Journal of Gerontological Nursing

EDITORIAL 

DETERMINANTS OF QUALITY NURSING CARE

H Terri Brower, EdD, RN, FAAN

Abstract

Quality nursing care is ever ambiguous, difficult to define or measure, and somewhat elusive. Although plagued by these characteristics, we can all agree there are numerous factors that impact on quality nursing care for older persons. Increased attention on gerontological nursing (GN| both in the development of graduate programs and funding for research has substantially increased the number of well-prepared nurses and the production of GN research studies.

The focus for GN research is changing to research studies that are grounded in theory and contain sound methodological approaches. A bandwagon effect is occurring with GN research, all of a sudden becoming the "in thing" to do. As the research findings are slowly disseminated and integrated into nursing practice, older persons will benefit.

Perhaps the most disturbing problem to consider when discussing the provision of quality care, is the current nursing shortage. The nursing shortage continues to grow and is having a significant impact on the availability of the predominant care providers for the elderly - nurses. While most of the news media attention is being devoted to the critical shortages in hospital settings, the consequences in other settings that are specifically geared to the aged are even greater. The salary lag for long-term care facilities and outpatient settings is increasing as hospitals raise their wages in the competitive scramble to employ nurses.

Nursing care is increasingly being relegated to less educated workers or the care goes unfinished. The shortage creates conditions in which nurses are working understaffed, in addition to being pressured into working overtime. The vicious cycle of low job satisfaction due to the exacerbation of negative working conditions results in adverse publicity and even more nurses dropping out of nursing. There also will be fewer who choose to prepare for a profession being cast in an unfavorable limelight. Under these conditions, the quality of care is unequivocably suffering.

A strategic influence over the nurse's ability to provide quality care is the knowledge base used to guide nursing practice. Continuing analysis is needed into what passes for GN theory and how much time is devoted to the teaching of GN content in basic nursing programs. The most popular method of teaching GN content is to integrate it into other courses which frequently amounts to no more than a few passing comments.

The majority of students and graduate nurses alike do not readily identify any substantive theoretical underpinnings in their care for older clients. Edel's1 study of 197 BSN programs found that only 2,79% of faculty were prepared with a master's degree in GN. Yet Kilpatrick's2 recent survey indicated that 31% of all nursing faculty are involved in aging-related teaching. Knowing that there are so few faculty knowledgeable in GN, anyone can lay claim to the teaching of GN content.

Unfortunately, regulatory boards are often the least knowledgeable of the need to include specific content in GN. In written communication to Auburn University (September 1987|, the Alabama Board of Nursing provides a good example. They recently recommended that a school in Alabama "evaluate the essentiality and appropriateness of a proposed nine quarter-hour GN course. " The course was one found in seven continuous quarters of a professional nursing program and comprised only 7% of total professional nursing credits. Although nine credits were required for both parentinfant nursing and child nursing courses (total 18], the appropriateness of those courses was not questioned. The unspoken message was: there is nothing specific to teach, learn, or practice concerning the older client, Those of us in GN know only too well how far that impression is from reality.

With the advent of the prospective…

Quality nursing care is ever ambiguous, difficult to define or measure, and somewhat elusive. Although plagued by these characteristics, we can all agree there are numerous factors that impact on quality nursing care for older persons. Increased attention on gerontological nursing (GN| both in the development of graduate programs and funding for research has substantially increased the number of well-prepared nurses and the production of GN research studies.

The focus for GN research is changing to research studies that are grounded in theory and contain sound methodological approaches. A bandwagon effect is occurring with GN research, all of a sudden becoming the "in thing" to do. As the research findings are slowly disseminated and integrated into nursing practice, older persons will benefit.

Perhaps the most disturbing problem to consider when discussing the provision of quality care, is the current nursing shortage. The nursing shortage continues to grow and is having a significant impact on the availability of the predominant care providers for the elderly - nurses. While most of the news media attention is being devoted to the critical shortages in hospital settings, the consequences in other settings that are specifically geared to the aged are even greater. The salary lag for long-term care facilities and outpatient settings is increasing as hospitals raise their wages in the competitive scramble to employ nurses.

Nursing care is increasingly being relegated to less educated workers or the care goes unfinished. The shortage creates conditions in which nurses are working understaffed, in addition to being pressured into working overtime. The vicious cycle of low job satisfaction due to the exacerbation of negative working conditions results in adverse publicity and even more nurses dropping out of nursing. There also will be fewer who choose to prepare for a profession being cast in an unfavorable limelight. Under these conditions, the quality of care is unequivocably suffering.

A strategic influence over the nurse's ability to provide quality care is the knowledge base used to guide nursing practice. Continuing analysis is needed into what passes for GN theory and how much time is devoted to the teaching of GN content in basic nursing programs. The most popular method of teaching GN content is to integrate it into other courses which frequently amounts to no more than a few passing comments.

The majority of students and graduate nurses alike do not readily identify any substantive theoretical underpinnings in their care for older clients. Edel's1 study of 197 BSN programs found that only 2,79% of faculty were prepared with a master's degree in GN. Yet Kilpatrick's2 recent survey indicated that 31% of all nursing faculty are involved in aging-related teaching. Knowing that there are so few faculty knowledgeable in GN, anyone can lay claim to the teaching of GN content.

Unfortunately, regulatory boards are often the least knowledgeable of the need to include specific content in GN. In written communication to Auburn University (September 1987|, the Alabama Board of Nursing provides a good example. They recently recommended that a school in Alabama "evaluate the essentiality and appropriateness of a proposed nine quarter-hour GN course. " The course was one found in seven continuous quarters of a professional nursing program and comprised only 7% of total professional nursing credits. Although nine credits were required for both parentinfant nursing and child nursing courses (total 18], the appropriateness of those courses was not questioned. The unspoken message was: there is nothing specific to teach, learn, or practice concerning the older client, Those of us in GN know only too well how far that impression is from reality.

With the advent of the prospective payment system in the acute care setting, many are concerned for the effects already impacting on quality care. Older patients who present financial burdens for the profit-motivated healthcare industry are seen as a threat to fiscal health and many are considered undesirable patients. When older patients are discharged before they have recuperated sufficiently or when there is a lack of social support in the home, the likelihood for complications and readmission is heightened.

A number of favorable outcomes, however, are resulting from the new cost consciousness in healthcare delivery increased competition for patients has resulted in an increasing awareness of the older person as a consumer of health care with a number of hospitals designing and marketing services to older persons. Many hospitals have increased their qualify assurance programs as activities are examined for quality care indicators, as well as cost accounting measures.

Current and pending reforms are positive outcomes as Congress strives to get a handle on the phenomenal increases in healthcare costs. The opening up of reimbursement mechanisms to nurses in rural health clinics c/earfy had a positive impact on accessib/% for Americans, including older clients. Proposals to reimburse community nursing centers and nurse practitioners in nursing homes will increase the availability of nurses who will be providing direct care for older clients.

Although there are a number of positive external forces occurring that have an impact on quality nursing care, the overall picture requires our continued vigilance, joint endeavors, love, and earnest work as we strive to provide the highest quality care possible.

References

  • 1. Edel MK: Recognize gerontological content. J Geranio/ Nurs 1986; 12(12);29.
  • 2 Kilpatfick N: Aging-related education in baccalaureate nursing curricula: Unpublished report. Washington. DC. Bureau of Health Professions/Health Resources and Services Administration. 1987.

10.3928/0098-9134-19880201-03

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