It's always an exciting and challenging professional opportunity to develop a new area of specialization in nursing. My colleague and I had just such an opportunity when the Montefiore Hospital and Medical Center established a four-bed geriatric unit within the Medical Division in 1975.
Initially, vie looked at the need of our Bronx geriatric population and our own needs for geriatric expertise. According to a report of the Institutional Priorities Committee on Geriatrics, persons 65 years of age and over comprised about 10% of the national population and about 12% of the New York City population in 1970. In addition, 21.29% of the population in Community Planning District #7, in which the hospital is located, were age 65 and over.1
As nurses, we developed our knowledge of gerontology by attending a three-month geriatric nursing course developed by the Inservice Nursing Education Department. In addition to the didactic material and application of our learnings in daily nursing assessments and informal consultations, we went on field trips to other geriatric centers and attended lectures by geriatric experts in the New York area. We then worked with the nurses, physicians, and social workers to attempt to define the goals of a multiservice geriatric delivery system. Working closely with the Assistant Director of Nursing, we formulated the following broad goals:
1. To develop nursing screening criteria for admission to the unit;
2. To develop a safe and psychologically stimulating environment for the geriatric patient (see Figure 1);
3. To identify the role of the nurse in caring for adults within a primary nursing care framework;
4. To orient the staff to the knowledge, skills, and coping mechanisms necessary to deal with our previously identified geriatric population;
5. To provide consultation services for nurses dealing with geriatric patients in other parts of the hospital;
6. To develop a system of documentation reflecting the geriatric nursing process (see Figure 2-Current Nursing Care Plan); and
7. To develop a system of multidisciplinary rounds with nurses, physicians, psychia- trists, and social workers on a weekly basis.
The initial planning, the educational program, and the establishment of the four-bed geriatric nursing unit goals were accomplished in a period of three months.
Nursing Care on the Geriatric Unit
The decision to accept a patient to the geriatric unit is made by the geriatric nurse. On questionable admissions, we enlist the expertise of other geriatric team members (ie, the psychiatric fellow and the social worker) to assist us in determining a better data base upon which the geriatric nurses can make the final decision.
The day-to-day nursing care of geriatric patients includes many factors. Once the patient has been accepted to the geriatric unit, the patient is approached about transfer to that unit. The unit and its goals are discussed with the patient, as well as our immediate goals for him/her and his/her goals for him/herself. Family members are contacted and included in future plans with the patient. If the patient and the family are agreeable, the patient is transferred as soon as a bed is available.
On admission to the geriatric unit, the patient is greeted by the nurse and introduced to the other patients. The patient is oriented to the physical layout of the room and given an opportunity to express his/her feelings about the transfer and to ask any questions he/she may have. At this time, further assessment is made of the patient's ability to balance, stand, transfer, and ambulate. Mental status and orientation are also re-evaluated.
The geriatric nurse tells the patient that she/he is his/her primary nurse and will be responsible for his/her care. During the evening and night shifts, he/she will be cared for by the associate nurses on the unit, who will carry out the prescribed plan of care.
In the morning of the first full day in the unit, the patient's ability to manage personal care is assessed and assistance given as needed. We discuss with the patient a plan for increasing independence in personal care. For example, he/she begins sponge bathing using a basin at the bedside, progresses to going to the sink in a wheelchair to wash, and finally, to ambulating independently or with a walker or cane to the sink to wash.
The patient's ability to perform activities of daily living is evaluated. Included in this is his/her ability to manage dressing, setting up a tray for meals, feeding him/ herself, and using the toilet.
Activities of the day include ambulation, exercises, and range of motion. Reality orientation is an ongoing process. It includes both mental and physical activities. For example, an orientation board2 is used to help patients be aware of the day, date, mealtime, weather, nurse on duty, and unit location. Other environmental stimuli utilized include a clock, a radio, television, and newspapers. We have access to talking books and large print books through the patient's library.
Additional reality orientation includes nurse-patient interactions and encouragement of patient-topatient interactions. For example, nurses facilitate patient-to-patient reminiscence therapy, which patients initiate on their own. An illustration of nurse-patient interactions is mutual planning and daily scheduling of the patient's activities of daily living. The large clock in the geriatric unit assists the patient in adhering to this daily schedule. Planned times are scheduled between activities for rest and conservation of energy.
Medication administration is generally a time for teaching the patient. Medications are described by color, size, purpose, name, action, frequency, and possible side effects. Patients are encouraged to request medications of the nurse at the specified times. We've implemented this practice for those patients who are mentally competent. We believe that such patients have to assume more responsibility for their care at home, or even to some degree in an institution, if they are to be optimally independent, functioning community members. Through assuming the responsibility, the patient i^more likely to be motivated to ask further questions to clarify what medication he/she is taking, time, dosage, rationale, therapeutic results to be expected, and nontherapeutic effects that need to be acted upon by the patient.
As the patient progresses and his needs change, additional referrals are made to various departments in the hospital: physical therapy, occupational therapy, speech and hearing, eye clinic, and podiatry. On occasion, through our nursing assessments and observations, wt have been able to note some medical problem. By reporting these to the house staff, and/or attending physicians, referrals to other specialties (eg, cardiology, psychiatry, urology, ophthalmology, vascular, and plastic) have been made.
Inpatient Discharge Planning
All patients admitted to the unit are seen by the psychiatric fellow and the social worker. Psychiatric evaluation is done with follow-up as necessary. The social worker sees each patient regarding the discharge plans and contacts family members to assist in planning for the patient's needs.
ENVIRONMENTAL ADAPTATIONS IMPLEMENTED IN THE GERIATRIC UNIT
A formal team conference is held every Tuesday afternoon to discuss patient progress and future plans. The house staff and physicians of record are encouraged to attend these meetings. Other informal meetings are held throughout the week as different situations arise. On occasion, family members are invited to these meetings to further their understanding of the patient's problems and of how they can help the patient cope with these problems, both in the hospital and at home.
To facilitate follow-up care of the patient at home, referrals are made to home care and the visiting nurse service, depending on the patient's capabilities to manage activities of daily living and evaluation of how much assistance he/she will need at home. If the patient is to be discharged home, family members are encouraged to visit in the daytime so that they may be included in the patient teaching.
MONTEFIORE HOSPITAL AND MEDICAL CENTER
Medication cards are made for the patient describing the medications and indicating the times they are to be taken. Schedules are set up that can be easily followed.
After discharge, we follow our patients by phone calls, home care reports, visiting nurse service reports, private physicians, clinic follow-up, and occasional home visits. By our follow-ups, we can: ( 1 ) see the patient's adjustment or failure to adjust following his illness; (2) be a resource person for the patient and his family; and (3) anticipate or identify any problems and assist the patient in finding a solution to them. The patients are called frequently immediately after discharge, then weekly, monthly, and finally, every three months for a year after discharge.
The reality of the community situation often calls for modification of a teaching plan. For example, one of our patients was on 0.125 mg of digoxin every other day, alternating with 0.25 mg. In the geriatric unit, the nurse would give the patient the alternate dosage, which the patient recognized as different by taking a yellow pill one day and a white pill the alternate day. When the nurse from the geriatric unit routinely followed up on the patient's discharge progress 48 hours later by telephone, she learned that the patient received and was taking only white pills. This situation resulted in her taking 0.25 mg daily. The patient was then reinstructed on how to arrive at the correct alternating dosages and was monitored to assure that she was taking the correct dosage. Reteaching involved dealing with the reality of the local pharmacy's medication dispensing system. Rather than giving the patient two separate containers with different dosages clearly labeled, the pharmacist gave her one container with 0.25 mg dosage and did not instruct her about the need to divide the pills in half on alternate days to achieve the 0.125 mg dosage. The correction of the situation was due to careful and timely follow-up. This medication dosage situation had the potential of becoming a lethal one, or at least a cause of digoxin toxicity and possible rehospitalization.
To provide better understanding of the types of patients that we have cared for, we have chosen to present a typical patient admitted to the geriatric unit.
An 84-year-old hypertensive woman was admitted to Montefiore in May 1975 with a diagnosis of coronary insufficiency and possible myocardial infarction. She had a history of high blood pressure. During her hospitalization, her medical course was stable. After transfer to another part of the hospital, she had frequent coronary insufficiency marked by EKG and enzyme changes. The coronary insufficiency was so severe that both the private MD and cardiologist believed that nursing home placement would be necessary, especially since she lived alone and had little community support.
She was alert and oriented and needed much assistance to accept her limitations. On coming to the geriatric unit, she needed to have her activities paced and slowly increased from walking about the room to ambulating in the hallway, eventually being able to shower independently. One of the mechanisms used to decrease her anxiety and increase her activity was teaching her how to prophylactically utilize nitroglycerine prior to any strenuous activity in order to avoid pain and potential cardiac damage. It was our feeling that the patient could manage at home if she had adequate help. Discussions about discharge plan were made at the team conference with the social worker, nurse, and doctor. Application was made for help at home. When the application was not immediately approved, the son agreed to pay for help while awaiting approval.
Our patient was discharged on August 10, 1975. She had increased her tolerance for physical activities to include returning to a senior citizen's club and shopping around the neighborhood. At her own decision, she had cut down on help from three days a week to one day a week. She had seen her doctor monthly. She was very involved in all plans made concerning for dis charge and was maintaining her home within her cardiac limitations. This pattern was maintained for a year and a half. Recently, she decided to enter a senior citizen's residence, where she has maintained her independence in the activities of daily living for another year.
Because of the continued progression of her cardiac and other diseases, she had been obliged to utilize the services of a home health aide for four hours a day, five days a week. Fortunately, she is still in the residence and the home health aid support system has enabled her to stay out of a nursing home. For a patient who was originally told she would require nursing home placement, she has managed to maintain a remarkable record of non-nursing home placement for the past four years. These four years have given her the opportunity to maintain her optimal level of independence despite her physical limitations.
Nongeriatric Unit Consultations
Throughout the hospital there are many geriatric patients who are not eligible for the geriatric unit but who need expert geriatric nursing care. To serve the needs of these patients, the geriatric unit provides a nursing consultation service for other nurses.
A plan of care is established with the nurse who is caring for these nongeriatric unit patients. Suggestions are made for any necessary referrals-rehabilitation, eye clinic, podiatry, social service, psychiatry, home care, visiting nurse service, senior citizens, and geriatric day care. The patients are seen twice a week during hospitalization and any necessary adjustments in the care plan are made. We meet informally with the social worker regarding the patient's discharge plans and arrangements for help at home. The patients are followed at home by phone for two to six months after discharge depending on each patient's needs and how he is managing at home.
SUMMARY OF GERIATRIC UNIT ADMISSION CRITERIA
A Retrospective Overview
Through our experience as geriatric nurses, we have learned a great deal about caring for the geriatric population. We see the geriatric unit as a mechanism for providing a better quality of care to geriatric patients. The nurse is able to utilize the initial assessment and the patient's current physical and mental status to establish a care plan for and with the patient. Long- and short-term goals are established. Follow-up and necessary changes in care plans are made by the nurse. Family members are included in the plans. We work with the patient, the family, and the social worker to establish discharge plans that are realistic for the patient and his immediate situation.
Primary nursing gives us an opportunity to establish a better communication with other disciplines, thereby providing better continuity of care for the patient. One of the best examples of this is our ability to accompany the patient to rehabilitation as he progresses to different levels, observe the teaching done, and be able to continue this on the unit. For example, we can follow through with a stroke patient who has to learn balancing and proper foot advancing to be able to walk with a tripod cane.
The focus of the care plan is to encourage and instruct the patient to be able to do for himself.3 The ultimate goal in establishing a plan of care with the patient is that the patient reach his/her potential for maximum independence in activities of daily living.
In the beginning of this project, we encountered some problems we did not anticipate and initially some resistance from some members of our own profession and also from those in other disciplines. Most of this, we believe, was due to the lack of understanding of the special needs of older people. Other problems were the result of frustration over the inability to cope with the special needs of these patients and to provide comprehensive care for them.
During the few months before the inception of the unit, we had been on the units familiarizing ourselves with geriatric patients, assessing their needs, and speaking with nurses and doctors about the proposed unit and what we hoped to accomplish. There were many questions and many people were skeptical about how such a unit would work. Initially, referrals were very few. Most of the time we had to make rounds on the floors to find appropriate patients who would meet the criteria for admission to the geriatric unit (Figure 3).
The attending physicians were most helpful right from the beginning and were anxious for any type of assistance that would enable their patients to be able to return home and function to their potential after discharge. The attending physicians were also very influential in helping the patients to agree to come to the geriatric unit, as most times it necessitated moving to a different floor having to meet new people. The fear of moving was a large part of the patient's reluctance to come to the unit, but after the transfer they settled in easily and were generally very happy. They were pleased with being able to start to manage their own care and be involved in making plans for discharge and follow-up at home.
At first, the house staff doctors were reluctant to send their patients to the geriatric unit because it meant having to care for a patient on another unit. Some staff felt that we were wasting our time and that nothing could be done to help these patients anyway. Most of the referrals we did get initially were patients who were very confused and difficult to manage, incontinent, or just waiting for a bed in a nursing home.
Our informal professional interactions and formal consultations with physicians and nurses have increased their awareness of the needs of the geriatric patients and have shown that these patients still have much potential to be utilized. The geriatric unit has provided an environment in which a geriatric patient can realize his potential and be assisted in attaining it. The rehabilitation and support provided by the unit has been instrumental in enabling most patients to return to the community. The patients who are unable to return home are given assistance in making alternative plans for either a nursing home or health-related facility. The unit provides the patient with the support to adequately prepare for his new lifestyle.
As the unit developed, we recognized that continuing education in geriatric nursing was essential for all nursing staff. Consequently, programs were established for the nursing and para-nursing staff. We are finding more awareness of the needs of geriatric patients among hospital personnel. More people are taking the first step in initiating rehabilitation and other services to provide comprehensive care for elderly patients. We feel that the planning of continuing education programs, increasing referrals and/or consultations, and growing awareness of patient needs will ultimately help to improve the quality of care for the aged.
Retrospectively viewing our goals and professional experiences, we have established a nucleus of geriatric nursing practice. Currently, we are developing a geriatric audit to look more carefully at the results of our nursing care. It is our hope that our hospital will become a center for new learnings in geriatric nursing practice.
- 1. Task Force on Geriatrics: Report of the "Quality of Life" Subcommittee. Montefiore Hospital and Medical Center, Bronx, New York, October 1977, p 3.
- 2. Barns EK, Sock A, Shre H: Guideline to treatment approaches. Gerontologist 13(4):516, Winter 1973.
- 3. Anderson HC: Newton's Geriatric Nursing. St Louis, CV Mosby Co, 1971, p 126.
- Alvermann MM: Toward improving geriatric care with environmental intervention emphasizing a homelike atmosphere: An environmental experience. J Gerontol Nurs 5(3): 13, 1979.
- Anderson HC: Newton's Geriatric Nursing. St Louis, CV Mosby Co, 1971.
- Burnside IM: Nursing and the Aged. New York, McGraw-Hill, 1976, pp 559-571.
- Manthey M: Primary nursing is alive and well in the hospital. Am J Nurs 73(1):8387.
- Rossman I: Clinical Geriatrics. Philadelphia, JPLippincottCo, 1971, pp 491-503
ENVIRONMENTAL ADAPTATIONS IMPLEMENTED IN THE GERIATRIC UNIT
MONTEFIORE HOSPITAL AND MEDICAL CENTER