Community Models of Care: A Scoping Review.

Nurse preparation and role in community models of care for older adults is not well documented. The purpose of the current structured scoping literature review was to identify nurse-led or nurse-involved community models of care for older adults, articulate the nurse's role and preparation in the model, and identify Triple Aim policy implications. Literature from 2008 through 2014 yielded 34 models identified in 51 articles. Twenty-one of 34 models were evaluated and none clearly articulated the full impact of a nurse role. Policy implications include: (a) consensus on degree preparation for nurses working in communities with older adults; (b) clearly defined nurse-sensitive measurements that capture the role of nursing in ambulatory and community care; (c) nonrestrictive scopes of practice for gerontological nurses and adult-gerontological nurse practitioners to extend their role beyond clinic settings; and (d) extending beyond value-based payment, which currently is largely physician awarded, and including additional Medicare and Medicaid policy to support nurses, community-level practice, and reimbursement. [Journal of Gerontological Nursing, 42(12), 12-20.].

Doing it my way.

PURPOSE: Historically, hotels and single-room occupancy residences have provided room, board, and social support services to elders, in particular the poor and the disenfranchised. This article presents the results of a case study drawn from a larger ethnographic community study that set forth to describe how and why elders from one rural community chose to live in a motel in that same rural community. The focus of this study is a description of 7 middle-income and affluent rural elders living in a motel setting as a housing option that enabled them to remain independent in their community. DESIGN AND METHODS: Using a community study ethnographic design and the strategies of formal and informal interviews, participant observation, and inductive comparative case study analysis, this study provides a description of why these elders decided to live in the motel and how this facilitated their living in the community. RESULTS AND IMPLICATIONS: Reasons that these elders decided to live at the motel included "saving my energy for living," "safety," "connections and privacy," and "the freedom to come and go." This study informs elder care policy, emphasizing the importance of naturally occurring networks to develop community capacity for healthy aging in one rural setting.

Implications of electronic health record meaningful use legislation for nursing clinical information system development and refinement.

PURPOSE: To describe what electronic health record meaningful use requirements mean for nursing clinical information system (CIS) development. CONCLUSIONS: The nursing CIS in many, if not most hospitals, has a number of critical design inadequacies that constrain the meaningful use of nursing data to ensure quality outcomes for patients and data-based maturing of the nursing profession. IMPLICATIONS: It is the responsibility and obligation of nurses to ensure that CISs are designed for the meaningful use of nursing clinical data. To accomplish these ends, interoperable clinical nursing data must be documented in a properly integrated operational CIS, and must be retrievable and stored in data repositories for analysis and reports.

Evaluation of outcome change scores for patients with pneumonia or heart failure.

This study was conducted to describe the variance in selected Nursing Outcomes Classification (NOC) outcome change scores of hospitalized older patients with pneumonia (n = 216) or heart failure (HF; n = 67) that could be explained by age, length of stay (LOS), number of comorbid conditions, number of nursing diagnoses, and number of nursing interventions. Investigators used a descriptive correlational design to analyze data sets from three U.S. community hospitals. Study participants had at least two ratings on one of nine outcomes selected for their frequency and use across the three hospitals. A significant portion of the variance in the outcomes Knowledge: Illness Care and Fall Prevention Behavior was explained for pneumonia patients. None of the regression models for HF patients showed significance. Individual independent variables were significant in some of the models (i.e., LOS [pneumonia], number of nursing diagnoses [pneumonia and HF]). Implications for research and clinical practice are discussed.

Nursing clinical documentation data retrieval for hospitalized older adults with heart failure: part 2.

PURPOSE: The study aims to discuss the implications for retrieval of nursing data and building a multiorganizational data warehouse. METHODS: The method used was a descriptive comparative multisite study of documented care for 302 older adults with heart failure. Unit and patient level variables were retrieved. FINDINGS: Data regarding the most identified variables were retrievable electronically. Important linkages among nursing data elements were not present. CONCLUSIONS: Data were retrievable and the building of a data warehouse was possible and lessons were learned. IMPLICATIONS: When clinical information systems (CISs) are developed, developers and nurses must discuss how standardized data will be entered to ensure retrieval and usefulness in evaluating nursing care. For nursing effectiveness research, CISs must also provide linkages among nursing diagnoses and specific interventions, and nursing-sensitive patient outcomes.

Most frequent nursing diagnoses, nursing interventions, and nursing-sensitive patient outcomes of hospitalized older adults with heart failure: part 1.

PURPOSE: Rank and compare the 10 most frequently documented nursing diagnoses, interventions, and patient outcomes using NANDA International, Nursing Interventions Classification, and Nursing Outcomes Classification for care of patients with heart failure (HF). METHODS: A descriptive comparative multisite study of documented care for 302 older adults with HF. FINDINGS: There were four common nursing diagnoses, two interventions, and only three common outcomes across three sites. CONCLUSIONS: This and similar analyses of clinical nursing data can be used by nursing administrators and clinicians to monitor the quality and effectiveness of nursing care. IMPLICATIONS: Similar analyses may be used for continuing education, quality improvement, and documentation system refinement. Part 2 will discuss data retrieval and implications for building a multiorganizational data warehouse.

Measuring gerontological research intensity in schools of nursing.

Because of the urgent need for more gerontological nursing research, it is critical for more schools of nursing to develop research-intensive environments within which faculty can develop programs of gerontological nursing research. Unfortunately, many schools have limited resources for developing the needed infrastructures and for acquiring the required expertise in gerontology and research. Many also lack the expertise and methods for assessing their current status so they may increase their gerontological nursing research intensity. To help schools assess their status and gaps in the essentials required for a research-intensive environment and gerontological nursing research, an instrument was developed to measure benchmarks of research intensity; it is described in this article. Initial results of pilot testing of the instrument, the revised instrument, and plans for future research are presented. Uses of the instrument for assessing and strengthening a school's research infrastructure and culture and for assisting with the development of faculty programs of gerontological nursing research are also discussed.

Aging issues: nursing imperatives for healthcare reform.

The people of the United States sent a clear message in November 2008 that they wanted a change in the nation's priorities, including healthcare. The question is whether healthcare reform will extend to the care of older adults, especially in the face of complex needs in the last years of their lives. This article addresses this question by examining the demographics of the older adult population, the eldercare workforce, and the current inadequate patchwork of financing. Some aging issues, such as chronic care, are being addressed in the broad context of healthcare reform, whereas health information technology and others remain marginal. The window of opportunity for a clear and coherent voice in a reformed/reshaped healthcare system is narrow. Now is the time for the "trusted" profession to advocate for meaningful change that will meet the current and future needs of older adults. The article concludes with strategies and Web-based resources for nurses to bring aging issues to the healthcare reform debate at both the national and local levels.

Increasing nursing faculty research: the Iowa gerontological nursing research and regional research consortium strategies.

PURPOSE: Research development and regional consortium strategies are described to assist schools in all countries extend their gerontological nursing research productivity. The strategies, collaboration and mentoring experiences, and outcomes are also shared to illustrate a highly successful approach in increasing faculty programs of nursing research in a focused area of inquiry. DESIGN: A case description of gerontological nursing research development and regional consortium strategies in schools of nursing is used. The regional consortium included 17 schools of nursing that are working to increase faculty programs of gerontological nursing research. Survey responses describing publications, presentations, and research funding awards from 65 of 114 total faculty participants in consortium opportunities (pilot and mentoring grant participants, participants in summer scholars' grantsmanship seminars) were collected annually from 1995 through 2008 to describe outcomes. FINDINGS: From 1994 through 2008, faculty participants from the consortium schools who responded to the annual surveys reported a total of 597 gerontological nursing publications, 527 presentations at research conferences, funding of 221 small and internal grants, and 130 external grant awards, including 47R-series grants and 4 K awards. CONCLUSIONS: There is an urgent need for more nurse faculty with programs of research to inform the health care of persons and support the preparation of nurse clinicians and faculty. The shortage of nurse scientists with active programs of gerontological research is especially serious and limits the number of faculty who are needed to prepare future gerontological nurses, particularly those with doctoral degrees who will assume faculty positions. Further, junior faculty with a gerontological nursing research foci often lack the colleagues, mentors, and environments needed to develop successful research careers. The outcomes of the development and regional consortium strategies suggest that the principles of extending collaboration, mentoring, and resource sharing are useful to augment faculty research opportunities, networking and support, and to increase productivity in individual schools. CLINICAL RELEVANCE: Clinical relevance includes: (a) implications for preparing nurse scientists and academicians who are and will be needed to train nurses for clinical practice, and (b) development of more faculty programs of research to provide systematic evidence to inform nursing practice.

A trial of a comprehensive nursing rehabilitation program for nursing home residents post-hospitalization.

This pilot study examined the feasibility of implementing a comprehensive nursing rehabilitation program (CNRP) designed to promote the physical functioning of moderately frail nursing home residents post-hospitalization. The 4-week to 8-week CNRP incorporated three interventions: the Capacity Intervention (improving strength and balance), Performance Intervention (fostering daily mobility and activity), and Facilitating Intervention (providing education, support, and stress management). A longitudinal design was used with a convenience sample of 24 moderately frail residents. The CNRP was found to be not practical as designed because the intervention occurred too close to hospital discharge, and many prospective participants did not "feel up" to participating in a voluntary nursing rehabilitation program in addition to other prescribed rehabilitation. Regardless, participants were found to be able to perform the exercises safely and the CNRP was easily implemented in nursing homes. Testing the efficacy of the CNRP with nursing home residents is recommended after the initial post-hospitalization period.

Field testing, refinement, and psychometric evaluation of a new measure of quality of care for assisted living.

Field test results are reported for the Observable Indicators of Nursing Home Care Quality Instrument-Assisted Living Version, an instrument designed to measure the quality of care in assisted living facilities after a brief 30-minute walk-through. The OIQ-AL was tested in 207 assisted-living facilities in two states using classical test theory, generalizability theory, and exploratory factor analysis. The 34-item scale has a coherent six-factor structure that conceptually describes the multidimensional concept of care quality in assisted living. The six factors can be logically clustered into process (Homelike and Caring, 21 items) and structure (Access and Choice; Lighting; Plants and Pets; Outdoor Spaces) subscales and for a total quality score. Classical test theory results indicate most subscales and the total quality score from the OIQ-AL have acceptable interrater, test-retest, and strong internal consistency reliabilities. Generalizability theory analyses reveal that dependability of scores from the instrument are strong, particularly by including a second observer who conducts a site visit and independently completes an instrument, or by a single observer conducting two site visits and completing instruments during each visit. Scoring guidelines based on the total sample of observations (N = 358) help guide those who want to use the measure to interpret both subscale and total scores. Content validity was supported by two expert panels of people experienced in the assisted-living field, and a content validity index calculated for the first version of the scale is high (3.43 on a four-point scale). The OIQ-AL gives reliable and valid scores for researchers, and may be useful for consumers, providers, and others interested in measuring quality of care in assisted-living facilities.

Everyday excellence. A framework for professional nursing practice in long-term care.

RNs make measurable contributions to the health and wellness of individuals living in nursing homes. However, most nursing homes do not employ adequate numbers of professional nurses with specialized training in the nursing care of older adults to positively affect resident outcomes. As a result, many people never receive excellent geriatric nursing while living in a long-term care facility. Nurses have introduced various professional practice models into health care institutions as tools for leading nursing practice, improving client outcomes, and achieving organizational goals. Problematically, few professional practice models have been implemented in nursing homes. This article introduces an evidence-based framework for professional nursing practice in long-term care. The Everyday Excellence framework is based on eight guiding principles: Valuing, Envisioning, Peopling, Securing, Learning, Empowering, Leading, and Advancing Excellence. Future research will evaluate the usefulness of this framework for professional nursing practice.

Nursing home staffing and training recommendations for promoting older adults' quality of care and life: Part 1. Deficits in the quality of care due to understaffing and undertraining.

Caught between the inability or unwillingness of nursing home corporations and owners to redistribute revenue and the reluctance of federal and state agencies to increase payments to nursing homes, the nation's most vulnerable older adults are not receiving the care they deserve. Widespread recognition of substandard care and quality of life of older adults in nursing homes has existed for decades. In addition, there is substantial evidence that poor quality of care is related to inadequate numbers and training of nursing staff. Still, policy makers and nursing home owners have failed to take needed action. In the first article of this two-part series, major deficits in the care of older adult nursing home residents are reviewed, and research documenting the relationship between nursing home staffing and the quality of care and life of residents is summarized.

Nursing home staffing and training recommendations for promoting older adults' quality of care and life: Part 2. Increasing nurse staffing and training.

In the second article of this two-part series, research supporting the need for more RNs and assisting staff (licensed practical nurses [LPNs] and certified nursing assistants [CNAs]) with gerontological nursing training in nursing homes is reviewed. Using the literature, time studies, the judgments of experts, and the expected quality and quantity of care older adults should rightfully receive, recommended standards are set forth for RN and assisting staff hours per resident day, their training, and compensation. Leadership training is recommended for RNs and increased gerontological nursing training is recommended for RNs and assisting staff. Finally, to address the shortage of RNs with gerontological nursing and leadership training in nursing homes, a program to prepare RNs as geriatric nursing long-term care specialists is proposed.

Nursing home staff's views on quality improvement interventions: a follow-up study.

Ongoing problems with nursing home care mandates understanding nursing home staff's perspectives on innovative quality improvement programs. This follow-up study used focus groups to examine the experiences of staff who participated in a clinical trial that involved Quality Indicator (QI) feedback reports, quality improvement training, and APN consultation. The authors found that QI reports provided staff with a benchmark to judge their care and a means to track problems; APN consultation was essential for staff to learn best practices; and staff questioned the validity of the QI reports, which hindered them from seeking new solutions to problems identified in the QI reports. Findings indicate that innovative QI programs and APN consultation can positively influence nursing home quality improvement efforts and improve care.