Structure evaluation of the implementation of geriatric models in primary care: a multiple-case study of models involving advanced geriatric nurses in five municipalities in Norway.

BACKGROUND: The Advanced Geriatric Nurse role recently has been introduced into Norway's primary healthcare system, and our study's purpose was to examine the implementation of models of care developed for Advanced Geriatric Nurse in primary care. With a structure evaluation, we tried to identify conditions that affect the implementation of different models of care and understand how these conditions affected the realisation of each model's intentions and goals. METHODS: An embedded multiple-case study was used that included five Norwegian municipalities and seven AGNs. The study included data from August 2014 through September 2018. We used data from 25 semi-structured face-to-face interviews with AGNs and stakeholders, documents and statistical information. We used a cross-case procedure with an emphasis on case findings for the analysis of the multiple case study. RESULTS: We analysed the structure-related conditions on two levels: the meso-level and the micro-level. On the meso-level, we found that the conditions that affected the implementation of the different models of care were related to each municipality's structure characteristics, stakeholders' involvement in the design of the models of care, the clarity of the models and their goals, the evaluation of the models and their adaptation. At the micro-level, we found that the conditions that affected the models' implementation were related to the collaboration within the implemented models of care, the role clarity of Advanced Geriatric Nurses themselves and adjustments within the models. CONCLUSIONS: The implementation of the AGN role in Norway seems to have been implemented in ways that can impact patients and municipalities positively. Potential improvements include extensive stakeholder involvement, improved roles, goal clarity and better documentation of structures and outcomes. The models' dynamic nature seemed to be a beneficial characteristic, but adaptation should be systematic and a necessary time should be considered for a new model of care to be integrated and produce results.

Care providers' troubled conscience related to an implementation of a time management system in residential care for older people-a participatory action research study.

BACKGROUND: Care providers in residential care for older people often refer to time shortage, a problem that may generate troubled conscience. AIM: The aim of the study was to describe a PAR process to assist care providers in municipal residential care for older people to constructively deal with their troubled conscience related to an implemented time management system. METHOD: This intervention study was carried out with 14 care providers and their manager in residential care for older people with the support of participatory action research (PAR). The recorded PAR sessions were transcribed and compiled with inspiration from content analysis. ETHICAL CONSIDERATIONS: The participants were given oral and written information and gave their written informed consent. FINDINGS: The PAR process was found to empower the participants to form their own structure of the practical professional planning, adapted to the residents needs and to their daily work. In this process, participants used their troubled conscience as a driving force and as an asset. CONCLUSION: Instead of launching change without any deeper information, it is important to carefully prepare, involve and inform those who are going to execute the change. Meeting places should be arranged wherein care providers have the opportunity to share and reflect on challenging situations that can generate troubled conscience, especially when comprehensive changes in their work are going to be implemented.

Family- and Person-Centered Interdisciplinary Telehealth: Policy and Practice Implications Following Onset of the COVID-19 Pandemic.

With the onset of the COVID-19 pandemic, telehealth was thrust to the forefront, becoming one of the most predominant forms of care almost overnight. Despite years of research, practice, and policymaking, tenets for providing telehealth in an interdisciplinary, family- and person-centered fashion, and across a wide breadth of settings remain underdeveloped. In addition, although telehealth has the potential to increase equity in care, it can also further exacerbate disparities. The current article discusses the opening created by the pandemic and provides recommendations for how to make permanent changes in telehealth policy and practice to allow for interdisciplinary, person- and family-centered care while also taking care to address issues of equity and ethics and privacy issues related to telehealth and remote monitoring. [Journal of Gerontological Nursing, 46(9), 9-13.].

Visionaries in geriatric nursing: A legacy for the future.

There are many nurses who had a significant impact on the development and growth of gerontological nursing. There are those that provided the foundation and were the building blocks of gerontological nursing. Those following served as the cornerstones to fortify the foundation of gerontological nursing. Today there are rising scholars serving as the stepping-stones for the future of gerontological nursing. This article highlights the exemplary gerontological nurses that contributed and are contributing to the research, practice, and education of the mature specialization of gerontological nursing.

Gerontological nursing: Growth, adaptation and change after John A. Hartford Foundation investments.

This article chronicles the John A. Hartford Foundation (JAHF) funded gerontological nursing initiatives 1996-present. These initiatives, in particular BAGNC, were designed to impact the health of older adults through building gerontological nursing capacity by preparing new and retooling current faculty with expert gerontological nursing competencies, preparing new researchers, developing a knowledgeable nurse workforce with competency in gerontological nursing and prepare leaders in academics and health care systems. A description of major programs funded by the Foundation is presented and the impact, adaptation, and change in gerontological nursing resulting from over $86 million in funding awarded to these efforts is examined and intended to inform our way forward. NHCGNE, Legacy Affiliates and partners named in this article continue to innovate and transform healthcare systems as a way forward.

The integration of new nurse practitioners into care of older adults: A survey study.

AIMS AND OBJECTIVES: To assess Norwegian advanced geriatric nurses' (AGNs) use of their knowledge and skills, and factors that may influence AGNs' opportunities to use their knowledge and skills to reach their full potential. BACKGROUND: Despite the need for nurses with advanced knowledge and skill in the care of older adults, the introduction of new advanced nursing roles has been challenging. Countries in the process of establishing advanced roles need to monitor and identify possible implementation issues. DESIGN: A cross-sectional descriptive survey. METHODS: We invited the total population of AGNs in Norway (n = 26) and some of their colleagues (n = 465) to answer an online questionnaire. Twenty-three (88.5%) of the AGNs and 195 (42.0%) of the invited colleagues completed and submitted the questionnaires. The data were analysed with descriptive statistics. STROBE guidelines were used in reporting this study. RESULTS: Of the AGNs, 16 (69.6%) used their knowledge and skills to their full potential when providing direct care. However, a minority used their knowledge and skills to their full potential when proving indirect care (n = 11, 47.8%), teaching/supervision (n = 11, 47.8%) and coordination (n = 5, 21.8%). A total of 47 (24.1%) colleagues experienced the AGNs' scope of practice as completely clear, and 52 (26.6%) collaborated with the AGNs several times a week. Of the colleagues, 131 (67.2%) considered the AGNs' role and scope of practice contributed positively to a high degree to health service for older adults. CONCLUSION: The results indicate the need for greater focus on organisational adjustment for the AGNs to utilise their knowledge and skills to their full potential. RELEVANCE TO CLINICAL PRACTICE: There is a need for greater focus on organisational adjustment to integrate AGNs at the workplace, as complete integration may improve the AGNs' use of their knowledge and skills.

The educational needs of nursing staff when working with hospitalised older people.

OBJECTIVES: To examine nursing staffs' geriatric knowledge, perceptions about interprofessional collaboration and patient-centred care, and perceived learning needs related to working with hospitalised older people. METHOD: A triangulation mixed methods design was used. A survey was administered to nursing staff that contained the Knowledge About Older Patients Quiz, the patient-centered Care measure and the Modified Index of Interdisciplinary Collaboration measure. Interviews were conducted to understand nursing staffs' learning needs. Survey data were analysed using descriptive statistics. Interview data were analysed using content analysis. Survey and interview data were then compared and contrasted. RESULTS: Twenty-two nursing staff (response rate 26%) completed surveys and 14 participated in interviews. The mean knowledge about older patients score was 22.95, indicating moderately high gerontological knowledge. The mean scores on the patient-centered Care measure and Modified Index of Interdisciplinary Collaboration were moderately high at 3.75 and 3.86, respectively. Themes developed from analysis of the interview data were as follows: complex vulnerable population, clinical care concerns and working as a team. In spite of scores on knowledge surveys, nursing staff identified learning needs related to managing the responsive behaviours of older patients with cognitive impairment, chemical and physical restraints, mobility and continence. CONCLUSIONS: There was an incongruence between survey and interview data as nursing staff reported gaps in their knowledge despite moderately high scores on the Knowledge about Older People Quiz. Further research is needed to understand additional factors that influence nurses' educational needs.

Older patients' experiences of nurse-to-nurse collaboration between hospital and primary health care in the care chain for older people.

BACKGROUND: Nurse-to-nurse collaboration between nurses working in hospital and primary health care in the older people care chain is essential to ensure the continuity of care. The nature of good collaboration in this context is understood usually from the perspective of collaborating nurses. However, there seems to be a lack of research about this collaboration from the older patient's perspective who are at the centre of the collaboration. AIMS AND OBJECTIVES: To describe older patient's experiences of the collaboration between hospital and primary healthcare nurses delivering care to older people. DESIGN: A qualitative approach based on a descriptive phenomenological methodology was used. METHODS: Individual interviews were conducted using a purposeful sample of older patients (n = 18) who were cared for both in hospital and primary healthcare organisations. A qualitative data analysis method informed by Giorgi was used. RESULTS: The essence of the experience of nurse-to-nurse collaboration between hospital and primary health care was expressed as follows: the meaning of collaboration; the elements of collaboration valued; the visibility of collaboration; older patient involvement in collaboration; interaction within collaboration; and future expectations of collaboration. CONCLUSIONS: Although nurse-to-nurse collaboration between hospital and primary health care was not often visible to older patients, they highlighted the importance of this collaboration to ensure the continuity of care. The participants would have liked to be part of the collaborating group, at the centre of care, cared for by motivated nurses who had a clear understanding of their patients' health status. This study emphasises the need for improving collaboration between hospital and primary healthcare nurses by making it more visible and facilitating older patients' participation. The results demonstrate the need to understand patient perspectives in the development of care and the services provided for older people.

Intentional Rounding With Certified Nursing Assistants in Long-Term Care: A Pilot Project.

Intentional rounding (IR) is a strategy used by predominately acute care nursing staff to proactively address patients' needs at regular and consistent intervals. The current project piloted the use of IR with certified nursing assistants (CNAs) on a 60-bed unit of a 120-bed skilled nursing facility (SNF). Using a pre/post intervention design and the Plan-Do-Study-Act (PDSA) framework, the authors measured knowledge of IR's "4Ps" (potty, position, possessions, and pain) and the incidence of falls and lost possessions. Uptake of IR over 10 weeks of implementation and CNAs' perceptions of intervention were also assessed. The pilot showed positive outcomes for each of the five aims. Data suggest that IR was well received by CNAs and changed practice patterns regarding quality, safety, and satisfaction. Based on these findings, replication of this project in other SNFs is recommended, given the current small and underpowered study. [Journal of Gerontological Nursing, 45(6), 15-21.].

Effects of an Interdisciplinary Care Team on the Management of Alzheimer's Disease in China.

The current study aimed to evaluate the multidimensional effects of an interdisciplinary care team in patients with Alzheimer's disease (AD). A total of 129 patients with AD were randomly assigned to an interdisciplinary care group (n = 69) or usual care group (n = 60). Behavioral and psychological symptoms of patients with AD were measured during a 6-month treatment period. No differences were found in the baseline characteristics between the interdisciplinary care and usual care groups. Compared to usual care, interdisciplinary care greatly increased patients' activities of daily living (ADL) scores when measured at 3 and 6 months (p < 0.001). Findings provide evidence that an interdisciplinary care team approach is beneficial in improving ADL performance; thus, an interdisciplinary care team should be implemented in the care arrangements for patients with AD. [Journal of Gerontological Nursing, 45(5), 39-45.].

Mental Health Nurses Supporting the Routine Assessment of Anxiety of Older People in Primary Care Settings: Insights from an Australian Study.

Anxiety in older age is a worldwide problem and co-associated with other mental health problems, physical health conditions, disability, reduced quality of life and increased healthcare utilisation. Yet the symptoms of anxiety are often unrecognised in older people, challenging early diagnosis and increasing the risk of older people developing more chronic and disabling illness. This article reports on research led by mental health nurses and a primary care nurse that supported primary care practitioners to undertake a routine assessment of anxiety in older people in Australia. The Geriatric Anxiety Inventory-Short Form was incorporated into the annual, in-depth 75 years and older, health assessment that is undertaken in primary care settings and funded by Australia's Medicare. An initial feasibility study demonstrated good acceptance levels of the routine assessment by the primary care practitioners. These findings suggest fertile ground for the everyday use of the routine assessment in primary care settings in Australia, with transferability internationally in low-, middle- and high-income global communities. Mental health nurses can play a key role in supporting primary care nurses to recognise and respond to anxiety in older people. Illness prevention and health promotion activities are low cost and have the potential to make a difference worldwide to the health of people across the lifespan.

The Family in Europe: Structure, Intergenerational Solidarity, and New Challenges to Family Health.

Understanding the family experience of health and illness within the family's social and cultural context helps health professionals understand a family's stories. The purpose of this article is to present salient characteristics of the Western European family to extend understanding about family structure and values in relation to caring and intergenerational solidarity. The goal is to provide nurses and other health professionals with culturally competent knowledge that can inform practice with families. Evidence suggests that a family model, characterized by strong-family type societies consisting of coresidence, solidarity, and intergenerational relationships, stalwartly continues in Mediterranean countries. However, due to the recent economic crisis in Spain and other European countries, there is a trend toward the withdrawal of state responsibility toward the family, and an increasing weight on families' responsibility, particularly for women, toward the care of their old and chronically ill relative. Therefore, there is a need to make health and social systems more effective, sustainable, and focused on family care.

Partnership integration for rural health resource access.

Increasing numbers of older adults are residing in rural areas of the USA. Many of these individuals experience greater rates of chronic diseases and lower income levels compared to their urban-residing counterparts. Aging in rural environments creates greater challenges in the provision of funding, staff and resources to meet the needs of these older adults, and contributes to immense health disparities and health inequities. Urban and rural older adult residents alike need healthcare, gerontological and public health resources to promote successful aging in place. Due to the nature of rural environments, many of these resources often exist great distances from these residents, which creates access challenges. There are also limitations in locally available facilities and trained practitioners, resulting in resource shortages for addressing chronic health conditions. The creation and use of interdisciplinary partnerships provides this much-needed support while addressing ever-increasing funding and staffing limitations. This article provides an innovative conceptual interdisciplinary partnership model that combines nursing, public health and gerontology to address the health and social challenges that rural-residing older adults face. Although well-trained practitioners who work within their discipline are an important contributor to assist with the needs of rural-residing older adults, this silo approach is expensive, inefficient, and clearly cannot support all of the needs for older adults in this type of environment. There is a need to blend the complementary skills provided by each of the presented disciplines so that the focus of the interdisciplinary partnership is on person-centered care addressing the health disparities and health inequities experienced by these older adults. To illustrate the integration of nursing, public health and gerontology disciplines, these disciplines are initially combined and presented as dyads, and are then incorporated into the full conceptual model. The dyads are public health and gerontology, public health and nursing, and gerontology and nursing. Steps are provided for the development of this (or any) interdisciplinary partnership. An example of the model's use through clinical and non-clinical disciplines and a community engagement framework is also described. Interdisciplinary approaches focused on person-centered care provide more well-rounded health and social support for rural older adults than any one discipline in isolation. Allocation of shared resources, roles, responsibilities and expenses allows practitioners engaged in interdisciplinary teams to provide superior economic and capacity efficiency. This efficiency is crucial at a time when many entities experience limitations in sustainable resources. Thus, practitioners and community agencies collaborating through interdisciplinary partnerships are better able to address the complex issues experienced by rural-residing community members.

Student Nurses' Perceptions About Older People.

Educating nursing students about the ageing population is situated within negative societal, heath care and nursing perceptions. A cross-sectional design using Burbank's perceptions towards older people scale was used to survey students in a pre-licensure nursing program in western Canada. Findings revealed that students' perceptions about older people were lower in the third year of the nursing program and after four clinical experiences. We suggest that students' first experiences in long-term care settings, in which they learn to provide basic care to older people, be balanced with experiences of older people in a variety of settings. Such experiences would allow students to develop the knowledge and skill needed to work with an ageing population with complex healthcare needs. More research is needed to better understand students' experiences and perceptions about where in the program more learning strategies about how to best work with older people would be helpful.

[The organization of medical nurse support of patients of elderly age in geriatric practice].

In recent years, the concept of nursing process has been actively introduced. It is especially important in geriatric practice, where the issues of nursing support prevail over those in the young and middle age. There are forms of organization of care, where it is the average medical staff is leading in the provision of medical care (hospices, nursing care hospitals, homes for the elderly, etc.). In these conditions, the responsibility of nurses in making and implementing medical decisions in the event of emergency conditions increases.

The Relationships Between the Geriatric Practice Environment, Nursing Practice, and the Quality of Hospitalized Older Adults' Care.

PURPOSE: To test the relationships between the geriatric practice environment, geriatric nursing practice, and overall quality of care for older adults and their families as reported by nurses working in hospitals, while controlling for nurse and hospital characteristics. DESIGN: A cross-sectional tailored survey design was employed. A questionnaire was mailed to a randomly selected sample of nurses whose primary practice area was medicine, surgery, geriatrics, emergency, or critical care in acute care hospitals in Ontario, Canada. METHODS: Participants (N = 2,005) working in 148 hospitals responded to validated measures of the geriatric practice environment, geriatric nursing practice, overall quality of care for older adults and their families, and nurse and hospital characteristics. The relationships were tested using structural equation modeling. FINDINGS: Controlling for nurse and hospital characteristics, the geriatric practice environment had a statistically significant positive relationship of large magnitude with both geriatric nursing practice (ß = 0.52) and overall quality of care (ß = 0.92); however, the indirect relationship between the geriatric practice environment and overall quality of care, mediated by geriatric nursing practice, was not significant (ß = -0.02). Final model fit was acceptable, with the root mean square error of approximation = 0.07, comparative fit index = 0.93, and Tucker-Lewis Index = 0.87. CONCLUSIONS: A strong geriatric practice environment positively and directly influences geriatric nursing practice and overall quality of care for older adults and their families but does not appear to influence overall quality of care indirectly through geriatric nursing practice. CLINICAL RELEVANCE: The results can be used as the basis for promoting practice environments that support overall quality of care and geriatric nursing practice in acute care hospitals.

Systems Addressing Frail Elder Care: Description of a Successful Model.

OBJECTIVE: The aim of this article is to describe the Systems Addressing Frail Elder (SAFE) Care model, features of the interprofessional team and reengineered workflow, and details of the intervention. BACKGROUND: Older inpatients are vulnerable to adverse events related to frailty. SAFE Care, an interprofessional team-based program, was developed and evaluated in a cluster randomized controlled trial (C-RCT). Results found reduced length of stay and complications. The purpose of this article is to support and encourage the replication of this innovation or to help facilitate implementation of a similar process of organizational change. METHODS: This was a review of model features and intervention data abstracted from electronic health records. RESULTS: Salient features of team composition, training, and workflow are presented. The C-RCT intention-to-treat sample included 792 patients, of whom 307 received the SAFE Care huddle intervention. The most frequent problem was mobility (85.7%), and most frequent recommendation was fall precautions protocol (83.1%). CONCLUSIONS: The SAFE Care model may provide a standardized framework to approach, assess, and address the risks of hospitalized older adults.

The sustainability of a community nurses programme aimed at supporting active ageing in mountain areas.

BACKGROUND: Community Nurse Supporting Elderly iN a changing SOciety is a project funded by the European Union, which is aimed at developing an innovative care model based on community nurses to support active ageing in mountain areas. The planned sustainability of this innovative approach relies on social entrepreneurship, and this work highlights the necessary conditions for the existence of these entrepreneurial initiatives on the market, with community nurses' services purchased by the public health care system. METHODS: The authors propose a sustainability framework for this project based on three relevant dimensions (ie, health, organisation, and context), highlighting the necessary conditions for continued provision of health services beyond project conclusion. Then, considering the Piedmont Region and those aged 65 or older as target population, health outcomes are analysed, proposing a break-even analysis to calculate expected levels. RESULTS: According to our results, in order to care for 191 977 elderly people for 3 years, a successful pro-active approach is needed to prevent 1657 falls with hip fracture, reducing the prevalence of this adverse outcome by 36%. These are the expected health outcome levels for the existence of a social market, which can be achieved through the successful involvement of local public health organisations and stakeholders. CONCLUSIONS: Policy makers need clear information on the economic impact of extending this new intervention to the whole target population and on the required preconditions for its financial sustainability in terms of health outcomes. However, a participatory process involving all relevant local stakeholders and organisations is crucial to extend current achievements beyond project conclusion.

Leadership and registered nurses (RNs) working after-hours in Residential Aged Care Facilities (RACFs): A structured literature review.

AIMS AND OBJECTIVES: The aim of this literature review is to synthesise and analyse the literature pertinent to the RN's competence and confidence to undertake the leadership role when working in residential aged care facilities after-hours and to determine any association of leadership with quality resident outcomes. BACKGROUND: Registered nurses (RNs) working in Residential Aged Care Facilities are required to undertake complex management tasks including leading nursing care teams, supervising non-nursing staff and allocating workloads according to residents' care needs, staff skills and experience. Registered nurses plan, assess, manage medication, evaluate each resident's care, liaise with doctors and allied health professionals and are responsible for evidence-based practice in accordance with the Nursing Standards for Practice (2016). Researchers have commented that effective nurse leadership can improve quality of care, improved resident outcomes and reduce adverse events. DESIGN: A review of original research papers based on the structured methodology described by Kable, Pich, and Maslin-Prothero (Nurse Education Today, 32, 2012, 878-886). METHODS: The review was conducted according to the 12-step structured framework by Kable et al. (Nurse Education Today, 32, 2012, 878-886). The search included peer-reviewed papers published between 2002-2017 on RN leadership after-hours, factors contributing to or with relationships to nursing leadership. Nineteen papers were found that researched the impact of leadership in aged care settings. RESULTS: The literature review concluded that nursing leadership has been linked to the quality of care and clinical outcomes in the aged care setting. However, RNs in the aged care setting have limited opportunities to develop key leadership competencies and confidence in order to meet the many challenges found in this environment due to lack of access to aged-care-specific leadership education. Minimal publications address the importance of the leadership of after-hours RNs. Results from this literature review will inform future research in this area. CONCLUSION: Nineteen papers identified the leadership required of RNs in aged care settings. However, limited research investigating the association between nursing leadership and clinical outcomes was found. The findings from this literature review suggest that leadership in the aged care setting may be facilitated through specific educational activities such as RN shadowing shifts, continuing professional development, working with peers and by demonstrating and practising leadership competencies. Based on the literature reviewed, a need for more research in this area is required. In a specific manner, research into RN leadership, competence and confidence in aged care facilities after-hours is needed. RELEVANCE TO CLINICAL PRACTICE: Registered nurses working in the aged care setting after-hours need access to leadership education. Better quality of care, improved resident outcomes and reduced adverse events are associated with sound leadership.

Job strain in nursing homes-Exploring the impact of leadership.

AIMS AND OBJECTIVES: To explore the association between nursing home managers' leadership, job strain and social support as perceived by direct care staff in nursing homes. BACKGROUND: It is well known that aged care staff experience high levels of job strain, and that aged care staff experiencing job strain are exposed to increased risk for adverse health effects. Leadership styles have been associated with job strain in the literature; however, the impact of perceived leadership on staff job strain and social support has not been clarified within nursing home contexts. DESIGN: This study had a cross-sectional design. METHODS: Participating staff (n = 3,605) completed surveys which included questions about staff characteristics, valid and reliable measures of nursing home managers' leadership, perceived job strain and social support. Statistical analyses of correlations and multiple regression analysis with interaction terms were conducted. RESULTS: Nursing home managers' leadership were significantly associated with lower level of job strain and higher level of social support among direct care staff. A multiple regression analysis including an interaction term indicated individual and joint effects of nursing home managers' leadership and social support on job strain. CONCLUSIONS: Nursing home managers' leadership and social support were both individually and in combination associated with staff perception of lesser job strain. Thus, nursing home managers' leadership are beneficial for the working situation and strain of staff. RELEVANCE TO CLINICAL PRACTICE: Promoting a supporting work environment through leadership is an important implication for nursing home managers as it can influence staff perception of job strain and social support within the unit. By providing leadership, offering support and strategies towards a healthy work environment, nursing home managers can buffer adverse health effects among staff.