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The Future History of Gerontological Nursing

^a The John A. Hartford Foundation Institute for Geriatric Nursing, New York University, Steinhardt School of Education, Division of Nursing, New York

Mathy Mezey, Independence Foundation Professor of Nursing Education, Director, The John A. Hartford Foundation Institute for Geriatric Nursing, New York University, Steinhardt School of Education, Division of Nursing, 246 Greene Street, New York, NY 10003-6677 E-mail: mathy.mezey{at}nyu.edu.

	Abstract

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Having established an academic and clinical infrastructure, geriatric nursing is well positioned to play a central role in improving the health of the nation's older adults now and in the future. Currently, whether working independently, in collaborative practice with physicians, or as members of geriatric teams, geriatric nurse practitioners and clinical specialists have been shown to improve care to older adults in the community, in hospitals, and in skilled nursing facilities. Sixty-three master's programs now prepare advanced practice geriatric nurses. Geriatric nurse researchers have contributed to our understanding of the most pressing problems that impact profoundly on the health and quality of life of older adults. Despite these advances, the number of geriatric nurse specialists remains small, with only 4200 certified specialists and a serious shortage of geriatric nursing faculty. Geriatric nursing is moving to ensure geriatric competency in all nurses who work with older adults in the future. The future should see the benefits of current efforts to infuse geriatric content into baccalaureate programs that prepare registered nurses, into master's programs that prepare adult and family nurse practitioners, and into the day-to-day practice of the nation's 2.2 million practicing registered nurses.

THE history of geriatric nursing in the United States is notable for the scope of its response to the burgeoning demands of older adults and their families. The American Nurses Association (ANA) convened its first focus group on gerontological nursing in 1962; the first gerontological practice group convened in 1966. In 1968, the Geriatric Division of the ANA published the first geriatric nursing standards, followed shortly by ANA certification of the first gerontological nurses. This flurry of activity coincides with the attention generated by Titles 18 and 19 of the Social Security Act, which established Medicare and Medicaid.

Since then, the increased number of older adults, the changing face of American health care, and substantial shifts in health policy and funding have helped to shape geriatric nursing education, research, and practice. In this article, we focus on the current status of geriatric nursing and address its future history. Although the ANA emphasizes the term gerontological nursing for this area of special expertise and knowledge, the term geriatric nursing is equivalent and will be used interchangeably in this article.

Foundation commitment and support nationally has substantially shaped the recent history of gerontological nursing. In 1981, the Robert Wood Johnson Foundation supported the Teaching Nursing Home to demonstrate patient and educational outcomes related to collaborations between academic nursing and nursing homes ⁽¹⁾. The Kellogg Foundation funded a national project to develop geriatric curriculum for associate degree nursing programs, with an emphasis on long-term care ⁽²⁾. During the past 25 years, the John A. Hartford Foundation has supported the academic preparation, practice, and research capacity of geriatric medicine. Beginning in 1990, the Hartford Foundation began to invest in geriatric nursing. Foundation funding for 2001 represents a $35 million investment in geriatric nursing (http://www.gerontologicalnursing.info/). This commitment, which represents the largest funding commitment of any foundation in nursing, has served to stimulate curriculum reform, the development of academic centers of excellence, and pre- and postdoctoral scholarships, thus positioning geriatrics as a substantial area of future research and practice within nursing.

	The Clinical and Educational Perspective

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Advanced Practice Geriatric Nurses
For almost 35 years, the overwhelming emphasis in geriatric nursing has been to prepare a cadre of advanced practice geriatric nurse specialists. In 1966, Duke University started the first gerontological master's program. Advanced practice geriatric nurses are registered nurses who have completed a master's program to specialize as geriatric nurse practitioners, geriatric nurse clinical specialists, and geropsychiatric nurses. These advanced practice geriatric nurses work in collaboration with geriatric physicians and social workers to render care to older adults and serve as faculty to prepare increasingly large numbers of geriatric nurses. Their practice is recognized through state and professional certification, and they are reimbursed by both Medicaid and Medicare.

Several studies have underscored the national imperative for advanced practice nurses prepared to care for America's older adults ⁽³⁾⁽⁴⁾. The need for advanced practice nurses with geriatric skills is particularly dramatic among the "oldest-old," those persons 85 and older who constitute the fastest growing segment of our older population and who are most likely to require management of multiple chronic conditions and functional losses. The majority of these older adults have a disproportionate number of untoward acute health events and chronic illnesses that require primary, acute, and long-term care ⁽⁵⁾. Normal age changes and the increased risk of illness associated with advanced age exacerbate poor health in this group of older adults. On average, 53% of people 80 and older have one or more severe disabilities, 79% have at least one chronic disability, and 36% have moderate or severe memory impairment ⁽⁵⁾.

In the face of regulatory barriers, and a general antipathy on the part of health care professionals to geriatrics, advanced practice geriatric nurses have achieved an impressive record in managing the complex health needs of older adults. Evidence is strong that advanced practice geriatric nurses, often as part of geriatric teams, ensure quality care to older people and significantly improve health outcomes in ambulatory ⁽⁶⁾, acute ⁽⁷⁾, ⁽⁸⁾, and institutional long-term care ^{(9)(10)(11)(12)}.

Yet, despite a 30-year effort on the part of academic and professional nursing organizations ^{(13)(14)(15)(16)}, and substantial federal support for training, the number of advanced practice geriatric nurses remains very small. The 63 programs that prepare advanced geriatric nurses graduate a mean of three students annually ^(16)(17). Since 1991, only approximately 4200 nurses nationally have been certified by the American Nurses Credentialing Center (ANCC) as advanced practice geriatric nurses (GNPs: 3400; GCNS: 800) (M. Smolensky, Executive Director, The American Nurses Credentialing Center, January 2002). Because they are so few in number, and because they practice predominantly in institutional long-term care and in urban settings, advanced practice geriatric nurses exert a minimal impact on the health care needs of the majority of older adults.

Adult and Family Advanced Practice Nurses
Given the failure to attract large numbers of nurses to the specialization of geriatrics, during the past few years, there has evolved a growing appreciation within nursing that adult and family practice advanced practice nurses represent an untapped pool of health care providers for older adults. Currently, approximately 12,500 nurses are ANCC certified as advanced practice adult practitioners, and 24,400 are advanced practice nurses certified in family practice (M. Smolensky, Executive Director, The American Nurses Credentialing Center, January 2002).

It is highly likely that the practice of these advanced practice nurses involves the care for large numbers of older adults. Older adults' use of health care services is very high. They make up 60% of all ambulatory visits, 48% of adult hospital admissions, 80% of home care visits, and 85% of all nursing home residents ⁽¹⁸⁾. In home care, the fastest growing area of health care, in 1995, the 5600 Medicare-certified agencies made more than 38 million visits to 1.6 million Medicare beneficiaries; 52% of these were nursing visits ⁽¹⁹⁾. On any given day, more than 1.7 million older persons are cared for in 16,700 long-term care facilities. One in three Americans will spend some time in such a facility prior to death; 1% of persons aged 65 and older but 19% of persons 85 and older currently reside in long-term care facilities ⁽²⁰⁾.

The field of geriatrics/gerontology has evolved to the point where there now exist recognized standards for "best practice" in care of older adults ^{(6)(16)(21)(22)}. Nevertheless, there is general consensus that the health care that most older people receive fails to adhere to agreed-upon quality standards ^(7)(23)(24).

While lacking definitive data, a cursory review of curricula in programs preparing adult and family advanced practice nurses suggests that geriatric content and best practices, for example best practices in relationship to pain management and use of physical restraints, have been minimally addressed. Thus, there are several new initiatives with the specific goal to introduce concepts of best practice in geriatric care into the adult and family practice nursing educational curriculum ⁽¹⁷⁾. These initiatives include the development of nationally recognized competencies in geriatrics for all programs preparing advanced practice nurses likely to work with older adults (adult, family, women's health, critical care, and psychiatric advanced practice nurses). They also include the development of curriculum materials, ongoing professional education, and a push to encourage the creation of programs for adult, family, women's health, critical care, and psychiatric advanced practice nurses to acquire certification in geriatric nursing as a second credential to their existing area of specialization.

"Gerontologicalizing" the Practicing Nurse
In addition to focusing on master's prepared advanced practice nurses, during the past 5 years, the profession has slowly embraced a strategy to prepare all practicing nurses with basic geriatric competencies as a way to ensure that older adults experience appropriate nursing care. Virtually all nurses in the course of their careers care for older adults: providing preventive and wellness programs; helping patients manage multiple chronic conditions and deal with increased mental and physical frailty; and facilitating a peaceful death. It is, therefore, imperative that these nurses have basic competence to deliver care to older adults.

To date, there have been two initiatives to ensure geriatric competency in the practicing nurse. The first is to ensure geriatric competency in all students who graduate from a nursing program. Nursing schools have only recently begun to include geriatrics in their curricula, and most still do not have geriatrics as a significant and integral part ⁽¹⁸⁾. The Hartford Institute initially championed this initiative for geriatric nursing. Working collaboratively with the American Association of Colleges of Nursing, the national organization that accredits schools of nursing, the Hartford Institute developed geriatric competencies and curriculum materials for baccalaureate nursing programs, activities that have now been expanded through additional support from the Hartford Foundation (www.hartfordign.org).

The second initiative, which is only now developing, involves preparing all 2.2 million practicing nurses and the 40,000 registered nurses newly licensed each year with competency in geriatrics. Most new graduates and virtually all practicing nurses have had inadequate preparation in geriatrics. Practicing nurses receive little continuing education in geriatrics. It is only recently that the Joint Commission on the Accreditation of Healthcare Organizations, the accrediting body for hospitals and nursing homes, has required that their member facilities begin to demonstrate age-specific competencies of their personnel.

Initial efforts to ensure geriatric competency in the practicing nurse have focused on the organizations representing the elite group of professional nurses who have an interest and expertise in a specific area of nursing, such as oncology, emergency room, rehabilitation, and intensive care. There are 78 nursing specialty associations that collaborate in a national forum called the Nursing Organization Liaison Forum (NOLF). NOLF functions as a structure of the American Nurses Association. Eliminating the obvious specialties such as pediatrics and midwifery, 60 of these 78 associations, representing a total of 400,000 nurses, focus on a care specialty with a direct impact on older adults. The membership size of these nursing organizations ranges from several hundred to more than 62,000. Ensuring geriatric competency in specialty nurses offers an opportunity to make substantial inroads into "gerontologizing" practicing nurses. Effort to introduce geriatric competencies has involved presentations and a booth to create a geriatric presence at national conferences, providing ready-made materials for use in organization newsletters, journals, and web sites, and creating and/or supporting geriatric focus groups or special interest group that allows for formalizing a sustained interest in geriatrics (www.hartfordign.org).

	Gerontological Nursing: a Research and Policy Perspective

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Research productivity is one of the most impressive outcomes of geriatric nursing during the past 20 years. Often beginning with small qualitative studies, and substantially bolstered by funding from the National Institute for Nursing Research and the National Institute on Aging, geriatric nursing has made substantial contributions to improved patient care and to policy decisions that influence the structure in which care is delivered.

Geriatric nursing research has been influential in changing the paradigm for the use of physical restraints in nursing homes and hospitals ^(25)(26), improving the assessment and management of pressure ulcers ^(27)(28), pioneering improvements in assessment and management of urinary incontinence ⁽²⁹⁾, and ensuring appropriate end-of-life care ^(30)(31). In nursing homes, nursing research has led in exploring strategies to improve care for physically and cognitively frail and vulnerable older adults: creating and testing strategies to improve bathing, feeding, and managing difficult and disruptive behaviors ⁽³²⁾. Nursing research has been instrumental in identifying outcomes associated with evolving models of geriatric care, for example the Geriatric Resource Nurse and Acute Care of the Elderly units in hospitals ^(33)(34), nurse practitioner models in nursing homes ⁽³⁵⁾, a home visit program for older adults as part of a home care agency ⁽⁸⁾, and the use of interdisciplinary teams to provide geriatric care ⁽³⁶⁾. Nursing research is beginning to document the relationship between nurse staffing models and patient outcomes in hospitals ⁽⁷⁾ and nursing homes ^{(11)(35)(37)(38)}, and to document improvements in care that are attributable to the use of geriatric advanced practice nurses ^(10)(35)(39).

Data from these and other studies have been influential in changing policy, reimbursement, and regulations. Especially in nursing homes, these data have changed standards for the use of physical restraints, influenced efforts to create higher standards for nurse staffing in nursing homes, and shown how advance directives can be used to improve end-of-life care.

	Projections for Future Directions

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The evidence of the past 30 years suggests that geriatric nursing will be a force for continued improvements in care to older adults during the next decade. There is good evidence that, in the future, older adults are more likely to be cared for by a nurse who has received special preparation in geriatrics ⁽⁴⁰⁾. The movement toward ensuring geriatric competencies for all practicing nurses should accelerate as curriculum revisions take hold and thus ensure geriatric competency in the future nursing workforce. Expanded efforts hold promise in increasing the number of nurses prepared with geriatric specialization above the current level and ensuring that adult, family, and psychiatric advanced practice nurses will complete their academic programs with a strong preparation in geriatric nursing. These efforts should also serve to ensure geriatric capacity in nurses working with older patients who have comorbidity such as heart disease, cancer, and neurological disorders.

The establishment of Centers for Geriatric Nursing Excellence (http://www.gerontologicalnursing.info/) and programs to support pre- and postdoctoral fellowships in geriatric nursing (www.hartfordign.org; www.gerontologicalnursing.info) are instrumental in ensuring a "pipeline" of well-prepared academic nurses who can sustain programs of geriatric research and educate the next generation of geriatric nursing leaders. Of special note is the past and current commitment of geriatric nurses to tackle difficult but exceptionally meaningful issues that impact profoundly on the health and quality of life of older adults, for example elder mistreatment ⁽⁴¹⁾, the decision-making capacity of cognitively impaired elders ⁽⁴²⁾, and pain assessment and management ⁽⁴³⁾. Continued support from the National Institutes of Health will be crucial if geriatric research is to continue to grow and flourish.

There are several areas of geriatric nursing where the crystal ball is cloudy. The first relates to the role of geriatric teams generally. While care by geriatric teams has consistently been shown to substantially improve outcomes for older adults ⁽⁴⁴⁾, geriatric teams will flourish only in a climate of improved empirical evidence of academic and clinical support. The second area relates to the involvement of geriatric nurses in health policy. While they have made inroads in influencing health care policy, the voice of geriatric nurses at the policy table continues to be underrepresented and undervalued. Several of the new Hartford Foundation-funded geriatric nursing initiatives are addressing the need for leadership preparation. The extent to which they capitalize on this support will directly influence the effectiveness of geriatric nurses to shape and direct policy on behalf of older adults.

	Acknowledgments

 
We express our gratitude to Abraham A. Brody for his assistance in preparing this manuscript.

Received February 21, 2002

Accepted February 22, 2002

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