Journal of Gerontological Nursing

A CONCEPTUAL MODEL FOR CNS PRACTICE

Anne Paremski, BSN, RN; Kathryn H Schams, BSN, RN; Peggy Yurkovich, MSN, RN

Abstract

Specialization in nursing practice has been a response by the profession to meet the increasingly complex health needs of society.1*3 Nursing has responded to the complex healthcare needs of the elderly, the fastest growing segment of society, by increasing the number of gerontological clinical nurse specialists (CNS). Since the elderly react in a variety of ways to an array of health problems, the gerontological CNS requires a conceptual framework for practice that is holistic in nature.

Loomis and Wood4 developed a model for clinical nursing practice that depicts a variety of human responses interacting with actual or potential health problems. The purpose of this article is to propose Loomis and Wood's model as an appropriate framework for gerontological clinical nurse specialist practice.

Specialization

The clinical nurse specialist (CNS) is described by the American Nurses' Association1 as a nurse prepared at the master's or doctoral level who is an expert in a selected area of clinical practice. Graduate education provides the gerontological clinical nurse specialist with the theoretical knowledge and skills necessary to diagnose and treat the human responses of the elderly to actual or potential health problems in a variety of settings.1'3 Historically, specialization in nursing has risen from societal forces, including development of new technologies, increase in knowledge in specific areas, response to a previously little known area of public need and interest, and complexity of services exceeding the prevailing knowledge and skills of general practitioners.1,5 Specialization in gerontological nursing has risen from similar societal forces, ie, the development of new technology with the potential to prolong life, an increase in gerontological knowledge, increased interest in health care of the elderly, and current and projected demographic trends of the elderly that affect their health care.1,3,6,7

Demographic and Healthcare Ibends

Although the estimated number of elderly, aged 65 years and over, is currently 25 million, that number is expected to increase to 55.5 million by the year 2030. 8 Thus, the gerontologicai CNS is expected to encounter an increasing number of elderly in all healthcare settings.

According to the Department of Health, Education, and Welfare9 a white male reaching age 60 is likely to live to age 77, whereas a white female is expected to live until age 82. Life expectancy of nonwhites is slightly less . The sex ratio (number of males per 100 females) in the 65 and older age group is projected to decrease to 65 in the year 2000. 10

Due to the improved availability of health care in the community, many chronically ill elderly, who would have required nursing home placement in the past, are now able to remain in their own homes. According to the US Census Bureau, well over 80% of those 65 and over live independently. Though most elderly live in two-person households, almost 30% live alone. Fifty-five percent of those 85 and older maintain independent households, whether alone or with a spouse.

Nursing care for the elderly has historically been based on the medical model, involving short-term treatment of acute illness. Since the health needs of this group are primarily chronic in nature, the medical model alone is insufficient to serve as a basis for care of the aged. Proposals to provide health care based on chronic care," functional status,12 and self-care13 nursing models are now found in the literature.

Loomis and WoodV1 Model

Loomis and Wood proposed that all human response systems interact with all actual or potential health problems as well as the clinical decision-making processes. Loomis and Wood also stated that nurses are capable of curing the actual or potential health problem by diagnosing and treating the human…

Specialization in nursing practice has been a response by the profession to meet the increasingly complex health needs of society.1*3 Nursing has responded to the complex healthcare needs of the elderly, the fastest growing segment of society, by increasing the number of gerontological clinical nurse specialists (CNS). Since the elderly react in a variety of ways to an array of health problems, the gerontological CNS requires a conceptual framework for practice that is holistic in nature.

Loomis and Wood4 developed a model for clinical nursing practice that depicts a variety of human responses interacting with actual or potential health problems. The purpose of this article is to propose Loomis and Wood's model as an appropriate framework for gerontological clinical nurse specialist practice.

Specialization

The clinical nurse specialist (CNS) is described by the American Nurses' Association1 as a nurse prepared at the master's or doctoral level who is an expert in a selected area of clinical practice. Graduate education provides the gerontological clinical nurse specialist with the theoretical knowledge and skills necessary to diagnose and treat the human responses of the elderly to actual or potential health problems in a variety of settings.1'3 Historically, specialization in nursing has risen from societal forces, including development of new technologies, increase in knowledge in specific areas, response to a previously little known area of public need and interest, and complexity of services exceeding the prevailing knowledge and skills of general practitioners.1,5 Specialization in gerontological nursing has risen from similar societal forces, ie, the development of new technology with the potential to prolong life, an increase in gerontological knowledge, increased interest in health care of the elderly, and current and projected demographic trends of the elderly that affect their health care.1,3,6,7

Demographic and Healthcare Ibends

Although the estimated number of elderly, aged 65 years and over, is currently 25 million, that number is expected to increase to 55.5 million by the year 2030. 8 Thus, the gerontologicai CNS is expected to encounter an increasing number of elderly in all healthcare settings.

According to the Department of Health, Education, and Welfare9 a white male reaching age 60 is likely to live to age 77, whereas a white female is expected to live until age 82. Life expectancy of nonwhites is slightly less . The sex ratio (number of males per 100 females) in the 65 and older age group is projected to decrease to 65 in the year 2000. 10

Due to the improved availability of health care in the community, many chronically ill elderly, who would have required nursing home placement in the past, are now able to remain in their own homes. According to the US Census Bureau, well over 80% of those 65 and over live independently. Though most elderly live in two-person households, almost 30% live alone. Fifty-five percent of those 85 and older maintain independent households, whether alone or with a spouse.

Nursing care for the elderly has historically been based on the medical model, involving short-term treatment of acute illness. Since the health needs of this group are primarily chronic in nature, the medical model alone is insufficient to serve as a basis for care of the aged. Proposals to provide health care based on chronic care," functional status,12 and self-care13 nursing models are now found in the literature.

Loomis and WoodV1 Model

Loomis and Wood proposed that all human response systems interact with all actual or potential health problems as well as the clinical decision-making processes. Loomis and Wood also stated that nurses are capable of curing the actual or potential health problem by diagnosing and treating the human responses they elicit. Actual or potential health problems are defined as developmental life changes, acute health deviations, chronic health deviations, and culturally and environmentally induced Stressors.

Human response systems are identified by Loomis and Wood4 as physical, emotional, cognitive, family, social, and cultural. The model allows for the probability that more than one human response system is activated simultaneously by the actual or potential health problem. The model employs the clinical decision-making process and offers several prototypes of healthcare situations.

They include: a) health problems precede human responses; b) human responses precede health problems; c) health problems are defined by human responses; and d) health problems interact with human responses. Further application of the model to specific healthcare needs of the elderly follows. Typical human responses of the aged to actual or potential health problems are presented in addition to examples of the four Loomis and Wood clinical prototypes.

Human Responses to the Developmental Process of Aging

Aging is associated with changes in work roles and loss of spouse and friends. For a growing number of elderly Americans, a number of whom are women, the possibility of retirement is becoming a reality, as life expectancy increases.14 Associated with an increase in leisure time, retirement may also yield feelings of decreased usefulness and decreased productivity.14 Work-related roles no longer provide the retiree with a sense of identity, selfesteem, and social support, and even roles and relationships at home are redefined.

As age advances, the elderly are particularly vulnerable to disruption in social support networks due to death, retirement, or relocation of network members. Lowenthal and Haven15 found the presence of a confidant to be a buffer against such social decrements as loss of role and reduction in social interaction.

Loss of a confidant, however, increases the likelihood of depression and low morale. Estimations vary, but it has been suggested that 5% to 65% of the elderly in community and institutional settings display depressive symptomatology. 16

Human Response to Acute and Chronic

Health Deviations Although the majority of the elderly appear to enjoy good health, 86% of people over 65 have one or more chronic conditions.17 Chronic healthcare deviations are the major healthcare problem of the aged population.6,10 Of those aged adults with chronic conditions, one-half are limited to function.10,18 Restricted activity and confinement to bed due to disability is twice as common among those elderly age 75 and over than younger individuals age 45 to 64. 19 Acute illness may exacerbate chronic health problems and lead to further functional decrements.18

Acute illness accounts for more days of disability in the elderly than in young adults. The individual aged 65 and over is also twice as likely to be hospitalized in a given year than his/her younger counterpart under the age of 65. Once hospitalized, the aged individual's length of stay is twice as long as that of younger individuals.20 Patients over the age of 65 represent approximately 40% of the persons occupying general surgical beds.21

Human Responses to Cultural and Environmental Stressors

As age advances, the elderly are susceptible to the effects of ageism, relocation, and potential poverty. Unlike other countries in which the wisdom and experience of old age are valued, American culture values youth, speed, progress, and scientific discovery.22,23 Subsequently, value conflicts often result for the elderly who are segregated from the mainstream of society. The devaluing of the elderly, referred to as ageism, has resulted in reduced numbers of healthcare personnel who are interested and willing to care for the aged.24-25 Ageism can therefore promote such responses as depression, powerlessness, and lack of self worth in the aged population.

Emotional responses of the elderly to relocation are influenced by the reasons for the move. The elderly individual relocates for many reasons, such as decreasing personal finances and ill health.26 In the past, relocation of the aged was primarily associated with a move to a long-term care facility. Due to the growth of various elderly housing options and availability of health care in the community, the elderly individual is now more likely to relocate for such reasons as personal security, safety, and companionship. They may respond to a move with anxiety, disorientation, and depression, especially if the move was not of their choosing.26,27

Responses among the elderly population to limited financial resources are anticipated to affect their ability to seek appropriate health care. Medicare benefits are expected to remain inadequate to pay for the total health care bill of the aged. Thus, the elderly individual's out-of-pocket cost for health care is expected to continue to rise at an average annual rate of 14%. 10 Inadequate financial resources may prevent the elderly individual from obtaining the appropriate level of health care. The aged individual's response to inadequate financial resources may be neglect of needed services to maintain optimal health status and an inability to accept self-responsibility for health maintenance.

Responses of the elderly to acute and chronic health deviations and cultural and environmental Stressors can be viewed within four prototypes or healthcare situations, according to Loomis and Wood's4 model. An explanation and example of each prototype is provided within the scope of the gerontological clinical nurse specialist practice.

Health Problems Precede Human Responses

The first prototype of Loomis and Wood's model is health problems precede human responses. The medical model is reflected in this clinical situation. To illustrate this prototype, consider the case of an 82-year-old woman who was brought to the emergency room with head injuries and a fractured hip resulting from a fall.

Since the elderly patient required both orthopedic and neurologic attention, medical and nursing interventions focused on her physiological human responses to acute health deviations. The physical human response system is the primary concern to both physicians and nurses, although emotional, family and cognitive responses are recognized by the nurse. Efforts are directed at correcting physiological damage and preventing further complications.

The elderly woman's level of consciousness was assessed while fluid balance and pain levels were monitored and adjusted in collaboration with the physician. The initial treatment phase was directed at curing the temporary physiological imbalance. As the patient recovered physically, the nurse shifted the focus of cure to collaboration with the patient and significant others to promote coping with the acute health deviation. Emotional, cognitive, and family response system gradually assumed greater priority as the physical response system stabilized.

Human Responses Precede Health Problems

The second prototype of Loomis and Wood's4 model is human responses precede health problems. Both developmental life changes associated with aging, and cultural and environmental Stressors can precipitate healthcare problems. The focus of nursing treatment in this situation is on the human responses to the problem. For example, a 65-year-old male presented to Health Services at his place of employment, complained of insomnia, indigestion, and depression. The man offered that work had always been of primary importance in his life, and with retirement approaching, he was worried that his life would be meaningless and nonproductive.

Nursing interventions focused on the emotional, cognitive, family, and social responses to improve the man's ability to cope with the developmental life change. The nurse discussed with the client and significant others the new role he was about to experience, and how role transition was affecting those involved.14 Facilitating resolution of role conflict, the nurse assisted the client to clarify roles and deal with role reversals. The nurse also assisted the client to identify ways that existing relationships could be made more meaningful and encouraged the development of new relationships ie, community volunteer. Cognizant that other employees may be experiencing similar reactions to retirement, the nurse facilitated the formation of a support group within the workplace. Cure was demonstrated by a smooth transition to retirement, without dysfunctional physical or emotional responses.

Health Problems Defined by Human Responses

Health problems are defined by human responses represents the third prototype described by Loomis and Wood.4 Many psychiatric diagnoses are included in this prototype as identification and definition of the health problem is based on associated human responses. For example, a 70- year-old female was admitted to a nursing home for a short period of respite care. The woman's primary caregiver, her 79year-old husband, recently had cataract surgery and was unable to provide the demanding care she required.

After admission, the woman suffered periods of anxiety attributed to relocation trauma. Nursing interventions were directed at curing the anxiety by promoting relaxation, orienting the patient to the environment, increasing the patient's social interactions with other residents, and bringing familiar items from her home.26,27 Evaluation of the nursing interventions was based on patient outcomes represented by a decrease in the woman's anxiety, demonstrated by increased social interaction with staff and peers, and continued orientation to time, person, and place.

Health Problems Interact with Human Responses

The fourth prototype of Loomis and Wood's4 model is health problems interact with human responses. Chronic health deviations may interact with human responses of the client which necessitate nursing interventions focused on both the health problems and the human responses they elicit. These health problems require the cooperation of the patient and often entail a change in lifestyle. Consider the example of a 67-year-old male seen at a local health department free screening clinic for the elderly, who was found to be noncompliant with his antihypertensive medication instructions. In addition, he smoked two packs of cigarettes daily and consumed a diet high in salt and calories. Nursing interventions were directed at collaborating with the patient to increase his understanding of the factors associated with hypertension and compliance with his regimen of care. The patient was able to achieve compliance with his medication instructions, restrict the salt and calories in his diet, and identify and reduce the stress in his life.

The four prototypes depicted by Loomis and Wood's clinical decisionmaking model have been illustrated through case examples of clients treated by the gerontological clinical nurse specialist in a variety of settings. The possibilities of the model for clinical practice of the gerontological CNS are abundant. Nursing interventions focused on the various prototypes of elderly clients are limited only by the amount of creativity of the practicing CNS.

Summary

Increasing numbers of gerontological clinical nurse specialists will be needed in the future to meet the nursing care needs of the fastest growing segment of society. The complex Healthcare needs of the elderly require nursing care based on a versatile framework for clinical practice. Loomis and Wood's4 model for clinical nursing provides the flexibility necessary to diagnose and treat the variety of human responses elicited in the aged by an array of actual or potential health problems.

The gerontological CNS is likely to encounter all of the prototypes proposed in the model in a variety of clinical settings. Loomis and Wood recognize the potential of nursing to cure actual or potential health problems by focusing on the human responses to these health problems. Nursing care based on the model provides a holistic approach to health care for a segment of society whose needs are both challenging and complex.

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