APRN Consensus Model
The APRN Consensus Work Group and the APRN Advisory Committee of the National Council of State Boards of Nursing developed the Consensus Model for APRN Regulation, Licensure, Accreditation, Certification and Education in 2008. The APRN Consensus Model was designed to standardize and align the interrelationships among licensure, accreditation, certification, and education across all advanced practice areas (APRN Joint Dialogue Group, 2008; Stanley, 2012). This model also identifies the nurse practitioner (NP) role, outlining the educational and clinical standards one must meet in order to earn national certification, state licensure, and scope of practice privileges (APRN Joint Dialogue Group, 2008; Online FNP Programs, 2020; Stanley, 2012).
APRNs must be educated in a graduate or postgraduate certificate program that equips the nurse with nationally recognized APRN core, role, and population-focused competencies. The APRN Consensus Model requires all students enrolled in adult-gerontology NP and FNP programs receive education and training to meet competencies in treating the older adult population (APRN Joint Dialogue Group, 2008; Stanley, 2012). As stated in the APRN Consensus Model, practice is not restricted by setting, but rather is patient centered and based on patient needs (APRN Joint Dialogue Group, 2008; Stanley, 2012).
FNP and AGPCNP students are required to complete a minimum of 500 hours of direct patient primary care within their population-focused area. The FNP student should receive experiences with individuals and their families across the life span, including older adults, and the AGPCNP should receive experience with individuals from adolescents to older adults, including frail older adults (National Task Force on Quality Nurse Practitioner Education, 2016). LTC settings provide FNP and AGPCNP students with the opportunity to treat acute and chronic diagnoses and follow evidence-based health promotion and prevention guidelines in the older adult population (Stanley, 2012). This is a crucial component of primary care practice.
In 2016, there were 15,600 licensed nursing homes with 1.7 million beds; 1.3 million older adults resided in these facilities in 2015 (Centers for Disease Control and Prevention [CDC], 2016). Graduate programs have autonomy in determining appropriate primary care clinical experiences. A repository of all academic programs and their policies regarding clinical sites does not exist. In recent years, GAPNA has received anecdotal reports from faculty and NP students across the country stating the inability to use LTC settings for primary care clinical sites due to the belief that these experiences would provide specialty hours and not approved primary care hours. The GAPNA Board of Directors identified a gap in educating future NP providers for older adults and determined a position statement supporting that LTC sites, as appropriate toward the completion of the required clinical hours for AGPCNP and FNP students, should be developed.
Two literature searches were done in 2019 for purposes of needs assessment and position statement development. Although a formal review of the literature with a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-type format was not followed, the first search used CINAHL®, PsycINFO®, and MEDLINE®. A search for NP use in LTC facilities was done using the search terms primary care education, education, LTC clinical site selection, and NP primary care clinical sites, yielding 25 articles. All articles were reviewed; four were deemed relevant and included in the position statement. A second internet search for NP academic programs allowing clinical placement in LTC facilities was done with the search terms NP clinical placement requirements, NP hour requirements, and NP preceptor handbooks, yielding 43 NP programs. Four (9%) programs did not allow LTC placements, 11 (26%) considered LTC as specialty hours, 25 (58%) did not mention LTC placements, and only 3 (7%) stated that LTC was allowed as primary care hours.
Primary Care in LTC Settings
Primary care is a person's main source of regular medical and overall health care, and includes health promotion, disease prevention, health maintenance, counseling, education, and diagnosis and treatment of acute and chronic conditions. Primary care occurs in a variety of health care settings, including LTC facilities (National Institute on Aging, 2017b). Older adults receiving primary care in LTC settings have a wide variety of health care needs, including assessment and management of acute and chronic conditions, management of preventive and routine care, and treatment of frail older patients requiring management of multiple acute and chronic diagnoses, including geriatric syndromes (CDC, 2013; Stanley, 2012).
Harris-Kojetin et al. (2019) reported the top diagnoses treated in nursing homes were hypertension, dementia, depression, heart disease, diabetes, and arthritis. These diagnoses parallel with community-dwelling older adults seen in the typical primary care setting: hypertension, heart disease, arthritis, cancer, diabetes, and stroke (Crimmins, 2018).
Types of LTC Facilities
According to the CDC (2013), LTC facilities provide a continuum of medical, nursing, and custodial care depending on the needs of the individual. All LTC facilities provide some level of basic services, such as assistance with activities of daily living (ADLs)—such as dressing, bathing, and toileting— and instrumental activities of daily living (IADLs)—such as managing medications and cooking. LTC facilities assist older adults in maintaining or improving an optimal level of physical and functional well-being and can include care from other health care providers. The most frequently used LTC sites are assisted living facilities (ALFs) and nursing homes (CDC, 2013); therefore, these facilities would be the most logical locations for NP students to gain clinical experiences within the LTC setting.
ALFs are appropriate for older adults who primarily need help with custodial care. Several levels of care are typically offered, depending on the degree of assistance needed with ADLs and IADLs. Assistance available to ALF residents include meals, personal care, help with medications, housekeeping, laundry, 24-hour supervision, and social and recreational activities (National Center for Assisted Living, 2020). There are no federal regulations for ALFs, only state laws that vary from state to state. Older adults residing in ALFs are responsible for their own medical needs, often requiring trips to their primary care provider's office. Some facilities provide clinic space for a primary care provider to maintain limited onsite office hours for the convenience of their residents (Kaldy, 2014). Occasionally, providers, following the House Calls model, will visit the resident in their ALF apartment (Ledbetter, 2015).
The terms nursing home and skilled nursing facilities (SNFs) are often used interchangeably. Nursing homes focus more on medical care needs than ALFs, although they provide assistance with ADLs and IADLs (National Institute on Aging, 2017a). All nursing homes receiving federal money from Medicare or Medicaid must meet federal regulations and provide sufficient staff to meet the needs of all residents, including continuous licensed nurse coverage. Federal regulations also require frequent evaluations by NPs or physicians (Requirements for Long Term Care Facilities, 2011). The term SNF refers to rehabilitation services (physical, occupation, and speech therapy) and licensed nursing care such as medication monitoring, enteral feedings, intravenous therapy, complex wound dressings, and monitoring acute illnesses (Center for Medicare Advocacy, 2015; Medicare.gov, n.d.). When discharged from the hospital, many older adults are Medicare eligible for short-term skilled rehabilitation and nursing services at an SNF (Medicare.gov, n.d.). After Medicare eligibility expires, some residents will opt to remain at the facility for continued care needs. These residents are medically stable but may develop acute illnesses or have exacerbations in chronic health diagnoses.
Care Provided by NPs in LTC Settings
Studies have shown decreased depression, polypharmacy, urinary incontinence, pressure injuries, falls, restraint use, aggressive behaviors, and acute care rehospitalizations in LTC facilities that use NPs (Kilpatrick et al., 2020; Donald et al., 2013). NPs are also associated with improvement in pain management, functional ability, and other positive measures of health status, behavioral and psychological symptoms of older adults including those with dementia living in LTC settings, and family satisfaction (Donald et al., 2013; Kaasalainen et al., 2016). The NP serves as an integral member of the health care team when managing conditions commonly encountered in LTC settings (Stefanacci & Cusack, 2016).
Development of Position Statement Expertise
The GAPNA Education Committee was charged with developing a position statement that could be validated and endorsed by those in academia and other stakeholders. The Education Committee is composed of 30 nationally certified gerontology, adult, adult-gerontology acute and primary care, and FNPs with demonstrated expertise in gerontological nursing practice and education. Members of the committee include clinically active NPs experienced with precepting NP students and the majority hold faculty appointments in schools of nursing. Many of the committee members are recognized nationally for their contributions to the literature related to gerontological nursing and education and remain actively engaged in multiple inter-professional and nursing organizations. In 2018, a subgroup of the Education Committee was charged to develop the position statement. The final position statement was completed in 2019.
Iterative Development Process
The charge to the subgroup was to complete a comprehensive literature review on primary care settings and develop a position statement supporting LTC as appropriate clinical placement for primary care NP students. The development of the position statement was initiated via conference calls of the subgroup focusing on identification of essential background and components for the position statement. The literature review was guided by expert facilitators. After the initial draft of the position statement was developed by the subgroup, the document underwent several revisions prior to external reviews.
The position statement was validated through a three-phase process. The initial validation phase included review by the entire Education Committee—a diverse group from across the nation, representing academia, health care organizations, and community-based practice sites. This committee reviewed the draft position statement three times, with revisions made for additional background, clarification of definitions, formatting, and additional references. The second validation phase included review by the GAPNA Board of Directors. The final validation phase was publication on the GAPNA website for a 2-week public comment period. Only two comments were received, both supportive, with no major revisions needed. The GAPNA Board of Directors approved the position statement, Primary Care in Long-Term Care Sites: Long-Term Care Sites as Appropriate Clinical Placements for Primary Care Nurse Practitioner Students (GAPNA, 2019), after the public comment period ended.
After the validation process, the GAPNA Board of Directors disseminated the position statement to various professional organizations and nursing schools seeking endorsement. To date, this position statement has been endorsed by 10 professional organizations (American Assisted Living Nurses Association, American Association of Nurse Practitioners, American Association of Post-Acute Care Nursing, Commission on Collegiate Nursing Education, Hartford Institute for Geriatric Nursing, National Association of Directors of Nursing Administration in Long Term Care, National Association of Pediatric Nurse Practitioners, National Council of State Boards of Nursing, National Hartford Center of Gerontological Nursing Excellence, and National Organization of Nurse Practitioner Faculties), as well as 12 nursing schools (Duke University School of Nursing, Emory Nell Hodgson Woodruff School of Nursing, Madonna University School of Nursing, New York University College of Nursing, Rush University College of Nursing, Seton Hall University College of Nursing, University of Alabama at Birmingham School of Nursing, University of Maryland School of Nursing, University of Massachusetts Lowell Solomont School of Nursing, University of Tennessee at Chattanooga School of Nursing, University of Wisconsin-Madison School of Nursing, and Vanderbilt School of Nursing).