Johnson, et al, reveal how the University of Connecticut's School of Nursing designed and implemented a nursemanaged center for ambulatory in/ell older adults. At the project's completion, clients were appreciative, vocal, articulated their needs, and assumed much responsibility for their own care.
The number of older adults in our population is increasing annually. That number has reached approximately 27 million.' Most of these persons have remained in the community; only about 5% of seniors are in institutions. Thus, the care of older adults has continued to be community based. Nurses are in prime positions to offer care to well older adults and those who have chronic conditions that do not impair functioning to a degree that necessitates continuous skilled nursing care. This article discusses the design, implementation, and evaluation of a nurse-managed wellness center for ambulatory older adults.
Design of the Center
In 1981 the School of Nursing at the University of Connecticut responded to a request for a proposal from the Division of Nursing, HRA, USPHS, to design, implement, and evaluate a nursing center and was awarded the contract for a 33-month period. Prior to the award of the contract, the School of Nursing had operated a nursing clinic for older adults in the senior center of the town in which the university is located.2 The contract made possible the development of a nurse-managed center with full-time staff. It also provided money to rent a modular unit so that space could be expanded from 240 to 600 square feet and to ensure that the wellness center remained adjacent to the senior center and to two complexes of housing units for older adults.
The staff for the nursing center implemented the concept of an intradisciplinary nursing team composed of representatives of the four functional areas of nursing: research, practice, teaching, and administration. To that end, at the beginning of the project, the team was composed of a project director (a certified nurse practitioner, educator, researcher, and primary administrator for the project), a full-time nurse administrator-educator-practitioner responsible for the day-to-day functioning of the center, a full-time nurse practitioner-educator (a certified nurse practitioner with clinical research and educational preceptor responsibilities), and a part-time nurse researcher (who is also a clinician in gerontology and an educator). The team was complemented by a half-time secretary-receptionist. For the final year of the project, the nurse administrator-educator-practitioner assumed the role of project director, and the project director (no longer at the university), the role of team member.
DEMOGRAPHIC PROFILE OF CLIENTS*
CLIENT SATISFACTION INVENTORY
The advisory board for the project also reflected the intradisciplinary team concept: a certified nurse practitioner who was also a nurse educator and researcher, a nurse administrator, a nurse educator and member of the faculty, a nurse administrator from the local visiting nurse association, and a nurse researcher-educator.
Principles in designing the center included sensitivity to community needs and wants, inclusion of town and community members in planning, and implementation of a conceptual nursing model for operation. The model contained a philosophy for care within the center and identified the target population and its needs.
To ensure community involvement, a health advisory board for the center was established consisting of five members of the senior community who met regularly to advise the Wellness Center project team. Members of the Wellness Center project team also met regularly with the director of social services for the town, the director of the senior center, and the president of the senior center association.
The target population consisted of all adults 55 and older residing in the town, consistent with the population served by the senior center. Community assessment included a survey of older women in the community as to their gynecologic needs and reasons for visits to the Wellness Center.
The operational philosophy developed for the nursing center reflected emphasis on client participation in care and on the nursing aspects of the care needs of older adults in the community. Excerpts from and explanation of the philosophy follow.
The intradisciplinary nursing Wellness Center was a health clinic dedicated to preventive health care. As such, its services were designed to promote an optimal level of wellness for each individual, to explore both developmental and situational events that affect the individual 's ability to carry on activities of daily living, and to assist in maintenance of the highest possible level of functioning, preserving dignity and independence. The clinic provided eariy detection of those risks common to older adults, nursing management for long-term conditions, and referral to other healthcare providers.
The setting for care included the wellness clinic facilities, the senior center, clients' homes, and the community at large. Individual visits took place in the Wellness Center, the housing complexes, or clients1 homes. Group sessions and educational programs were offered in the senior center, in meeting rooms of the housing complexes, and in various community settings; a walking exercise group met outdoors. The staff believed in holistic, humanistic health care - that is, care that considers the whole person, his or her goals and activities of daily living - and considered individual differences and preferences. The individual was an active participant in the processes of health care and interacted with the community and healthcare providers. Care was designed to be facultative -rather than intrusive or overly directive. Care also capitalized on individual potential, not deficit.
The Wellness Center was designed as a model for the intradisciplinary practice of nursing. It was based on the belief that the provision of nursing care is best accomplished when nurse educators, administrators, researchers, and practitioners work closely together and when all the roles are integrated in the care setting. To that end, the center was comprised of a team of nurse providers. For too long, education, research, administration, and hands-on provision of care existed in separate spheres, often overlapping only minimally. Yet, all claim a common goal: improving the quality of care to clients. The interdependent role of nurses was recognized. Thus, we believed that nurses as primary care providers needed to coordinate care and collaborate with other healthcare providers.
It was our belief that the practice of nursing should be based on a conceptual nursing model to provide a framework for provision of care , evaluation of care, and research. The crisis nursing model was chosen as a foundation for practice, administration, education, and research in the nursing center.
The crisis model defined the individual as a physiological, psychological, and social being, functioning as an open system within the larger system, the environment, and existing on developmental continuum that is orderly and consistent. Perpetually confronted with vulnerability to crisis through occurrence of developmental and situational hazardous events, the individual was perceived as utilizing coping mechanisms, internal and external resources to deal with these events. He or she was viewed as an active participant, capable of using problem-solving and decision-making skills. The environment was defined as the internal and external forces that surround the individual. Health was viewed as existing in relation to illness and environment and illness as a prolonged state of disequilibrium or maladaptation. Wellness was seen as holistic in nature, including physical, emotional, and social well-being. Nursing was regarded as a process, based on the sciences and humanities, which augments the coping behaviors of an individual, mobilizes additional resources when needed, and intervenes to provide for needs the individual is incapable of meeting. The nursing process functioned to prevent crisis and restore wellness, intervene when crisis occurs, and restore maximum possible level of wellness post crisis. The process was interpreted as an interactional one, implying an active role for both client and nurse.3,4
PROFILE OF CUEMTS HEALTH STATUS*
As the nursing center moved toward the implementation phase, the nurse practitioner-administrator-educator focused her time on community assessment and outreach, the nurse educatorpractitioner on giving care to clients and precepting students, the researcher on plans for evaluation of the center, and the project director on a wide variety of tasks including testifying before the zoning board, publicizing the center, acquiring furnishings and equipment, and attending to all the inevitable details. The advisory committee began meeting in July 1981 to help develop the philosophy, objectives, and policies for operation of the center. The team for the project was completed and began meeting in September 1981.
The nursing center, now housed in the modular unit, began to admit clients in March 1982. Services were marketed through a brochure, the senior center newsletter, newspaper publicity, and word of mouth.
Project team members began work on research questions for the project as they evolved from the caseload of clients seen in the center. In addition to demographic data, several research studies were conducted to examine the relationship between multiple health locus of control patterns and change in behavior and weight loss in older adults, the effects of Kegel exercises on stress incontinence in a well, ambulatory population of older women, the effect of teaching selected breathing exercises to older adults, and the cost effectiveness of the nursing center.
The Wellness Center averaged 60 or more individual client visits a month, out of a total caseload of 318 (see Tables 1 and 2). The practitioners offered numerous group programs (obesity, death and dying, developmental tasks of aging, walking), screening sessions foot care, glaucoma, hypertension, physical fitness), educational sessions (Alzheimer's, the older intestinal tract, sleep, the older genitourinary tract, intergenerational relationships, learning to live with handicaps, depression, coping with holidays), relationships and sexuality, choosing a nursing home, and outreach programs at the adjacent senior housing complexes. They also precepted undergraduate and graduate nursing students, made some home visits (for evaluation and to assist and support families with terminally ill older members), coordinated with other healthcare professionals in the community, and publicized the center. Because we saw our role as complementary to, rather than competitive with, those of other providers, we examined what we were doing for clients, through assessment of frequency of visits, nature of the problems presented, and nursing management strategies; how we differed in our practice, and clients' perceptions and expectations of our services.
SERVICE UTIUZATlON DATA MARCH 1982-DECEMBER 1983
One of the major emphases of the center was assuming responsibility for one's own care. Thus, clients were active participants in the care process. Program planning was directed toward providing clients with knowledge and skills directed toward self-care and control within the healthcare system. Programs generated from community assessments and requests from our clients for services. Additionally, the health advisory committee comprised of community members played a very active role in program planning and in guiding and conducting special events such as open houses.
The nurse practitioners of the Wellness Center organized case conferences with other healthcare professionals involved in the care of individuals or families. They helped clients to identify community resources such as senior center programs, the Social Service Department, the VNA, dental clinics, and Meals on Wheels.
An ongoing project was developing protocols for nursing management of the target population's common concerns. These included hypertension, gynecological processes, stress incontinence, removal of ear cerumen, foot care, and teaching the client with diabetes.
All the data collection forms for clients were redesigned to reflect use of the crisis nursing model in identifying developmental and situational risks, coping mechanisms, and resources available.
Evaluation was a very important part of the Wellness Center. In addition to case review between providers, team members collected data on clients, elicited evaluations from clients for both individual and group sessions (see Figure), and designed and collected data to address several questions related to evaluation of the Wellness Center as a whole.
Evaluations completed by clients reflected both satisfaction with the care provided in the Wellness Center and a forthrightedness in sharing perceptions of care and expectations of the nurse practitioners. Comments of two clients summed up clients' feelings: "I felt very good and very happy" and "my expectations were met in every way."
Perceptions of clients as to what the nurse practitioner would do for them demonstrated a very high level of understanding of the role: "listen to me," "check and advise on my health," "listen, suggest and encourage," "help and questions answered," "help me improve my health," "talk things over, check physical condition and tell me about it," "take my blood pressure and be helpful."
Other data that were collected on the target population include number and characteristics of visits to the nursing center, visits to other healthcare providers, and hospitalizations. Thirteen clients reported hospitalizations since initiating care at the nursing center; reasons spanned 15 medical diagnoses. The length of stay ranged from 1 to 20 days; half stayed I to 7 days and half 13 to 20 days. For March 1982 through December 1983 (see Table 3), the total individual client visits (appointments and walk-ins) numbered 1,190.
The design, implementation, and evaluation of our nurse-managed center encompassed the following:
1. Clear identification of the purpose, goals, philosophy, and operational objectives for the center.
2. Collaboration with the town and community members.
3. Communication with the community as a whole and individual members.
4. Recognition of and input from the target population on a regular basis . This was done through periodic random survey using a tool designed to elicit indications of client satisfaction or dissatisfaction.
5. Sensitivity to all community politics, both in the town and the university through regular meetings of the health advisory committee and meetings with town members.
This project is an exciting, challenging, and dynamic example of a nursemanaged wellness center. Our clients were appreciative, vocal, assumed much responsibility for their own care, and were articulate about what we could do for them and how they perceived our roles.
- 1. US Department of Commerce, Bureau of the Census: Projections of ihe Population of the United Slates: 1977 to 2050, Population Esiimates and Projections, Series P-25, No 704.
- 2. Thibodeau JP, Heben F: A clinic for senior citizens. The Nurse Practitioner 1978, 11.
- 3. Hawkins JW: Description, analysis, and evaluation of a developmental model, in Thibodeau JW: Analysis of Conceptual Models of Nursing. Monterey, Calif, Wadsworth, 1982.
- 4. Infante MS (ed); Crisis lheory: A framework for nursing practice. Reston, Va: Reston Publishing. 1982.
DEMOGRAPHIC PROFILE OF CLIENTS*
CLIENT SATISFACTION INVENTORY
PROFILE OF CUEMTS HEALTH STATUS*
SERVICE UTIUZATlON DATA MARCH 1982-DECEMBER 1983