The Journal of Continuing Education in Nursing

Original Article 

Partnering to Educate Nurses in Long-Term Care

Cynthia Selleck, PhD, RN, FAAN; Rita Jablonski, PhD, RN, FAAN; Rebecca S. Miltner, PhD, RN, CNL, NEA-BC; Joy Deupree, PhD, RN, CRNP, WHNP-BC; Gwen McGhan, PhD, RN; Julia Powell, BSN, RN, MA, NEA-BC

Abstract

Despite a 2008 national call to retool a health care workforce for an aging America, the geriatrics-trained workforce is declining while the U.S. population continues to age. Formalized academic–practice partnerships between long-term care facilities and schools of nursing are one response to strengthening the work-force caring for older adults. This article details the activities of an intentional, synergistic, 3-year partnership between National HealthCare Corporation (NHC) and University of Alabama at Birmingham (UAB) School of Nursing. The partnership focused on providing continuing education and leadership development for NHC nurses while also providing nursing faculty with access to clinicians and patients in long-term care for the purposes of education, research, and quality improvement. The ultimate goal for both partners was improved patient outcomes. [J Contin Educ Nurs. 2020;51(2):75–81.]

Abstract

Despite a 2008 national call to retool a health care workforce for an aging America, the geriatrics-trained workforce is declining while the U.S. population continues to age. Formalized academic–practice partnerships between long-term care facilities and schools of nursing are one response to strengthening the work-force caring for older adults. This article details the activities of an intentional, synergistic, 3-year partnership between National HealthCare Corporation (NHC) and University of Alabama at Birmingham (UAB) School of Nursing. The partnership focused on providing continuing education and leadership development for NHC nurses while also providing nursing faculty with access to clinicians and patients in long-term care for the purposes of education, research, and quality improvement. The ultimate goal for both partners was improved patient outcomes. [J Contin Educ Nurs. 2020;51(2):75–81.]

The U.S. population is rapidly aging. Adults age 65 and older represented one of every seven Americans, or 49.2 million people, in 2016 and this is expected to increase to 98 million by 2060. Those age 85 and older (the oldest old) are growing the fastest, more than doubling from 6.4 million in 2016 to an expected 14.6 million in 2040 (University of Pittsburgh Health Policy Institute, 2015; U.S. Department of Health and Human Services, 2018). This demographic shift is due primarily to two events—people living longer and Baby Boomers entering old age (Rowe et al., 2016). As the population ages, care needs are also changing. More and more older adults are living with one or more chronic conditions, as well as age-related functional impairments, that necessitate assistance with activities of daily living. The need for long-term care and supportive services is expected to double by 2050 (University of Pittsburgh Health Policy Institute, 2015). Meanwhile, the geriatrics-trained workforce is declining across health professions despite the Institute of Medicine's 2008 call to retool a health care workforce for an aging America (Hawkley et al., 2018; Institute of Medicine, 2008; Lee & Sumaya, 2013). Experts estimate the 7,500 board-certified geriatricians in the United States is approximately half of what is currently needed, and the pipeline remains inadequate (Rowe et al., 2016; U.S. Department of Health and Human Services, 2017). Nurses fare no better with less than 1% of RNs and only 3% of advanced practice registered nurses (APRNs) certified in geriatrics (Rowe et al., 2016; University of Pittsburgh Health Policy Institute, 2015). Further, nurses working in long-term care often have minimal to no geriatrics training and opportunities for ongoing training are often limited or nonexistent (Hawkley et al., 2018). Clearly, educating the nursing workforce to deliver high-quality care to a growing elderly population is an urgent need.

Background

In 2014, the Vice President of Patient Care Services for National HealthCare Corporation (NHC) met with faculty and administration at the University of Alabama at Birmingham (UAB) School of Nursing (SON) to discuss a possible academic–practice partnership, the ultimate goal of which was to improve patient care outcomes throughout NHC facilities. NHC and its affiliates operate more than 150 skilled nursing health care centers, homecare programs, residential living centers, and assisted living communities within 10 states, mostly in the southeastern United States. They are a recognized national innovator in the delivery of quality long-term care.

The UAB SON is a large school of nursing that offers programs at the baccalaureate, master's, doctoral, and postdoctoral levels. One of the school's strategic goals is to build mutually beneficial partnerships that transform health and health care delivery; thus, there was a strong commitment to develop a partnership with NHC that would ultimately increase collaboration opportunities for education, research, quality improvement, and positive patient outcomes.

Academic–practice partnerships, as envisioned by the American Organization of Nurse Executives (AONE) and American Association of Colleges of Nursing (AACN), help strengthen nursing practice while positioning nurses to lead change and advance health (AONE & AACN, 2012). Although partnerships have been more common between schools of nursing and large acute care institutions, emerging models have included a variety of community, as well as post-acute care, facilities (National Organization of Nurse Practitioner Faculties [NONPF], 2016). These partnerships are meant to be intentional and formalized relationships built on mutual goals, trust, respect, and shared knowledge, with the goal of improving patient outcomes (AONE & AACN, 2012; NONPF, 2016). True academic–practice partnerships go well beyond the clinical training of students, which is the case described here. This article details the partnership developed between NHC and UAB SON for the purpose of strengthening the nursing workforce for long-term care. Partnership activities are described, including successes and lessons learned, for others who may wish to replicate similar academic–practice partnership programs.

Method

Development, Implementation, and Evolution of the Partnership

The first step in the partnership process was to determine goals and outcomes and develop a formal relationship. This was accomplished through a series of discussions about NHC's needs and how UAB SON could help meet those needs. NHC uses a decentralized organizational structure; thus, discussions included how to meet needs of nurses across the organization and across 10 states. Initially, the Vice President for Patient Care Services at NHC, a master's-prepared nurse, expressed significant interest in having someone who could serve as a clinical resource to NHC's eight Regional Nurses whose role is to support and guide the Directors of Nursing within the facilities in their respective regions. Further, there was interest in bringing the Regional Nurses and select others together for an annual meeting focused on clinical and leadership topics. Leadership workshops and development in quality improvement (QI) for select center Directors of Nursing were additional needs identified by the Vice President for Patient Care Services. Conducting needs assessment surveys of NHC's more than 3,100 nurses, including both RNs and licensed practical nurses (LPNs), was a further goal. Using data from the needs assessments to develop webinars for nursing staff was also of interest.

Meeting the Needs of NHC Partners

Several initiatives were developed to meet the needs of NHC nurses from Regional Nurse Leaders to Directors and Assistant Directors of Nursing to staff nurses, including both RNs (45% of nurses) and LPNs (55% of nurses). UAB faculty planned learning activities to engage learners across regions, including customized online education, newsletters, face-to-face meetings, webinars, poster presentations, and interactive experiential learning. The seven-level outcomes model proposed by Moore, Green, and Gallis (2009) was used as an evaluation framework. This model includes evaluation of continuing education from very basic participation (level 1) to improvement in population or community health (level 7). Table 1 lists the seven levels of this framework.

The Seven-Level Outcomes Modela

Table 1:

The Seven-Level Outcomes Model

Clinical Resource Development

The NHC leadership desired access to a clinical expert who could provide up-to-date and evidence-based resources. A geriatrics-trained APRN faculty member was selected as the initial clinical expert because of her research activities in long-term care and her active clinical practice in a memory disorders clinic. Initially, this APRN faculty member created an online course for the Regional Nurses and all center Directors and Assistant Directors of Nursing. She used the university's learning platform, Canvas™, to build the self-directed course, which included a repository for archived webinars, handouts, slides, and selected clinical resources. The course, named Gero Central, contained a landing page with an introductory video and basic directions for accessing the content. The content was organized as pages inside specific modules. Individual pages typically consisted of a succinct (400 to 600 words) explanation of the topic with resources, such as companion articles, readily accessible via hyperlinks. For example, Figure A (available in the online version of this article) shows the page “Urinary Tract Infections,” which was composed of five hyperlinks: asymptomatic bacteriuria, identifying residents at highest risk for urinary tract infections (UTIs), practice guidelines for preventing UTIs in catheterized individuals, preventing UTIs in noncatheterized individuals, and antimicrobial stewardship and UTIs. The use of hyperlinks improved site navigation while maintaining aesthetic appeal.

Example of Gero Central Course Module on Urinary Tract InfectionsNote: All items underlined are hyperlinks to additional resources.

Figure A.

Example of Gero Central Course Module on Urinary Tract Infections

Note: All items underlined are hyperlinks to additional resources.

The course went live in August 2015 and was met with initial enthusiasm. Content continued to be added based on questions and requests received; however, usage of the course waned over time. In year two, this same APRN instituted “Tuesday Tidbits.” Every Tuesday, a virtual newsletter highlighting a specific topic on Gero Central was e-mailed to all Gero Central participants using the Canvas e-mail feature. Despite ongoing efforts to promote the online resource, usage never met expectations and the decision was made to replace Gero Central with monthly printed newsletters starting in year three.

Unlike the virtual newsletters which required the readers to sign into Gero Central to access content, the new monthly newsletters were designed to be e-mailed to all facilities, printed out, and distributed directly or posted for staff members. Anecdotally, these newsletters were better received because the recipients could access the information directly without logging into a learner management system. The first three newsletters covered updated popular Gero Central topics (e.g., dementia and UTIs, preventing UTIs, and dementia and falls). Each newsletter included contact information for the faculty expert who encouraged nurses to contact her with questions. When she was contacted with questions and clinical problems, these issues became future newsletter topics. Additional newsletter topics included tracheostomy care, gastrointestinal tube placement practices, decisional capacity for individuals with dementia, managing behaviors exhibited by individuals with frontotemporal dementia, and strategies for preventing and managing care refusals.

NHC holds annual Patient Care Conferences that are attended by individuals in positions of center leadership from nursing, social work, rehabilitation, and nutrition. These conferences are important venues for continuing education activities. SON faculty presented keynote presentations at the past four conferences (2015–2018), including presentations on dementia care, evidence-based strategies to prevent and manage care resistance and refusals, updated Code of Federal Regulations changes, the need for more dementia education for all staff, and the Code of Federal Regulations mandate that nursing homes provide trauma-informed care.

Regional Nurse Leaders Annual Meetings

An annual 2-day meeting held at the SON was planned for the eight Regional Nurses and select others from the corporate office. Nursing faculty experts developed and presented clinical and education offerings based on needs identified by the Regional Nurses. Topics for the annual Regional Nurse meetings for the past 3 years are depicted in Table 2. These meetings also provided an opportunity for formative assessment of partnership activities and process improvement changes needed, as well as discussion of additional needs or opportunities that had been identified.

Geriatrics-Focused Education Presented At Regional Nurse Leader Annual Meetings

Table 2:

Geriatrics-Focused Education Presented At Regional Nurse Leader Annual Meetings

Leadership Workshops

To meet the needs of other nurse leaders within NHC, a 1-day Leadership Workshop was held during years one and two of the partnership for 10 to 12 center Directors of Nursing selected by the Vice President for Patient Care Services because they were new to their roles. These workshops included exploration and identification of personal leadership strengths (using the book StrengthsFinder 2.0 [Roth, 2007]) and development of an individualized leadership development plan. Leadership topics for the first 2 years included:

  • Emotional Intelligence within the Leadership Role.
  • Identifying and Capitalizing on Signature Strengths.
  • Leadership and Quality Improvement.
  • Leadership Practices for Safety and Quality Improvement—Next Steps.
  • Communicating with Confidence.

In lieu of a face-to-face Leadership Workshop in year three, an interactive self-reflection activity on conflict management was planned. A webinar on the topic was presented to identified Regional Nurses and Directors of Nursing. Following the webinar, these nurse leaders were e-mailed a link to complete the Thomas-Kilmann Conflict Mode Instrument (TKI)©, which assesses an individual's behavior in conflict situations across the dimensions of assertiveness and cooperativeness. The group reconvened at the annual Patient Care Conference to review and discuss their individual profiles from the TKI and learn how to develop skills in other areas, if needed.

Leadership Development in Quality Improvement

Starting in year two, use of a QI Collaborative model was included to focus on leadership for quality and safety. QI Collaboratives were developed by the Institute for Healthcare Improvement and are short-term (6- to 15-month) processes that bring together teams from different sites to seek improvement in a focused topic area (Institute for Healthcare Improvement, 2003). Participants were center Directors of Nursing who attended the Leadership Workshops and who also participated in the year-long QI Collaborative. The program began with the Leadership Workshop at the SON and was followed by a series of webinars with a faculty expert that covered QI methods and tools. Each participating Director of Nursing was tasked with implementing a focused improvement project at their facility over the course of the next year. The projects were conducted with faculty oversight and allowed these nurse leaders to transfer their new knowledge and skills into practice.

The first QI Collaborative cohort of nurse leaders tackled strategies to better prevent falls. The change interventions were selected based on individual facility needs: specific patient population (rehabilitation versus long-term care residents), facility size, staffing models, and other contextual factors. Falls interventions included purposeful rounding on residents, making falls data visible to all staff, and proactive risk assessment prior to admission. One facility created an alert (Code Purple) for all department heads to report immediately to the location of the fall and begin an investigation of the fall. This intervention not only identified risks that could be proactively corrected, but it also improved teamwork and collaboration across departments in the facility. The intervention also changed the culture around falls and fall risk. Falls became everyone's problem to solve rather than the responsibility of one or two departments.

The second cohort of nurse leaders in the QI Collaborative focused on antibiotic stewardship. Using the Centers for Disease Control and Prevention (2015) checklist for Core Elements of Antibiotic Stewardship for Nursing Homes, these Directors of Nursing conducted a precollaborative assessment and found there was variability between their facilities for all core elements except accountability. At the end of the QI Collaborative, a post-survey showed that all facilities reported evidence of all antibiotic stewardship core elements with the exception of one facility that needed to establish a formal policy to improve antibiotic prescribing. Facilities reported that better protocols for managing suspected UTIs, as well as better tracking and reporting facilitated reduction of antibiotic use.

Both cohorts of Directors of Nursing that were involved in the QI Collaboratives presented their work via professional poster presentations at the annual NHC Patient Care Conference at the end of the year-long collaborative. These presentations gave the Directors the opportunity to share their work with other members across the health care system.

Needs Assessments and Webinars

During the first and third years of the partnership, needs assessment surveys of the corporation's RNs and LPNs were conducted using a web-based instrument that was developed specifically for NHC. The objective of the surveys was to develop an employee profile, assess both informational and educational needs, and identify challenges. Responses were similar in both years. In terms of employee challenges, time management was cited as the leading challenge for nurses in 2016 and again in 2018, followed by communication with staff and family members. Nurses were asked to describe desired resources to help them do their job better. Responses were numerous and fell into the categories of staffing/employee benefits/communication, facilities, education, equipment, processes, and resident needs and programs. Nurses were also provided with a lengthy list of topics regarding caring for older adults and asked which of these they would be interested in learning more about. Dementia and management of dementia-related symptoms were by far the top choices both years, followed by falls, assessment techniques, interpretation of laboratory results, psychosis, palliative care, pain, and self-care/avoiding burnout/stress management. A large majority of respondents said they would participate in webinars addressing these topics and indicated that recorded sessions accessed on demand would be their preference.

Faculty members used data from the needs assessments to plan two live webinars each year for nursing staff. These webinars were also archived for later viewing. Webinar topics included the following:

  • Innovative Strategies to Manage Dementia-Related Behavior: Mouth Care as Exemplar.
  • From Falls Prevention to Safe Mobility: What Does the Evidence Suggest?
  • Making Care Better for Residents: An Introduction to Quality Improvement in Long-Term Care.
  • Building Better Relationships through Effective Communication.
  • Identification of Your Leadership Style.
  • Understanding Your Conflict Management Style for Effective Leadership.

Evaluation

Evaluation of each learning activity took place and varied from level 1, participation, to participant evaluation of their satisfaction with educational content and intention to use the information in their practice (level 2), to the QI Collaboratives where nurse leaders learned and performed with faculty feedback (level 5). Participation evaluation included counts of numbers of attendees at all learning opportunities, as well as the number of weekly page views in the Gero Central course, which allowed faculty to determine usage. Participant satisfaction was assessed at all Regional Nurse Leader Annual Meetings, Leadership Workshops, Patient Care Conference faculty presentations, and webinars and was consistently very high. Scores for all activities ranged from 4.7 to 5.0 on a 5-point Likert-type scale. UAB nurses reported feeling better prepared after engaging with nationally recognized faculty experts on related topics and included comments such as the following:

  • Awesome experience! The education that you provide us can help us achieve so much more! (2015 Regional Nurse Annual Meeting)
  • Thoroughly enjoy coming here and improving knowledge skills. We are always met with such hospitality and passionate instructors about our topics. Thank you! (2016 Regional Nurse Annual Meeting)
  • I wish this seminar was longer. I felt it to be extremely valuable and very interesting. (2017 Leadership Workshop)
  • This lady needs an entire day! She is great…enjoy her… was excited for her to be in the lineup. Thank you for bringing her back. (2018 Patient Care Conference faculty presentation)

Nurse leaders involved in the QI Collaboratives reported more confidence in using these skills in their home facilities. In addition, David Gifford, Senior Vice President of Quality and Regulatory Affairs at the American Health Care Association, called attention to their QI posters in his keynote presentation at the 2017 Patient Care Conference, stating that the improvement work at the facilities underscored the importance of the use of data, interprofessional teamwork, use of prevention measures, and root cause analysis when falls occur. Ideally, next steps in the evaluation process will be for these nurses to review records to determine changes in individual patient health status (level 6) and improvement in health status across the facility or population (level 7). Although this is the ultimate goal of any academic–practice partnership, changes at these levels take time, are harder to assess, and are beyond the scope of this article.

Discussion

The synergistic academic–practice partnership developed between NHC and UAB SON has been successful in providing needed continuing education and leadership development for NHC nursing staff while also providing nursing faculty with access to clinicians in long-term care for the purposes of enhancing their own scholarship, especially in the areas of quality improvement. Note that this partnership focused on the education of practicing nurses in long-term care and did not include students. Although the training of nursing students in long-term care is important to their future practice in such settings, there were no NHC facilities located near the academic partner, nor was student clinical training a focus of this initiative.

A variety of activities were developed over the initial 3 years of the partnership with variations in success. For instance, there was great interest in the Gero Central clinical resource developed specifically for NHC nurse leaders, but usage of this self-directed, web-based resource did not meet expectations. Unintentional barriers, such as the required access to a learner management system that was cumbersome for some, coupled with lack of time and lack of computer access by busy clinicians were likely reasons for the lack of uptake.

Face-to-face meetings and workshops with Regional Nurses and selected Directors of Nursing were consistently positively evaluated. Nurse leaders valued both the educational and leadership content and faculty benefitted from challenges and opportunities presented by the nurses. The QI Collaboratives were particularly successful and allowed selected Directors of Nursing to remain engaged with one another as well as with SON faculty throughout the year while conducting and evaluating a needed quality and safety project within their individual facilities.

Needs assessment surveys were helpful in determining the educational needs of nurses across levels (RN and LPN) and across facilities. NHC leadership benefited from the wealth of data collected and reported back to them. The webinars conducted on topics of interest from the needs assessments had varying attendance during the live sessions, which were scheduled during lunch time or early afternoons. Marketing the webinars to nursing staff across facilities and busy staff having access to a computer, or at least a telephone, for an hour during the day were challenges. Archived webinars remain available on the NHC intranet site for nurses to access at a later, more convenient time; however, because access does not require registration, we are unable to capture how many do so.

The culmination of annual partnership activities occurred each year at the corporation's Patient Care Conference. Three SON faculty members consistently attended and presented at the conferences, which also provided an opportunity to network and collaborate with NHC leadership, nurses, and other health care providers. More recently, conferences also provided a venue to highlight the QI Collaborative work taking place at several facilities.

During the initial 3 years, the NHC and UAB SON relationship has successfully transitioned from an exploratory acquaintance to an engaged, working partnership that has set the stage for further collaborations. For instance, the partners are planning a federal grant submission during the coming months on improving patient safety in long-term care.

Conclusion

Academic–practice partnerships can be an important component of strengthening the workforce caring for our growing aging population, especially those in long-term care. Schools of nursing and long-term care facilities share some common goals that may be met through formal partnership activities. As in the best academic–practice partnerships, NHC and UAB SON have learned from each other. For instance, the SON discovered that nurse leaders in long-term care are innovative in finding solutions to complex problems—yet, the rest of the nursing community is often unaware of this. One important role for the academic partner is to help practice partners disseminate their innovative practices so others can learn from their success.

Academic partners also need to be flexible to meet the needs of busy clinicians and clinical leaders. Long-term care facilities have limited resources, and although an SON can help meet educational, leadership, and QI needs, how to best meet those needs is a prime consideration. Academic partners can also benefit, as in this case, by improving their own scholarly activities, expanding their programs of research, and disseminating the results into clinical areas. Finally, partnerships take perseverance and time to grow and develop. The academic–practice partnership described here is one example of a successful collaboration that can be replicated or modified to meet the needs of other potential partners interested in supporting continued career competence for nurses in long-term care.

References

The Seven-Level Outcomes Modela

Continuing Education Outcomes Level
Level 1 – Participation
Level 2 – Satisfaction
Level 3a – Learning: Declarative Knowledge (knows)
Level 3b – Learning: Procedural Knowledge (knows how)
Level 4 – Learning: Competence (shows how)
Level 5 – Performance (does)
Level 6 – Patient Health
Level 7 – Community/Population Health

Geriatrics-Focused Education Presented At Regional Nurse Leader Annual Meetings

Year One TopicsYear Two TopicsYear Three Topics
Innovative Strategies to Manage DementiaDiabetes Management in the Older Adult With ComorbiditiesPrevention and Management of Urinary Tract Infections
Quality and Safety in the Long-Term Care SettingTransitional Care Across the ContinuumSymptoms of Sepsis
Management of Heart Failure in the Frail ElderlyDementia Part 1: Relationship Between Neurodegeneration and Neuropsychiatric Behaviors of DistressPost-Acute Care Coordination: Beginning the Palliative Care Journey
Falls Prevention: What Does the Research Show?Dementia Part 2: Drug and Non-Drug Management of Behavioral and Psychiatric Symptoms of DistressRetain and Reinvigorate Employees: Tackling the Quadruple Aim
How to Avoid Burnout in the Workplace
Employee Retention: How to Manage Stress and Promote Self-care
Authors

Dr. Selleck is Professor Emerita, Dr. Jablonski is Professor, Dr. Miltner is Associate Professor, and Dr. Deupree is Associate Professor, University of Alabama at Birmingham School of Nursing, Birmingham, Alabama; Dr. McGhan is Assistant Professor, Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada; and Ms. Powell is Retired Chief Nursing Officer and Senior Vice President, Patient Services, National HealthCare Corporation, Murfreesboro, Tennessee.

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

Address correspondence to Cynthia Selleck, PhD, RN, FAAN, Professor Emerita, University of Alabama at Birmingham School of Nursing, 1720 2nd Avenue South, Birmingham, AL 35294; e-mail: cselleck@uab.edu.

Received: April 17, 2019
Accepted: September 04, 2019

10.3928/00220124-20200115-06

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