Two recurring themes have emerged in recent health care literature: the burgeoning elderly population with a resultant increased demand for hospital services, and the rapidly escalating cost of health care. Demographic data indicate that a major emphasis of health care in the near future will be geriatrics. Persons aged 65 and older currently represent more than one third of patients seen in hospitals; in the next century, it is predicted that every other adult patient will be an elderly person (Projection of the population, 1977).
The relationship between an increasing elderly population and the demand for health care is apparent when one considers that health problems of the elderly can be multiple, complex, and chronic. Indeed, one of the landmarks of aging is an individual's decreased ability to respond to stress, including the stress of illness and disease. In a younger person, coping with the demands that illness or injury put on the body does not pose as much of a problem because there is a greater reserve from which to draw. As the individual ages, however, this reserve diminishes. As a consequence, the older person is unable to mobilize the energy to cope with the major physical stresses of illness.
The increased number of elderly and their lessened abilities to cope with illness results in an increased demand for health services, especially inpatient care. Unfortunately, in addition to the primary health problems that necessitated the admission, hospitalization itself represents a major site of functional decline for elderly patients. In particular, confusion, falling, appetite loss, and incontinence represent areas of functional decline not attributed to the patient's underlying medical illness. These problems, in combination with the physical ailments that originally necessitated the hospitalization, prolong the period of hospitalization. This growing need for health services is rapidly increasing at a time when the ability and desire of government to meet them are in decline. New approaches are needed; health care professionals are being challenged to provide leadership in meeting the health care needs of our aging population within the existing framework.
The challenge of elder care for all health care professionals is twofold: "(1) Careful clinical assessment and management to identify remediable problems and (2) equally careful and competent functional assessment to ascertain how the patient's autonomy can be maximized by appropriate human and mechanical assistance and environmental manipulation" (Kane, 1984).
Nursing, in particular, is the profession at the forefront of assessing and managing the care of elderly patients. Nursing is faced with the challenge of continuing to provide comprehensive quality care as demand for services increases in an era of fiscal restraint.
This article describes one approach to meeting the needs of the hospitalized elderly patient in which nurses assumed leadership roles as members of an interdisciplinary health care team. In addition to nurses, the team, using existing hospital staff without specialized geriatrics training, was composed of one representative from medical, social work, dietary, physical therapy, and pharmacy departments.
THE SENIOR CARE UNIT PROJECT
On admission to the hospital, 549 patients 75 years of age and older were placed into random groups: 267 were in the control group and 282 were in the experimental group. Only patients whose medical diagnoses necessitated admission to the critical care areas or specialty units (oncology or dermatology) were excluded from the selection process. The control and experimental groups were similar at study entry. Control group patients received the usual hospital care on general medical surgical units; study patients were admitted to the Senior Care Unit, an 18-bed geriatric unit. Each study patient received the usual hospital care as well as an interdisciplinary team assessment and care planning conference directed by the nurse coordinator (Senior Care Coordinator) within 72 hours of admission.
Upon the study patients' arrival on the senior care unit, a registered nurse interviewed them using the hospital's usual nursing assessment form (Figure 1) in addition to a functional status assessment instrument (Figure 2). Mental status, sensory impairment, nutrition, functional dependence status, activities of daily living (ADLs) prior to admission, orientation, and mood and behavior were the areas assessed. Data derived from these two assessment tools as well as information gathered by the primary nurse while caring for the patient were presented by the primary nurse at the interdisciplinary team conference. Team members from the other professions also interviewed and assessed the patients and contributed to the data base at the conference, which was directed by the Senior Care Coordinator or the patient's primary nurse (Figure 3). Information contributed by nurses and other team members was used in formulating the Geriatric Team Care Plan (Figure 4). Each discipline was responsible for followthrough, including discharge planning.
In addition to interdisciplinary recommendations, the team also estimated a length of stay suitable for the diagnosis related group category and a time frame for accomplishing the recommendations. If the patient remained hospitalized past the scheduled discharge date or was discharged before the estimated discharge date and there were unresolved problems, the study design provided for a reconference involving the primary nurse and other appropriate team members. The Senior Care Coordinator was responsible for scheduling the meeting and informing team members of the reconference. The Geriatric Team Care Plan was reviewed during the conference. Modifications were made as needed, resulting in a discharge care plan listing unresolved problems, assessments, and recommendations (Figure 5). A copy of this plan was sent to the attending physician, one accompanied the patient, and one remained on the unit in the Senior Care Coordinator's file for use during follow-up telephone conferences.
Nursing Assessment Form
After the patient's discharge, the Senior Care Coordinator maintained a file of concerns and recommendations and recorded the patient's progress or lack thereof as determined from five follow-up telephone conversations with the patient or caregiver at weeks 1, 2, 3, 4, and 8 whether the patient was in the home or in an institutional setting (Figure 6).
The Role of Nursing
The nursing department had a vital, multifaceted leadership role in the overall functioning of the team during the entire interdisciplinary process. The staff of the Senior Care Unit, which was predominately registered nurses (11 RNs, 3 LPNs), already had a reputation for delivering high quality care to elderly patients. They agreed to participate in the research project with the primary goal of increasing their level of sophistication in the care of geriatric patients. The plan was to increase the nurses' knowledge base by teaching them methods of assessing mental status, nutrition, incontinence, and mobility; how to work with and on a team; how to direct a team conference; methods for following patients' progress after discharge; and the research process.
Although the nurses on the Senior Care Unit were eager to learn more effective ways to manage their elderly patients' hospital stays, this project represented a change. According to Byars and Rue (1982), how an employee perceives a change greatly affects how that person reacts to the change. Although many variations are possible, there are four basic situations that occur:
* If employees cannot foresee how the change will affect them, they will resist the change or be neutral at best.
* If it is clearly seen that the change is incompatible with the employees' needs and aspirations, they will resist the change.
* If employees see that the change is going to take place regardless of their views, they may initially resist and then resignedly accept the change.
* If employees see that the change is in their best interests, they will be motivated to accept the change.
In this case, the changes were subtle, but were changes nonetheless. The nursing staff was familiar and comfortable with working together as a team, but the interdisciplinary nature of this project represented a variation. Patient assessment had long been integral to nursing practice, but the functional status assessment was a new tool that required a different level of data interpretation. Patient care conferences had been held regularly, but they were informal and for nurses only. Now there were formal presentations directed by a registered nurse with a multidisciplinary group. The last major change this project incorporated was the postdischarge followup activity. The focus of nursing practice had previously been on the period from admission to discharge; the advent of the Senior Care Unit broadened that focus to include postdischarge follow-up.
Enhancing Hospital Care: Team Conference Worksheet
Informal classes were held to introduce the project. The interdisciplinary team members presented and attended scheduled, formal classes on such topics as functional assessment, the aging process, medication, nutrition, and mobility concerns in the elderly. Team members presented classes related to their profession, ie, the pharmacologist presented a class on drugs and the elderly. The classes had the effect of preparing each discipline to present at the patient care conferences, enhancing each member's knowledge of the many facets of care of the elderly, and providing the opportunity for team members to get to know each other and each other's role better.
When the project began, the primary nurses attended the conference, then they began to present the nursing data base, and finally the registered nurses directed the conference. However, this change in the nurse's role from attendee to participant and then conference leader took time to develop. Initially, articulating the specific role and contribution of the nurse within the team conference was problematic. Nurses listened to the assessments of the other disciplines and felt they had little additional information to offer. In an attempt to delineate nursing's contribution, one registered nurse developed a guide for nursing information (Figure 7).
Geriatric Team Care Plan
It was at this time that the nursing staff members began to work with the project as if it was their own. They presented ideas at weekly meetings, participated at team conferences with a critical eye to patient outcomes, identified the need for follow-up information to be communicated, and developed the model for that.
The role of the Senior Care Coordinator was developed to enhance integration and ensure follow through of the plan of patient care. Relieved of direct patient care responsibility, each primary nurse had a 10- week rotation in this position. As the name implies, the individual coordinated the process. The coordinator assisted other primary nurses in collecting data, assigned conference dates and times (within 72 hours of the patient's admission), recorded the team's recommendations for care, and oversaw the follow-through for all team members (Figure 3).
Senior Care Unit Recommended Care Plan
To determine the implementation of and patient response to the interdisciplinary care plan, the Senior Care Coordinator conducted chart reviews, made daily rounds on current study patients, and met informally with team members involved in the patients' care. During these meetings, the Senior Care Coordinator also updated the primary nurse and other team members on the progress of discharged study patients as determined by telephone followup.
It became apparent early in the study that the Senior Care Coordinator's role was the key to the success of the project. Despite variability in educational preparation, work experience, and personal style, the role of Senior Care Coordinator was an effective way to maintain communication with patients and other team members and to ensure continuity of the care plan.
During the 2-year course of the data collection, 282 hospitalized elderly participated in the experimental group and 267 were members of the control group. No statistical control for baseline differences was employed because the randomization of eligible subjects yielded comparable groups at baseline for variables at each interval. Simple f-tests were used to examine between-group differences in outcomes measured by interval scales. Contingency table analyses using Pearson's chi-square statistic as well as the Mann- Whitney test of ranks were employed to examine differences in dichotomous and ordinal scale outcomes. Significance was set at p<.05. Analysis of data yielded the following results in relation to the original goals of the study:
* There was a difference of 1 day in the hospital length of stay between the experimental and control groups. Experimental group patients stayed an average of 11.6 days, whereas control group patients stayed an average of 12.8 days. This difference was not statistically significant.
* There was not a statistically significant difference in functional status relative to performance of ADLs between the experimental and control groups (χp 2 = 3.4).
* Postdischarge follow-up of members of the experimental group was conducted by the Senior Care Coordinator.
* Hospital charges were comparable for both groups.
Because decreasing the duration of hospital stay for patients was one of the primary goals, the finding that the 1-day difference in length of stay was not statistically significant was disappointing. However, even a 1day difference in length of hospital stay has important financial and functional implications. Multiplying the cost of a 1-day hospital stay by the number of admissions of elderly patients in 1 year yields a substantial savings, considering the deleterious effects on the elderly associated with hospitalizations; a stay shortened by 1 day may prevent or ameliorate functional decline. The team believes that sequestering like patients on one particular unit, enhancing the skills of the staff on that unit, and standardizing the interdisciplinary team intervention for this group led to the shorter length of stay. The comprehensive assessment of geriatric clients is thought to have been the key to meeting mis objective.
The study has had a significant impact on the practice of the nursing staff both individually and collectively. Nursing participation in this project was multifaceted, resulting in an increased level of expertise in using the nursing process with geriatric patients.
Follow-Up Telephone Contacts
The staff grew professionally during the study. Clinically, they learned and used new skills. Their increased ability to assess patients' needs and intervene at interdisciplinary levels was evident. They became more autonomous, demonstrating critical thinking and decision making. The nursing staff members began to consult with each other and with other team members as a routine part of patient care. It became a daily practice to discuss aspects of care with a member of the appropriate discipline.
This collaborative effort not only resulted in a more complete holistic plan of care for the patient, but also increased the nurses' and other team members' knowledge of each others' areas of expertise. For example, nurses were able to develop strategies for ambulating patients using knowledge learned from the physical therapist. These approaches were beneficial to the particular needs of certain patients. In a separate, concomitant study, the physical therapy department documented that there were fewer formal consults ordered from the Senior Care Unit because the nursing staff was more assertive in mobilizing patients.
Guide for Nursing Information: Senior Care Unit Team Conference
The collaborative model "spilled over" into nurses sharing concerns with other team members about patients who were not part of the study, which was especially evident after the study was completed. The staff reported an effect on communication because of increased collaborative efforts. They specifically identified an increased level of comfort discussing the nurse's assessment of the patient with attending physicians as well as with members of other healthcare disciplines.
Of equal significance were the reports from staff about the effect this study had on nursing process. The RNs concur there was an increase in refinement of nursing assessment skills, including mental status and functional assessment (ADL). This practice led to an increased ability to individualize care plans; ie, be more specific about clients' needs and abilities. Staff reported improved organization, implementation, and evaluation skills. Because of increased collaboration, goals of two disciplines were sometimes reached by a certain action; ie, physical therapy staff wanted a patient to strengthen particular muscle groups affected by a cerebrovascular accident, and nursing staff wanted the patient to be out of bed and mobile. Physical therapy staff collaborated with nursing staff to plan a particular approach to increase mobility that had the patient out of bed and walking while focusing on muscle strength.
Through collaborative efforts, the nursing staff also approached patients' nutritional deficits in new ways. Individuals who were nutritionally compromised were offered three meals per day; based on the discrepancy between their oral caloric intake and caloric requirements, nasogastric feedings were instituted for overnight hours to make up the deficit. By discontinuing the enterai feedings at 5 AM, the patients could experience hunger and therefore take in an oral diet. In this way, the nursing staff members began to individualize their approach toward elderly patients with nutritional deficits.
Similarly, incontinence was examined closely. The nurses frequently requested urology consultations and worked closely with the urologists to maintain or improve the patients' status. For example, in one group of patients with overflow incontinence, nurses inserted straight catheters every 8 to 12 hours. Because their bladders were empty, the patients remained dry and their dignity and self-esteem were restored. Nurses incorporated these approaches to individualize their care plans.
From the theoretical perspective, the nurses also began to understand the role of research in health care. The staff's knowledge of research grew from learning about the concept of randomization to determine sample selection, developing interrater reliability in the use of assessment tools, and discussing the meaning of data analysis in the practice setting. During the 2-year course of the project, the nurses changed from being somewhat reticent participants to enthusiastic supporters exceeding all expectations, including their own. Even now after the official period of the study has ended, the nurses' practice continues to reflect their commitment to using the knowledge and expertise they had developed during the Senior Care Project.
In addition to enhancing the care of patients on the Senior Care Unit, the nurses' expertise is being shared to enhance care in other area hospitals. A separate project, developed as a continuation of the interdisciplinary team concept, was initiated in response to the interest and excitement in the senior care model exhibited at four local community hospitals. Many of the staff nurses from the Senior Care Unit volunteered to act as clinical consultants to the interdisciplinary teams. Observing the confidence and commitment communicated by the nurses further demonstrates the success of the project. As consultants, they have demonstrated the ability to explain their approach to multidisciplinary care and offer suggestions for implementation when they critique the team process in the consulting institutions.
Participation in the senior care study exerted a strong influence on the practice of the nurses directly involved in the project. Of equal or greater importance are the implications that the concept of an interdisciplinary team has on nursing practice in general. Hospitalized patients, elderly in particular, frequently present with health needs of considerable complexity that cannot be met adequately by a single professional group. The biopsychosocial problems presented by one aged patient are diverse yet inter-related, and frequently are not amenable to treatment by any one discipline. Rather, the knowledge, abilities, and skills of a number of different professionals (nurses, social workers, dietitians, pharmacists, physical therapists, and physicians) are needed in almost every case.
Too often when these professionals are used, it is one by one, each approaching the patient unilaterally with the nurse trying to determine their plans to communicate them to patients and family members. Problems of fragmentation and duplication are created that complicate the health care situation. In addition to causing frustration, fragmentation results in delays, overlap, and lapses in treatment. These problems frequently cause patient dissatisfaction plus increased lengths of stay and costs. This project demonstrated that it is feasible to introduce a comprehensive, interdisciplinary geriatric team coordinated by nurses into an existing staff, resulting in quality care without increasing the length of stay or hospital costs.
- Byars, L., Rue, L.W. Supervision: Key link to productivity. Homewood, IL: Richard D. Irvin, Ine, 1982.
- Fretwell, M., Raymond, P., McGarvey, S., Owens, N., Trainee, M., Silliman, R., et al. The Senior Care Study: A controlled trial of a consultative/ unit-based geriatric assessment program in acute care. / Am GeriatrSoc 2990; 38:1073-1081.
- Kane, R.L., Ouslander, J.G., Abrams, LB. Essentials of clinical geriatrics. New York: McGraw-Hill, 1984.
- Projection of the population of the United States, 1977-2030, current population report series. Washington, DC: US Department of Commerce, Bureau of the Census. 1977, No. 74, p. 25.
Enhancing Hospital Care: Team Conference Worksheet
Guide for Nursing Information: Senior Care Unit Team Conference