Age-related health conditions are expected to rise with the increase of the older adult population. Anemia is one of the most common age-related health conditions and is a significant public health indicator in the United States (Le, 2016). The condition is associated with poor health outcomes, including worsening of cardiovascular disease, cognitive impairment, falls, functional dependence, disability, and death (Abrahamsen et al., 2016; Honda et al., 2017). Of the various populations affected, anemia is a significant health concern in older adults, with an estimated frequency of 11% to 12% in community-dwelling older adults age 65 and older, and approximately 40% to 47% in hospitalized patients or nursing home residents (Artz & Besa, 2015; Bach et al., 2014). Thus, it is important to further explore anemia in the growing U.S. older adult population.
Although anemia is frequently reported in older adults, it often remains untreated despite its association with functional and cognitive impairment and numerous geriatric syndromes, including dementia, delirium, depression, and executive function disorder (Macedo et al., 2017). When concurrently present with other comorbidities or disorders with similar symptoms, the problem is confounded. In such cases, the manifestations of anemia may not be recognized, nor the condition properly treated (Girelli et al., 2018). Geropsychiatric patients are particularly vulnerable considering alterations in their physiological health may be masked by symptoms of mental health disorders or side effects of medications (Korkmaz et al., 2015). Patients with chronic psychiatric disorders have a high rate of coexisting physiological health alterations, anemia being one with established correlation. According to Korkmaz et al. (2015), if left untreated, anemia can lead to cognitive function disorders, depression, or worsening of existing psychiatric conditions. Thus, anemia in geropsychiatric patients should be assessed and the underlying cause treated whenever possible (Goodnough & Schrier, 2014; Macedo et al., 2017). With a focus on mental health care, clinicians working in psychiatric settings may quickly recognize improvement or deterioration in psychiatric conditions but may not readily recognize symptoms of physiological disorders that can lead to treatment delays (Culpepper, 2014).
Anemia in the older adult population is commonly overlooked, and sometimes considered a normal consequence of aging despite proof that even mild anemia can lead to physiological decline (De Amicis et al., 2015; Kamel et al., 2015). Beginning at age 50, the risk of anemia progressively increases and prevalence rates are estimated to rise further due to a growing U.S. older adult population (Bach et al., 2014). In 2015, there were 901 million people age 60 or older, comprising 12% of the global population (United Nations Department of Economic and Social Affairs, 2015). Future estimates predict there may be 1.4 billion older adults living globally by 2030, 2.1 billion by 2050, and an estimated rise to 3.2 billion in 2100 (United Nations Department of Economic and Social Affairs, 2015). Thus, it is inevitable that the incidence of anemia will continue to increase (Girelli et al., 2018; Stauder & Thein, 2014). In a secondary data analysis of The Third National Health and Nutrition Examination Survey (NHANES III), there was an approximate doubling of anemia prevalence rates from 4% to 7.1% over a 10-year period from 2002 to 2012 (Le, 2016). The sequelae of improperly managed anemia in older adults cannot be overemphasized as health outcomes that include falls, hospitalization, morbidity, and mortality have been reported (Goodnough & Schrier, 2014). Additional literature emphasizes that lower hemoglobin levels result in greater risk for cardiovascular diseases, cognitive impairment, insomnia, impaired mood, and decreased quality of life (Stauder et al., 2018).
Moreover, prior research has indicated that anemia among chronic psychiatry patients is more frequent than that of the general population, putting psychiatry patients at greater risk for experiencing untoward outcomes. In 2015, Korkmaz et al. published the results of a cross-sectional study of inpatient psychiatric clinic patients to evaluate the incidence of anemia and discovered that 25.4% of chronic psychiatric patients were found to have coexisting anemia. Macedo et al. (2017) further discussed the correlation between anemia and neuro-psychiatric disorders, noting that the coexisting morbidity with depression, bipolar, and conversion disorders is 22%, 25%, and 24%, respectively.
The most common types of anemia in the older adult population are divided into three broad groups: (a) nutritional deficiency anemia; (b) anemia of chronic disease; and (c) unexplained anemia (Stauder & Thein, 2014; Vanalli, 2017). A review of the literature found varying guidelines, protocols, and algorithms for the management of each of these types of anemia (Goodnough & Schrier, 2014; Lanier et al., 2018). There are, however, limited educational programs and interventions that target educating caretakers of older adults on all three broad groups of anemia. As the primary caregivers at the forefront of direct patient care, it is essential that nurses are equipped with adequate knowledge about the causes, symptoms, and management of anemia in geropsychiatric patients. Geropsychiatric nurses are well positioned to assess the physical symptoms of patients and subsequently perform or recommend the necessary evaluation measures to determine if a patient with a psychiatric condition has co-existing anemia (Korkmaz et al., 2015). Concerted efforts should be made to increase nursing knowledge about the evaluation and management of anemia in geropsychiatric patients in an effort to achieve the national goal of improved health outcomes and avoid the deleterious effects of anemia (Healthy People 2020; Nagamatsu et al., 2014).
In the targeted facility, there were no distinct guidelines to support clinicians in the management of affected patients or programs dedicated to educating caretakers of this population. To respond to this need, the current quantitative, quasi-experimental pilot study was conducted to evaluate the effectiveness of an educational intervention for geropsychiatric nurses about the causes, symptoms, and treatment of anemia in older adults.
To achieve the goal of increasing knowledge among nurses, the current quasi-experimental pilot study was conducted to evaluate the effectiveness of an educational intervention for psychiatric nurses caring for patients on two 26-bed geropsychiatric units within an inpatient psychiatric facility about the causes, symptoms, and treatment of nutritional deficiency anemia, anemia of chronic disease, and unexplained anemia in older adults.
Quasi-experimental designs are used in studies where true experimental designs cannot be used or when the criteria for a randomized control clinical trial are not met (Price et al., 2015). Quasi-experimental research designs evaluate causal relationships between independent and dependent variables.
The completed study used a one group pretest/posttest quasi-experimental design. In this approach, the current authors convened an experimental treatment group with no comparison or control to estimate the causal impact of a 45-minute educational intervention (Price et al., 2015). The educational intervention was implemented in four phases: (1) a pretest phase when a knowledge evaluation questionnaire was administered; (2) an educational phase during which content relative to the causes, symptoms, and treatment of anemia were presented through use of a PowerPoint® presentation; (3) a facilitator-led discussion phase focusing on participant questions and concerns about the topic reviewed; and (4) a posttest phase involving readministration of the initial questionnaire to evaluate the effectiveness of the educational intervention. Appropriate institutional review board approvals were granted prior to implementation of the pilot study. The entirety of the four phases of the study was led by a board-certified family nurse practitioner with expertise in caring for older adults. Table 1 provides an overview of implementation procedures.
RNs with primary working assignments in geropsychiatric units were targeted for recruitment. According to facility administration, 40 nurses were assigned to one of two geropsychiatric units in the inpatient facility. In addition, nurses with assignments in other areas of the facility that rotated to geropsychiatric units were invited to participate. Through purposeful sampling, a total of 50 nurses participated in the current pilot study. Forty participants were geropsychiatric nurses and 10 were adult psychiatric nurses with primary responsibilities in other units but rotate to care for geropsychiatric patients.
Participant knowledge was assessed immediately preceding and following the educational intervention. The pre-test and posttest were derived from a knowledge evaluation questionnaire developed by NetCE, an accredited provider of continuing medical education (CME). The tool has been reviewed by medical experts in the clinical area of anemia and gerontology (Waterbury, 2015). A continuing education (CE) learning module pertaining to anemia in older adults, also developed and reviewed by medical experts, accompanied the knowledge evaluation questionnaire. The learning module and anemia knowledge questionnaire were delivered online by NetCE for health care professionals. Although psychometrics for the questionnaire are not available, the complete anemia learning module and knowledge questionnaire tool meet CE standards for the American Nurses Credentialing Center. In addition, the content has been approved by the Florida Board of Nursing Home Administrators and the California Nursing Home Administrator Program (Waterbury, 2015).
The original knowledge evaluation questionnaire contains 20 multiple-choice items and is targeted to physicians, physician assistants, nurses, and other health care professionals involved in the care of older adults (Waterbury, 2015). For the current pilot study, 10 items (Questions 1, 2, 3, 4, 6, 7, 8, 12, 13, and 14) of the original 20-item multiple-choice questionnaire were used for the pretest/posttest evaluation. The remaining 10 items were excluded as they were not related to the study's purpose. Scoring of submitted questionnaire responses considered only one correct option of four presented choices. Approval was obtained from the CME provider NetCE to use relevant content.
Using SPSS version 25, a frequency distribution was constructed for organized tabulation and graphical representation of output data. Descriptive statistics were used to determine the number of correct answers before the intervention in comparison to the number of correct answers after the intervention. Lastly, a comparison of the mean scores of the 10-item questionnaire was made between the answers to the pretest and the post test using the paired t test to assess if the mean scores were significantly different.
The current pilot study involved a single site and focused on care of older adults with comorbid psychiatric conditions. Participants were all RNs, 60% of whom held a Bachelor's degree (n = 30), and 40% (n = 20) held an Associate's degree. Mean participant age was 42.7 years (SD = 10.5, range = 25 to 65), with a mean of 16.3 years of practice (SD = 12.1, range = 1 to 40). Furthermore, 80% (n = 40) of participants were female, and 20% (n = 10) were male.
Participant responses to the knowledge evaluation questionnaire were evaluated on a discrete analog scale of 0% to 100%, with 0% depicting absolutely no knowledge and 100% depicting full knowledge. Prior to implementation of the educational intervention, the pretest score ranged from 0% to 70%, with a mean score of 36.8%. Eighty-eight percent of participants (n = 44) scored between 0% and 50% overall on the pretest, 8% (n = 4) of participants scored 60%, and only 4% (n = 2) of participants scored 70%. Post-implementation composite scores indicated an increase in knowledge in that 0% of participants (n = 0) scored between 0% and 50%, 10% (n = 5) of participants scored between 60% and 70%, and 90% (n = 45) of participants scored ≥80%.
A comparison was made between the mean scores of the answers to the 10-item pretest and posttest to assess if the mean scores were significantly different following the educational intervention. There was a significant difference in the pretest scores (mean = 36.8, SD = 16.3) and posttest scores (mean = 90.8, SD = 10.66). The standard deviation of the difference was found to be 19.48, whereas the change in mean difference between the pre- and posttest was 54% (95% confidence interval [−59.54, −48.46]) (p < 0.001). A descriptive overview of participant responses is presented in Table 2.
Descriptive Statistics of Nurses' Correct Answers on the 10-Item Questionnaire
The current quasi-experimental pilot study was conducted to evaluate the effectiveness of an educational intervention for geropsychiatric nurses about causes, symptoms, and treatment of anemia in older adults. Results indicate that nurses working in the selected inpatient psychiatric facility had some knowledge regarding aspects of anemia in older adults but lacked knowledge in other areas. The lowest pretest scores were for Question 1, “Which group of patients has the highest incidence of anemia?,” which initially had an accurate response rate of 10%. Participants also demonstrated lack of understanding of the most common cause of iron-deficiency anemia in older adults as evidenced by an 18% accuracy rate on the corresponding questionnaire item. It should be noted that, despite the significant improvement in the posttest scores on all questions, the item addressing anemia of inflammation (Question 4) had the lowest correct posttest score of 66% (n = 33) when compared with performance on other questions. Despite pretest scores reflecting initial knowledge gaps, significant improvement in nursing knowledge was noted following the intervention.
Limitations exist in the current pilot study. Participants were narrowed to nurses working in a single psychiatric facility in the Mid-Atlantic region. Although results of the pilot study can be found applicable to other psychiatric facilities, generalizability to non-psychiatric facilities and/or other clinical settings should be approached with care. Immediate administration of the posttest versus time-delayed assessment following the intervention posed a limitation, considering sustainability of acquired knowledge was not determined. The biases inherent in a single group pre- and posttest design are also of concern; therefore, future evaluation with a randomized design could be considered. Lastly, despite expert review of the knowledge evaluation questionnaire, unavailability of psychometric data for the tool can impact interpretation of results.
Notwithstanding limitations, results of the current study contribute to the body of knowledge available to nurses who care for older adults, more specifically, those who are susceptible to nutritional deficiency anemia, anemia of chronic disease, and unexplained anemia. The pretest scores highlight the knowledge gap of participants caring for the population at risk. The posttest scores increased significantly postintervention, thereby indicating efficacy. Nurses can transform their new knowledge of anemia in older adults into clinically useful forms that can be reflected in the meaningful impact they have on patient health outcomes.
Educating nurses about anemia in geropsychiatric patients was important for the selected inpatient facility considering there were no educational programs in place to assist clinicians in recognizing and caring for older adult patients with coexisting anemia and psychiatric conditions. As the primary caregivers at the forefront of patient engagement efforts, it is essential that nurses are equipped with adequate knowledge about the symptoms and management of commonly prevalent conditions, such as anemia, in geropsychiatric patients. As a result of the educational intervention, RNs may be better able to recognize possible contributing factors of anemia as well as report signs and symptoms that commonly remain unnoticed in geropsychiatric patients with anemia. Maintaining a clinical care staff with enhanced clinical knowledge results in the slowing and/or prevention of disease progression, early intervention for symptom management, and appropriately tailored health care services, all of which contribute to improved patient health outcomes.
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|Procedure||10-item questionnaire||PowerPoint® presentation||Discussion (addressing questions and concerns)||10-item questionnaire|
Descriptive Statistics of Nurses' Correct Answers on the 10-Item Questionnaire
|10-Item Questionnaire||Correct Answers (n, %)||p Value|
|Which group of patients has the highest incidence of anemia?||5 (10)||46 (92)||<0.001|
|Which of the following is a defining characteristic of anemia?||25 (50)||49 (98)||<0.001|
|Of the following, which is the most prevalent cause of anemia in the older adult?||17 (34)||44 (88)||<0.001|
|Anemia of inflammation and chronic disease can be defined as a(an)?||6 (12)||33 (66)||<0.01|
|What is the most common cause of iron-deficiency anemia in the older adult?||9 (18)||45 (90)||<0.001|
|Pernicious anemia is an autoimmune disorder that causes?||28 (56)||47 (94)||<0.001|
|Which of the following are good sources of folate?||30 (60)||47 (94)||<0.001|
|Anemia of chronic kidney disease is associated with?||32 (64)||47 (94)||<0.001|
|Hemolysis cause the RBCs to?||22 (44)||48 (96)||<0.001|
|A normal erythrocyte (RBC) count is in the range of?||9 (18)||49 (98)||<0.001|