The percentage of elderly individuals in American society continues to grow. With that growth comes new demands for health care professionals to provide quality health care addressing the needs of older patients in a cost-effective manner. Health care professionals are particularly challenged to do this-in the acute care setting. Older individuals tend to have longer hospital stays for a variety of reasons and are also at increased risk for adverse incidents, such as confusion, falling, and incontinence. In addition, chronic illnesses common in this age group often are exacerbated during acute illnesses and may complicate management. Another contributing factor is the decline in functional ability that often occurs while the older patient is hospitalized. This functional decline may affect discharge plans and subsequent placement (Palmer fit BoUa, 1997).
Nationwide, patients older than 65 years of age account for 47% of inpatient days (The Sachs Newsletter, 1999). Care of this group presents major clinical and fiscal challenges to acute care institutions and highlights the need for greater numbers of staff with special training in geriatric patient care.
The University of Virginia (UVA) recognized the importance of this trend, and in 1994 became one of the four original sites for implementing the Nurses Improving Care to the Hospitalized Elderly Project (NICHE) funded by the John A. Hartford Foundation. Several models of nursing care with the aim of improving care to hospitalized elderly had previously been developed and tested in the Hospital Outcomes Project for the Elderly (HOPE) (NICHE Project Faculty, 1994).
At UVA, the Geriatric Resource Nurse (GRN) Model was selected and implemented early in 1994 (Francis, Fletcher, & Simon, 1998). This model was selected because a strong group of interested nurses was identified through their regular participation in geriatric continuing education programs. Additionally, there was a professional practice model with a clinical ladder in place, and the number of older patients at UVA was increasing.
The GRN Model, originally developed at Yale-New Haven Hospital in consultation with colleagues from Boston's Beth Israel Hospital, initially used primary nurses as GRNs. The model was modified at UVA to use staff nurses because primary nursing was not used consistently within the institution. The overall goal of the GRN Model is to develop unit-based nurses to provide excellent bedside geriatric nursing care and to be a resource to other unit staff. Emphasis is placed on mentoring the bedside nurses to increase their geriatric knowledge, thereby empowering them to be more effective in their interactions with other staff, patients, and families. This approach is in contrast to a more common gerontological nursing model using advanced practice gerontological nurses for clinical geriatrio consultation and education. Often these gerontological nursing experts are consulted only after clinical problems develop.
In establishing the GRN Model, recruiting bedside nurses with a strong interest in geriatrics is essential. These nurses work with an advanced practice gerontological nurse (APGN) who serves as their mentor. The model is based on the following concepts:
* Staff nurses are most familiar with the day-today work of the unit teams who address the problems of the elderly patients.
* The GRNs are more likely to integrate new practice behaviors because of their unitbased visibility in the role, and because they receive regular feedback and support from advanced practice nurses.
* The GRN Model recognizes expertise and may support advancement of nurses in institutions with clinical ladder programs (Fulmer, 1991).
At UVA, the GRNs make weekly patient-focused teaching rounds with an advanced practice gerontological nurse. These rounds, which last approximately 30 to 45 minutes, provide an opportunity for education, feedback, and support. The structure of the rounds generally involves a review of functional areas often problematic for hospitalized elderly. The acronym SPICES, developed by Fulmer at Yale-New Haven (Wallace & Fulmer, 1998), was adapted to SPPICES. The modified acronym reflects concerns in areas of sleep, problems with eating or feeding, pain, immobility, confusion, elimination, and skin. Additionally, all medications and pertinent laboratory findings are reviewed. Current functional abilities, as well as function prior to illness and hospitalization, available social supports, and discharge plans, are also discussed. After reviewing the record and discussing concerns, the APGN and GRN evaluate the geriatric patient at the bedside. The nursing care plan is then modified to address unmet needs or potential problems (Lee & Burnett, 1998).
In addition to weekly GRN rounds, another aspect of the GRN Model is a monthly multidisciplinary geriatric interest group meeting. This is a forum for education, information sharing, and support. A variety of professionals who work with elderly individuals within the hospital and broader community attend. Geriatric resource nurses are encouraged to attend additional classes and continuing education programs on geriatric topics and to become nationally certified as geriatric nurses through the American Nurses Association Credentialing Center (ANCC). Twice yearly, a half-day retreat is held where institution-wide issues are identified and prioritized. Small work groups are formed to address the issues throughout the next 6 months.
PURPOSE OF STUDY
The purpose of this study was to evaluate the effectiveness of GRNs in meeting both quality and cost-related objectives associated with providing nursing services to hospitalized older adults. In this study, the GRN represents a structural element within the traditional quality of care paradigm. This paradigm defines quality as a linear function of structure, process, and outcome (Donabedian, 1980). The outcome results directly from the use of structure and resources (e.g., GRN) in performing activities or processes. The extent to which GRNs influence what patients ultimately experience while hospitalized represents the outcome dimension within this quality paradigm. Thus, this study focused on the relationship between structure (resources) and patient outcomes as evidenced in the following research questions:
* Do demographic characteristics of the sample influence administrative or health outcomes?
* Do administrative outcomes, including total costs and hospital use, differ significantly for the two groups of elderly patients?
* Do elderly patients who receive care where GRNs are part of the nursing staff have better health outcomes than elderly individuals who receive care where GRNs are not part of the staff?
* Do elderly patients who receive care where GRNs are part of the nursing staff perceive care and outcomes differently than elderly individuals who receive care where GRNs are not part of the staff?
This evaluation study used triangulation to evaluate the effectiveness of the GRN Model. Triangulation employs two or more research approaches in a single study (Duffy, 1987; Mitchell, 1986; Morse, 1991; Porter, 1989). The most common type of triangulation is the methodological form, which is frequently used in the examination of complex concepts. In regards to nursing, these concepts may include caring, health promotion, and coping with chronic illness. Methodological triangulation was deemed appropriate for this study because of the complexity of the research questions and the focus on outcomes as multifaceted constructs. Additionally, the numerous environmental factors that are not easily controlled in clinical research necessitated a rigorous approach to answering the research questions.
A quasi-experimental design was used to assess the GRNs' effect on quality and cost of care provided to two groups of elderly, hospitalized patients on comparable medical units of a large academic medical center. Patients' diagnoses were slightly more diverse on the intervention unit. Medical diagnoses predominated, but included a higher percentage of patients with cardiac problems. There were also a few surgical patients admitted to this unit. The capacity of each unit was 23 beds, but six short-stay beds reserved for patients having diagnostic cardiac studies on the intervention unit were excluded from the study. Structured interviews were conducted with a subset of participants from both groups to gather data about the elderly individuals' perceptions of their health and care experience while hospitalized.
Study participants were selected randomly from the total census (excluding the short-stay patients) of elderly patients on each of the two units. Selection criteria included: age 65 or older and at least a 24-hour length of stay (LOS) at the time of enrollment into the study. The ability to speak or understand English, and to respond appropriately to questions, were additional criteria for the subset of patients who were interviewed. This subset was a convenience sample from the larger group.
Results of a power analysis indicated that a total sample size equal to 130 participants was needed to detect statistically significant effects. Thus, 65 elderly patients from each unit were targeted. To offset anticipated reduction in sample size due to attrition, the researchers initial plan was to over-sample. However, due to a progressive increase in case-mix diversity on the intervention unit, data collection ended early to preserve sample integrity. The final sample included 131 participants. Preliminary data analysis revealed two cases to be outliers on several of the variables, and the decision was made to drop them from the final analysis. This left a final sample of 129 participants on which to report findings.
COMPLEXITY OF DIAGNOSIS BASED ON DRG WEIGHTS (N = 129)
COSTS OF INITIAL HOSPITALIZATION
Data were compiled from multiple sources. These included hospital databases (use and cost), patient records (health status and outcomes), and personal interview (care experience). Both quantitative and qualitative techniques were used to analyze these data. This triangulation of methods is seen as a strength of this investigation.
Both health and administrative outcomes were identified for measurement. Health status and outcomes data were gathered from the usual nursing documentation sources, physician orders, and progress notes. Intended health outcomes were functional status measures such as elimination problems, mobility, eating and feeding, and pain. Skin was assessed for the presence of decubitus ulcers and mental confusion was indirectly assessed. Administrative outcomes examined for each participant included average and total cost associated with their respective hospital stays. Information on use of resources was determined by examining initial hospital LOS, as well as number and LOS of any readmission within the 31 -day period after discharge.
One day each week, all potential participants 65 years of age or older were randomly selected into the study on both units. After determining that participants met the inclusion criteria, each was approached by a member of the research team, given an explanation of the study, and asked to sign a consent form indicating their willingness to participate and to be interviewed. The patient's history and admission numbers were obtained. During the next several days, a member of the research team not involved in implementing the GRN Model interviewed the subset of patients who agreed to answer questions about their hospital experience. Interviews were audiotaped and later transcribed for analysis. After the patient was discharged, chart reviews were conducted and information gathered on health status and outcomes. An instrument specifically designed for this study was used to gather the necessary patient data. Patient identification numbers were used to obtain additional information from hospital databases on administrative outcomes.
ADMINISTRATIVE STATISTICS FOR PARTICIPANTS READMITTED WITHIN 31 DAYS
Patient level data were analyzed using Statistical Analysis System (SAS) programs. Results were then aggregated to the unit level and subjected to a series of quantitative analyses that resulted in descriptive statistics, including mean, standard deviation, and range values. Additionally, interval level data were analyzed using i-test technique to determine 'n results differed significandy for control and study units. Similar information was obtained for nominal and ordinal data using chisquare analysis. Data from structured interviews were subjected to qualitative analysis using constant comparative content analysis method (Glaser Sc Strauss, 1967; Glaser, 1978; Lincoln and Guba, 1985; Strauss Oc Corbin, 1990; Taylor, Hudson, & Keeling, 1991).
The average age of participants was 77.5 years. Women tended to be older with an average age of 78.7 years, compared to men whose mean age was 76.4. Participants on the intervention unit were slightly older at 77.7 years with a range from 65 to 97 years, while the control participants had a mean age of 77.4 and ranged in age from 65 to 93 years. The majority of participants in both groups were White (73% control and 74.2% intervention groups). Equal numbers of men (33) and women (33) were in the intervention group. The gender split was similar in the control group, with 52.4% being women and 47.6% being men. Chi-square analysis revealed no significant differences in demographic characteristics between the two groups.
Two case-mix measures were used to determine comparability of participants from the two study units. These variables were created using diagnosis-related group (DRG) weights and represent measures of diagnosis complexity. The all-patient-DRG-weight (APDRGWT) variable represents the cumulative DRG weight for participants in either the control or study group. The weight-per-case (WTPCASE) measure is the mean DRG weight for each group. Findings reveal no statistically significant difference between the two groups. This result suggests control and study participants are generally comparable based on complexity of diagnosis (Table 1).
Initial hospital admission. Utilization statistics showed that the length of initial hospitalization ranged from one to 56 days with the average stay being 9.5 days. Elderly patients on the intervention unit stayed an average of 8.6 days compared to 10.4 days for those on the control unit. Differences in hospital LOS were not statistically significant for the two units.
Initial hospital costs. Cost data are displayed in Table 2. The average total cost of hospitalization for all participants was $10,712. Costs on both units were similar, but the average and range of costs were slightly higher on the intervention units. There was no significant difference in costs between groups.
Hospital readmission. Patients from both units were followed to determine if any were readmitted within 31days of initial discharge. A few patients from both groups were readmitted multiple times during that period. Twenty-one patients in the control group accounted for 25 readmissions. Thirteen patients ?? the intervention group had at least one readmission with a total of 18 occurring during that time frame. The readmission rate between the two groups was not statistically significant. For those participants who were readmitted the LOS was computed for both the initial hospitalization and for the first readmission. Results appear in Table 3. A significant difference in readmission LOS between the control and intervention unit participants was found. The readmission LOS for control participants ranged from 1 to 36 days, whereas, intervention participants' LOS was from 1 to 9 days. There was no significant difference between the groups in original LOS. The readmission LOS used in the test comparison was for the first readmission. Any subsequent readmissions within the 31 -day period were not included in the computation.
Costs of readmissions. For control participants, the average total cost of the originai admission was $15,891 compared to $11,526 on the unit that had GRNs on the staff. Readmission total costs averaged $11,884 for controls and $6,555 for participants on the intervention unit. A cost comparison of both the original hospital admission and readmission results reveals no significant difference between the control and intervention units. See Table 3 readmission data.
Health Status and Outcomes
Data for health status and outcomes were gleaned from multiple sources of documentation in the patient record. Findings for significant group differences appear in Table 4. Differences between groups were significant for at least one variable in each of the following categories: eating/feeding and pain; immobility; restraints; and elimination. However, several of these differences were present on admission. For example, 44% of the control group reported experiencing pain on hospital admission compared to 1 8.2% of intervention participants. This between group difference was highly significant (p = 0.001).
Several measures were used to assess immobility, including the presence of muscle contractures, the incidence of falls, the ordering of physical therapy consults and the use of mechanical devices for ambulating. Use of mechanical devices was the sole measure found to be significantly different for the intervention and control groups (p = 0.022).
Significant differences between intervention and control participants were present for two indicators of elimination problems: incontinence on admission and incontinence greater than once a day. A mere 7.6% of the intervention participants had documented incontinence on admission compared to 20.6% in the control group (p = 0.032). A similar pattern was found to exist for incontinence greater than once a day. For 27% of controls and 10.6% of intervention participants (p = 0.017), this the was case.
CHI-SQUARE ANALYSIS OF HEALTH OUTCOMES DATA
EXAMPLES OF RESPONSES IN IDENTIFIED CATEGORIES
Perception of Health
Outcomes and Care Received
A final difference between groups was noted in the use of vest restraints. Vest restraints were used in 12.7% of the controls and 1.5% of intervention participants (p ~ 0.013). However, there were no significant group differences in the overall use of restraints all types) or in the number of psychoactive medications used. Both these interventions were used more frequently on the control unit.
In analyzing the interview data, the categories of "special needs," "meeting needs," and "age training" were identified in both groups of respondents. "Special needs" were described as those needs elderly individuals have based on the normal aging process. "Fragility" (becoming ill easier) and "decreased reserve" (staying ill longer) were identified as associated factors. Ninety-four percent of the control group and 88% of the study group identified special needs.
"Meeting needs" was the second category of responses elicited. The areas of mobility, personal care, medication administration, monitoring, nutrition (providing food and fluids), and comfort (both physical and psychosocial) were identified as specific needs older adults often required help to meet. Eightytwo percent of the controls and 100% of the intervention group identified specific needs with which they required assistance. The needs identified correspond with the functional areas in the SPPICES acronym.
A sub-category of "meeting needs " was deterioration. "Deterioration" was defined as not having the ability (at the time of the interview) to meet the above needs as compared to their ability just prior to hospitalization. Deterioration was identified by fewer participants 7 (41%) in the intervention group than the 11 respondents (65%) in the control group.
"Age training" was identified in response to the question: "Should nurses who care for older adults have special training?* Fifty-three percent of the control .group and 65% of the study group (59% overall) stated that nurses should have specialized training in the care of older adults. They described this special training as the knowledge and understanding of older adults' special needs (as described above). In addition, both groups identified that nurses should be alert and attentive to health status changes that might be exacerbated by the aging process. However, when asked to expand on this, the respondents in both groups focused on interactive skills such as: patience, kindness, gentleness, caring, responsiveness, and liking older people. The respondents stated older, more experienced nurses seem to have these qualities, whereas the younger nurses often did not. One respondent described younger nurses as "age shy." However, only 18% of the control group and 6% of the intervention group stated that nurses caring for them demonstrated "age training" (Table 5).
The primary aim of this study was to determine the extent to which a specific approach to nursing care delivery, the GRN Model, influenced quality of care for hospitalized elderly patients. An additional objective was to examine use and cost data associated with this care. The investigators believe a significant strength of this study was the combination of methods from two research traditions in the study design, in methods of measurement, in the data collection process, and in approaches to data analysis.
Results of quantitative data analysis suggest several important differences between the two groups on both health status and outcome measures. These variances indicate differences on admission (e.g., prèsenee of pain, mobility limi- £ tations), during hospitalization (i.e., incontinence greater than once a day) and after discharge (i.e., number of re-admissions within 3 1 days of initial admission). Can any of these findings be solely attributed to the presence of the geriatric resource nurses? Because outcomes can be influenced by multiple factors that are often difficult to control, the answer is a very tentative "yes." The inherent difficulty of designing and conducting scientifically rigorous, clinical effectiveness studies necessitates caution in drawing conclusions regarding the influence of GRNs on outcomes for this elderly sample.
The respondents in both the control and study groups stated that elderly individuals have special needs related to normal aging changes and chronic illnesses that result in increased frequency of illnesses (fragility), which lasted longer (decreased reserve capacity). The special needs were specifically identified as functional needs, such as assistance with bathing, eating, sleeping, mobility, comfort (both physical and psychosocial), and elimination. These findings support the recent literature discussing and defining "frailty" in older adults (Brown, Renwick, & Raphael, 1995; Kempen, Steverink, Ormel, fie Deeg, 1996; Woodhouse & O'Mahony, 1997). The majority of the respondents stated nurses should have special training in how to identify and meet these needs. Their description of behaviors associated with this training included (1) knowledge and understanding of older individuals and (2) caring.
Although the study respondents were unable to perceive a difference in nursing care provided by nurses with specialized geriatric training, several important issues were identified. First, elderly individuals appear to be quite knowledgeable about the effects of aging changes and chronic diseases on their overall health. Secondly, the respondents emphasized the importance of the therapeutic nurse-patient relationship. They indicated that how nursing care is provided is just as important as what nursing care is provided. The need for kindness, understanding, patience, and responsiveness was identified as an imperative. These responses were consistent with those found by Taylor, Hudson, and Keeling (1991) and Hudson (1991) in which the concept of quality nursing care, defined by nurses and elderly patients, was the combination of the care given and the manner in which care was given.
Several limitations to this study are evident. Study design focused on unit level data that was relatively easy to retrieve from patient records; this resulted in limited outcome data for analysis. A documentation policy of "charting by exception" may be a contributing factor. Such an abbreviated approach to documentation makes it more difficult to measure outcomes. A more detailed examination of patient records would have helped clarify some of the clinical issues, such as the incidence of incontinence. The level of data retrieval dictated by the study design made the occurrence of incontinence within study groups unclear. Without more detailed examination of the patient records, it was not possible to differentiate between participants who were incontinent on admission and those who experienced incontinence during hospitalization. The likelihood of both incontinence measures applying to the same patients is great. However, it is possible that some of the episodes of incontinence were first time occurrences. Possible causes are new Foley catheter use, hospital acquired urinary tract infections, medication side effects and changes in mobility resulting in functional incontinence. Conversely, interventions begun by hospital staff may have made a positive difference for patients admitted with some types of incontinence. The study was not designed to retrieve this kind of detail.
Questions were also raised about the administrative practice of using DRGs and casemix to project patient acuity and care needs. Using these traditional measures, the two units in this study were deemed comparable. However, when nursing assessment data were factored in, important differences emerged. For example, patients on the control unit were frailer and had more nursing care needs on admission. They had more pain, more indwelling Foley catheters, more incontinence, more skin breakdown, and less mobility that the intervention group. Using only the standard measures such as DRGs to define unit comparability is a limitation of this study because these measures did not adequately measure level of frailty in the elderly patients.
One purpose of this study was to evaluate whether or not specific geriatric training of RNs would affect older hospitalized patients' perceptions of their nursing care and results of that care. The elderly individuals in this study were unable to verbalize a distinction between the care provided by RNs with specialized geriatric training and those without this training. Several things could have contributed to this. First, when the elderly individuals were asked why they thought "age training" was not provided, they stated that the most important knowledge for nurses was in respect to disease processes. Second, it may have been that many of the respondents did not view themselves as elderly. Note the use of third person responses in the category of special needs (Table 5). In fact several respondents explicitly stated they did not feel qualified to respond to the questions because they were not old. Finally, participants may have failed to recognize the specialty training of some of the RN staff because the term "nurse" was not defined during the interviews, making it impossible to determine if the elderly patients were describing the behavior of RNs or of attendants. Only RNs were given the special geriatric training.
A clearer sense of unit differences or similarities would also have been helpful. The two units were not assessed for discharge planning routines, consistency of staff assignments, similarities in staffing patterns, staff levels of experience, or staff turnover. And although only one unit had GRNs with additional geriatric training, actual staff knowledge of the special care of elderly patients was not objectively measured. An assumption was made that knowledge levels of GRNs were greater because of increased training and the support and reinforcement of the GRN Model structure but this was not confirmed.
This study explored the effect of a specific model of nursing care on the outcomes and perceptions of a group of elderly patients. It not only shows the importance of measuring outcomes but also highlights the importance of tying these outcomes to the knowledge and skill of the nurse providers. Advanced practice nurses and nurses with special training are expensive. Thus the impact these providers have on quality of care, outcomes, and cost needs to be clearly documented. If not, these nurses' jobs will be at risk because of the tight fiscal constraints of the current health care environment.
In addition, the critical connection between good documentation and the ability to conduct useful evaluation studies was underscored. Being able to retrieve data easily from patient records is essential. Charting by exception and the design of many documentation forms often makes gathering data difficult. In some instances adequate forms are available, but staff fail to document completely. Charting may not be a priority to staffs who are often overwhelmed by direct patient care responsibilities and other expectations. The importance of excellent documentation needs continued reinforcement not only for the obvious care and legai implications, but also because of the increasingly important need to conduct meaningful outcome research.
Two of the research questions aimed to evaluate whether or not specific geriatric training of RNs would affect older hospitalized patient's perceptions of their nursing care and outcomes. Analysis of interview data suggest that older adults' perceptions of whether or not their special needs were met is dependent on several factors. Nurses' knowledge of medical illness and specific nursing care is important, but also critical to their feeling cared for is the nurses* understanding of the aging process and the intricate interplay between the two. Thus, to the elderly individuals, "how" nursing care is provided often becomes as important as "what" nursing care is provided.
IMPLICATIONS FOR FUTURE RESEARCH
Future research that assesses the impact of enhanced nursing knowledge, specific nursing interventions, and models of nursing care delivery on outcomes such as functional status and complications associated with hospitalization in elderly populations is needed. Longer hospitalizations and an increased incidence of iatrogenic complication occur with older patients. The reasons for this must be directly addressed if the goals of managing health care costs and the length of hospitalizations are to be met. Many of the difficulties that elderly individuals face are associated with chronic disease, functional limitations, or both. It is critical that these problems, or potential problems, not be overlooked during episodes of hospitalization because they tend to increase risk of complications and prolonged stays. The challenge is to disseminate knowledge and put in place effective structures and models identifying and addressing these care issues. Then problems can be prevented, addressed early, or at least identified and linked to appropriate outpatient services for ongoing monitoring.
Phillips (1992) suggests the complexities of doing clinical research with the frail elderly are poorly defined because research methodologies do not consider the importance of functional status. In this study, the elderly individuals themselves suggest they are more "fragile" and thus require longer to recover. This fragility is modified by functional status: The less independent one is, the more assistance one needs. Thus, they are more likely to suffer complications such as skin breakdown, nutritional deficiencies, and pneumonia. By using models such as the GRN Model to educate RNs and other staff to integrate these special needs into plans of care, fewer complications would result and the traditional outcome measures of LOS and cost would be more meaningful.
The descriptive part of this study generates additional questions for future research:
* Why do many older adults not perceive themselves as old?
* Is this phenomenon related to functional status, perceived health status, or both?
* Who do older hospitalized patients identify as "nurses?"
* Do many older adults perceive that nurses* responsibilities are limited to assistance with personal hygiene?
* Do older adults have difficulty identifying various staff because of changes in dress codes?
* Have perceptions changed because of the recent trend toward increased delegation of tasks by professional nurses?
* Will the recent requirement of clear identification of licensure status on identification badges make a difference?
This study aimed to answer some questions and highlight several issues related to the care of hospitalized elderly individuals, which have important implications for both nursing education and practice. However, more research is needed to better understand the issues, to test models of care which effectively address the special needs of older populations, and to more clearly understand the factors influencing older individuals* perceptions of care and how their needs are met. The ultimate goal is to improve the quality of life for older adults - a population that is increasing in size and placing increased burdens on the health care system.
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COMPLEXITY OF DIAGNOSIS BASED ON DRG WEIGHTS (N = 129)
COSTS OF INITIAL HOSPITALIZATION
ADMINISTRATIVE STATISTICS FOR PARTICIPANTS READMITTED WITHIN 31 DAYS
CHI-SQUARE ANALYSIS OF HEALTH OUTCOMES DATA
EXAMPLES OF RESPONSES IN IDENTIFIED CATEGORIES