In the United States improved living conditions and advances in medical technology have increased the life span of Americans nearly 66% from 47 years at the turn of the century to 73 years in 1980.1 In 1900 only 4% of the people lived to be 65. In 1979 there were 24.5 million people 65 years of age or older in the United States.2 The over-75 age group is the fastest growing segment of the population. By the end of this decade, nearly 9.5 million people will be 75 or older and 2.3 million will be over 85 years of age,3,4 The conventional view is that the increase in the number of elderly people will bring an increased demand for health care and a doubling of nursing home beds.3
Although only 4% of the nation's elderly live in institutions, it is predicted that one person in four will spend some time in a nursing home.5 An individual's chance of being admitted to a nursing home increases with age. Today, 24% of all individuals over 85 years of age reside in nursing homes. In 1939 there were 1,200 facilities with 25,000 beds. In 1980 there were 18,000 nursing homes with 1.5 million beds.6 The phenomenal growth of nursing homes reflects demographic changes and the development of federal and state financial support for the care of the institutionalized elderly.7
Healthcare professionals have not responded as dramatically as institutional providers to the aging of American society. Gerontology is not a popular subject in medical and nursing schools nor is professional practice well established in the nation's nursing home industry. As a consequence, most professionals choose ambulatory or acute care practices. This fact is emphasized by survey data, which show that only 24% of the 18,000 nursing homes had 24-hour RN coverage.6
From the perspective of medical care, it is reported that the 17% of American physicians who make nursing home visits spend little time on the premises.8 Unfortunately, federal and state regulations require that physicians make routine visits to nursing homes no more frequently than once every 30 days. Restricted involvement of health professionals isolates nursing homes from the mainstream of healthcare institutions. The authors believe that professional inattention is a major obstacle to adding life to years rather than merely adding years to life for the nation's 1.5 million nursing home residents.
In response to this healthcare deficit, the Robert Wood Johnson Foundation issued a call to university-based schools of nursing to submit proposals for a teaching nursing home project. The intent of the request for proposals was to bring nursing homes under the aegis of university-based schools of nursing and to give nursing faculty and their students responsibility for improving care of the aged. Fifty-three schools submitted proposals to the Robert Wood Johnson Foundation. The 11 schools of nursing that were selected in 1982 are now actively engaged in the challenge of the teaching nursing home program.
This article, an overview of one funded project, describes the implementation of a model of advanced nursing practice in a long-term care setting. The structure of the advanced nursing practice model was based on an academic health center model that integrates education, research, administration, and practice. The educational element of the model engages students, who are encouraged and guided by faculty engaged in practice. The research component focuses on clinical research in care of the aged individual. The administrative activity is guided by organizational and management theory. The element of practice is directed by the use of nursing frameworks. Faculty in the setting teach, conduct research, manage, and provide patient care.
The site selected for testing this model was a partnership between Carroll Manor and The Catholic University of America School of Nursing, Within the first months of the project, the partnership was expanded to include Providence Hospital. These institutions, located within a 3-mile radius in metropolitan Washington, DC, share a common religious orientation. The new coalition pledged to:
RELATIONSHIPS OF PRINCIPALS AT THE PROJECT START-UP
1. Demonstrate the value and feasibility of collaboration between a university-based school of nursing and a nursing home,
2. Improve the quality of care of the nursing home residents,
3. Expand the nursing home's participation with other healthcare institutions, and
4. Educate health professionals in the field of gerontology and develop a model of gerontological nursing.
The relationships that existed in 1981 when the project was initiated are illustrated in Figure 1. Six years later, Carroll Manor is operating in the mainstream of healthcare and is open to the influence of the university, the School of Nursing, and the community hospital. The School of Nursing, through the agentry of the dean, faculty, and students, has served as a catalyst for change. Figure 2 demonstrates the current relationship between the School of Nursing and Carroll Manor and diagrams the four interrelated components of the advanced practice model to reflect education, research, administration, and practice.
Faculty and students engaged in the the educational portion of the model work closely with the staff development department. Faculty and graduate students present classes to staff nurses on human needs of the aging, nursing process, and clinical documentation. They also conduct support groups for nursing assistants. In concert with the Social Service Department, the faculty of nursing offers programs for the residents' families.
Another educational benefit is the clinical development of nursing students. Prior to the initiation of the project, Carroll Manor was not a teaching facility. Today, students compete for "a Carroll Manor experience." Students from other disciplines in the university, most notably social work, have become part of the project's educational mission. Students from other universities also study and conduct research with the teaching nursing home faculty. Faculty have presented programs on the aging to the community and to state nursing home associations.
Conducting research within nursing homes is new to the field of gerontological education. As a result of the project, there is an active Research and Education Committee composed of Carroll Manor staff, residents, and School of Nursing faculty. This committee approves proposals for the placement of students and requests to conduct research. Two of the major challenges for students, faculty, and staff are to present their proposals and address the residents' questions. Ongoing research includes studies of staff attitudes toward the elderly over time, the effects of eating bran cereal, the relationship between hypothermia and confusion, clinical decision making about the use of PRN sedation, and the effects of intrai nstitutional relocation on nursing home residents.
Although the research effort is carried out primarily by faculty and students, integration of research into all nursing roles remains an active project goal. We are encouraged by the staffs growth in the use of scientific method in problem analysis. Recently, the nursing coordinator in the staff development department initiated an inquiry into the pattern of falls that occur in the home. It was found that certain factors (eg, time of day, specific sections of the building, and levels of staffing) were positively correlated with residents' falling. The plan of risk reduction that has evolved uses these data. Although our hypotheses are still to be tested, we have preliminary evidence that research enhances decision making.
RELATIONSHIP FOLLOWING PROJECT IMPLEMENTATION
The administrative component of the model emphasizes the development and maintenance of a skilled care program, enhancement of management skills among professional staff, and improvement in the liaison relationships with Providence Hospital. Six months after the project began, 20 beds at Carroll Manor were certified by Medicare. The ability to offer skilled care changed the profile of residents admitted to the facility.
The collaboration with Providence Hospital, depicted in Figure 3, gives residents access to the hospital's laboratory and X-ray services and enables physicians and nurse practitioners to practice with increased efficiency and responsiveness. The licensed physical therapist, employed jointly by Providence Hospital and Canoll Manor, provides on-site treatments five days a week. Speech therapy is available through a referral network with Providence Hospital. Faculty nurse practitioners have been granted visiting privileges by the nursing department of Providence Hospital. The director of nurses at Providence serves on the board of trustees of Carroll Manor. A master's-prepared nurse clinician, employed jointly by Carroll Manor and the School of Nursing coordinates care conferences and serves as a liaison between Carroll Manor and area hospitals. These new relationships benefit all residents, not just those who need skilled care.
Certification to provide skilled care and the development of contracts with area hospitals occurred before prospective payment legislation (PL98-21) changed and intensified the case mix in nursing homes by limiting reimbursement for inpatient hospital care. Today, Carroll Manor contributes to better use of the area hospitals by accepting patients who need skilled care. The teaching nursing home faculty believes that because long-term care is underfunded and understaffed advanced practice models must include administration of care in combination with education, research, and practice.
One of the faculty's major contributions has been the introduction of a model for gerontology nursing practice that addresses clinical realities in longterm care. Two faculty members who are certified nurse practitioners have assumed responsibility for this aspect of the project. The emphasis of their practice has been on risk reduction and selfcare, clinical decision making, and collaboration with attending physicians and nursing staff in Carroll Manor and in the acute care hospitals.
Implementation of the model's practice dimension occurred in three stages: entry, action, and formalization. The entry phase lasted six months and involved defining and redefining nursing and nursing-medical roles. In 1981 the nurse practitioner role was new to Carroll Manor. Today, nurse practitioners function as members of the nursing staff and as colleagues to physicians.
An awareness of the particular constraints in nursing homes (eg, the high ratio of nonprofessional to professional staff and limited reimbursement of services) as well as an acceptance of the limitations of the practitioners shaped the direction of the action phase. The faculty moved into the action mode in response to multiple requests for consultation from medical and nursing colleagues. Staff nurses said, "We're glad you're here, we need you to look at. . . ." The physicians said, "You know, I've been thinking about your suggestion to call the family. Let's do that." The action phase included planning and negotiating a collaborative practice with an attending physician. The attending physicians at the nursing home were screened against the criteria of demonstrated medical expertise, methods of practice that demonstrated respect for individuals, responsiveness, ability to work with nurses and students, and openness to change.
The skills of the nurse practitioners gave them a negotiating position for initiating a collaborative practice plan. Their position was further enhanced when the nursing home administrator, adopting a common trend, required physicals for each resident. The practitioners offered to assume this responsibility. They also established weekly nurse-physician rounds and developed a liaison program for hospitalized residents. Rounds emphasize the strengths of the residents and afford another vehicle for staff involvement in collaborative practice. The hospital liaison links the nursing home with the acute healthcare system and lessens the relocation trauma.
RELATIONSHIP FOLLOWING PROJECT IMPLEMENTATION
The collaborating physician stated in March 1984, at a meeting held with government leaders: "The practitioner makes a difference. We are able to treat more residents earlier within the nursing home and avoid hospital ization." Practitioners are welcomed collaborators who work directly with supervisors and head nurses. Staff nurses seek advice about the conditions of residents. The skill of the practitioners and their willingness to answer questions have enhanced credibility. Sometimes staff nurses consult the practitioners about acute physical conditions: fevers or episodes of pain. At other times, they discuss chronic physical problems, such as decubiti or abnormal blood chemistries, or behavioral and family problems. Practitioners are seen as consultants who take the time to help.
During the action phase graduate students were introduced into the practice. Students have made dramatic changes in the lives of the residents . One student became actively involved in working with a depressed resident diagnosed with dementia. The resident, newly aware of her environment, opened her eyes and smiled for the first time in months. Another example of clinical nursing management illustrates the importance of assessment. On a routine examination an 85-year-old woman with dementia was found to be profoundly deaf. Interviews with her family were helpful in determining the relationship of her hearing impairment to her dysfunctional behavior. Today, assessment of hearing acuity is routinely performed for all residents.
The addition of undergraduate and graduate students has raised the profesional consciousness of the staff. This is manifest in their increased awareness of the functional status of the residents. Early detection of subtle changes in physical, social, and psychological functioning enables preventive interventions to be undertaken and improves the well-being of the residents.
Establishing an advanced nursing practice model has not been easy. Managing time, personnel, students, and multiple responsibilities in dual systems creates unique challenges and occasional headaches. A midterm review of the project's goals suggests positive results:
1 . A partnership among three churchrelated institutions - a nursing home, a university school of nursing, and a community hospital - has been developed and maintained. The nursing home, school, and hospital are benefiting from the effort.
2. An expansion of Carroll Manor's participation with other sectors of the healthcare system has occurred. The additional skilled beds have improved the long-term care capacity in the local community.
3. Clinical- and research-oriented experiences have been established for baccalaureate, master's, and doctoral students. Faculty are mentors and role models.
4. A collaborative model for clinical practice has been developed that involves physicians, nurse practitioners, staff nurses, and students.
The Catholic University of America and Carroll Manor's teaching nursing home program demonstrates a model of influence that enables the faculty of nursing to test a model of advanced gerontologie nursing practice.
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