The number of aged adults has tripled as a percentage of the total population since 1900. In 1987, a woman aged 65 could expect to live to 86 and a man to age 78. In the year 2030, the growth of the elderly population will peak.1
The fastest growing sector of the elderly population is over age 75. The old-old (85 and older) have more and longer hospital stays. ' Among the aged population as a whole, "the rate of hospitalization, the number of days of hospitalization per 1,000 persons, the rate of complications, and the average length of stay increases with age."2 It is evident that there are more aged people, and their subsequent hospitalizations bring complex problems requiring highly specialized nursing care.
At the same time, hospitals are experiencing a shortage of nurses, especially those experienced in specialty practice. The hospital nursing staff vacancy rate has doubled from September 1985 to December 1986.3 The estimated RN vacancy rate nationwide is 13. 6%. 4 Limited salary potential and a lack of status are just two reasons offered as contributing to the nursing shortage. Health experts are concerned that the quality of hospital care is suffering (New York Times. July 7, 1987:A1).
In summary, the aged population is expanding while the availability of nurses to care for hospitalized elderly people is shrinking. Additionally, care for older persons is complex, requiring specific knowledge. The Gerontological Nursing !fellowship is an effort to assist professional nursing staff in meeting the quantitative and qualitative needs of the aged patient. Staff retention is expected to increase as professional status is enhanced. This unique program prepares RNs in clinical practice with elderly patients for certification by the American Nurses' Association (ANA).
Certification is "regulated by professional standards" and "is a voluntary action of the nurse, not necessarily required for nursing practice nor based on geographic limits."5 The ANA defines certification as "the process by which an ANA Committee of Examiners validates, based upon predetermined standards, knowledge, and practice in a defined functional or clinical area in nursing."6 The professional organization is promoting certification as the career credential.
Established in 1973 , the ANA Certification program provides tangible recognition of professional achievement. As of March 1987, more than 4,570 nurses in the United States have been certified by the ANA in gerontological nursing. Certification is based on "assessment of knowledge, demonstration of professional achievement, and recognition by peers."6
ORGANIZATION AND DEVELOPMENT OF THE FELLOWSHIP
The Gerontological Nursing Fellowship is one of seven fellowships organized under the Institute for Advanced Nursing Clinical Education at the Jewish Hospital of Cincinnati. Under the aegis of the Department of Nursing, the Institute is administrated by a doctorally-prepared nurse educator. The Gerontological Nursing Fellowship is developed and coordinated by an ANAcertified mas ter 's- prepared clinical nurse specialist (CNS). The CNS chairs a task force of appropriate head nurses, directors, and assistant vice presidents for collaboration on program content and implementation.
Fellows are recruited by the CNS and head nurses based on specific qualifications. Fellows are RNs with 2 years of practice experience in working with the elderly prior to the application deadline for the ANA certification examination. The previous performance evaluation must be satisfactory. The fellow agrees to continue working in the position for 1 year after completion of the fellowship or reimburse the hospital for the cost of the program. The RN is expected to take and successfully pass the Gerontological Nursing Certification Examination.
Five fellows participate in each program, which ensures sufficient supervision by the CNS/instructor. RNs are recruited from all areas of the hospital that serve the elderly, including medical-surgical units as well as outpatient services.
THE FELLOWSHIP PROGRAM
The program is 3 days a week for 12 weeks and combines didactic learning experience with strong clinical learning opportunities. Lecture content, a unit-based clinical with a limited patient assignment, and a structured skills/rounds day make up the 3-day fellowship experience. Components integrated into the didactic and clinical curriculum include advanced health assessment and a research project.
The first day of each week is devoted to the didactic content, the framework of which is derived from the test content outline for the Gerontological Nursing Certification Examination. The core gerontological content features the use of the nursing process to assess, diagnose, plan, implement, and evaluate health care; nursing practice and policy issues; administrative management principles and evaluation; and advocacy and education. Contact hours are awarded.
The nursing process comprises 60% of the content and examines the elder's health status and environment, normal aging changes, family needs, and common health problems. Practice and policy issues include factors affecting the older person's quality of life, such as federal regulations, ethical/legal issues, the health-care continuum, research, and the history and future of gerontological nursing.
The administrative management content reviews policy and procedure development, resource allocation, peer review, quality assurance, documentation, and other topics. Advocacy and education components include learning and change theory, instructional methods appropriate for elders, the political process, to name a few.
The unit-based clinical experience, the focus of the second day of each week, implements the didactic content from the first day. The clinical day focuses on specific daily objectives ineluding physical assessment of a particular body system. Fellows also work on personal objectives based on individual learning needs, for example asserti veness and wound care. The CNS serves as the clinical preceptor and the fellows have a limited patient assignment.
The third day of each fellowship week is a skills/rounds day. Fellows view physical assessment videos and practice skills with one another and with patients. Patient cases are presented and reviewed utilizing nursing diagnosis and nursing care plans. Testtaking strategies are discussed and practiced, and sample test questions reviewed. Site visits to departments and facilities that provide special services to the elderly are an additional experience. Specific activities to meet objectives of the fellows are again scheduled.
Additionally, library time is allotted so that the fellows can conduct the research project. Fallows identify a clinical interest area or a problem on the clinical unit and review related Hterature. The information is then presented to staff on the nursing units or to the fellows. The purpose of the research project is for the fellows to learn about gerontological literature, reacquaint them with library resources, and promote problem-solving and critical thinking.
Funding and Costs
The fellowship programs are funded by a generous endowment from the Board of Trustees. Costs include CNS salaries and benefits, audiovisual and skills equipment, expansion of library resources, and secretarial assistance. Staff time off the unit and facility/ office space are costs to the operational budget.
Several tools have been developed to measure a change in the fellows' knowledge of gerontological nursing. The reliability and validity of these tools have not been tested. The tools include pre- and post-, subjective and objective tests of gerontological nursing knowledge. Additionally, accomplishment of daily and personal objectives, clinical performance, and passage of the ANA certification examination are monitored. Other tools to assess the efficacy of the program inelude evaluations of didactic lectures, preceptors, clinical areas, the overall program, and the skills/rounds day.
The Subjective Knowledge Pre-Post Test contains 20 content areas with a total of 141 items based on the Certification Examination test content outline. Of the 20 content areas, all five fellows had at least a 50% increase in knowledge in at least two content areas: nursing practice and policy issues, and federal regulation compliance. Four fellows had a 50% increase in three additional areas: health-care continuum, gerontological literature, and advocacy. Three fellows had at least a 50% increase in one other area: gerontological nursing research. Lastly, three fellows had a 50% increase in self-rated knowledge in at least half of the content areas.
The Objective Knowledge Pre-Post test, a 50-question test of gerontological nursing knowledge, was given before and after the fellowship. The increased change in correct answers ranged from 18.9% to 66.7% with a mean of 37.7%.
Generally, daily and clinical objectives were met with two fellows stating a need for further study in a particular area. Increased sensitivity to the needs of elderly patients and increased ease in identification of nursing diagnoses were evident in the fellows' clinical performances.
All five fellows took the ANA Gerontological Nursing Certification Examination in October 1988. Pour of five passed; the remaining fellow missed passing by one point.
Data from the tools used to assess the efficacy of the program yielded qualitative results. The preceptor evaluations were favorable. The fellows enjoyed having a role model to observe doing particular activities, such as physical assessments and interventions with families.
The didactic lecture, overall program, and final evaluations were favorable. Fellows verbalized increased knowledge of normal aging changes, increased confidence in caring for elderly patients, and a higher level of satisfaction at work. Improved physical assessment skills, ability to formulate nursing diagnoses, and knowledge of community agencies were also mentioned. All fellows plan to continue to work in gerontological nursing.
The fellows believed the skills/ rounds day activities were helpful and particularly liked the emphasis on nursing diagnosis formulation. Site visits to agencies that care for the aged were a favorite.
An important problem experienced and expected in future fellowships concerns the nursing shortage. At a time when RN vacancies are high, reassigning staff to clinical areas presents difficulties. Additionally, fellows with line management and administrative responsibilities must maintain management priorities above the fellowship.
Recommendations from the fellows for future fellowships included the following, !fellows identified the need for gerontological nursing textbooks in the nursing units and library. Additionally, the format of an 8-hour didactic lecture and the 12- week duration is intense and difficult. Fellows suggested splitting the didactic content between days 1 and 3 and decreasing the fellowship length to 10 weeks.
Currently, fellows with future plans to accept RNs from other hospitals are recruited from our own hospital. The didactic component is open to hospital, nursing home, and community nurses for a fee.
Benefits to Participants
The benefits to fellows include a significant increase in salary with passage of the certification examination and promotion to the clinical ladder CNIU position. Certification is one criterion in achieving the CNIII position. The new credential attained by passing the certification examination is recognized on the hospital badge. The certification examination fee and most travel costs are reimbursed by the hospital. R>rmer fellows who are certified are eligible to become clinical preceptors for future fellowships, fellows may experience an increase in selfesteem and job satisfaction.
National certification brings recognition by peers and other health-care professionals. More and more jobs require specialty certification and, therefore, additional employment opportunities may be available.
In a dual effort to better care for the hospitalized elderly as well as recruit and retain RNs in a declining market, a gerontological nursing fellowship has been developed. The fellowship is based on the professional organization's examination framework. The fellowship's unique clinical and didactic program is expected to profoundly affect critical thinking skills, patient care outcomes, and satisfaction of the nursing staff in this health-care setting.
- 1. Christ MA, Hohloch F. Gerontologie Nursing. Springhouse, PA: Springhouse; 1988.
- 2. Matteson MA, McConnell ES. Gerontological Nursing. Philadelphia: WB Saunders; 1988.
- 3. Aiken LH, Mullinix CF. The nurse shortage: Myth or reality? N Engl J Med. 1987; 317:641-645.
- 4. Setby TL. Nursing shortage: One state's experience. American Nurse. 1988; 20(3): 1,7.
- 5. Scofield R. Certification: What does it mean? Current Concepts in Nursing. 1988; 2(1):610.
- 6. American Nurses' Association. The Career Credential; Professional Certification: American Nurses' Association i988 Certification Catalog. Kansas City, MO: Author; 1987.