The Journal of Continuing Education in Nursing

CNE Article 

Improving Rural Geriatric Care Through Education: A Scalable, Collaborative Project

Harleah G. Buck, PhD, RN, FPCN, FAAN; Ann Kolanowski, PhD, RN, FGSA, FAAN; Donna Fick, PhD, RN, GCNS-BC, FGSA, FAAN; Lawrence Baronner, MS, MEd

Abstract

Rural elders are the fastest growing segment of the U.S. population, with a projected increase of 32% in the next 20 years. Shortages in geriatric-prepared workers are particularly critical in rural areas. This article describes Improving Rural Geriatric Care through Education (iRuGCE), a feasible, scalable, and collaborative continuing education project. iRuGCE was designed to improve geriatric nursing practice. Project goals were to identify, mentor, and facilitate an RN geriatric site champion in critical access hospitals (CAHs) to complete national certification in gerontological nursing, and to design a continuing education program that met the specific needs of the CAHs via delivery of three continuing education sessions per year. Evaluation of the project is promising. Preliminary results suggest that iRuGCE has a positive effect on nurse-sensitive patient satisfaction scores, such as communication with nurses, responsiveness of hospital staff, pain management, communication about medicine, discharge information, and willingness to recommend the hospital.

J Contin Educ Nurs. 2016;47(7):306–313.

How to Obtain Contact Hours by Reading this Issue

Instructions: 1.2 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded after you register, pay the registration fee, and complete the evaluation form online at http://goo.gl/gMfXaf. In order to obtain contact hours you must:

Read the article, “Improving Rural Geriatric Care Through Education: A Scalable, Collaborative Project,” found on pages 306–313, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz.

Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study.

Go to the Villanova website to register for contact hour credit. You will be asked to provide your name, contact information, and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated.

This activity is valid for continuing education credit until June 30, 2019.

Contact Hours

This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated.

Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

Objectives

Describe the unique nursing challenges that occur in caring for older adults in rural areas.

Discuss the Improving Rural Geriatric Care through Education (iRuGCE) project, including the facilitators and challenges to its implementation.

Disclosure Statement

Neither the planners nor the author have any conflicts of interest to disclose.

Do you want to Participate in the CNE activity?

 

Abstract

Rural elders are the fastest growing segment of the U.S. population, with a projected increase of 32% in the next 20 years. Shortages in geriatric-prepared workers are particularly critical in rural areas. This article describes Improving Rural Geriatric Care through Education (iRuGCE), a feasible, scalable, and collaborative continuing education project. iRuGCE was designed to improve geriatric nursing practice. Project goals were to identify, mentor, and facilitate an RN geriatric site champion in critical access hospitals (CAHs) to complete national certification in gerontological nursing, and to design a continuing education program that met the specific needs of the CAHs via delivery of three continuing education sessions per year. Evaluation of the project is promising. Preliminary results suggest that iRuGCE has a positive effect on nurse-sensitive patient satisfaction scores, such as communication with nurses, responsiveness of hospital staff, pain management, communication about medicine, discharge information, and willingness to recommend the hospital.

J Contin Educ Nurs. 2016;47(7):306–313.

How to Obtain Contact Hours by Reading this Issue

Instructions: 1.2 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded after you register, pay the registration fee, and complete the evaluation form online at http://goo.gl/gMfXaf. In order to obtain contact hours you must:

Read the article, “Improving Rural Geriatric Care Through Education: A Scalable, Collaborative Project,” found on pages 306–313, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz.

Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study.

Go to the Villanova website to register for contact hour credit. You will be asked to provide your name, contact information, and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated.

This activity is valid for continuing education credit until June 30, 2019.

Contact Hours

This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated.

Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

Objectives

Describe the unique nursing challenges that occur in caring for older adults in rural areas.

Discuss the Improving Rural Geriatric Care through Education (iRuGCE) project, including the facilitators and challenges to its implementation.

Disclosure Statement

Neither the planners nor the author have any conflicts of interest to disclose.

Do you want to Participate in the CNE activity?

 

The Institute of Medicine (IOM) report Retooling for an Aging America stressed the need to prepare the health care workforce for the coming increase in the older adult population (IOM, 2008). Shortages in geriatric nurses are particularly critical in rural areas, which are differentially affected by the demographic shift. Rural elders are the fastest growing segment of the population, with a projected increase of 32% in the next 20 years (Center for Rural Pennsylvania, 2014). In Pennsylvania, where the program described in this article was implemented, 30% of the commonwealth's 2 million older adults (595,000) reside in rural areas (Center for Rural Pennsylvania, 2014).

Rurality creates unique health care challenges. Rural elders are more likely than their urban counterparts to have ambulatory care-sensitive hospitalizations with poorer outcomes (Gamble et al., 2011; Thorpe, Van Houtven, Sleath, & Thorpe, 2010), multiple chronic conditions (Ward & Schiller, 2013), and increased risk of developing dementia because of their educational and economic disparities (American Public Health Association, 2010). One possible factor in these disparate outcomes may be the lack of quality geriatric nursing care. Colleges of nursing have the expertise to address this growing educational need. This article presents a quality geriatric nursing education project that was developed and evaluated in collaboration between the Pennsylvania Office of Rural Health (PORH) and the Hartford Center of Geriatric Nursing Excellence (HCGNE) at Penn State College of Nursing.

Background and Setting

Critical access hospitals (CAHs) are defined as rural, Medicare-participating hospitals that provide 24-hour emergency services and have no more than 25 acute care beds, with an average length of stay of 96 hours or less. In addition, the CAH must be located at least 35 miles from any hospital (15 miles in mountainous terrain or by secondary roads) (Department of Health and Human Services, 2016). The Pennsylvania CAH program is administered through the PORH. As part of that administration, the PORH conducts administrative surveys and face-to-face interviews with staff and hospital administrators assessing workforce development needs in the 13 CAHs in Pennsylvania (PORH, 2006). The PORH synthesized the data from 1,015 individual administrative surveys, 182 staff interviews, and 51 hospital administrator interviews to develop the Pennsylvania Critical Access Hospital Workforce Development Matrix (PORH, 2006). Key themes that arose from these data included significant constraints around workforce development: lack of knowledge of existing resources, lack of finances to support internal education programs, and lack of time to address the problem during the provision of care. Staff expressed feelings of professional isolation and inability to keep up to date with pharmacologic developments, new biomedical equipment, and the needs of special populations. When the survey data was presented internally at Penn State, where the PORH is located, the HCGNE responded.

Development of the Improving Rural Geriatric Care Through Education Project

The HCGNE is one of the original centers of excellence funded by the J.A Hartford Foundation. Its mission is to improve the care of older adults through research, education, and outreach. The HCGNE is housed at Penn State College of Nursing, an academic unit with faculty and students on 12 campuses across Pennsylvania, including in rural areas. The HCGNE is the only rural Center of Geriatric Nursing Excellence in the northeastern United States.

Because of the match between the center's outstanding geriatric nursing resources and the needs identified by the PORH, a unique opportunity presented itself for a collaborative project to improve rural geriatric education in CAHs, and the Improving Rural Geriatric Care through Education (iRuGCE) project was developed. The HCGNE provided evidence-based geriatric practice expertise and state-of-the-art video-conferencing ability. The PORH provided rural expertise and access to the CAHs. The iRuGCE project had two goals: (a) to identify, mentor, and facilitate an RN geriatric site champion in each CAH to complete national certification in gerontological nursing and (b) to design a continuing education (CE) program that met the specific needs of the CAHs and deliver three CE sessions per year via online modules, videos, and video conferencing. The Figure provides a logic model of the project, schematically presenting the target population, resources needed, goals and objectives, and outcomes of the iRuGCE. Table 1 provides the time line and activities for the 2-year project. Application was made and funding was obtained from the Highmark Foundation to cover the costs of board certification for the site champions and infrastructural program development support. The Highmark Foundation was interested in this project because it addressed two of its initiatives—chronic illnesses and healthy communities—and had the potential to be transferable to other rural states.


Logic model of the Improving Rural Geriatric Care through Education (iRuGCE) project.

Figure.

Logic model of the Improving Rural Geriatric Care through Education (iRuGCE) project.


Time Line and Activities for the Improving Rural Geriatric Care Through Education Project

Table 1:

Time Line and Activities for the Improving Rural Geriatric Care Through Education Project

Site Champions

Site champions are opinion leaders and peer resources (Manthorpe, 2012; Ploeg et al., 2010). A Cochrane review found that site champions were particularly successful in promoting evidence-based practice (Flodgren et al., 2011). Research conducted at Penn State supports this finding (Yevchak et al., 2014). To achieve this goal, the team worked with the executives of the CAHs to identify a nurse to participate. After that site champion was identified, faculty used a train-the-trainer mentoring model. Table 2 provides the content and time line for the seven mentoring sessions provided to the site champions. In addition, the board certification process for gerontological nursing awarded by the American Nurses Credentialing Center was facilitated through educational and financial support. Eligibility requirements for board certification included completing 30 hours of gerontological CE in the previous 3 years. Facilitation involved individually assessing each site champion's existing geriatric CE credits and then identifying additional hours of open-access CEs. These CEs were available from Penn State and other Hartford venues, such as the Hartford Institute at New York University and the Hartford Center at the University of Arizona. Access to an online preparation course and payment for certification was provided with Highmark funding.


Site Champion Mentoring Plan for the Improving Rural Geriatric Care Through Education Program

Table 2:

Site Champion Mentoring Plan for the Improving Rural Geriatric Care Through Education Program

Designing and Delivering CE

To achieve the second goal to design site-specific CE programs, site champions were trained to identify topics for virtual clinical rounds, conduct a CE needs survey in their CAH, and encourage staff attendance at journal clubs. Virtual clinical rounds involved collaboration between nursing faculty experts and CAH staff via distance technology. The CAH staff member presented the case, then a plan of care addressing the nursing issues in the case was jointly developed with nursing faculty. Site champions were trained to conduct an educational needs survey during one of the live mentoring sessions. For example, site champions surveyed CAH nurses and identified the need for updates on geriatric pharmacology. The College of Nursing responded by developing a new, two-credit CE online module on the topic. Site champions were then activated to return to their CAH and publicize the CE module, which could be completed asynchronously. The HCGNE journal club, which is a low-tech, high-impact vehicle to disseminate the latest geriatric research projects into rural areas, is one example of synchronous CE provided. For this project, the site champion coordinated the advertisement and distance technology for the journal club. Participants received CEs for each session.

Evaluation Plan

The evaluation of the iRuGCE project involved immediate and long-term measures of success. Immediate measures were collected at the end of the first year and included successful implementation of the site champion program (goal 1) and successful delivery of CE courses (goal 2). Long-term measures were collected at the end of the second year and assessed patient satisfaction with care received at the CAH.

Immediate Measures (Year 1)

The site champion goal (goal 1) was evaluated by collecting data on numbers of site champions recruited and numbers of site champions successfully certified within a 2-year period. Data on the CE programs (goal 2) were collected using an evaluation form used by the Penn State College of Nursing Office of Outreach and Continuing Education, an approved provider of continuing education by Pennsylvania State Nurses Association.

Long-Term Measures (Year 2)

At the end of year 2, the College of Nursing and PORH contracted with a program evaluator with expertise in rural sociology to evaluate changes in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) measures. HCAHPS is a national, standardized, publicly reported data survey developed by the Centers for Medicare and Medicaid in partnership with the Agency for Healthcare Research and Quality. National data were used to decrease the data collection burden on the CAH or site champions and to allow for establishing national benchmarks. Patient satisfaction with care as measured by the HCAHPS is a well-known indicator of quality of care (Cleary & McNeil, 1988; McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011) and predicts patient outcomes such as symptoms (Doyle, Lennox, & Bell, 2013) and health care use (Laschinger, Gilbert, & Smith, 2011).

Outcomes

Immediate Measures (Year 1)

RN site champions in six of the eight CAHs in our catchment area (two hospitals declined participation) were identified and mentored. Four of the six participating site champions successfully completed all parts of the program, including certification within the first year. Two of the site champions took new positions, which precluded completing the program. It should be noted that CEs were provided to CAHs that declined participation in the project or whose site champions did not complete the program. All of the three planned CE programs—two journal clubs and one virtual rounds session—were delivered. All CE programs were archived for later asynchronous access.

Long-Term Measures (Year 2)

Current and baseline mean scores for each item in the HCAHPS survey were available for the six participating iRuGCE CAHs. Five nonparticipating CAHs were used as a comparison group. Evaluation involved comparing the mean scores of the iRuGCE CAHs at baseline and current period and against the comparison group. Due to the small number of cases, statistical tests are not reported. Instead, evidence that iRuGCE had an effect on participating CAHs was based on the presence of consistent patterns across the HCAHPS items. Table 3 reports the percentage point change between the baseline and current periods for iRuGCE and comparison group hospitals (current period minus baseline period), which represents the change that occurred during the first two quarters of the intervention period.


Change Between Current and Baseline Periods for Improving Rural Geriatric Care Through Education (iRuGCE) and Comparison Group Critical Access Hospitals on Hospital HCAHPS Survey
Change Between Current and Baseline Periods for Improving Rural Geriatric Care Through Education (iRuGCE) and Comparison Group Critical Access Hospitals on Hospital HCAHPS Survey

Table 3:

Change Between Current and Baseline Periods for Improving Rural Geriatric Care Through Education (iRuGCE) and Comparison Group Critical Access Hospitals on Hospital HCAHPS Survey

Evaluation of the effect of the iRuGCE project on measures of patient satisfaction from the HCAHPS Survey are promising. These preliminary results suggest that iRuGCE has a positive effect on satisfaction with communication with nurses (composite 1), responsiveness of hospital staff (composite 3), pain management (composite 4), communication about medicine (composite 5), discharge information (composite 6), and willingness to recommend hospital (Question [Q] 22). The results also suggest that change between the current and baseline periods for iRuGCE hospitals was minimal with respect to patient satisfaction with communication with doctors (composite 2), patient satisfaction with cleanliness of the hospital environment (Q8), quietness of the hospital environment (Q9), or overall rating of the hospital (Q21).

All of the indicators that showed change (composites 1, 3, 4, 5, 6; Q22) can be thought of as nurse sensitive, suggesting that the iRuGCE met the project's overall aim to change nursing practice through education. These data also show that change was minimal in non–nurse-sensitive indicators, suggesting that the program deferentially impacted outcomes involving nursing practice and those that did not.

Challenges

Several challenges existed during the implementation of this innovative program. The greatest challenge was time limitations for the site champions. According to the PORH, the average number of RN full-time equivalents (FTEs) at the Pennsylvania CAHs is approximately 40 (range = 20–100). The average FTE of all employees is 200. None of the CAHs were able to offer the nurses time off to complete the program. Each site champion continued to work full time (some on the night shift) while completing 30 hours of CE, participating in mentoring sessions and preparatory courses, and sitting for a certification examination. The success of the site champions who completed the full program reinforced that they found it valuable to their current practice and were committed to evidence-based practice. Future implementation of the program could possibly use the Medicare Rural Hospital Flexibility Program (Flex Program) grant as a quality improvement initiative to overcome this challenge and provide buyout of the nurses' time. In addition, using other Medicare outcome datasets beyond HCAHPS may result in different outcomes for changes in other key patient-reported outcomes.

When reviewing this project, several caveats should be kept in mind. First, the project was conducted in one state, Pennsylvania, with a primarily Caucasian rural population (both staff and patients). Second, Penn State College of Nursing has vast experience with delivering content using distance technology, which may not be available in other states. Finally, because of a lag in the release of government data, the current evaluation data are available only for the first two quarters of the 2014 intervention period.

Conclusion

This article presents a feasible, scalable project to provide geriatric education in rural areas—the iRuGCE project. The authors recommend that other schools of nursing with distance educational capability in states with large numbers of rural older adults consider following this model to improve rural geriatric care through education.

References

  • American Public Health Association. (2010). Health disparities: The basics. Retrieved from https://www.apha.org/~/media/files/pdf/factsheets/hlthdisparty_primer_final.ashx
  • Center for Rural Pennsylvania. (2014). Looking ahead: Pennsylvania population projections 2010 to 2040. Retrieved from http://www.rural.palegislature.us/documents/factsheets/projections_2010-2014.pdf
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  • Doyle, C., Lennox, L. & Bell, D. (2013). A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ Open, 3(1), e001570. doi:10.1136/bmjopen-2012-001570 [CrossRef]
  • Flodgren, G., Parmelli, E., Doumit, G., Gattellari, M., O'Brien, M.A., Grimshaw, J. & Eccles, M.P. (2011). Local opinion leaders: Effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews, 8(8). doi:10.1002/14651858.CD000125.pub4 [CrossRef]
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  • Thorpe, J.M., Van Houtven, C.H., Sleath, B.L. & Thorpe, C.T. (2010). Rural urban-differences in preventable hospitalizations among community dwelling veterans with dementia. The Journal of Rural Health, 26, 146–155. doi:10.1111/j.1748-0361.2010.00276.x [CrossRef]
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  • Yevchak, A.M., Fick, D.M., McDowell, J., Monroe, T., May, K., Grove, L. & Inouye, S.K. (2014). Barriers and facilitators to implementing delirium rounds in a clinical trial across three diverse hospital settings. Clinical Nursing Research, 23, 201–215. doi:10.1177/1054773813505321 [CrossRef]

Time Line and Activities for the Improving Rural Geriatric Care Through Education Project

Time PeriodTask
Year 1
  Months 1–3Project leaders attend CAH CEO and PORH meetings to introduce the project
Identify and mentor site champions
Site champions identify cases for virtual rounds
Design a CE plan (30 credits for certification) in collaboration with the site champion using existing CE programs
  Months 4–6Develop three CE programs with input from site champions
  Months 7–9Bring site champions to Penn State for two half-day mentoring sessions
Deliver year 1 CE programs (3)
  Months 10–12Evaluate year 1 CE programs
Track site champions certification progress
Site champions conduct a CE needs survey at the CAHs for year 2
Archive video sessions and plan for ongoing access
Year 2
  Months 1–3Attend CAH CEO and PORH meetings to give an update on the project
  Months 4–6Develop new CE programs in response to needs survey
Track year 2 site champions' certification progress, continue mentoring
  Months 7–9Deliver three year 2 CE programs
  Months 10–12Archive video sessions and plan for ongoing access
Overall program evaluation

Site Champion Mentoring Plan for the Improving Rural Geriatric Care Through Education Program

Months123456789101112
Session 1 “meet and greet” virtual sessionX
  Discuss time line for RN-BC process
  Prepare for first journal club
Session 2 journal club virtual session
  Site champion advertises session
  Site champion arranges for room
  Site champion oversees roster and evaluationX
Site champion registers for Nursing Certification Review Course and continues to work on 30 geriatric continuing education (CE) creditsX
Session 3 “Using Penn State College of Nursing CE resources” virtual sessionX
Session 4 “Mentoring at Penn State” two half-day LIVE sessionsX
Site Champion begins gathering materials application for RN-BC examinationX
Session 5 “Developing a CE plan for your hospital” virtual session
  Site champion identifies the particular CE needs before the session
  A cross walk between the Penn State CE and hospital needs will be talked about
  Site champions will advocate in their hospital for free CE available at Penn StateX
Site champion mails application for RN-BC examinationX
Session 6 Virtual RoundsX
  Site champion identifies a geriatric clinical case at their hospital
  Site champion invites other nurses to the virtual rounds
  Site champion presents the case and evidence-based solutions are discussed.
Site champion takes American Nurses Credentialing Center gerontological nursing examinationXX
Booster session 7 “How is Certification Going” virtual session (if needed)X
  Site champions discuss their progress in certification
  Mentoring is provided by Penn State faculty

Change Between Current and Baseline Periods for Improving Rural Geriatric Care Through Education (iRuGCE) and Comparison Group Critical Access Hospitals on Hospital HCAHPS Survey

HCAHPS Survey ItemiRuGCE HospitalsComparison Hospitals


NumberMean Percentage Point ChangeNumberMean Percentage Point Change
HCAHPS composites
  Composite 1: Communication with nurses
     Sometimes to never60.550.4
     Usually6−1.550.2
     Always61.05−0.6
  Composite 2: Communication with doctors
     Sometimes to never6−0.35−0.2
     Usually60.351.6
     Always60.05−1.4
  Composite 3: Responsiveness of hospital staff
     Sometimes to never60.25−0.4
     Usually6−0.850.2
     Always60.750.2
  Composite 4: Pain management
     Sometimes to never6−1.351.2
     Usually6−3.25−3.0
     Always64.551.8
  Composite 5: Communication about medicines
     Sometimes to never60.85−1.6
     Usually6−4.55−0.8
     Always63.752.4
Hospital environment items
  Q8: Cleanliness of hospital environment
     Sometimes to never6−0.550.2
     Usually61.351.0
     Always6−0.85−1.2
  Q9: Quietness of hospital environment
     Sometimes to never60.250.0
     Usually6−1.75−2.8
     Always61.552.8
Discharge information composite
  Composite 6: Discharge information
    Yes61.75−1.6
    No6−1.751.6
HCAHPS global items
  Q21: Overall rating of hospital (1 = worst hospital, 10 = best hospital)
    0 to 660.05−0.6
    7 and 86−1.05−0.4
    9 and 1061.051.0
  Q22: Willingness to recommend hospital
     No: Definitely or probably not60.35−0.4
     Yes: Probably recommend6−1.75−0.2
     Yes: Definitely recommend61.350.6
Authors

Dr. Buck is Assistant Professor, Dr. Kolanowski is Professor of Nursing, Dr. Fick is Elouise Ross Eberly Professor of Nursing, College of Nursing, The Pennsylvania State University, University Park; Mr. Baronner is Rural Health Systems Manager and Deputy Director, Pennsylvania Office of Rural Health, State College, Pennsylvania.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Harleah G. Buck, PhD, RN, FPCN, FAAN, Assistant Professor, College of Nursing, The Pennsylvania State University, 201 Nursing Sciences Building, University Park, PA 16802; e-mail: hgb2@psu.edu.

Received: January 13, 2016
Accepted: April 20, 2016

10.3928/00220124-20160616-06

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