In 1981, Aiken presented to nursing a new challenge of accountability and autonomy in the changing health-care system. The scarcity of advanced nursing practice in the nation's nursing homes was a significant issue in this landmark article (Aiken, 1981). In May, 1981, The Robert Wood Johnson Foundation issued a call for proposals to improve the quality of care for nursing home residents through the establishment of Teaching Nursing Homes to the nation's academic nursing centers.
This was a major demonstration project in which professional nurses were invited to play the leading role; here was an unprecedented opportunity for nursing to influence a major segment of the healthcare delivery system. The challenge was accepted by 53 schools of nursing who responded to the call for proposals. From these responses, 11 schools were awarded grants to establish Teaching Nursing Homes. The main objective of the Teaching Nursing Home Projects was to bring the expertise of nursing faculty into long-term care institutions and improve the quality of care for the million and a half elderly who resided in the nation's nursing homes.
Historically, few nursing faculty have been involved in the care of nursing home residents. The nursing home was not used as a clinical teaching site for graduate or undergraduate nursing students. The understaffed nursing services both in numbers and preparation led to a perception of inadequate role models and unacceptable nursing care. Faculty frustration with the multiple impediments to improving the quality of care of the nursing home resident led to non-involvement with and under-utilization of the nursing home setting by academic nurses. Another reason for the under-utilization of the nursing home as a clinical teaching site was the perception of the learner; the student viewed nursing homes as unattractive and undesirable clinical assignments. Certainly, a portion of this perception was a reflection of prevailing societal views, as well as faculty attitudes, but the low incidence of advanced technology and the low pay of nursing home nurses also did not escape the notice of students. A nursing career in a nursing home was not an attractive choice.
Could nurse educators and nursing service practitioners collaborate in an effective, practical way to achieve better nursing care? It was the belief and hope of persons who participated in the leaching Nursing Home Projects (TNHP) that through collaboration, faculty attitudes could be changed, learning opportunities in the nursing home setting could be improved, and educational opportunities for nursing home staff could be enhanced. Margretta Styles once suggested that "collaboration sometimes remains more a theoretical idea than a tangible objective" (Styles, 1985). Indeed, collaboration among school of nursing faculty and nursing home staff was a theoretical idea in 1982. However, it became a tangible objective and a realistic outcome in at least one TNHP site. This is a report of the model that was developed by The Catholic University of America, Washington, D.C. and Carroll Manor Nursing Home in Hyattsville, Maryland (CUA/CM). The process by which collaboration was achieved and by which the TNHP was implemented at this site is an interesting and unique story.
At the outset, the following objectives were identified for the CUA/CM Project:
1. to improve the quality of care to nursing home residents;
2. to model a church-related affiliation (both institutions were under Catholic auspices);
3. to define new nursing career pathways and job opportunities for nurses interested in gerontological nursing; and
4. to develop a model of gerontological nursing practice and to promulgate the model via nursing education.
What were the essential components which formed the foundation for such collaboration? Members of the CUA/CM project identified four: the people, an agreement, a commitment, and knowledge.
THE PEOPLE- The single most important component of this successful model of the TNHP was the people who were involved at three levels of participation: indirect, direct, and consultative. The indirect level consisted of administrators, decision-makers, and policy setters who brought special knowledge and expertise for an overall perspective of the parent institutions. The major functions of the administrative levels were to sustain the collaborative linkage and to interpret the primary mission of the respective institutions. Sustaining the linkage took considerable effort because of the difference in primary mission of the collaborating institutions. In the case of the university, the primary mission was education and research with nursing service as a secondary goal; the nursing home had patient care and nursing service as its primary mission with education and research being secondary.
At the direct level, qualified faculty and clinical staff provided appropriate activities in the implementation of the specified project objectives. At the consultatwe level, experts provided advice and guidance both in the initial phase and throughout the project. Of special importance was the continuity provided by one nurse consultant whose presence was constant throughout the project. Progress toward meeting all four project objectives was realized due to the knowledge and insight provided by this one expert. Her objectivity assisted project personnel to meet the specified goals.
THE AGREEMENT- The agreement between the institutions was formal, in writing, and endorsed by both parties through the legal representatives. Each institution was aware of its responsibilities and rights as specified in the contract. Duration of the agreement was specified. All those directly and indirectly involved in the project were aware of and supportive of the agreement.
COMMITMENT- Commitment to the common goals of the project was the unifying force. The background of Catholic philosophy provided a common basis for this commitment. The philosophical beliefs included basic elements such as the unconditional rights and dignity of each human being. The commitment of all participating members was evident, authentic, and constant. In addition, there was an acceptance of the value of education and research as a means to improve nursing care in the nursing home and acceptance of the TNHP.
KNOWLEDGE- Knowledge and special expertise in the following areas were identified as important to the success of this project: understanding of the aging process, the demography of aging, chronic health problems, the long-term care system, and regulations governing nursing homes. The utilization and development of knowledge was an on-going process and required the use of consultants and advisors to assist in areas where special needs were identified. Both faculty and clinical nursing staff contributed to the devlopment of knowledge.
The CUA/CM project set in motion a number of activities that are on-going. The organizing framework of practice, education, administration, and research was productive for the CUA/CM project.
PRACTICE- The TNHP was an excellent site for nursing practice; it was available to the nursing faculty for the use of clinical skills and expertise in the care of the elderly. Functioning in a clinical setting with a close and unique liaison with the clinical staff resulted in many positive outcomes. The nursing faculty included certified gerontological specialists and practitioners; consultation with these experts provided the nursing home staff with an on-going resource for advice and counsel. The faculty encouraged the nursing home staff, enhanced their professional identity, and facilitated appropriate clinical decisions. All these activities contributed to improved care of the nursing home residents. Nursing home staff shared the practical perspective of their experiences in caring for the elderly chronically ill residents on a daily basis.
EDUCATION- Baccalaureate, masters, and doctoral students in nursing were assigned to the nursing home for various clinical practices; not only did students benefit from these experiences, but their presence created an atmosphere of challenge, stimulation, and learning in the clinical units of the nursing home. Residents described the students' presence as "a breath of fresh air."
Two successful series of classes were presented at the nursing home to update the nurses' knowledge of gerontological nursing and to prepare professional nurses for the Gerontological Certification Examination. The response to the series was positive and the success rate on the certification examination was high. Enrollees included nurses from the community and other nursing homes as well as nurses from the TNH site.
Since the initiation of the TNHP, the nursing home employees have demonstrated increased interest in education by attending continuing education workshops and seminars about the care of the elderly. They have pursued courses in leadership/ management in the long term-care setting; some have pursued and completed degree programs.
ADMINISTRATION- Faculty benefitted from involvement with the challenges and dilemmas experienced by the nursing home staff. Together, faculty and nursing administrative staff sought solutions to the multiple recurring problems, such as turnover of staff, changes in the survey process, etc. The faculty shared expertise as well as gained additional first-hand experience with the nursing home realities.
Qualified nursing home staffare eligible and have been appointed as adjunct or clinical faculty. This linkage with an academic institution provided recognition for the nursing home nurses and improved their status in the health-care system.
A number of administrative changes took place in the nursing home during the five years of the Teaching Nursing Home Project experience. These changes included:
* three new nursing administrative positions (an assistant director of nursing, a staff development coordinator, and a clinical care coordinator);
* three additional positions in the social services department;
* one additional position in the activities department;
* one new position - director of volunteers; and
* a newly employed medical director.
RESEARCH-At the outset of the TNHP, the faculty identified a myriad of potential research questions. The challenge involved in the TNHP was: how can research be introduced in this setting? This continues to be a challenge; however, several success stories can be cited.
A research and education committee was established in the first year of the project; it continues to function effectively to protect the rights of the nursing home residents and the personnel, as well as to provide opportunities for learning among nursing staff, faculty, and students. Committee membership includes two nursing home employees, two nursing home residents, and two nursing faculty persons. Requests for student placement and requests to pursue research questions are processed through this committee.
Research has been pursued by the nursing home staff, the school of nursing faculty, and students. The topics have focused on the clinical problems that are constantly faced in the nursing home, such as: mobility, bowel and bladder control, feeding problems, hypothermia, environmental influences, confusion, and spiritual needs. Positive experiences with these systematic studies stimulated the NH personnel to develop their own clinical studies, to relate positively to research, and to use the resources of academia to direct and guide activities.
The TNH at the CUA/CM site included a group of people who agreed to direct their mutual commitment to common goals; they operated within a shared belief system, agreed to model a liaison that would result in quality care for the elderly, and hoped to create interest in gerontological nursing by increasing the number of prepared gerontological nursing specialists. Four areas of clinical knowledge enabled the success of this project: practice, education, administration, and research.
The elements of this one situation can be · translated into criteria that guide the establishment and maintenance of a TNH, namely:
* Two critical ingrethents: a nursing home and a school of nursing with an undergraduate and a graduate nursing program;
* A formal agreement that specifies - a shared mission statement
- responsibilities in the school and in the nursing home for practice, education, administration, research, and consultation;
* Clearly defined roles for the nursing faculty in the nursing home, and for the professional nursing staff in the school of nursing;
* Opportunity for faculty and agency input into respective institutions at all levels, including the highest policy making level; and
* A steering committee with representation from the school of nursing and the nursing home that guides the functions of the teaching nursing home activities;
Depending upon the circumstances, the environment, and the people, other persons may or may not be able to replicate this model. Whether or not replication is possible, there may be some aspects of this experience that will suggest positive avenues to explore with the hope of establishing collaboration linkages, between nursing education and nursing service.
- Aiken, L. (1981). Nursing priorities for the 1980s in hospitals and nursing homes. American Journal of Nursing, 81(2), 324-330.
- Styles, M.M. (1985). Collaboration: Essential to public acceptance, guest editorial. Nursing and Health Care. 6(April), 175.