One of the most exciting and challenging experiences in gerontological nursing today is instituting the Teaching Nursing Home Concept (TNHP). In particular the model funded by the Robert Wood Johnson Foundation focuses on the clinical, research and educational contributions of gerontological nurses in long-term care settings.
As a combined entity, the TNHP is rapidly accumulating clinical/educational expertise in other areas which could be shared. One such area involves the conversion of nursing problems to clinical studies. A second area is that of staff development in long-term care. When university emphasis on "knowing" meets clinical "doing," can a "knowing/doing" emerge?
Despite a growing need for gerontological nurses, attracting students to this area remains difficult. Providing enriching student experiences with elderly persons in a retirement village is paramount in solving this problem. Experiences including poetry, writing, simulation gaming, group leadership with cogniti vely impaired elderly persons, student teaching projects, home health visits, etc. , have resulted in an enthusiastic response from students as well as from residents and families.
Historically, the Robert Wood Johnson Foundation has been an advocate, through funding, for projects which improved access to mainstream health care. In 1981, the Foundation in co-sponsorship with the American Academy of Nursing began a funding program entitled, "The Teaching Nursing Home Program," to assist nursing homes in gaining access to current research and educational efforts of the university community. Recognizing that the major interface of the nursing home resident and the health-care system was through nursing personnel, the particular university affiliate was designated as a university school of nursing.
A call for grants was issued in which prospective grantees responded with models which would foster gerontological nursing as an integral part of the university nursing curriculum and the university health-care system as an integral part of the clinical health care of individuals residing in nursing homes. Following the review of grants submitted and selected site visits, eleven national sites were chosen to integrate the Teaching Nursing Home Concept.
One site selected, the University of Cincinnati College of Nursing and Health (UCCNH) and Maple Knoll Village (MKV) (a resident retirement village with ambulatory, home care and nursing home health facilities), developed a model of shared primary nursing. Much of the recent nursing literature has focused on the trinitarian relationship of research, education and service delivery. The Shared Primary Nursing Model incorporates these aspects in a graduate prepared teacher/clinician who assumes clinical responsibility for resident cases and instructional responsibilities for students and staff. By incorporating students into case responsibilities under his/her supervision, the teacher/clinician both improves approaches to caregiving and teaches students through direct handson experience. Moreover, the teacher/ clinicians have appointments within the College of Nursing and Health where more traditional teaching responsibilities are carried out.
Teacher/clinicians bring to the clinical setting a valuing of research methods as an approach to solving clinical dilemmas, with the result that new nursing knowledge is generated as clinical questions are addressed through research. This new knowledge is then immediately channeled into the clinical practice and educational settings by the teacher/clinicians who have access to both the service and the academic settings.
The Shared Primary Nursing Model is but one of several models being explored in the Teaching Nursing Home Program. While sites may differ in models, the entire program has been focused on five major areas through the use, in every site, of an organizational tool, the Management Information System. The five major areas addressed by each site are: school of nursing focus, quality of care focus, staff development focus, systems focus and a professional decision-making focus.
Each site has expanded, made explicit and outlined specific objectives and strategies in each of these areas. Each objective has been addressed in a need assessment. Protocol development and/or intervention has been addressed in a need assessment. Protocol development and/or intervention and training education were specified to meet the objectives. Finally methods of quality assurance and evaluation are explicitly stated. Researchers on each project are collecting baseline data to determine the impact of the project on objectives. In addition, each site will cooperate in a national evaluation of the program by the University of Colorado Center for Health Services Research.
Throughout the past year and a half, the implementation of the TNHP at the Cincinnati site has been a challenge to both the College of Nursing and Health and Maple Knoll Village faculty and staff.
Through persistence and patience two systems, one with a primary objective of service delivery and the other with a primary objective of knowledge dissemination, have joined together to form a new entity - the TNHP - which has a three-part function; clinical care, education and research to improve the quality of health care for elderly persons.
As anticipated to date, the TNHP has influenced both the nursing home and the school of nursing. In the College of Nursing and Health, TNHP faculty members acting as advocates for the inclusion of gerontology in both graduate and undergraduate curricula have increased faculty awareness of the age mix of cases in all settings which has led to an increased emphasis on gerontological curricula.
Careful planning of clinical practicums for students in the areas of knowledge, skills, and attitude development, has resulted in experiences which foster increased respect for elderly individuals who are coping with the tasks that may accompany aging. Presently sophomore and senior undergraduate students and graduate medical-surgical and psychiatric-mental health students participate in the Teaching Nursing Home Project. Consistent with the sophomore curriculum focus on wellness, students at this level pair with elderly volunteers who live at Maple Knoll Village. While experiencing interview techniques, physical assessment skills, etc. , students gain an appreciation of the vitality and enthusiasm of well elderly persons. Students and clients identify an intergenerational valuing evolving from the experience.
Senior level students have joined the home health nurse at Maple Knoll Village who has been appointed as a voluntary faculty member of UCCNH. Home visits to cottages and apartments of residents comprise part of the senior level Community Health experience. Case study presentations by students at the conclusion of this experience reflect more in-depth knowledge of nursing interventions for the health deficits of community-based elderly and a growing respect for the efforts of elderly persons to maintain independence and dignity.
The impact of the TNHP is also reflected at the graduate level. In 1983 the UCCNH master's program was reduced from 90 credit quarter hours to 60 credit quarter hours. TNHP faculty appointed to graduate faculty positions in cooperation with the UCCNH graduate faculty have re-examined the gerontological content. While the MedicalSurgical Department has chosen to develop a strengthened tract in gerontological nursing, the Psychiatric Mental Health faculty is more fully integrating assessment and individual and group treatment modalities appropriate for the elderly into the total curriculum with a clinical focus in gerontology for those electing this area.
Cooperation with the Continuing Education Department at the College of Nursing and Health resulted in a Gerontological Overview course to assist registered nurses preparing for the American Nurses' Association Gerontological Nurse Certification examination. Response to this class by the community has been overwhelming. Eleven registered nurses from MKV, in addition to nurses from eleven other facilities enrolled in the course.
In the nursing home itself and in the related health-care facilities in the Village, the TNHP has resulted in a change in approach to nursing problems. Literature reviews are increasingly used to identify factors associated with a particular nursing problem. Emphasis is also placed on collecting the wisdom of practice by gathering nursing home staff input on factors which seem to be associated with a particular clinical problem. Simple data collection tools are designed to collect information on the factors identified. Specific interventions are designed based on the need indicated by data collected, and are followed by data collection to measure the impact of the intervention on the problem. To date this process has formally been applied to wandering behavior and decubitus ulcers. An added bonus has been the increasing adoption by the staff of a problem-solving process to other clinical problems.
Based on a needs assessment of nursing staff, an inservice schedule has been designed with monthly inservice sessions on all shifts. University nursing clinical specialists, TNHP staff and nursing home staff nurses have presented videotaped sessions to facilitate promulgation of material. Inservice bulletin boards have been placed on each nursing unit. Articles on the monthly inservice topic are placed on the bulletin board as are reports on clinical data collected and "The InService," an inservice news sheet. Included in the news sheet is news on clinical care, answers to questions or progress made on queries regarding clinical issues. Mini inservice sessions are held twice monthly on each unit, for each shift to address specific concerns and topics.
Perhaps the greatest evidence of the integration of the university and the nursing home is the increasing requests for consultation. Teacher/clinicians provide consultation for staff regarding residents not included in a clinician caseload but experiencing difficult nursing care problems. In addition other service providers in Maple Knoll Village such as the Senior Center staff sought the input of TNHP staff in the formulation of a policy for the safety and well-being of the frail elderly in Center activities and a nursing clinic to address health concerns of community elderly who visit the Center. In regard to all Village activities, project staff are continually enriched through knowledge shared by staff and residents at Maple Knoll.
Since the onset of the TNHP additional commitments to knowledge generation and dissemination have been made by the CNH and MKV. Recognizing this individual as well as collaborative responsibility, MKV has established a Gerontology Institute and hired a coordinator to further research and education in gerontology and to coordinate student activities for dietary, social work, administration and other interns. The College of Nursing and Health has become a Nursing Home Area Training Center, one of eleven centers in Ohio meeting the education needs of longterm care personnel. In a third new program the CNH senior librarian in cooperation with the TNHP has developed a model which facilitates the accessibility of University library resources for longterm care facilities.
To date the Teaching Nursing Home Program has been a challenging and rich experience making service delivery more knowledge-based and theoretical knowledge more practical. Students, staff and faculty have benefitted from the university-nursing home affiliation. Ultimately, the beneficiaries of the Teaching Nursing Home Program are the elderly.