Journal of Gerontological Nursing

Health Screening Practices IN RURAL LONG-TERM CARE FACILITIES

Susan D Bassett, RN, MS; Tish Smyer, RN, DNSc

Abstract

ABSTRACT

This report summarizes the descriptive data collected and analyzed as part of a larger study examining an educational intervention related to health screening practices in long-term care (LTC) facilities in a rural Midwestern state. The health screening practices examined were prostate-specific antigen testing, manual prostate examination, breast self-examination, clinical breast examination, and mammography. A review of the literature reveals health-screening practices are not being adequately provided to older adults. This includes older adults living in the community and those residing in LTC facilities. The director of nurses (DONs) in 41 LTC facilities were sent a questionnaire to ascertain the DONs' knowledge of American Cancer Society (ACS) guidelines for health screening practices, as well as written policies for, and implementation of, the screening practices in the LTC facility. The response rate was 73% (30 of 41). The major finding of this study was that health-screening practices according to ACS were not being implemented in LTC facilities in the rural state under study. This is congruent with current literature regarding health-screening practices in LTC facilities in more urban areas. These findings are not generalizable beyond the state studied, however, implications for nursing relate to increasing continuing education for nurses in LTC facilities about ACS guidelines.

Abstract

ABSTRACT

This report summarizes the descriptive data collected and analyzed as part of a larger study examining an educational intervention related to health screening practices in long-term care (LTC) facilities in a rural Midwestern state. The health screening practices examined were prostate-specific antigen testing, manual prostate examination, breast self-examination, clinical breast examination, and mammography. A review of the literature reveals health-screening practices are not being adequately provided to older adults. This includes older adults living in the community and those residing in LTC facilities. The director of nurses (DONs) in 41 LTC facilities were sent a questionnaire to ascertain the DONs' knowledge of American Cancer Society (ACS) guidelines for health screening practices, as well as written policies for, and implementation of, the screening practices in the LTC facility. The response rate was 73% (30 of 41). The major finding of this study was that health-screening practices according to ACS were not being implemented in LTC facilities in the rural state under study. This is congruent with current literature regarding health-screening practices in LTC facilities in more urban areas. These findings are not generalizable beyond the state studied, however, implications for nursing relate to increasing continuing education for nurses in LTC facilities about ACS guidelines.

Traditionally, older adults have not been viewed as being suitable targets for health-promotion efforts. Nurses are beginning to question the reasons for this view and to change their practices with respect to older adults in the community. However, nurses appear to be more passive in promoting the health of residents in long-term care (LTC) facilities (Kolcaba & Wykle, 1994).

Health promotion includes cancer screenings. The value of cancer screenings is established. Approximately 50% of new breast cancer and more than 65% of all deaths from breast cancer occur in women 65 years and older (Parnes, Smith, Conry, & Domke,2001).

Mammography screenings are performed half as often for women 80 or older as compared to their younger counterparts and metropolitan women have a 10% increase in screening compared to their rural counterparts (American Cancer Society [ACS], 2003b; Chu et al., 1996). In men, the ability to predict prostate cancer rises from 41% to greater than 78% when manual prostate examination (MPE), prostate-specific antigen (PSA), and ultrasound are performed in combination (McCance & Huether, 2002).

There is a paucity of literature related to health screening practices in LTC facilities. However, two studies cited lack of knowledge among health care providers related to health screening practices and guidelines as a reason for not conducting healthscreening practices (Kolcaba & Wykle, 1994; Lud wick, 1992). This article summarizes descriptive data related to demographic data, status of health screening practices in LTC facilities, and knowledge of directors of nursing (DONs) about recommended health screening guidelines. These data were collected as part of a larger study in which an educational intervention related to health screening practices in LTC facilities in a rural midwestern state were examined. The objectives of this report specifically are to:

* Determine the level of knowledge LTC facility DONs have pertaining to ACS guidelines.

* Determine the relationship between DON knowledge of healthscreening guidelines and selected demographic variables of the DON in the LTC facility.

* Describe how many LTC facilities have written protocols in place to ensure implementation of healthscreening practices.

* Describe how many LTC facilities implement health-screening practices and use available health screening services.

BACKGROUND AND SIGNIFICANCE

Breast cancer is the second most common type of cancer among women in the United States. It is projected there will be approximately 211,300 new cases in 2003. It is the second leading cause of cancer deaths in women. One of the major risk factors for developing breast cancer is age older than 50 years (ACS, 2003b). Several studies indicate elderly women diagnosed with breast cancer have more favorable tumor biology and their breast cancer survival is similar to survival in the general population (Diab, Elledge, & Clark, 2000; Golledge, Wiggins, Callara, 2000). Diab, Elledge, and Clark (2000) suggest this positive outcome in elderly women should be considered in clinical management, which includes health-screening practices.

Prostate cancer is the second leading cause of cancer deaths in men. The ACS (2003a) estimates that in 2003 some 220,900 new cases will occur in the United States. Black men are significantly at higher risk for developing prostate cancer than White men, and their risk of dying from prostate cancer is twice that of their White counterparts. The chances of acquiring prostate cancer increase rapidly after 50 years. More than 70% of all prostate cancers are diagnosed in men older than 65 (ACS, 2003a). Early detection is important because many cancers can be cured if detected and treated in the early stages. A significant number of cancer deaths could be prevented yearly through early detection and treatment (ACS, 2003a).

Rural health care is facing increasing difficulties in providing care to elderly adults. Long-term care facilities located in rural areas face challenges not found in urban or metropolitan locations. Shreffler (1998) states there are two reasons for the problems related to rural health care. The first reason is the decline in health care services available in the rural areas. Additionally, Shreffler (1998) relates "the increasing proportion of elderly and larger numbers in poverty, have resulted in a growing need for health care and, at the same time, a decreased ability to afford care" (p. 420). Approximately 25.4% of the elderly adult population in the United States reside in rural communities. However, approximately 18% of the nurses in the United States are employed in rural areas (Wakefield, 1990).

Medically underserved areas and health professional shortage areas have less availability and accessibility to health care providers and services. Additionally, the lack of a proper mix of RNs, physicians, social workers, and health services might lead to inappropriate placement of elderly adults in LTC acuities. The midwestern state in which this study took place has 42 health professional shortage areas and is largely rural, frontier, and reservation. The nursing home usage rate of beds is 82.7 per 1,000 older adults compared to the national usage rate of 53.3 beds per 1,000 older adults (Smith, 1995).

There are multiple variables related to nursing practice in a rural LTC facility. Among these is professional isolation of health care providers because of geographic, cultural, or social considerations. Isolation may add to the challenge of health care providers and decrease opportunities for maintaining and sharing practice issues. These issues, while not examined in this research, may be a factor when examining nurses' knowledge of health-screening guidelines and implementation of health-screening practices according to ACS national guidelines in LTC facilities located in rural environments.

REVIEW OF LITERATURE

Breast and Prostate Cancan Discussion and Incidence

Breast Cancer. Breast cancer is a malignant neoplasm arising from one of several types of tissue found in the breast. A painless lump is usually the first sign of breast cancer. Other presenting signs can include palpable lymph nodes in the axilla, retraction of breast tissue, or bone pain caused by metastasis. Tumor type and disease stage cause variances in presenting manifestations of the cancer. The risk factors and possible causes of breast cancer can be classified as reproductive, hormonal, environmental, and familial (McCance & Huether, 2002).

The question of whether mammography and breast self-examination (BSE) or clinical breast examination (CBE) screenings were worthwhile in older women was explored through literature reviews and extensive analysis of statistical data in a 1997 study. Breast cancer data from 19 countries were compiled. Areas analyzed were epidemiology, biological aspects, potential effects of screening, mortality reduction through screening after age 65, participation in screenings, and cost effectiveness. The conclusions of this study were (VanDijck, Broeders, & Verbeek, 1997):

* The incidence of breast cancer is highest among women older than 70.

* Distant metastasis at the time of diagnosis is more common in women older than 70 than in their younger counterparts.

* Mammography screening of women ages 65 to 74 has been shown to produce a reduction in breast cancer mortality of approximately 50%.

* All indications are that mammography and BSE/CBE benefits continue until at least age 85.

A 1996 study examined and analyzed mortality data from the National Center for Health Statistics and incidence and survival data from the Surveillance, Epidemiology, and End Results Program (SEER) of the National Cancer Institute (NCI). The SEER data was based on cases of breast cancer in White women diagnosed from 1973 through 1993. The National Center for Health Statistics mortality data encompassed the years from 1969 to 1993. The authors of the study included the deaths of White women in the United States with breast cancer as the underlying cause of death. The study indicated an increased incidence of cancer rates in all groups 40 years and older after 1982 (Chu et al., 19%).

After 1987, all age groups 40 and older showed decreasing disease rates. Breast cancer mortality rates showed a decline in every age group younger than 80. It is almost certain this decline in breast cancer disease and mortality rates is caused by early detection and treatment. It should be noted that mortality rates increased in the 80 years and older group. This group received mammography services half as often as those women in the 40 to 80 year age groups (Chu et al., 1996).

Prostate Cancer. More than 95% of cancerous prostate tumors are adenocarcinomas. Most of these occur in the periphery of the prostate. The aggressiveness of the cancer appears to be related to the degree of differentiation rather than the tumor size. The most frequent sites of distant metastasis are the lymph nodes, lung, liver, adrenals, and bones. Local extension is usually posterior. The cause and risk factors of prostate cancer are poorly understood. It is believed genetic and environmental influences both play a role (McCance & Huether, 2002). Prostate cancer often does not cause symptoms until the disease is advanced.

Rectal examination is important in diagnosing prostate cancer. A tumor is usually felt as an area of induration. However, abnormalities may not be palpable in early disease stages. Transrectal ultrasound and PSA blood tests are two newer procedures used for diagnosis (McCance & Huether, 2002). Prostate-specific antigen is a glycoprotein specific to and produced by the prostate gland in men (U.S. Public Health Service, 1998). Prostate-specific antigen levels increase in prostate cancer and benign prostatic hypertrophy It is recommended MPE should be combined with PSA testing for optimum screening (Fischbach, 2000). When transrectal ultrasound, PSA, and MPE are combined, the ability to predict cancer rises from 41% to greater than 78% (McCance & Huether, 2002).

Health Screening Gukfetines

For people older than 50 there is minimal divergence on health screening recommendations from various organizations. Prostate-specific antigen testing is the exception to this, and will be discussed further. The recommended guidelines from the ACS (2003a) were used for this study.

In women, a monthly BSE is recommended for all women older than 20. A CBE is recommended every year for women older than 40. A baseline mammogram is recommended for all women by age 40. Mammograms are recommended every year for women 40 years and older (ACS, 2003b).

In men, MPE and PSA testing are recommended every year for men older than 50 unless the patient's life expectancy is less than 10 years. It is recommended that Black men or those men with a positive family history of prostate cancer start MPE and PSA testing at age 45 (ACS, 2003a).

Opinions about PSA testing vary greatly. Williams, Boles, and Johnson (1995) caution that PSA testing has a limited ability to detect prostate cancer during the asymptomatic phase, and that sensitivity and specificity of PSA tests are not optimal. Concern has been raised that many patients will be diagnosed with and treated for tumors that may be so slow growing that the cancer would not have affected longevity (Garnick & Fair, 1996).

It should be noted that although many prostate tumors are slow growing, there is a wide range of biologic malignancy. Prostate tumors range from rapidly progressive and fatal, to those that do not grow and spread. Because of the inconclusive natural history of the disease, no test currently in use can reliably separate potentially aggressive tumors from those that remain indolent (Yarbro, Frogge, Goodman, & Groenwald, 2000).

A 1997 study which analyzed 208,234 prostate cancers diagnosed from 1973 to 1993 in nine populationbased registries (SEER data), concluded the following (Smart, 1997):

* There was a 20% increase in the overall survival rate for prostate cancer.

* There was a decrease in the incidence of advanced disease followed by a 6.3% decrease in the U.S. mortality rate for prostate cancer.

* It appears an annual PSA blood test and MPE on all men 50 years and older, followed by appropriate treatment if needed, has decreased deaths from prostate cancer.

Health Screening in Long-term Care Facilities

Kenny and Keenan conducted a study in 1991 to determine the extent of use of breast cancer detection methods among residents in LTC facilities. The sample consisted of 79 LTC facilities in New York Telephone interviews were conducted in which two predetermined open-ended questions were asked of the DONs in LTC facilities. The questions referred to existing policies in the LTC facility for mammography testing on female residents, and for a description of any established routine tests for breast cancer detection used at the facility.

Six of the 79 facilities in the study reponed having some type of breast cancer detection procedures in place. Two additional facilities had physicians on staff who routinely ordered yearly mammograms. Based on their data collection and personal experience, a breast cancer detection examination did not appear to be a part of routine physical examinations. Some of the responses received in this study indicated the attitudes of health providers toward aging and elderly adults might influence health-screening procedures being performed in LTC facilities. Educating selected personnel in LTC facilities about health screening guidelines and practices was one of the recommendations of the study.

A 1994 study by Kolcaba and Wykle examined a variety of health promotion practices, including health screenings in 140 LTC facilities. Selected screening practices and other health-promoting activities were measured in this study. Additional data were gathered related to health care provider attitudes toward health-promotion for LTC residents.

A questionnaire was sent to the DONs in the LTC faculties involved in the study. Mammography was one of the screening practices measured. Five percent of the LTC facilities in the study included mammography as part of the annual physical examination and 63% performed mammography as needed.

It was found that physicians and nurses relied on symptoms for ordering many screening tests. The majority of screening tests was performed "as needed." This study also showed the proximity of the LTC facilities to large medical facilities did not raise the frequency of health screening practices. Nurses played a passive role in planning health promotion care for elderly residents. Recommendations of this study included policies for proactive screening in LTC facilities, expanded roles for nurses in health promotion of older adults, and health promotion education for residents and staff.

Educating the health care provider about health screening needs and practices was also found to be important in Lud wick's (1992) study. This study examined RNs' knowledge and practices of teaching and performing breast examinations on elderly female residents in LTC facilities. It was found that 71 % of the nurses did not perform breast examinations on residents, and 80% did not teach breast examination to the female residents. The most frequent reasons given for not doing the examination were:

* Not a written policy.

* No directions/orders.

* Not a nursing responsibility.

* No time.

* Never thought of .

The nurses' knowledge of and confidence in BSE skills increased the likelihood of doing an examination. The author showed that programs and research have focused on educating the older adult, not on changing the behavior of the heath care provider (Ludwick, 1992).

Two studies addressed the issue of acuity or multiple health problems in the elderly adult population. Among the reasons given by respondents in Kenny and Keenan's (1991) study for not performing breast screenings on residents in LTC facilities, was that residents often have numerous health problems with higher priorities than screening practices. Kenny and Keenan pointed out that this might be a reflection of health provider attitudes. It could also be an accurate assessment of the ever-increasing acuity of residents living in LTC facilities.

Smart (1997) also pointed out that co-morbid states are a factor in the treatment of prostate cancer. When prostate cancer is detected in an elderly man who has serious or multiple coexisting health problems, treatment may not always be advisable. Death would result from a cause other than the cancer with or without treatment. Policies for health screenings should not be dependent on resident acuity. However, policies need to be carefully considered and treatments need to be viewed in light of the resident's existing health state.

METHODOLOGY

Design

The data presented in the article was collected and analyzed as part of a larger study examining an educational intervention related to health-screening practices in LTC facilities in a rural midwestern state. The primary study was a two-group quasi-experimental design. The information collected from the initial questionnaire is the data used in this report.

Sample

A list of all LTC f acuities in the sute was obtained from the state's department of health. The target population was the DONs in all LTC facilities in the state (113). The accessible population was those facilities meeting the criteria of listing 100% of their beds as Medicare beds. The sample population was the DON in 41 LTC facilities. The DONs in these 41 f acuities received the questionnaire. The final sample used for the study was LTC faculties in which the DONs returned the questionnaire (n - 30), for a response rate of 73%.

Table

TABLE 1DIRECTOR OF NURSES' KNOWLEDGE OF AMERICAN CANCER SOCIETY GUIDELINES (n = 30)

TABLE 1

DIRECTOR OF NURSES' KNOWLEDGE OF AMERICAN CANCER SOCIETY GUIDELINES (n = 30)

Table

TABLE 2PERCENT OF DIRECTOR OF NURSES WTIH KNOWLEDGE OF AMERICAN CANCER SOQETY GUIDEUNES BY EDUCATION (N= 30)

TABLE 2

PERCENT OF DIRECTOR OF NURSES WTIH KNOWLEDGE OF AMERICAN CANCER SOQETY GUIDEUNES BY EDUCATION (N= 30)

Table

TABLE 3WRITTEN POLICIES IN PLACE FOR HEALTH SCREENING PRACTICES (n = 30)

TABLE 3

WRITTEN POLICIES IN PLACE FOR HEALTH SCREENING PRACTICES (n = 30)

Table

TABLE 4IMPLEMENTATION OF HEALTH SCREENING PRACTICES (n = 30)

TABLE 4

IMPLEMENTATION OF HEALTH SCREENING PRACTICES (n = 30)

Questionnaire

The questionnaire was generated from the literature review by the researcher. Validity, both face and content, were established using a panel of experts. The instrument objectives and a coding plan were given to three advanced practice RNs with gerontological background or specialization to determine validity and readability of the tool. The instrument was pre-tested by giving the questionnaire to the DONs of three LTC facilities.

Data Collection

Data collection was obtained through completion of the questionnaires. A cover letter was sent to the DONs in all of the LTC facilities in the state that met study criteria. The letter included the purpose of the study, introduction of research activities, and an explanation of procedures. A self-addressed envelope for returning the survey was included. The returned questionnaires were analyzed for demographic data, status of health screening practices in LTC facilities, and knowledge of DONs related to recommended health screening guidelines.

Ethical Considerations

After approval by the University Human Subjects Committee, a cover letter accompanying the questionnaire provided an introduction to the research with a detailed explanation of the project. Risks and benefits were described. Confidentiality issues were addressed. Returning the questionnaire implied consent.

Data Analysis

Descriptive statistics were used to describe demographic characteristics, DONs' knowledge level of ACS guidelines, number of LTC facilities with written protocols, and number of LTC facilities that implement health-screening protocols. Chisquare testing and biserial correlations were used to examine relationships in the data.

RESULTS

Demographic Information

The 30 DONs who responded to this questionnaire were women. The mean age was 43, with a range of 27 to 60. In examining education preparation of the DONs in this study, 40% were associate degree, 27% diploma, and 33% were bachelor'sprepared RNs. The mean years of licensed nursing experience was 19, with a range of 1 to 41. The mean years of licensed nursing experience in geriatrics was 12.3, with a range of 1 to 26. Two of the 30 DONs had advanced training in geriatrics. The facilities mean number of beds was 76 with a range of 44 to 204.

Knowledge Level

The level of knowledge LTC facility DONs had pertaining to ACS guidelines was determined (Table 1). Depending on the screening practice examined, the scores ranged from 87% with knowledge of MPE to 70% with knowledge of mammography screening.

Knowledge Level and Demographics

The relationship between DON knowledge of health-screening guidelines and selected demographic variables of the DON in the LTC facility was determined. Chi-square testing was conducted to determine relationships between the educational preparation of the DON and knowledge the DON had related to ACS guidelines for health-screening practices (Table 2). Computation of biserial correlations revealed the relationships between DON age, licensed nursing experience, geriatric experience, and DON knowledge of ACS guidelines.

There was a statistically significant inverse relationship (r = -.367, p = .05) between DONs' years of geriatric experience and knowledge of ACS recommended BSE guidelines. There were no other statistically significant findings in the remainder of the data analysis.

Written Policies

The majority of LTC facilities did not have written policies in place related to implementation of health screening practices (Table 3). Depending on the screening practice examined, the scores ranged from 13% with written policies pertaining to BSE to 0%, with no facilities having PSA testing, MPE, or mammography policies.

Implementation of Screening Practices

The majority of LTC facilities did not implement health-screening practices (Table 4). Depending on the screening practice examined, the scores ranged from 23% with implementation of BSE to 0%, with no facilities implementing PSA testing. Eightythree percent of the facilities had PSA screening services available at a nearby hospital and 73% had these services available at a nearby clinic (Table 5); PSA testing was not available in any LTC facility. Ninety percent of the facilities had mammography screening services available at a nearby hospital and 67% had these services available at a nearby clinic. Ten percent had mammography screening available within the LTC facility.

DISCUSSION OF FINDINGS

The findings of this study supported the literature that health-screening practices are not being implemented in LTC faculties. Of interest from the questionnaire, 70% to 87% of respondents were knowledgeable of ACS guidelines for health screenings. However, actual implementation of the practices in the LTC facilities ranged from 0% to 23%. Written policies in existence in LTC facilities for health-screening practices were present in 0% to 13% of the facilities. This finding, while not unexpected, supports Ludwick's (1992) study finding that one of the reasons given by nurses for not screening was that there was not a written policy.

Identification of barriers to implementation of health screening related to the ACS guidelines is appropriate and past due for investigation. The researchers can only hypothesize that time, work hour issues, attitudes toward health promotion in the elderly adult population, acuity of the residents in LTC facilities, and budgetary constraints may play a role.

Of statistical significance (p = .05) was the correlation of DON geriatric experience with DON knowledge of ACS recommended BSE guidelines. The more geriatric experience of the DON, the less knowledgeable they were of guidelines. This is a surprising finding, but may relate to the lack of educational focus within geriatric nursing on health promotion issues, as well as lack of ACS guideline education in previous nursing educational programs.

The inverse relationship between DON years of geriatric experience and knowledge of BSE guidelines supports the findings of two previous studies (Kolcaba & Wykle, 1994; Ludwick, 1992) citing a lack of knowledge as a reason for not conducting healthscreening practices in LTC facilities. However, from the current study, it appears a lack of knowledge was not an issue with the majority of nurses in the study who displayed sufficient knowledge to implement healthscreening practices, except as it relates to years of geriatric experience. Because of the lack of focus on gerontology in earlier nursing education programs, continuing education is a way to meet this deficiency in LTC nursing practice (Cudney, 1998).

IMPLICATIONS

Implications for nursing practice can be related to the educational arena as well as the clinical arena. Each is addressed separately.

Implications for Education

Nursing education at the undergraduate and graduate levels can focus on health promotion in elderly adults in curriculum content as well as clinical components. It is recommended the following be taught:

Table

TABLE 5PERCENT OF FACILITIES WITH SCREENING SERVICES AVAILABLE AND LOCATION OF SERVICE (n = 30)

TABLE 5

PERCENT OF FACILITIES WITH SCREENING SERVICES AVAILABLE AND LOCATION OF SERVICE (n = 30)

* American Cancer Society guidelines for health screening practices along with physiological rationale.

* Proper assessment techniques for MPE, BSE, and CBE.

* Education on the benefits of health promotion in the elderly adult population.

Continuing education for health care providers related to health screening guidelines and implementation should be mandatory. Annual or biannual refresher courses on the screening practices would be beneficial. These courses should include any recent changes in recommended ACS guidelines and in implementation of the screening practices. It appears, from the current study, an appropriate focus would be topics addressing the structure and process of implementation procedures rather than merely the content of the ACS guidelines. However, it is also necessary, as mentioned in the discussion section, that because of lack of educational preparation in earlier generations of nurses, continuing educational programs need to address upto-date specific and pertinent topics of gerontological nursing.

Rural nursing has challenging needs related to obtaining continuing nursing education. Technology has, to some extent, relieved some of this with web-based continuing education programs, video productions, and interactive video presentations via telemedicine channels. Obstacles such as budget for travel and workshop expense, remote geographical locations that have access issues related to weather and lengthy travel time, and a shortage of nurses to replace staff who do attend continuing education courses, continue to exist.

Clinical Implications

Residents of LTC facilities commonly have co-morbid disease states. This can cloud the picture when one is examining the efficacy of health screening in this group of individuals. The ACS (2003 a) does not recommend MPE or PSA testing in a man who has a life expectancy of fewer than 10 years. This is because most cancers of the prostate are slow growing. Indications of all studies related to breast cancer screening reflect a favorable prognosis in the elderly female adult population. As always, it is essential for nurse clinicians to assess each individual in a holistic framework.

Often in health care, when a change is mandated, it encompasses everyone, regardless of need or desire. Mandated health screening practices for all residents in LTC facilities is not feasible because of the variation in physical or mental states of individual residents. The solution is for the decision to be made by the resident or the resident's family members, depending on the resident's status.

Long-term care facility personnel should have the knowledge and training to implement health-screening practices. Written policies for the screening practices should be in place in all LTC facilities. Education about health-screening practices should be made available to residents and their families by health care providers to ensure an informed decision from the resident or family. Long-term care facilities are then in a position to offer screening practices to residents on admission and periodically reassess the need during the resident's stay.

Education for elderly adults, their families, and society at large on health screening practices and guidelines should be the responsibility of every health care provider. This study indicates the nursing roles essential to solving the problem of inadequate health screenings in LTC facilities are educator and patient advocate. These roles should function in tandem to be most effective. Nurses as teachers and advocates can serve as role models and leaders to promote positive change in this area.

LIMITATIONS AND RECOMMENDATIONS FOR RESEARCH

The study sampled LTC facilities in one midwestern state, making generalization of results limited to this area and to these five health-screening practices included in the study.

Replication of this study using a larger sample size would be useful to detemune the presence of significant relationships among the variables. Exploring barriers to implementation of these guidelines is a significant research project that needs to be addressed. Additionally, a study correlating health care provider attitudes and implementation of health screening practices in LTC facilities might provide useful information. This issue was a concern in Kenny and Keenan's 1991 study.

CONCLUSION

The major finding of this study is that health-screening practices according to ACS guidelines are not being implemented in LTC facilities in the rural state being studied. Seventy percent to 87% of DONs responding to the questionnaire were knowledgeable of ACS guidelines for health screenings. However, actual implementation of the practices in the LTC facilities ranged from 0% to 23%. Written policies in existence in LTC facilities for health-screening practices were present in 0% to 13% of the facilities. This is congruent with current literature related to health-screening practices in LTC facilities in more urban areas. A discussion of rural nursing and LTC issues related to the rural environment was addressed. The challenge of access to continuing education was also a topic and focus for discussion. Written policies for the screening practices should be in place in all LTC facilities.

Education related to health-screening practices should be made available to residents and their families by health care providers to ensure an informed decision from the resident or family. Long-term care facilities are then in a position to offer screening practices to residents on admission and periodically reassess the need during the resident's stay.

The present and projected growth of the elderly adult population in society is having and will have a major impact on all health care disciplines. Nursing is faced with the historically unique challenge of promoting the health of the elderly adult population. A proactive stance by the discipline of nursing to support health promotion in elderly adults, particularly health screening practices, must be embraced by the profession in the 21st century.

REFERENCES

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TABLE 1

DIRECTOR OF NURSES' KNOWLEDGE OF AMERICAN CANCER SOCIETY GUIDELINES (n = 30)

TABLE 2

PERCENT OF DIRECTOR OF NURSES WTIH KNOWLEDGE OF AMERICAN CANCER SOQETY GUIDEUNES BY EDUCATION (N= 30)

TABLE 3

WRITTEN POLICIES IN PLACE FOR HEALTH SCREENING PRACTICES (n = 30)

TABLE 4

IMPLEMENTATION OF HEALTH SCREENING PRACTICES (n = 30)

TABLE 5

PERCENT OF FACILITIES WITH SCREENING SERVICES AVAILABLE AND LOCATION OF SERVICE (n = 30)

10.3928/0098-9134-20030401-10

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