford Foundation establishes the Institute for Geriatric Nursing at New York University under the direction of Mathy Mezey.
2000	Recommended baccalaureate competencies and curricular guidelines for geriatric nursing care published by the American Association of Colleges of Nursing and the John A. Hartford Foundation Institute for Geriatric Nursing. The American Academy of Nursing established Building Academic Geriatric Nursing Capacity (BAGNC) in 2000 with support from the John A. Hartford Foundation.
2001	Hartford Coalition of Geriatric Nursing Associations formed.
2002	Nurse Competence in Aging (funded by the Atlantic Philanthropies Inc.) initiative to improve the quality of health care to older adults by enhancing the geriatric competence of nurses who are members of specialty nursing.
2004	Nurse Practitioner and Clinical Nurse Specialist Competencies for Older Adult Care published by the American Association of Colleges of Nursing and the Hartford Institute for Geriatric Nursing. Atlantic Philanthropies committed its resources to postdoctoral fellowships in gerontology nursing.
2007	Atlantic Philanthropies provides a grant to the American Academy of Nursing of $500,000 to improve care of older adults in nursing homes by improving the clinical skills of professional nurses. American Association for Long-Term Care Nurses formed.
2008	Four new Centers of Geriatric Nursing Excellence (CGNE) are funded by the John A. Hartford Foundation bringing the total number of Centers to nine. Existing Centers are at the University of Iowa, University of California San Francisco, Oregon Health Sciences University, University of Arkansas, University of Pennsylvania, Arizona State University, Pennsylvania State University, University of Minnesota, and University of Utah. Research in Gerontological Nursing launched by Slack Inc; Dr. Kitty Buckwalter, Editor. Geriatric Nursing Leadership Academy established by Sigma Theta Tau International with funding from the John A. Hartford Foundation. John A. Hartford Foundation funds the Geropsychiatric Nursing Collaborative (Universities of Iowa, Arkansas, Pennsylvania, American Academy of Nursing) Institute of Medicine publishes Retooling for an aging America: building the health care workforce report.
2009	National Consensus Model for APRN Regulation, Licensure, Accreditation, Certification and Education designates adult-gerontology as one of 6 population foci for APRNs. John A. Hartford Foundation funds Phase 2 of the Fostering Geriatrics in Pre-Licensure Nursing Education, a partnership between the Community College of Philadelphia and the National League for Nursing.
2010	Adult-gerontology primary care nurse practitioner competencies published by the John A. Hartford Foundation Institute for Geriatric Nursing, the AACN, and NONPF. Sigma Theta Tau’s Center for Nursing Excellence established. ANCC Pathways to Excellence – Long-Term Care Program.
2012	The Gerontological Society of America is now home to the Coordinating Center for the National Hartford Centers of Gerontological Nursing Excellence (HCGNE), also known as the Building Academic Geriatric Nursing Capacity Initiative. U.S. Department of Health and Human Services provides funding to five designated medical center hospitals for clinical training to newly enrolled APRNs to deliver primary care, preventive care, transitional care, chronic case management, and other services appropriate for Medicare recipients.
2013	Adult-Gerontology Acute Care Nurse Practitioner and Adult-Gerontology Primary Care Nurse Practitioner certifications through ANCC begin.

For a complete listing of John A. Hartford Foundation funding for geriatric nursing, see http://www.hgni.org/091008%20HGNI%20Project% 20Descriptions.pdf.

Early history

The origins of gerontological nursing are rooted in England and began with Florence Nightingale as she accepted a position in the Institution for the Care of Sick Gentlewomen in Distressed Circumstances. Nightingale’s concern for the frail and sick elderly was continued by Agnes Jones, a wealthy Nightingale-trained nurse, who in 1864 was sent to Liverpool Infirmary, a large Poor Law institution. The care in the institution was poor, the diet meager, and the nurses often drunk. But Miss Jones, under the tutelage of Nightingale, improved the care dramatically, as well as reduced the costs.

In the United States, almshouses were the destination of destitute older people and were insufferable places with “deplorable conditions, neglect, preventable suffering, contagion, and death from lack of proper medical and nursing care” (Crane, 1907, p. 873). As early as 1906, Lavinia Dock and other early leaders in nursing addressed, in the American Journal of Nursing (AJN), the needs of the elderly chronically ill in almshouses. Dock and her colleagues cited the immediate need for trained nurses and pupil education in almshouses, “so that these evils, all of which lie strictly in the sphere of housekeeping and nursing,—two spheres which have always been lauded as women’s own—might not occur” (Dock, 1908, p. 523). In 1912 the American Nurses Association (ANA) Board of Directors appointed an Almshouse Committee to continue to oversee nursing in these institutions. World War I distracted them from attention to these needs. But in 1925, the ANA advanced the idea of a specialty in the nursing care of the aged.

With the passage of the Social Security Act of 1935, federal monies were provided for old-age insurance and public assistance for needy older people not covered by insurance. To combat the fear of almshouse placement, Congress stipulated that the Social Security funds could not be used to pay for care in almshouses or other public institutions. This move is thought to have been the genesis of commercial nursing homes. During the next 10 years, many almshouses closed and the number of private boarding homes providing care to elders increased. Because retired and widowed nurses often converted their homes into such living quarters and gave care when their boarders became ill, they can be considered the first geriatric nurses and their homes the first nursing homes.

Two nursing journals in the 1940s described centers of excellence for geriatric care: the Cuyahoga County Nursing Home in Ohio and the Hebrew Home for the Aged in New York. An article in the AJN by Sarah Gelbach (1943) recommended that nurses should have not only an aptitude for working with the elderly but also specific geriatric education. The first textbook on nursing care of the elderly was published by Newton and Anderson in 1950, and the first published nursing research on chronic disease and the elderly (Mack, 1952) appeared in the premier issue of Nursing Research in 1952.

In 1962 a focus group was formed to discuss geriatric nursing, and in 1966 a geriatric practice group was convened. However, it was not until 1966 that the ANA formed a Division of Geriatric Nursing. The first geriatric standards were published by the ANA in 1968, and soon after, geriatric nursing certification was offered. Geriatric nursing was the first specialty to establish standards of practice within the ANA. In 1976 the Division of Geriatric Nursing changed its name to the Gerontological Nursing Division to reflect the broad role nurses play in the care of older people. In the mid 1970s, certificate and master’s programs to prepare gerontological nurse practitioners were begun with funding from the Department of Health, Education, and Welfare. Whereas most specialties in nursing practice developed from those identified in medicine, this was not the case with the specialty of gerontological nursing since health care of older adults was traditionally considered to fall within the domain of nursing (Davis, 1984).

In 1984 the Council on Gerontological Nursing was formed and certification for geriatric nurse practitioners (GNPs) and gerontological clinical nurse specialists (GCNSs) became available. Nursing was the first of the professions to develop standards of gerontological care and the first to provide a certification mechanism to ensure specific professional expertise through credentialing (Ebersole & Touhy, 2006). The most recent edition of Scope and Standards of Gerontological Nursing Practice (ANA, 2010) provides a comprehensive overview of the scope of gerontological nursing and identifies levels of gerontological nursing practice (basic and advanced) and standards of clinical gerontological nursing care and gerontological nursing performance.

Current initiatives

The most significant influence in enhancing gerontological nursing has been the work of the Hartford Institute for Geriatric Nursing, funded by the John A. Hartford Foundation. Mathy Mezey, EdD, RN, FAAN, directed the institute, located in the College of Nursing at New York University, from its inception in 1996 until 2010 and now serves as an Associate Director. It is the only nurse-led organization in the country seeking to shape the quality of the nation’s health care for older Americans by promoting geriatric nursing excellence to both the nursing profession and the larger health care community. Initiatives in nursing education, nursing practice, nursing research, and nursing policy include enhancing geriatrics in nursing education programs through curricular reform and faculty development; the development of nine Centers of Geriatric Nursing Excellence; predoctoral and postdoctoral scholarships for study and research in geriatric nursing; and clinical practice improvement projects to enhance care for older adults (Mackin et al., 2006; Miller et al., 2006; Souder et al., 2006) (see www.hartfordign.org).

Another significant influence on improving care for older adults was the Nurse Competence in Aging (NCA) project, a five-year initiative created in 2002 through an alliance of the ANA, the American Nurses Credentialing Center (ANCC), and the Hartford Institute for Geriatric Nursing. Funded by Atlantic Philanthropies, through the American Nurses Foundation, the initiative addressed the need to ensure competence in geriatrics among nursing specialty organizations. The initiative provided grant and technical assistance to more than 50 specialty nursing organizations; developed a free web-based comprehensive gerontological nursing resource center (http://consultgerirn.org) where nurses can access evidence-based information on topics related to the care of older adults; and conducted a national gerontological nursing certification outreach (Stierle et al., 2006). An extension of this work, the Resourcefully Enhancing Aging in Specialty Nursing (REASN) project, will focuses on building intensive collaborations with 13 hospital-based specialty associations to create geriatric educational products and resources to ensure the geriatric competencies of their members (see http://hartfordign.org/practice/reasn/).

In 2008 a $1.6 million grant from the John A. Hartford Foundation was awarded to Sigma Theta Tau International (STTI) to establish the Geriatric Nursing Leadership Academy (GNLA). Working with the Hartford Centers of Geriatric Nursing Excellence, the purpose of the GNLA is to develop the leadership skills of geriatric nurses in positions of influence in a variety of health care settings and to improve the quality of health care for older adults and their families (www.nursingsociety.org/LeadershipInstitute/GeriatricAcademy/Pages/introduction.aspx).

Gerontological nursing education

According to the ANA Scope and Standards of Gerontological Nursing Practice (2010), “Nurses require the knowledge and skills to assist older adults in a broad range of nursing care issues, from maintaining health and preventing illnesses, to managing complex, overlapping chronic conditions and progressive/protracted frailty in physical and mental functions, to palliative care” (p. 12-13). Basic competence is critical to ensure the best possible care for diverse populations of older adults. All nursing education programs, from entry-level to advanced practice, should be “gerontologized” to ensure that graduates are competent to meet the needs of an aging population.

Essential educational competencies and academic standards for care of older adults have been developed by national organizations such as the American Association of Colleges of Nursing (AACN) for both basic and advanced nursing education (ANA, 2010). The Essentials of Baccalaureate Education for Professional Nursing Practice (AACN, 2008) specifically address the importance of geriatric content and structured clinical experiences with older adults across the continuum in the education of students. In 2010, AACN and the Hartford Institute for Geriatric Nursing, New York University, published the Recommended Baccalaureate Competencies and Curricular Guidelines for the Nursing Care of Older Adults, a supplement to The Essentials document. In addition, gerontological nursing competencies for advanced practice graduate programs have also been developed. All of these documents can be accessed from http://www.aacn.nche.edu/education-resources/competencies-older-adults.

“Despite these lists of competencies, however, there remains a lack of consistency among nursing schools in helping students gain needed gerontological nursing information and skills” (ANA, 2010, p.12). Those in the field of nursing education must seriously consider specific minimal requirements in the care of older adults at each level of education to fulfill the responsibility of nurses to the public and the profession and to meet accreditation criteria. However, schools of nursing have only begun to include gerontological nursing content in their curricula and most still do not have freestanding courses in the specialty similar to courses in maternal/child or psychiatric nursing. When content is integrated throughout the curriculum, less than 25% of the content is devoted to geriatric care (Berman et al., 2005). “Gerontological nursing content needs to be integrated throughout the curriculum, in addition to a stand-alone course, so that gerontology is valued and viewed as an integral part of nursing care” (Miller et al., 2009, p. 198).

It is important to provide students with nursing practice experiences caring for elders across the continuum of care. For clinical practice sites, one is not limited to the acute care setting or the nursing home. Experiences with well elders in the community and opportunities to focus on health promotion should be the first experience for students. This will assist them to develop more positive attitudes toward older people, understand the full scope of nursing practice with older adults, and learn nursing responses to enhance health and wellness. Rehabilitation centers, subacute and skilled nursing facilities, and hospice settings provide opportunities for leadership experience, nursing management of complex problems, interprofessional teamwork, and research application for more advanced students.

Faculty with expertise in gerontological nursing are scarce; less than 30% of baccalaureate programs have at least one full-time faculty member certified in gerontological nursing (Berman et al., 2005; Mackin et al., 2006). Important resources for faculty education in gerontological nursing include the Geriatric Nursing Education Consortium (GNEC), the Advancing Care Excellence for Seniors (ACES), the Hartford Geriatric Nursing Initiative (HGNI), and the Building Academic Geriatric Nursing Capacity (BAGNC).

The purpose of the GNEC, a national initiative of the American Association of Colleges of Nursing (AACN) with funding from the John A. Hartford Foundation, is to enhance geriatric content in senior-level undergraduate courses. The GNEC educational curriculum and evidence-based modules reflecting the state-of-the-science approach to care for older adults are available electronically and via webinars (see http://www.aacn.nche.edu/gnec.htm).

Advancing Care Excellence for Seniors (ACES), a three-year grant funded by the John A. Hartford Foundation to foster gerontological nursing education in prelicensure programs, is a collaborative effort between the National League for Nursing (NLN) and the Community College of Philadelphia. ACES provides faculty with development materials, teaching tools and strategies, curricular guidelines, and essential nursing actions (see www.nln.org/ACES).

The BAGNC initiative includes the Building Geriatric Nursing Capacity Scholars and Fellows Awards Program and the nine Hartford Centers of Geriatric Nursing Excellence. This program, coordinated by the American Academy of Nursing, has stimulated increasing interest in academic geriatric nursing through scholarships and fellowships for research, faculty, and leadership development (see http://www.geriatricnursing.org/about/about.asp).

The Patient Protection and Affordable Care Act, signed into law in March 2010, provides many initiatives that will have a direct impact on gerontological nursing with regard to workforce, education, and practice. It is anticipated that there will be additional federal funding to support advanced education in gerontological nursing, education of faculty, and advanced training for direct care workers employed in long-term care settings.