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/.

TABLE 1–1

DEVELOPMENT OF GERONTOLOGIC NURSING: 1960–1970

YEAR	EVENT
1961	Formation of a specialty group for geriatric nurses is recommended by the American Nurses Association (ANA).
1962	First national meeting of the ANA Conference on Geriatric Nursing Practice is held in Detroit, Mich.
	American Nurses’ Foundation receives a grant for a workshop on the aged.
	First research in geriatric nursing is published in England (Norton D et al: An investigation of geriatric nursing problems in hospital, London 1962, National Corporation for the Care of Old People).
1966	First gerontologic clinical specialist nursing program is developed at Duke University by Virginia Stone.
	Geriatric Nursing Division of the ANA is formed; a monograph is published, entitled Exploring Progress in Geriatric Nursing Practice.
1968	Laurie Gunter is the first nurse to present a paper at the International Congress of Gerontology in Washington, DC. First gerontologic nursing interest group, Geriatric Nursing, is formed.
	Barbara Davis is the first nurse to speak before the American Geriatric Society.
	First article on nursing curriculum regarding gerontologic nursing is published (Delora JR, Moses DV: Specialty preferences and characteristics of nursing students in baccalaureate programs, Nurs Res March/April, 1969).
	The nine standards for geriatric nursing practice are developed.
1970	Standards of Geriatric Nursing Practice is first published.
	First gerontologic clinical nurse specialists graduate from Duke University.

Modified from Burnside IM: Nursing and the aged: a self care approach, ed 3, New York, 1988, McGraw-Hill.

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.

BOX 1–1 AMERICAN NURSES CREDENTIALING CENTER ELIGIBILITY REQUIREMENTS FOR CERTIFICATION IN GERONTOLOGIC NURSING

Gerontologic Nurse (Registered Nurse—Board Certified [BC])

The nurse must meet all of the following requirements before application for examination:

1. Currently hold an active registered nurse (RN) license in the United States or its territories or the professional, legally recognized equivalent in another country.

2. Have practiced the equivalent of 2 years, full time, as an RN.

3. Have completed clinical practice of at least 2000 hours in gerontologic nursing within the past 3 years.

4. Have had 30 contact hours of continuing education applicable to gerontology/gerontologic nursing within the past 3 years.

More details on this option can be found by contacting the ANCC directly or online at www.nursingworld.org/ancc/certification.

Gerontologic Nurse Practitioner (GNP—BC)

The nurse must meet all of the following requirements:

1. Currently hold an active RN license in the United States or its territories or the professional, legally recognized equivalent in another country.

2. Hold a master’s, postmaster’s, or doctorate degree from a gerontologic nurse practitioner program accredited by the Commission on the Collegiate of Nursing Education (CCNE) or the National League for Nursing Accrediting Commission (NLNAC).

3. A minimum of 500 faculty-supervised clinical hours must be included in your gerontologic nurse practitioner program. The GNP graduate program must include course work in the following:

a. Advanced health assessment

b. Advanced pharmacology

c. Advanced pathophysiology, and

d. Content across the life span in health promotion and disease prevention; differential diagnosis, and disease management.

4. Alternative eligibility is available for an Acute Care Nurse Practitioner, Adult Nurse Practitioner, or Family Nurse Practitioner holding an active certification and who is licensed or authorized to practice as a nurse practitioner by a state or territory. More details on this option can be found by contacting the ANCC directly or online at www.nursingworld.org/ancc/certification.

Clinical Specialist In Gerontologic Nursing (GCNS—BC)

The nurse must meet all the following requirements before the application process:

1. Currently hold an active RN license in the United States or its territories or the professional, legally recognized equivalent in another country.

2. Hold a master’s, postmaster’s, or doctorate degree from a clinical nurse specialist in gerontologic nursing program accredited by the CCNE or the NLNAC; CNS role and specialty must be included in the educational program. This gerontologic CNS graduate program must include course work in the following:

a. Advanced health assessment

b. Advanced pharmacology

c. Advanced pathophysiology

More details on this option can be found by contacting the ANCC directly or online at www.nursingworld.org/ancc/certification.

Modified from American Nurses Credentialing Center Certification 2009, Washington DC, and retrieved August 14, 2009 from website at www.nursingworld.org/ancc/certify.htm. To keep current with the changing scope, standards, and education requirements, the eligibility criteria are reviewed yearly and are subject to change. Therefore if applying to take a certification examination, one must request a current catalog from the center; compliance with the current eligibility criteria is required. Applications can be downloaded from the Internet.

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:

• Geriatrics—from the Greek geras, meaning “old age,” geriatrics is the branch of medicine that deals with the diseases and problems of old age. Viewed by many nurses as having limited application to nursing because of its medical and disease orientation, the term geriatrics is generally not used when describing the nursing of older adults.

• Gerontology—from the Greek geron, meaning “old man,” gerontology is the scientific study of the process of aging and the problems of aged persons; it includes biologic, sociologic, psychologic, and economic aspects.

• Gerontologic nursing—this specialty of nursing involves assessing the health and functional status of older adults, planning and implementing health care and services to meet the identified needs, and evaluating the effectiveness of such care. Gerontologic nursing is the term most often used by nurses specializing in this field.

• Gerontic nursing—this term was developed by Gunter and Estes in 1979 and is meant to be more inclusive than geriatric or gerontologic nursing because it is not limited to diseases or scientific principles. Gerontic nursing connotes the nursing of older persons—the art and practice of nurturing, caring, and comforting. This term has not gained wide acceptance, but it is viewed by some as a more appropriate description of the specialty.

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.

Demographic Profile of the Older Population

Far from the beginnings of gerontologic nursing practice in almshouses and nursing homes, nurses today find themselves caring for older adults in a wider variety of settings. Emergency rooms, medical-surgical and critical care units in hospitals, outpatient surgical centers, home care agencies, clinics, and rehabilitation centers are just some of the sites where nurses are caring for the older population that is rapidly growing. Nurses in any of these settings need only count the number of adults 65 or older to understand firsthand what demographers have termed the graying of America. Although this trend has already attracted the attention of the health care marketplace, it promises to become an even greater influence on health care organizations. It is clearly a trend that promises to shape the future practice of nursing in profound and dramatic ways.

Demography is the science dealing with the distribution, density, and vital statistics of human populations. In the following review of basic demographic facts about older persons, the reader is cautioned against believing that age 65 automatically defines a person as being old. The rate and intensity of aging is highly variable and individual. It occurs gradually and in no predictable sequence.

Butler (1975), in his classic book, Why Survive? Being Old in America, cautions against using chronologic age as a measure of being old. He offers the following on why age 65 is the discretionary cutoff for defining old age:

Society has arbitrarily chosen ages 60 to 65 as the beginning of late life (borrowing the idea from Bismarck’s social legislation in Germany in the 1880s) primarily for the purpose of determining a point for retirement and eligibility for services and financial entitlements for the elderly.

When the social security program was established in 1935, it was believed that age 65 would be a reasonable age for the purpose of allocating benefits and services. Today, with so many older persons living productive, highly functional lives well beyond age 65, this age is obviously an inappropriate one for determining whether a person is old. However, demographic information and other forms of data are still reported using age 65 as the defining standard for old. For example, older adults are categorized by cohort for some research and public policy purposes. Consequently, it is not uncommon to see older persons classified as young-old, middle-old, or old-old.

Although grouping older persons is useful in some circumstances, the nurse is cautioned against thinking of all persons older than age 65 as similar. In fact, older persons are far from being a homogenous group. Landmarks for human growth and development are well established for infancy through middle age, but few norms have been as discretely defined for older adulthood. In fact, most developmental norms that have been described for later life categorize all older persons in the older-than-65 group. One could argue from a developmental perspective that as great a difference exists among 65-, 75-, 85-, and 95-year-olds as it does among 2-, 3-, 4-, and 5-year-olds, yet no definitive standards for older adult development have been established. Consequently, the nurse is urged to view each older client as one would any client—a being with a richly diverse and unique array of internal and external variables that ultimately influence how the person thinks and acts. Understanding how the variables interact and affect older adults enables the nurse to provide individualized care. Additionally, the nurse is encouraged to use the individual client as the standard, comparing a client’s previous level and pattern of health and function with the current status.