A Bill of Rights for Hospitalized Older Adults.

Acute-care hospitals have few structures, programs, or staff prepared to address the special needs of older adults. To address this issue, the Hartford Institute for Geriatric Nursing [including the Nurses Improving Care for Hospitalized Elders (NICHE) program] and the Coalition of Geriatric Nursing Organizations proposed language for a Bill of Rights for Hospitalized Older Adults. The Bill of Rights moves from general value statements to the specific knowledge, skills, and actions necessary to provide quality of care to older adults. The authors describe the development and testing of the Bill of Rights and suggest steps for its adoption and dissemination.

Iatrogenesis, frailty, and geriatric syndromes.

Older adults are at risk for iatrogenesis, especially if they are frail and have 1 or more geriatric syndromes. Iatrogenic events do not occur only in acute care; in nursing homes they affect 65% of residents annually. It is therefore likely that they are occurring in assisted living communities, though perhaps called by another name. Most commonly, iatrogenesis is an adverse drug event or reaction. Knowing more about the characteristics of frailty and the contributing factors to geriatric syndrome(s), assisted living nurses can be better prepared to monitor, detect, describe, and communicate an iatrogenic event or outcome. This article describes the signs and symptoms of atypical presentation of illness that can mask or are associated with iatrogenesis. Evidence-based assessment instruments are suggested for each geriatric syndrome.

An assisted living community environment that optimizes function: housing enabler assessment.

Aspects of the physical and temporal environment can optimize and preserve function, or they can impede if not imperil it. Older adults have a temporal relationship to their environment with regard to their present and future needs, the influence of the environment on their sense of well-being, their ability to adapt to age-related changes and chronic illness, and the types of positive or adaptive responses that the environment can facilitate. Because older individuals differ in motivation and cognitive and physical abilities, they differentially use features in their environment to support their wishes and activities-that is, they use them to further their quality of life. Lawton's ecological theory of aging model defines the individual as a set of competencies; the environment is defined as demands (ie, internal/endogenous; external/exogenous).

Storytelling.

Storytelling can be therapeutic. For the person, it is both validating and valuing--as nothing else can do. There is a connection between old age and spirituality and a quest for transcendence--to express one's self as part of the human condition. This article seeks to describe the links among spirituality, nursing care, and patient/resident storytelling, and includes suggestions on how to help older adults tell their stories, even if they are cognitively challenged by memory and language loss. It describes a worldview as expressed in several of the new nursing theories as "humanness": a life cycle of continuous growth leading, perhaps, to "self-transcendence." Storytelling can be peacemaking and transformative. The voice of the "wounded storyteller" and how nurses can make that voice heard might be the takeaway message.

Medication adherence is a partnership, medication compliance is not.

Medication adherence is a complex phenomenon. As individuals assume greater responsibility for, and participation in, decisions about their health care, teaching and supporting adherence behaviors that reflect a person's unique lifestyle are the essence of a clinician-patient partnership-and it is a perfect fit with assisted living communities and nursing practice. The notion of compliance is an outdated concept and should be abandoned as a clinical practice/goal in the medical management of patient and illness. It connotes dependence and blame and does not move the patient forward on a pathway of better clinical outcomes. This article discusses the differences between compliance and adherence, identifies purposeful and unintentional reasons for nonadherence, and describes assessment tools for adherence, medication effect, and self-management capacity. Drawing on the scholarly work of others, we introduce a model for medication adherence, the ACE-ME Model: assessment, collaboration, education, monitoring, and evaluation. This model draws on the strengths and science of nursing and engages nursing participation in the continuing evolution of adherence strategies. For purposes of clarity in discussing these concepts, we use the word patient in this article rather than the word resident-that is, the older adult living in an assisted living community.

Pain management and the U.S. Department of Justice.

The Drug Enforcement Agency (DEA) may be restricting the ability of RNs and LPNs in assisted living communities (ALCs) in some states to provide pain relief for residents. The DEAs enforcement of the requirements of the Controlled Substances Act (CSA) to reduce diversion of controlled substances (particularly Schedule II meds) for criminal or nefarious reasons, has generated a variety of responses by pharmacies, ALCs, and practitioners. Residents are at risk for--and some residents have already experienced--inadequate pain management. The argument seems to turn on whether an ALC (or nursing home or home health nurse) is an "agent" of the physician. The term "agent" is poorly defined in section 1300 of the CSA. It neither confirms that an ALC/long-term care (LTC) nurse/medical aide may function as an agent of the provider nor does the definition preclude the ALC/LTC nurse/medical aide as the agent of the provider. This article is an alert to ALCs to examine their controlled drug procurement and pain management procedures and is also a call to advocacy by ALC nurses.

Nursing delegation and medication administration in assisted living.

Assisted living (AL) residences are residential long-term care settings that provide housing, 24-hour oversight, personal care services, health-related services, or a combination of these on an as-needed basis. Most residents require some assistance with activities of daily living and instrumental activities of daily living, such as medication management. A resident plan of care (ie, service agreement) is developed to address the health and psychosocial needs of the resident. The amount and type of care provided, and the individual who provides that care, vary on the basis of state regulations and what services are provided within the facility. Some states require that an RN hold a leadership position to oversee medication management and other aspects of care within the facility. A licensed practical nurse/licensed vocational nurse can supervise the day-to-day direct care within the facility. The majority of direct care in AL settings is provided by direct care workers (DCWs), including certified nursing assistants or unlicensed providers. The scope of practice of a DCW varies by state and the legal structure within that state. In some states, the DCW is exempt from the nurse practice act, and in some states, the DCW may practice within a specific scope such as being a medication aide. In most states, however, the DCW scope of practice is conscribed, in part, by the delegation of responsibilities (such as medication administration) by a supervising RN. The issue of RN delegation has become the subject of ongoing discussion for AL residents, facilities, and regulators and for the nursing profession. The purpose of this article is to review delegation in AL and to provide recommendations for future practice and research in this area.

The choices, choosing model of quality of life: clinical evaluation and intervention.

Two previous papers presented a conjectured model of quality of life featuring the personal management of accessing choices and choosing among them (the c-c process). Those papers made the case that this model unifies the pathways leading to impaired quality of life, especially with regard to age associated multiple co-morbidities, changes in perception and functioning, and the effects of long term care environments; it also introduces a science base for understanding and guiding interventions that can assist people to achieve their quality-of-life goals. Our aim in this paper is to outline interprofessional strategies that could relieve restrictions or distortions of the c-c process imposed by aging, ill-health, or a restricting environment. We do so by outlining potential deficits in the c-c process and matching these with restorative person-centered interprofessional interventions including interprofessional teamwork. Findings suggest that interprofessional assessment and team work is well suited to assisting the c-c process. We conclude that the groundwork has been prepared for developing training programs and clinical trials for interprofessional interventions targeting the c-c process.

Nursing care of the aging foot.

Feet are not necessarily the most attractive part of the body as it ages, and given the choice, most older adults would rather ignore them. In fact, many older adults cannot even see them, reach them, or care for them properly. And when they ache or look misshapen and oddly colored; well, that's just part of growing old, isn't it? The feet are important for weight bearing, balance, and mobility. Over an average life span, the feet are subject to considerable stress and trauma. Age-related changes of the foot predispose the older adult to discomfort if not pain, fungal infection, reduced range of motion, and itchy dry skin. More than three fourths of older adults (i.e., those age over 65 years) complain of foot pain that is associated with a significant foot problem and have evidence of arthritic changes on x-ray. Impaired ambulation can make the difference between independence versus dependency on others, engagement versus isolation. Assisted living is about choices. Being unable to get where one wants to go or do what one wants to do because of foot problems is a barrier to full enjoyment of the opportunities in assisted living communities. This article describes foot problems associated with aging, diabetes, nursing assessment of the feet, and nursing interventions in the service of accessing and optimizing choices for quality of life.

Infection control practices in assisted living communities.

Few states require assisted living communities (ALCs) to have an infection control plan (ICP), nor do they provide guidelines about infection control practices in ALCs or require communicable disease reporting to appropriate health agencies or even within the community itself. Most communities do not have an ICP that addresses prevention, detection, investigation, control, monitoring, or communication of an infectious outbreak. This article discusses the presentation and management of pneumonia, influenza, tuberculosis, methicillin-resistant Staphylococcus aureus (MRSA), and Clostridium difficile infection; describes common (i.e., standard) infection control practices in long-term care; and provides the most recent information and recommendations from the Centers for Disease Control and other sources regarding prevention and treatment of the H1N1 viral influenza. The key to prevention is education and appropriate handwashing and respiratory hygiene practices. Internet sources for up-to-date information are also provided.

There's no place like home.

The notion of home in assisted living is intrinsically connected to aging-and dying-in place. Yet little is known about what makes a house a home, an interactive environment imprinted with individual choices, styles, relationships, and histories. This article presents meanings of home, from playground to prison, and theories of home and well-being. Intended to provoke thoughtful discussion about the meaning of home for assisted living residents and staff, the article includes the Experience of Home Scale that could be used for quality improvement purposes. Implications for assisted living nursing practice with regard to person-environment interactions that constitute home (for better or worse) are discussed.

Complementary and alternative medicine (CAM).

The use of complementary and alternative medicine (CAM) appears to be on the rise in all adult age groups, including the elderly population. Many herbal and biologic preparations offer promise, but they are largely of unproven benefit. The content(s) are unregulated by government agencies, such as the Food and Drug Administration, making their use problematic to recommend and guide. Use of CAM modalities in assisted living communities (ALCs) is by and large a hidden practice, but it is estimated that 5%-9% of residents ingest some kind of herbal remedy. Belief systems among residents and their families-for example, that a certain kind of tea is a cure for dementia-can be persuasive. Responsible for resident well-being, assisted living nurses are caught in the middle. Nurse licensure considers herbals as medications, yet physicians refuse to prescribe them, and nurses (or certified med techs) cannot administer them. In some states, "alternative practitioners" are not viewed as legal prescribers. Undaunted, residents (or their families) purchase alternative "medicines" that are contraindicated by their traditional medical regimen. Secreted in their room, nurses are unaware of the stash and the self-administrating practice. This article describes the state of the science regarding the efficacy and safety of CAM modalities and actions that ALC nurses might undertake to collaborate with residents to address their CAM interest and use respectfully.

Rethinking teaching nursing homes: potential for improving long-term care.

To meet the special needs of and provide quality health care to nursing home residents, the health care workforce must be knowledgeable about the aging process. Health professionals are minimally prepared in their academic programs to care for older adults, and few programs have required rotations in geriatrics. Teaching nursing homes (TNHs) have shown promise as sites for the preparation of a health workforce to care for older adults in nursing homes as well as improvement of quality outcomes. This article reports on the process and recommendations of a TNH summit of experts in geriatric education and practice as to the feasibility of developing a sustainable and replicable TNH model that would prepare a professional workforce knowledgeable about and prepared to work in long-term care. The TNH summit identified characteristics of partnerships between academia, nursing home(s), and other stakeholders that would constitute a successful TNH collaboration. Goals of a TNH partnership between service and academia include interdisciplinary education and practice, research and dissemination of evidence-based practices, and benchmarks of a nursing home professional learning environment.

What impact do setting and transitions have on the quality of life at the end of life and the quality of the dying process?

PURPOSE: The aim of this article was to identify major research needs related to quality of life at the end of life and quality of the dying process for vulnerable older people at home, in assisted living facilities, in skilled nursing facilities, and in prisons. DESIGN AND METHODS: Review and analysis of the literature was used. RESULTS: The science is generally weak in relationship to what is known about quality of life at the end of life and quality of dying for vulnerable older adults in different settings. Few studies address actively dying patients and the reasons for transfers between home and other settings. Existing studies are primarily anecdotal, descriptive, have small samples, and involve a single setting. Participant decisional capacity is a barrier to conducting research in these settings. IMPLICATIONS: Research recommendations for each setting and across settings are provided. The National Institutes of Health should clarify criteria for enrollment of persons with diminished, fluctuating, and absent decisional capacity in research.

Medication management in assisted living: a national survey of policies and practices.

OBJECTIVE: To obtain information about actual medication management practices in assisted living residences (ALRs). DESIGN: An online survey; data were collected and reported as frequencies. Operational definitions were provided for "assist with" and "administration of" medications. SETTING: All 50 states. PARTICIPANTS: Members of the key assisted living professional and provider associations. RESULTS: More than half of ALRs (n = 547) administer medications to 80% to 100% of their residents. Almost half of ALRs use unlicensed assistive personal (UAP)/medication aides to administer medications, as permitted by state regulations. In those states where UAPs are not permitted, unlicensed staff may assist residents with their medications. More than half of ALRs have written policies regarding medication storage and documentation of administration. A slightly smaller percentage of ALRs have policies regarding medication administration by a UAP/med aide, quality improvement programs, and error reporting. As much as 30% of ALRs lack policies regarding drug regimen review and monitoring for adverse drug events (ADEs). CONCLUSION: Intensive education for practitioners about appropriate prescribing is warranted, as is improved methods for assessment of an older adult's ability to safely self-administer medications. The role of Boards of Nursing in every state, and nationally, should take a leadership role in establishing the curriculum, training, competencies, and performance evaluation criteria of UAP/med aides.