History and Evolution

Burnside (1988) conducted an extensive review of the American Journal of Nursing (AJN) for historical materials related to gerontologic nursing. Between 1900 and 1940, she found 23 writings, including works by Lavinia Dock, with a focus on older adults that covered such topics as rural nursing, almshouses, and private duty nursing, as well as early case studies and clinical issues addressing home care for fractured femur, dementia, and delirium. Burnside discovered an anonymous column in AJN entitled “Care of the Aged” that was written in 1925, and it is now thought to be one of the earliest references to the need for a specialty in older adult care.

The modern health movement is constantly increasing life expectancy by its steady research and implementation of medical actions fighting preventable disease. Therefore nursing professionals must expect to care for steadily increasing numbers of patients with chronic and degenerative conditions.

During World War II and the postwar years (1940 to 1960), the population of older persons steadily increased, but articles about the care of older adults were general and not particularly comprehensive (Burnside, 1988). It was not until 1962, when the geriatric nursing conference group was established during the American Nurses Association (ANA) convention, that the question posed by the anonymous AJN columnist was finally addressed.

Professional Origins

In 1966 the ANA established the Division of Geriatric Nursing Practice and defined geriatric nursing as “concerned with the assessment of nursing needs of older people; planning and implementing nursing care to meet those needs; and evaluating the effectiveness of such care.” In 1976 the Division of Geriatric Nursing Practice was changed to the Division of Gerontologic Nursing Practice to reflect the nursing roles of providing care to healthy, ill, and frail older persons. The division became the Council of Gerontologic Nursing in 1984 to encompass issues beyond clinical practice. Certification for Gerontologic Clinical Nurse Specialist was established through the ANA in 1989.

Standards of Practice

The years 1960 to 1970 were characterized by many “firsts,” as the specialty devoted to the care of older adults began its exciting development (Table 1–1). Journals, textbooks, workshops and seminars, formal education programs, professional certification, and research with a focus on gerontologic nursing have since evolved. However, the singular event that truly legitimized the specialty occurred in 1969, when a committee appointed by the ANA Division of Geriatric Nursing Practice completed the first Standards of Practice for Geriatric Nursing (ANA, 1991). These standards were widely circulated during the next several years; in 1976 they were revised, and the title was changed to Standards of Gerontological Nursing Practice. In 1981 A Statement on the Scope of Gerontological Nursing Practice was published. The revised Standards and Scope of Gerontological Nursing Practice were published in 1987, 1995, and the current 2010 edition is in press. The changes to this document reflect the comprehensive concepts and dimensions of practice for the nurse working with older adults. In 1995 the revised Scope and Standards of Gerontological Nursing Practice reflected the nature and scope of current gerontologic nursing practice but also incorporated the concepts of health promotion, health maintenance, disease prevention, and self-care. In 2004 all scope and standards of practice were combined into a set of three books known as the Nursing Scope & Standards of Practice, Nursing’s Social Policy Statement (ANA, 2003), and the Code of Ethics for Nurses with Interpretive Statements (ANA, 2001). “These three resources provide a complete and definitive description for better understanding by specialty nursing organizations, policy makers, and the public of nursing practice and nursing’s accountability to the public in the United States” (ANA, 2004, p. vi). This merging of the standards of practice of all the specialties was an effort to outline the expectations of the professional role within which all registered nurses must practice nursing. However, with the tremendous increase in care of the older adult, the ANA has again published Scope and Standards of Gerontological Nursing Practice with input from nurses across the United States before the final publishing in 2010. This document can be obtained from the ANA website: www.nursingworld.org/.

Another hallmark in the continued growth of the gerontologic nursing specialty occurred in 1973, when the first gerontologic nurses were certified through the ANA. Certification is an additional credential granted by the ANA, providing a means for recognizing excellence in a clinical or functional area (ANA, 1995). Certification is usually voluntary, enabling the nurse to demonstrate to peers and others that a distinct degree of knowledge and expertise has been achieved. In some cases, certification can mean eligibility for third-party reimbursement for nursing services rendered. From the initial certification offering as a generalist in gerontologic nursing, to the first gerontologic nurse practitioner (GNP) examination offering in 1979, to the most recent gerontologic clinical nurse specialist (GCNS) examination (first administered in 1989), this specialty has continued to grow and attract a high level of interest. Eligibility criteria for the application process to take any one of the three certification examinations can be found in Box 1–1.

Roles

The growth of the nursing profession as a whole, increasing educational opportunities, demographic changes, and changes in health care delivery systems have all influenced the development of the generalist role in gerontologic nursing, as well as the advanced practice roles of gerontologic CNS and GNP. The generalist in gerontologic nursing has completed a basic entry-level educational program. A generalist nurse may practice in a wide variety of environments, including the home and community. The challenge of the gerontologic nurse generalist is to identify older clients’ strengths and assist them with maximizing their independence. Clients participate as much as possible in making decisions about their care. The generalist consults with the advanced practice nurse and other interdisciplinary health professionals for assistance in meeting the complex care needs of older adults.

The gerontologic CNS has at least a master’s degree in nursing. The first program was launched in 1966 at Duke University. The gerontologic master’s program typically focuses on the advanced knowledge and skills required to care for older adults in a wide variety of settings, and the graduate is prepared to assume a leadership role in the delivery of that care. GCNSs have an expert understanding of the dynamics, pathophysiology, and psychosocial aspects of aging. They use advanced diagnostic and assessment skills and nursing interventions to manage and improve patient care (American Nurses Credentialing Center [ANCC], 2009). The GCNS functions as a clinician, educator, consultant, administrator, or researcher to plan care or improve the quality of nursing care for older adults and their families. Specialists provide comprehensive care based on theory and research. Today, GCNSs can be found practicing in acute hospitals, long-term care or home care settings, or independent practices.

The GNP may be educationally prepared in various ways. In the early 1970s the first GNPs were prepared primarily through continuing education programs. Another early group of GNPs received their training and clinical supervision from physicians. Only since the late 1980s has master’s-level education with a focus on primary care been available. As a provider of primary care and a case manager, the GNP conducts health assessments; identifies nursing diagnoses; and plans, implements, and evaluates nursing care for older clients. A GNP has the knowledge and skills to detect and manage limited acute and chronic stable conditions; coordination and collaboration with other health care providers is a related essential function. The GNP’s activities include interventions for health promotion, maintenance, and restoration. GNPs provide primary ambulatory care in an independent practice or a collaborative practice with a physician; they also practice in settings across the continuum of care, including the acute care hospital, subacute care center, ambulatory care, and long-term care setting. Health maintenance organizations (HMOs) are now including GNPs on their provider panels. Certification can elevate the status of the nurse practicing with older adults in any setting. More importantly, it enables the nurse to ensure the delivery of quality care to older adult clients. In most states within the United States, GNPs hold prescriptive authority for nearly all classes of medications. Each state has determined the type and extent of prescriptive authority permitted.

Terminology

Any discussion of older adult nursing is complicated by the wide variety of terms used interchangeably to describe the specialty. Some terms are used because of personal preference or because they suggest a certain perspective. Still others are avoided because of the negative inferences they evoke. As described in the preceding overview of the evolution of the specialty, the terminology has changed over the years. The following are the most commonly used terms and definitions:

These terms and their usage spark a great deal of interest and controversy among nurses practicing with older adults. As the specialty continues to grow and develop, it is likely that the terminology will also.

The Older Population

For several decades, the American Association of Retired Persons (AARP) maintained a yearly update of the profile of older adults in America. This organization is a nonprofit, nonpartisan membership organization for people age 50 or older. The AARP is dedicated to enhancing the quality of life for all Americans as they age. The association acknowledges that its members receive a wide range of unique benefits, special products, and services. Additional information can be found at their website: www.aarp.org. In 1997 the organization stopped compiling profile demographics and began to collect more specific data on a narrower scope. The federal government maintains aging statistics that are available to the public. These publications include an annual chart book with the name of the year. Information can be found at www.agingstats.gov/agingstatsdotnet/Main_Site/Data/2008_Documents/OA_2008.pdf. Use the exact year (e.g., 2010) at the end of the web address for a specific year. This is now a part of public census and reporting efforts.

Before review of current statistics of older adults in America, a look at past issues that have lead to these numbers is appropriate. The relatively high birth rate during the late nineteenth and early twentieth centuries accounts in part for the large number of older persons today (Burnside, 1988). Reduced infant and child mortality as a result of improved sanitation, advances in vaccination, and the development of antibiotics has also contributed. The large influx of immigrants before World War I is an additional important factor. The net effect, associated with a reduction in mortality for all ages and fertility rates at a replacement level, has been an increase in the older adult population.

Highlights of the Profile of Older Americans

Not only are large numbers of persons living to age 65 but they are also living to older ages. When the current figures are validated, the population aged 85 or older is expected to be 5.7 million in 2010 and increase to 6.6 million by 2020. Data obtained in 2007 found that adults 65 or older numbered 3.8 million, which is an increase of 11.2% since 1997. The number of Americans aged 45 to 64, who will reach 65 over the next 20 years, increased by 38% during this past decade. One person in every eight is an older American. That accounts for 12.6% of the United States population (AOA, 2008). See Fig. 1–1 for population trends of persons 65 years or older through 2030.