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U n i t O n e

Core Knowledge

1

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S E C T I O N

1

CHAPTER 1Introduction to Gerontological Nursing

CHAPTER 2The Aging Population

CHAPTER 3Theories of Aging

Critical Thinking

(Competencies 1, 2)

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• Continuing care retirement community• Core competencies• Financial gerontology• Geriatrics• Gerontological nursing• Gerontological rehabilitation nursing• Gerontology• Geropharmacology• Geropsychology• Hospice• Independent living• Middle old• Old old• Rehabilitation• Skilled care• Social gerontology• Subacute care• Unlicensed assistive personnel (UAP)• Young old

Introduction to

Gerontological Nursing

Jeanne St. Pierre, MN, RN, GCNS-BC

Deborah Conley, MSN, APRN-CNS-BC, FNGNA

L E A R N I N G O B J E C T I V E S

At the end of this chapter, the reader will beable to:

• Define important terms related to nursingand the aging process.

• Outline significant landmarks that haveinfluenced the development of geronto-logical nursing as a specialty.

• Identify several subfields of gerontologi-cal nursing.

• Develop the beginnings of a personal phi-losophy of aging.

• Describe the unique roles of the geronto-logical nurse.

• Discuss the scope and standards of prac-tice in gerontological nursing.

• Examine core competencies in geronto-logical nursing.

• Contrast various settings in which nursescare for older adults.

• Distinguish the educational preparation,practice roles, and certification require-ments of the various levels of gerontolog-ical nursing practice.

K E Y T E R M S

• Activities of daily living (ADLs)• Ageism• Assisted living facility• Certification

C H A P T E R 1

THE HISTORY OF GERONTOLOGICALNURSINGThe history and development of gerontologicalnursing is rich in diversity and experiences, as is thepopulation it serves. There has never been a moreopportune time than now to be a gerontologicalnurse. No matter where nurses practice, they will atsome time in their career care for older adults. Thehealth care movement is constantly increasing lifeexpectancy; therefore, nurses must expect to care

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The History of Gerontological Nursing 5

for relatively larger numbers of older people overthe next decades. With the increasing numbers ofacute and chronic health conditions experienced byelders, nurses are in key positions to provide dis-ease prevention and health promotion, and to pro-mote positive aging.

The American Journal of Nursing, the AmericanNurses Association (ANA), and the John A. HartfordFoundation Institute for Geriatric Nursing at NewYork University contributed significantly to thedevelopment of the specialty of gerontological nurs-ing. The specialty was formally recognized in theearly 1960s when the ANA recommended a spe-cialty group for geriatric nurses and the formation ofa geriatric nursing division, and convened the firstnational nursing meeting on geriatric nursing prac-tice. The growth of the specialty soared over thenext three decades. In the early 1970s, the ANAStandards for Geriatric Practice and the Journal ofGerontological Nursing were first published (in 1970and 1975, respectively). Following the enactment offederal programs such as Medicare and Medicaid,rapid growth in the health care industry for eldersoccurred. In the 1970s, the Veterans Administrationfunded a number of Geriatric Research Educationand Clinical Centers (GRECCs) at VA medical centersacross the United States. Nurses were provided sub-stantial educational opportunities to learn about thecare of older veterans through the development ofGRECCs. The Kellogg Foundation also fundednumerous certificate nurse practitioner programs atcolleges of nursing for nurses to become geriatricnurse practitioners. These were not master’s innursing–level programs, but provided needed nurseswho were trained in geriatrics to meet the growingneeds of an aging population.

Terminology used to describe nurses caring forelders has included geriatric nurses, geronticnurses, and gerontological nurses. These terms allhave various meanings; however, gerontologicalnursing provides an encompassing view of the careof older adults. In 1976, the ANA Geriatric NursingDivision changed its name to Gerontological Nurs-ing Division and published the Standards of Geron-tological Nursing (Ebersole & Touhy, 2006; Meiner& Lueckenotte, 2006).

The decade of the 1980s saw a substantialgrowth in gerontological nursing when the NationalGerontological Nursing Association was estab-

lished, along with the ANA statement on the Scopeand Standards of Gerontological Nursing Practice.Increased numbers of nurses began to obtain mas-ter’s and doctoral preparation in gerontology, andhigher education established programs to preparenurses as advanced practice nurses in the field(geriatric nurse practitioners and gerontologicalclinical nurse specialists). Thus, interest in theoryto build nursing as a science grew and nurses werebeginning to consider gerontological nursingresearch as an area of study. Implementation of fiveRobert Wood Johnson (RWJ) Foundation Teaching-Nursing Homes provided the opportunity for nurs-ing faculty and nursing homes to collaborate toenhance care to institutionalized elders. An addi-tional eight community-based RWJ grant–fundeddemonstration projects enabled older adults toremain in their homes and fostered cooperationbetween social service and health care agencies topartner in providing in-home care.

In the 1990s, the John A. Hartford FoundationInstitute for Geriatric Nursing was established at theNYU Division of Nursing. It provided unprecedentedmomentum to improve nursing education andpractice and increase nursing research in the careof older adults. In addition, it focused on geriatricpublic policy and consumer education. The NursesImproving Care for Healthsystem Elders (NICHE)program gained a national reputation as the modelof acute care for older adults.

The 21st century has provided a resurgency ingerontological care, as older adults are gaining fullstatus and recognition by society. As the babyboomers enter the older age group in 2011, thiscadre of individuals will not only expect butdemand excellence in geriatric care. In 2003, thecollaborative efforts of the John A. Hartford Institutefor Geriatric Nursing, the American Academy ofNursing, and the American Association of Collegesof Nursing (AACN) led to the development of theHartford Geriatric Nursing Initiative (HGNI). This ini-tiative substantially increased the number of geron-tological nurse scientists and the development ofevidence-based gerontological nursing practice.Today, there are multiple professional journals,books, Web sites, and organizations dedicated tothe nursing care of older adults. One of the newestjournals to emerge in 2008 was the Journal ofGerontological Nursing Research.

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6 Chapter 1: Introduction to Gerontological Nursing

The development of gerontological nursing as aspecialty is attributed to a host of nursing pioneers.The majority of these nurses were from the UnitedStates; however, two key trailblazers were fromEngland. Florence Nightingale and Doreen Nortonprovided early insights into the “care of the aged.”Nightingale was truly the first geriatric nurse,because she accepted the nurse superintendentposition in an English institution comparable toour current nursing homes. She cared for wealthywomen’s maids and helpers in an institution calledthe Care of Sick Gentlewomen in Distressed Cir-cumstances (Wykle & McDonald, 1997). DoreenNorton summarized her thoughts on geriatric nurs-ing in a 1956 speech at the annual conference ofthe Student Nurses Association in London. Shelater focused her career on care of the aged andwrote often about the unique and specific needs ofelders and the nurses caring for them. She identi-fied the advantages of learning geriatric care inbasic nursing education as: 1) learning patience,tolerance, understanding, and basic nursing skills;2) witnessing the terminal stages of disease andthe importance of skilled nursing care at that time;3) preparing for the future, because no matterwhere one works in nursing the aged will be agreat part of the care; 4) recognizing the impor-tance of appropriate rehabilitation, which callsupon all the skill that nurses possess; and 5) beingaware of the need to undertake research in geri-atric nursing (Norton, 1956).

LANDMARKS IN THE DEVELOPMENTOF GERONTOLOGICAL NURSINGNurse scientists, educators, authors, and cliniciansforged the way for the overall development ofgerontological nursing as we know it today. Someof the most notable pioneers were Irene Burnside,Sister Rose Theresa Barr, Virginia Stone, LucilleGress, Laurie Gunter, Doris Schwartz, Eleanor Pin-grey, Terri Brower, Thelma Wells, Pricilla Ebersole,Patricia Hess, Mary Opal Wolanin, Cynthia Kelly,Florence Cellar, Neville Strumpf, Bernita Steffl, EdnaStilwell, Charlotte Eliopoulos, Lois Evans, MathyMezey, Terry Fulmer, Jeannie Kyser-Jones, CorneliaBeck, Meridean Maas, Kathleen Buckwalter, andAnne Leukenotte.

The following is a summary of significant land-marks in the development of gerontological nurs-ing as a specialty:

1902 American Journal of Nursing (AJN) publishesfirst geriatric article by an MD

1904 AJN publishes first geriatric article by an RN

1925 AJN considers geriatric nursing as a poten-tial specialty

Anonymous column entitled “Care of the Aged”appears in AJN

1950 First geriatric nursing textbook, GeriatricNursing (Newton), published

First master’s thesis in geriatric nursing completedby Eleanor Pingrey

Geriatrics becomes a specialization in nursing

1952 First geriatric nursing study published inNursing Research

1961 ANA recommends specialty group for geri-atric nurses

1962 ANA holds first National Nursing Meeting onGeriatric Nursing Practice

1966 ANA forms a geriatric nursing division

First Gerontological Clinical Nurse Specialist mas-ter’s program begins at Duke University

1968 First RN (Gunter) presents at the Interna-tional Congress of Gerontology

1970 ANA creates the Standards of Practice forGeriatric Nursing

1973 ANA offers the first generalist certificationin gerontological nursing (74 nurses certified)

1975 First nursing journal for the care of older adultspublished: Journal of Gerontological Nursing by Slack, Inc.

First nursing conference held at the InternationalCongress of Gerontology

1976 ANA Geriatric Nursing Division changesname to Gerontological Nursing Division

ANA publishes Standards of Gerontological Nursing

1977 Kellogg Foundation funds Geriatric NursePractitioner certificate education

First gerontological nursing track funded by theDivision of Nursing at the University of Kansas

1979 First national conference on gerontologicalnursing sponsored by the Journal of GerontologicalNursing

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Attitudes Towards Aging and Older Adults 7

1980 AJN publishes Geriatric Nursing journal

Education for Gerontic Nurses by Gunter and Estessuggests curricula for all levels of nursing education

ANA establishes Council of Long Term Care Nurses

1980 First Robert Wood Johnson (RWJ) Foundationgrants for health-impaired elders given (eight in theUnited States)

1981 First International Conference on Geronto-logical Nursing sponsored by the InternationalCouncil of Nursing (Los Angeles, California)

ANA Division of Gerontological Nursing publishesstatement on scope of practice

John A. Hartford Foundation’s Hospital OutcomesProgram for the Elderly (HOPE) using a geriatricresource nurse (GRN) model developed at Yale Uni-versity under the direction of Terry Fulmer

1982 Development of RWJF Teaching-NursingHome Program (five programs in the United States)

1983 First endowed university chair in geronto-logical nursing (Florence Cellar Endowed Geronto-logical Nursing Chair) established at Case WesternReserve University

1984 National Gerontological Nursing Association(NGNA) established

ANA Division on Gerontological Nursing Practicebecomes Council on Gerontological Nursing

1986 National Association for Directors of Nurs-ing Administration in Long Term Care established

ANA publishes Survey of Gerontological Nurses inClinical Practice

1987 ANA revises Standards and Scope of Geron-tological Nursing Practice

1988 First PhD program in gerontological nursingestablished (Case Western Reserve University)

1989 ANA certification established for ClinicalSpecialist in Gerontological Nursing

1990 ANA establishes Division of Long Term Carewithin the Council of Gerontological Nursing

1992 Nurses Improving Care for HealthsystemElders (NICHE) established at New York University(NYU) Division of Nursing based on the HOPEprograms

1996 John A. Hartford Foundation Institute forGeriatric Nursing established at NYU Division ofNursing

NICHE administered through the John A. HartfordFoundation Institute for Geriatric Nursing

1998 ANA certification available for geriatricadvanced practice nurses as geriatric nurse practi-tioners or gerontological clinical nurse specialists

2000 American Academy of Nursing, the John A.Hartford Foundation, and the NYU Division of Nurs-ing develop the Building Academic Geriatric Nurs-ing Capacity (BAGNC) program

2002 American Nurses Foundation (ANF) andANA fund the Nurse Competence in Aging (NCA)joint venture with the John A. Hartford FoundationInstitute for Geriatric Nursing

2003 The John A. Hartford Foundation Institute forGeriatric Nursing, the American Academy of Nurs-ing, and the American Association of Colleges ofNursing (AACN) combine efforts to develop theHartford Geriatric Nursing Initiative (HGNI)

John A. Hartford Foundation Institute for GeriatricNursing at NYU awards Specialty Nursing Associa-tion Programs-in Geriatrics (SNAP-G) grants

2004 American Nurses Credentialing Center’s firstcomputerized generalist certification exam is for thegerontological nurse

2005 Journal of Gerontological Nursing celebrates30 years

2007 NICHE program at John A. Hartford Founda-tion Institute for Geriatric Nursing at NYU receivesadditional funding from the Atlantic Philanthropiesand U.S. Aging Program

2008 Geriatric Nursing journal celebrates 30 years

Journal of Gerontological Nursing Research emerges

ATTITUDES TOWARD AGING ANDOLDER ADULTSAs a nursing student, you may have preconceivedideas about caring for older adults. Such ideas areinfluenced by your observations of family members,friends, neighbors, and the media, and your ownexperience with older adults. Perhaps you have aclose relationship with your grandparents or youhave noticed the aging of your own parents. Forsome of you, the aging process may have becomenoticeable when you look at yourself in the mirror.But for all of us, this universal phenomenon we call

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aging has some type of meaning, whether or not wehave taken the time to consciously think about it.

The way you view aging and older adults is oftena product of your environment and the experiencesto which you have been exposed. Negative attitudestoward aging or older adults (ageism) often arisein the same way—from negative past experiences.Many of our attitudes and ideas about older adultsmay not be grounded in fact. Some of you mayhave already been exposed to ageism, which isoften displayed in much the same way as sexism orracism—via attitudes and actions. This is one rea-son for studying the aging process—to examine themyths and realities, to separate fact from fiction,and to gain an appreciation for what older adultshave to offer.

Population statistics show that the majority ofyour careers as nurses will include caring for olderadults. As Mathy Mezey, director of the John A.Hartford Foundation Institute for Geriatric Nursingat NYU, stated, “The population of older Americansis exploding. Geriatric patients are not one sub-group of patients but rather the core business ofhealth systems” (Mezey, 2005). Providing high-quality care to elders requires knowledge of theintricacies of the aging process as well as theunique syndromes and disease conditions that canaccompany growing older.

As you read and study this book, you areencouraged to examine your own thoughts, values,feelings, and attitudes about growing older. Per-haps you already have a positive attitude towardcaring for older adults. Build on that value, and con-sider devoting your time and efforts to the practiceof gerontological nursing. If, however, you arereading this chapter with the idea that gerontolog-ical nursing is a less desirable field of nursing, orthat only those nurses who cannot find jobs else-where work in nursing homes, or that working witholder people would be an option of last resort, thenyou may need to re-examine these feelings. Armedwith the facts and some positive experiences witholder adults, you may change your mind.

Advocates for older adults, such as Nobel lau-reate Elie Wiesel, feel that older adults, as reposito-ries of our collective memories, should beappreciated and respected. As the 1997 AmericanPsychological Association’s keynote conventionspeaker, Wiesel said, “. . . an old person represents

wisdom and the promise of living a full life . . . theworst curse is to make him or her feel worthless”(American Psychological Association, 2008).

The older population is changing dramatically asthe baby boomers (those born from 1946–1964)reach retirement age (as of 2011). Because this phe-nomenon is happening in many places around theglobe (see Chapters 2 and 23), gerontology is theplace to be! Caring for the largest number of olderadults in history will present enormous opportuni-ties. With the over-85 age group being the fastestgrowing, the complexity of caring for so many peo-ple with multiple physical and psychosocialchanges will present a challenge for the most dar-ing of nurses. Will you be ready?

The purpose of this book is to provide the essen-tial information needed by students of gerontolog-ical nursing to provide quality care to older adults.In your study of this text, you will be presented withknowledge and insights from experienced profes-sionals with expertise in various areas of geronto-logical nursing and geriatrics. Each chapter containsthought-provoking activities and questions for per-sonal reflection. Case studies will help you to thinkabout and apply the information. A glossary isincluded at the end of the chapter to help you mas-ter key terms, and plenty of tables and figures sum-marize key information. Web sites are included asa means of expanding your knowledge. Use thistext as a guidebook for your study. Use all theresources available, including your instructors, toimmerse yourself in the study of the aging process.By the end of this book, you will have learned aboutthe essential competencies needed to provideexcellent care to older adults.

DEFINITIONSGerontology is the broad term used to define thestudy of aging and/or the aged. This includes thebiopsychosocial aspects of aging. Under theumbrella of gerontology are several subfieldsincluding geriatrics, social gerontology, geropsy-chology, geropharmacology, financial gerontology,gerontological nursing, and gerontological rehabil-itation nursing, to name a few.

What is old and who defines old age? Interest-ingly, although “old” is often defined as over 65years of age, this is an arbitrary number set by the

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Roles of the Gerontological Nurse 9

Social Security Administration. Today, the older agegroup is often divided into the young old (ages65–74), the middle old (ages 75–84), and the oldold, very old, or frail elderly (ages 85 and up). How-ever, these numbers merely provide a guideline anddo not actually define the various strata of the agingpopulation. Among individuals, vast differencesexist between biological and chronological aging,and between the physical, emotional, and socialaspects of aging. How and at what rate a personages depends upon a host of factors that will be dis-cussed throughout this book. The aging populationas well as theories and concepts related to agingare discussed further in Chapters 2 and 3.

Geriatrics is often used as a generic term relat-ing to the aged, but specifically refers to medicalcare of the aged. For this reason, many nursingjournals and texts have chosen to use the termgerontological nursing instead of geriatric nursing.

Social gerontology is concerned mainly withthe social aspects of aging versus the biological orpsychological. “Social gerontologists not only drawon research from all the social sciences—sociology,psychology, economics, and political science—theyalso seek to understand how the biologicalprocesses of aging influence the social aspects ofaging” (Quadagno, 2005, p. 4). Geropsychologyis a branch of psychology concerned with helpingolder persons and their families maintain well-being, overcome problems, and achieve maximumpotential during later life. Geropharmacology isthe study of pharmacology as it relates to olderadults. The credential for a pharmacist certifiedin geropharmacology is CGP (certified geriatricpharmacist).

Financial gerontology is another emergingsubfield that combines knowledge of financial plan-ning and services with a special expertise in theneeds of older adults. Cutler (2004) defines financialgerontology as “the intellectual intersection of twofields, gerontology and finance, each of which haspractitioner and academic components” (p. 29).This field is further discussed in Chapter 25.

Gerontological rehabilitation nursing com-bines expertise in gerontological nursing with reha-bilitation concepts and practice. Nurses working ingerontological rehabilitation often care for olderadults with chronic illnesses and long-term func-tional limitations such as stroke, head injury, mul-

tiple sclerosis, Parkinson’s disease, spinal cordinjury, arthritis, joint replacements, and amputa-tions. The purpose of gerontological rehabilitationnursing is to assist older adults to regain and main-tain the highest level of function and independencepossible while preventing complications andenhancing quality of life.

Gerontological nursing, then, falls within thediscipline of nursing and the scope of nursing prac-tice. It involves nurses advocating for the health ofolder persons at all levels of prevention. Geronto-logical nurses work with healthy elderly persons intheir communities, acutely ill elders requiring hos-pitalization and treatment, and chronically ill or dis-abled elders in long-term care facilities, skilled care,home care, and hospice. The scope of practice forgerontological nursing includes all older adultsfrom the time of “old age” until death. Gerontolog-ical nursing is guided by standards of practice thatwill be discussed later in this chapter. Several rolesof the gerontological nurse will be discussed in thefollowing sections.

ROLES OF THE GERONTOLOGICALNURSE

Provider of CareIn the role of caregiver or provider of care, thegerontological nurse gives direct, hands-on care toolder adults in a variety of settings. Older adultsoften present with atypical symptoms that compli-cate diagnosis and treatment. Thus, the nurse as acare provider should be educated about diseaseprocesses and syndromes commonly seen in theolder population. This may include knowledge ofrisk factors, signs and symptoms, usual medicaltreatment, rehabilitation, and end-of-life care.Chapters 13, 14, and 15 cover management of com-mon illnesses, diseases, and health conditions,imparting essential information for providing qual-ity care.

TeacherAn essential part of all nursing is teaching. Geron-tological nurses focus their teaching on modifiablerisk factors and health promotion (see Chapters 9,11, and 12). Many diseases and debilitating condi-tions of aging can be prevented through lifestyle

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modifications such as a healthy diet, smoking ces-sation, appropriate weight maintenance, increasedphysical activity, and stress management. Nurseshave a responsibility to educate the older adult pop-ulation about ways to decrease the risk of certaindisorders such as heart disease, cancer, and stroke,the leading causes of death for this group. Nursesalso may develop expertise in specialized areas andteach skills to other nurses in order to promotequality patient care among older adults.

ManagerGerontological nurses act as managers duringeveryday practice as they balance the concerns ofthe patient, family, nursing, and the rest of the inter-disciplinary team. Nurse managers must be skilledin leadership, time management, building relation-ships, communication, and managing change.Nurse managers may supervise other nursing per-sonnel including licensed practical nurses (LPNs),certified nursing assistants (CNAs), technicians,nursing students, and other unlicensed assistivepersonnel (UAP). The role of the gerontologicalnurse as manager and leader is further discussed inChapter 23.

AdvocateAs an advocate, the gerontological nurse acts onbehalf of older adults to promote their best interestsand strengthen their autonomy and decision mak-ing. Advocacy may take many forms, includingactive involvement at the political level or helpingto explain medical or nursing procedures to familymembers on a unit level. Nurses may also advocatefor patients through other activities such as helpingfamily members choose the best nursing home fortheir loved one or listening to family members venttheir frustrations about health problems encoun-tered. Whatever the situation, gerontological nursesmust remember that being an advocate does notmean making decisions for older adults, butempowering them to remain independent andretain dignity, even in difficult situations.

Research ConsumerThe appropriate level of involvement for nurses at the baccalaureate level is that of research con-sumer. Gerontological nurses must remain abreastof current research literature, reading and put-

ting into practice the results of reliable and validstudies. Using evidence-based practice, gerontol-ogical nurses can improve the quality of patientcare in all settings. Although nurses with under-graduate degrees may be involved in research insome facilities, such as assisting with data collec-

Case Study 1-1

Rose is a 52-year-old nursing student who hasreturned to school for her BSN after raising a fam-ily. She is the divorced mother of two grown chil-dren and has one young grandson. In addition tobeing a full-time student in an accelerated program,Rose also cares for her 85-year-old mother in herown home and occasionally helps provide childcarefor her grandson while his parents work. Rose’smother has diabetes and is legally blind. Rose is tak-ing a gerontology course this semester and findsherself going home quite upset after the first weekof classes when attitudes toward aging were dis-cussed. While sharing with the course instructor herfeelings and surprising emotional discomfort, Roseis helped to identify that she is afraid of getting olderand being unable to care for her ailing mother andherself. As a single woman, she is unsure that shecan handle what lies ahead for her as she is begin-ning to feel the effects of aging herself.

Questions:1. What can Rose do to become more comfort-

able with facing her own advancing age?2. What factors may have influenced her discom-

fort with the course material?3. Is there anything the instructor of the course

might do to help Rose cope with the feelingsshe is having as she completes the requiredcoursework?

4. There may be some activities that Rose can doin order to understand her feelings aboutaging better. Can you think of some suchactivities?

5. What is Rose’s role as the caregiver in this sit-uation? How may the role change over time?

6. How much does Rose’s present home and liv-ing situation contribute to her fears and per-ceptions of aging?

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Certification 11

tion or providing research ideas inspired by clinicalproblems, their basic preparation is aimed prima-rily at using research in practice. All nurses shouldread professional journals specific to their specialtyand continue their education by attending seminarsand workshops, participating in professional orga-nizations, pursuing additional formal education ordegrees, and obtaining certification. In being aresearch consumer, gerontological nurses canimprove the quality of patient care in all settings.

Expanded roles of the gerontological nurse mayalso include counselor, case manager, coordinatorof services, collaborator, geriatric care manager,and others. Several of these roles are discussed inChapters 20, 23, and 25.

CERTIFICATIONTo provide competent, current care to elders, nursesneed to have gerontological nursing content in theirbasic undergraduate nursing curricula and areencouraged to become certified in gerontologicalnursing. Less than 1% of nurses in the United Statesare certified in gerontological nursing; however,more than 50% of the patients cared for are elders.Adults age 65 or older utilize 48–50% of the nation’stotal health care resources and represent approxi-mately 38% of all admissions to hospitals (Stierleet al., 2006). Patients and their families are knowl-edgeable about quality health care and patient safetyand want the most expert clinicians at the bedside.Certification provides reassurance to patients andtheir families that the nurses caring for them arehighly skilled and possess expert knowledge in pro-viding excellence in gerontological nursing care(Hartford Institute for Geriatric Nursing, 2008).

Nurse certification is a formal process by whicha certifying agency validates a nurse’s knowledge,skills, and competencies through a written exami-nation in a specialty area of practice. There are twolevels of certification: generalist and advancedpractice level. Each has different eligibility stan-dards. The American Nurses Credentialing Center(ANCC) is the certifying body for both levels ofgerontological nursing practice.

Generalist CertificationThe generalist in gerontological nursing has com-pleted a basic entry-level program in nursing, which

can be a diploma in nursing, or an associate or bach-elor of science degree in nursing. Before meetingadditional eligibility requirements to become certifiedin gerontological nursing, the applicant must be alicensed registered nurse for at least 2 years. ANCCoffers the generalist computerized exam in geronto-logical nursing at over 300 computer-based testingsites across the country. This exam was the first oneto become computerized, increasing the convenienceof sitting for gerontological nursing certification.

Certified gerontological nurses utilize principlesof gerontological nursing and gerontological com-petencies as they implement the nursing processwith patients. Gerontological certified nurses:

• Assess, manage, and deliver health care thatmeets the needs of older adults

• Evaluate the effectiveness of their care• Identify the strengths and limitations of their

patients• Maximize patient independence• Involve patients and family members (Ameri-

can Nurses Credentialing Center [ANCC], 2008)

There are a number of compelling reasons fornurses to pursue gerontological nurse certification.Certified gerontological nurses:

• Experience a high degree of professionalaccomplishment and satisfaction

• Demonstrate a commitment to their profession• Provide higher quality of care to older adults• Act as resources for other nurses and interdis-

ciplinary team members• Demonstrate evidence-based gerontological

nursing care• Are recognized as national leaders in geronto-

logical nursing care• Create the potential for higher salaries and

benefits• Are actively recruited for employment at nurs-

ing faculty, in Magnet and NICHE designatedhospitals, in long-term care facilities, in acuterehab, and in community health agencies(ANCC, 2008; Hartford Institute for GeriatricNursing, 2008)

See the ANCC Web site (http://www.nursecredentialing.org) for eligibility requirements and informa-tion about gerontological nurse certification andrecertification.

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Advanced CertificationThe ANCC offers two separate advanced practice cer-tification exams in gerontological nursing: the clinicalspecialist in gerontological nursing (GCNS-BC) andthe gerontological nurse practitioner (GNP-BC). Thereare different eligibility requirements for each exam. TheANCC Web site (http://www.nursecredentialing.org) provides eligibility requirements and informationon certification and recertification. As with mostcertifications, minimum educational and practicerequirements must be met and maintained. Bothcertifications are considered to signify expert clini-cians; those certified must hold a minimum of amaster’s degree in nursing, which includes at least500 hours of precepted clinical practice. Recertifi-cation mandates retaking the exam or submitting aportfolio that demonstrates that the candidate hasmet specific requirements.

Many states require advanced practice regis-tered nurses (APRNs) to hold a separate license asan APRN. The advanced practice role encompasseseducation, consultation, research, case manage-ment, administration, and advocacy in the care ofolder adults. In addition, APRNs develop advancedknowledge of nursing theory, research, and clinicalpractice. The APRN is an expert in providing carefor older adults, families, and groups in a variety ofsettings.

The gerontological clinical nurse specialistfocuses on three spheres of influence: patient/family care, developing nurses, and impactingorganizations and systems. Gerontological clinicalnurse specialists (CNSs) play important roles inacute care by developing and implementing geron-tological nursing evidence-based practice. In addi-tion, some roles involve a collaborative practice orconsultative role with hospitals or long-term care

facilities and interdisciplinary teams. In somestates, gerontological CNSs may obtain prescriptiveauthority and broaden their scope of practice.Gerontological CNSs have developed and managedclinics for common conditions in the older popula-tion such as incontinence, falls, wounds, or cogni-tive impairments. The ANCC describes the role ofthe gerontological CNS as follows:

The Clinical Nurse Specialist in Gerontolog-ical Nursing (GCNS) is a registered nurse pre-pared in a graduate level gerontological clinicalnurse specialist program to provide advancedcare for older adults, their families, and signifi-cant others. The GCNS has an expert under-standing of the dynamics, pathophysiology, andpsychosocial aspects of aging. The GCNS usesadvanced diagnostic and assessment skills andnursing interventions to manage and improvepatient care. Using theory and research, theGCNS’s practice considers all influences on apatient’s health status and the related psychoso-cial and behavioral problems arising from thepatient’s altered physiological condition. TheGCNS practices in diverse settings and is activelyengaged in education (e.g., patient, staff, stu-dents, and colleagues), case management,expert clinical practice, consultation, research,and administration. (ANCC, 2008)

The gerontological nurse practitioner (GNP) prac-tices in acute or long-term care settings and in col-laborative practice with physicians who maintainlarge geriatric practices. GNPs make regular visitsto nursing homes where patients in their collabora-tive practice reside. GNPs practice in rehabilitationfacilities, working in outpatient clinics for rehabili-tation patients after discharge or with specialty

TABLE 1-1 Web Sites for Test Content Outlines

http://www.nursecredentialing.org/NurseSpecialties/Gerontological.aspxhttp://www.nursecredentialing.org/NurseSpecialties/GerontologicalCNS.aspxhttp://www.nursecredentialing.org/NurseSpecialties/GerontologicalNP.aspx

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Scope and Standards of Practice 13

physicians, managing caseloads, and diagnosingand treating geriatric syndromes. The ANCCdescribes the role of the gerontological nurse prac-titioner as follows:

The Gerontological Nurse Practitioner (GNP)is a registered nurse prepared in a graduatelevel gerontological nurse practitioner programto provide a full range of health care services onthe wellness-illness health care continuum atan advanced level to older adults. The GNPpractice includes independent and interdepend-ent decision making, and is directly account-able for clinical judgments. The graduate levelpreparation expands the GNP’s role to includedifferential diagnosis and disease management,participation in and use of research, develop-ment and implementation of health policy,

leadership, education, case management, andconsultation. (ANCC, 2008, p. 1)

SCOPE AND STANDARDS OFPRACTICEThe scope of nursing practice is defined by stateregulation, but is also influenced by the uniqueneeds of the population being served in a given set-ting. The needs of older adults are complex andmultifaceted, and the focus of nursing care dependson the setting in which the nurse practices.Gerontological nursing is practiced in accordancewith standards developed by the profession of nurs-ing. In 2001, the ANA Division of GerontologicalNursing Practice developed the second edition ofthe Scope and Standards of Gerontological Nursing

BOX 1-1 Web Exploration

Explore the following Web sites for furtherinformation on certification and geronto-logical associations of interest to nurses.

Educational Web Sites

Hartford Geriatric Nursing Initiative, AboutHGNI

www.gerontologicalnursing.info

Hartford Geriatric Nursing Initiative, Consult-GeriRN.org

www.consultgeriRN.com

American Nurses Association (ANA)www.nursingworld.org

Associations

U.S. Administration on Agingwww.aoa.dhhs.gov

American Geriatrics Societywww.americangeriatrics.org

American Nurses Credentialing Center (ANCC)www.nursecredentialing.org

Gerontological Society of Americawww.geron.org

Hospice and Palliative Nurses Association(HPNA)

www.hpna.org

John A. Hartford Foundation Institute for Geri-atric Nursing

www.hartfordign.org

National Adult Day Services Associationwww.nadsa.org

National Association of Geriatric NursingAssistants (NAGNA)

www.culturechangenow.com/stories/nagna.html

National Association of Professional GeriatricCare Managers

www.caremanager.org

National Council on the Agingwww.ncoa.org/

National Gerontological Nursing Associationwww.ngna.org

National Institute on Agingwww.nia.nih.gov

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Practice, in collaboration with the National Geron-tological Nursing Association, the National Asso-ciation of Directors of Nursing Administrators inLong Term Care, and the National Conference ofGerontological Nurse Practitioners. Standards areprovided both for clinical care and for the profes-sional role of the nurse. These standards includeassessment, diagnosis, outcome identification,planning, implementation, and evaluation. Thestandards of professional gerontological nursingperformance include quality of care, performanceappraisals, education, collegiality, ethics, collabo-ration, research, and research utilization. Studentsshould note that these are the basic standards forprofessional nursing, but here they are applied to thecare of the older adult. Core competencies, discussedin the next section, provide specific guidelines forgerontological nursing care. A full description and

copy of the scope and standards is available atwww.nursingworld.org or www.ngna.org.

CORE COMPETENCIESSpecific core competencies have been identifiedfor gerontological nursing in addition to generalprofessional nursing preparation. These competen-cies are influenced by the level at which the nursewill function and the role expectations of the nurse.Core competencies provide a foundation of addedknowledge and skills necessary for the nurse toimplement in daily practice. For example, thegerontological nurse in advanced practice hasexpanded expertise and skills to fulfill specializedroles. Common bodies of assumptions, knowledge,skills, and attitudes that are essential for excellentclinical nursing practice with older adults havebeen developed and provide the basic foundationfor all levels of gerontological nursing practice.

The American Association of Colleges of Nursing(AACN) and the John A. Hartford Foundation Institutefor Geriatric Nursing gathered input from qualifiedgerontological nursing experts to publish OlderAdults: Recommended Baccalaureate Competenciesand Curricular Guidelines for Geriatric Nursing Care(2000). This document also provided the frameworkfor this text. The core competencies set forth forgerontological nursing appear in Table 1-2. Thepurpose of this document specific to gerontologicalnursing was to use the AACN’s Essentials of Baccalau-reate Education for Professional Nursing Practice(1998) as a framework to help nurse educators inte-grate specific nursing content into their programs.The original AACN document suggested core com-petencies, knowledge, and role development for pro-fessional nurses. These appear in Table 1-3. Thegeriatric competencies in Table 1-2 correlate withand were derived from the suggestions in the moregeneral AACN document in Table 1-3. By using thesepublished documents as guides, nursing professorsand others who educate in the area of gerontologi-cal nursing should be able to prepare students to becompetent to provide excellent care to older adults.

CONTINUUM OF CAREGerontological nurses practice in a multitude of set-tings. Adults over age 65 comprise 48% of patients

BOX 1-2 Additional Resources

American Nurses Credentialing Center (ANCC)

P.O. Box 791333Baltimore, MD 21279-1333202-651-7000800-284-2378www.nursecredentialing.com

John A. Hartford Foundation

55 East 59th Street16th FloorNew York, NY 10022-1178212-832-7788E-mail: [email protected]

Geriatric Nursing Review Syllabus: A CoreCurriculum in Advanced Practice GeriatricNursing (GNRS) (2003–2005)

Available from the American GeriatricsSociety

1-800-334-1429 ext. 2529

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TABLE 1-2 Competencies Necessary for Nurses to Provide High-Quality Careto Older Adults and Their Families

1. Recognize one’s own and others’ attitudes, values, and expectations about aging and their impacton care of older adults and their families.

2. Adopt the concept of individualized care as the standard of practice with older adults.3. Communicate effectively, respectfully, and compassionately with older adults and their families.4. Recognize that sensation and perception in older adults are mediated by functional, physical, cog-

nitive, psychological, and social changes common in old age.5. Incorporate into daily practice valid and reliable tools to assess the functional, physical, cognitive,

psychological, social, and spiritual status of older adults.6. Assess older adults’ living environment with special awareness of the functional, physical, cogni-

tive, psychological, and social changes common in old age.7. Analyze the effectiveness of community resources in assisting older adults and their families to retain

personal goals, maximize function, maintain independence, and live in the least restrictive environment.8. Assess family knowledge of skills necessary to deliver care to older adults.9. Adapt technical skills to meet the functional, physical, cognitive, psychological, social, and

endurance capacities of older adults.10. Individualize care and prevent morbidity and mortality associated with the use of physical and

chemical restraints in older adults.11. Prevent or reduce common risk factors that contribute to functional decline, impaired quality of

life, and excess disability in older adults.12. Establish and follow standards of care to recognize and report elder mistreatment.13. Apply evidence-based standards to screen, immunize, and promote healthy activities in older adults.14. Recognize and manage geriatric syndromes common to older adults.15. Recognize the complex interaction of acute and chronic co-morbid conditions common to older adults.16. Use technology to enhance older adults’ function, independence, and safety.17. Facilitate communication as older adults transition across and between home, hospital, and nurs-

ing home, with a particular focus on the use of technology.18. Assist older adults, families, and caregivers to understand and balance “everyday” autonomy and

safety decisions.19. Apply ethical and legal principles to the complex issues that arise in care of older adults.20. Appreciate the influence of attitudes, roles, language, culture, race, religion, gender, and lifestyle

on how families and assistive personnel provide long-term care to older adults.21. Evaluate differing international models of geriatric care.22. Analyze the impact of an aging society on the health care system.23. Evaluate the influence of payer systems on access, availability, and affordability of health care for

older adults.24. Contrast the opportunities and constraints of a supportive living arrangement on the function and

independence of older adults and on their families.25. Recognize the benefits of interdisciplinary team participation in care of older adults.26. Evaluate the utility of complementary and integrative health care practices on health promotion

and symptom management for older adults.27. Facilitate older adults’ active participation in all aspects of their own health care.

Continuum of Care 15

(continues)

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seen in the hospital, 80% of home care patients, and90% of those in nursing homes (Mezey, 2005). A fewof these settings will be discussed here. Some addi-tional unique areas of employment are suggestedin Chapter 23.

Because of the nature of the aging process, it islikely that older adults will enter and exit the healthcare system at many different points throughout oldage. Figure 1-1 presents the web of health carethat often occurs when older adults enter the sys-tem due to illness or accident.

Settings of care can be described and titled in avariety of ways. Following is a brief description ofsome of the most common settings of care, employ-ing commonly used nomenclature.

Acute Care HospitalThe acute care hospital is often the point of entryinto the health care system for older adults. Nursesworking in hospitals are likely to care for olderadults even if they do not specialize in geriatrics,because about half of all patients in this setting are65 years of age or older. In this setting, gerontolog-ical nurses focus on nursing care of acute problems,often involving exacerbations of cardiopulmonaryconditions, cancer treatment, and orthopedic prob-lems. All nursing units (with the exception of laborand delivery, postpartum, and pediatrics) in acutecare hospitals admit older adults, so nurses mayencounter elderly patients in critical care or reha-bilitative services or anywhere in between. Thegoal of inpatient care will be to promote recoveryand prevent complications.

Acute RehabilitationRehabilitation may be found in various degrees inseveral settings, including the acute care hospital,

TABLE 1-3 AACN Essentials(1998)

Core CompetenciesCritical thinkingCommunicationAssessmentTechnical skills

Core KnowledgeHealth promotion, risk reduction, and disease

preventionIllness and disease managementInformation and health care technologiesEthicsHuman diversityGlobal health careHealth care systems and policy

Role DevelopmentProvider of careDesigner/manager/coordinator of careMember of a profession

SOURCE: American Association of Colleges of Nursing.(1998). Essentials of baccalaureate education for profes-sional nursing practice. Washington, DC: Author.

28. Involve, educate, and when appropriate, supervise family, friends, and assistive personnel in imple-menting best practices for older adults.

29. Ensure quality of care commensurate with older adults’ vulnerability and frequency and intensityof care needs.

30. Promote the desirability of quality end-of-life care for older adults, including pain and symptommanagement, as essential, desirable, and integral components of nursing practice.

SOURCE: American Association of Colleges of Nursing and the John A. Hartford Institute for Geriatric Nursing. (2000). Older adults:Recommended baccalaureate competencies and curricular guidelines for geriatric nursing care. Washington, DC: Author.

TABLE 1-2 (continued)

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subacute care or transitional care, and long-termcare facilities (LTCFs). Regardless of the setting,rehabilitation is accomplished through the work ofan interdisciplinary team that includes nurses, ther-apists, and physicians as well as other professionalstaff. The goals of rehabilitation are to maximizeindependence, promote maximal function, preventcomplications, and promote quality of life withineach person’s strengths and limitations.

The level of intensity of acute rehabilitation isgreater than for subacute or long-term care. Forolder adults to qualify for rehabilitation in the acutecare hospital, they must be able to tolerate at least3 hours of therapy per day. The interdisciplinaryteam will work together to set up mutually estab-lished goals with the patient. Inpatient rehabilitationin the acute setting is beneficial to help persons

recovering from or adapting to such conditions asstroke, head trauma, neurological diseases, ampu-tation, orthopedic surgery, and spinal cord injury.

Home Health CareIndependent-living older adults requiring a longerperiod of observation or care from nurses may becandidates for home health care services. Homehealth care is designed for those who are home-bound due to severity of illness or immobility. Vis-iting nurse associations (VNAs) have long beenknown for their positive reputation in providinghome health care. For reimbursement of allowableexpenses, home health care services must beordered by a physician and the person must be con-sidered homebound. There has been record growthin the number of home health agencies in the past

FIGURE 1-1 The “web” of health care for older adults.

Inpatient subacute�unit

Home

Inpatient rehabilitation�unit

Long-term care facility�(Nursing home)

ACUTE CARE HOSPITAL

–Long-term transitional�–General�–Chronic�–Transitional

–PT�–OT�–Speech therapy�–Social services�–Nursing care�–Ancillary services

–OP therapies�–Home health care�–Adult day care�–Vocational rehab�–Hospice

–Skilled�–Intermediate�–Assisted living�–Residential�–Group homes�–Hospice�–Subacute

SOURCE: Easton, K. L., 1999, Gerontological Rehabilitation Nursing, p. 14. Philadelphia: W.B. Saunders. Used with permission.

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decade. People’s desire to be cared for in familiarsurroundings by their families, versus an institution,has fueled the need for more agencies.

Although physical, occupational, and speechtherapies may be obtained through home care, aswell as home health aide services, a nurse mustopen the case file and the individual must warrantsome type of nursing services to qualify. The major-ity of home health care patients are elderly with avariety of nursing needs, such as wound care, intra-venous therapy, management of newly diagnoseddiabetes, and tube feedings.

Long-Term Care FacilityTraditionally referred to as nursing homes, long-term care facilities (LTCFs) provide support to per-sons of any age who have lost some or all of theircapacity for self-care due to illness, disability, ordementia. Though not acutely ill, residents ofLTCFs, like hospitalized patients, require 24-hournursing care (SeniorHousingNet, 2008).

Registered nurses working in long-term careprovide care planning and oversight of numerousresidents, often directing and coordinating the carevia licensed practical nurses and certified nursingassistants or other unlicensed assistive personnel(UAP). Nurses working in long-term care will bechallenged to maintain the functional and nutri-tional status of residents, while preventing compli-cations of impaired mobility such as pressure ulcersand falls. Dementia care is often a substantial partof the nursing care provided, as is managing resi-dents’ health conditions and medication regimens.Long-term care facilities often house specialty careunits such as skilled nursing units and Alzheimer’scare units, described in the next section.

Skilled Nursing Facilities

Skilled nursing facilities (SNFs), sometimes calledsubacute or transitional care, are for those patientsrequiring more intensive nursing care than pro-vided in long-term care and are usually found asspecially designated units within long-term carefacilities or occasionally within hospitals(SeniorOutlook.com, 2008). SNF patients are oftentransferred from the hospital to continue theirrecovery from an acute episode and often requirecontinued therapy (physical, occupational, and/orspeech). Frequent patient assessments are needed

for a limited time period for stabilization or com-pletion of a treatment regimen. “Typical individu-als seen in subacute care are those needingassistance as a result of non-healing wounds,chronic ventilator dependence, renal problems,intravenous therapy, and coma management andthose with complex medical and/or rehabilitativeneeds, including pediatrics, orthopedics, and neu-rological. These units are designed to promoteoptimum outcomes in the least expensive cost set-ting” (Easton, 1999, p. 15).

Good assessment and communication skillsare needed to care for these complex patients. Theskilled care nurse should have knowledge oftransfer techniques, prevention and assessment ofswallowing problems, bowel and bladder man-agement, and nutrition. The gerontological nurseworking in skilled care must have expertise in pre-venting the hazards of immobility such as pres-sure ulcers and contractures. Gerontologicalnurses working in this setting would benefit fromhaving a critical care background and rehabilita-tion experience as well.

Alzheimer’s Care

A growing trend in LTCFs is to offer dedicated unitsfor the care of persons with Alzheimer’s diseaseand other dementing illnesses. Because of the highrate of Alzheimer’s with advanced age, there is agrowing need for units that provide nursing care forelders in the various stages of dementia. Often,family members can care for their loved ones athome during the early stages. However, due toimpaired judgment that may pose safety issues,during middle and late stage dementia the olderadult cannot be left alone. As memory loss pro-gresses, home caregivers often feel overwhelmedand unable to provide the required care.

The goal of dementia care is to preserve thefunctional status of the demented person via sup-portive care that fosters self-worth and socializa-tion even within the context of diminishingcognitive capacity. Alzheimer’s units can be a greatbenefit to the community by having gerontologicalnursing staff with expertise in the management ofthis challenging disease. Nurses can help familymembers understand disease progression andassure them that their loved one is being well caredfor even to the end of this ultimately fatal disease.

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HospiceGerontological nurses may also choose to work inhospice, caring for dying persons and their fami-lies. Although many patients in hospice are not eld-erly, the majority of the dying are older. The conceptof hospice is centered on holistic, interdisciplinarycare that helps the dying person “live until they die.”(See Chapter 24 for further discussion.) A numberof team members who specialize in thanatologyand palliative care work together to provide qualitycare for patients in their last months, weeks, days,and hours of life. Pain management and comfortcare are the standards upon which treatment isbased. Nurses and physicians work closely withsocial workers, chaplains, psychologists, and otherhospice professionals to make death as comfort-able and as easy a transition as possible.

Hospice care is found in a variety of facilities.Some hospices are stand-alone organizationswith their own building. Home care often offershospice, and certain nursing homes will offer ahospice unit or care within the skilled unit or froman outside hospice nurse. Clinical nurse special-ists provide a great service as expert clinicians andconsultants to the hospice team. Whatever thesetting, hospice requires a great deal of patience,expertise, understanding, interdisciplinary com-munication, and compassion on the part of thegerontological nurse.

Respite CareCaregiving for a dependent older adult can be ademanding task. Caregivers often need a breakfrom caregiving to relieve stress and preventburnout. Respite care provides time off for familymembers who care for someone who is ill, injured,frail, or demented. Respite care can be provided inan adult daycare center, in the home of the personbeing cared for, or in an assisted living facility orlong-term care facility. Although there are differentapproaches to respite care, all have the same basicobjective: to provide caregivers with temporary,intermittent, substitute care, allowing for relief fromthe daily responsibilities of caregiving.

Respite care is not covered by Medicaid orMedicare, but may be covered by long-term careinsurance policies or by local social service agencies,with fees based on a sliding scale of financial need.

Continuing Care RetirementCommunity (CCRC)Also referred to as a life care community, a con-tinuing care retirement community (CCRC)provides a continuum of care from independentliving to skilled care (the latter consisting of caretypically provided by traditional nursing homes), allwithin a single campus, with levels of care adjustedto individual needs. Depending on the facility’scontract, additional services are provided for anadditional fee or are included in a lump-sumupfront payment. Older adults can move seam-lessly among independent living, assisted living,skilled care, or long-term care as their conditionswarrant. Some CCRCs include independent andassisted living, but provide home health serviceswithin the facility instead of moving the resident toa skilled unit. Nurses play a role in the care ofCCRC residents as they progress from independentliving to requiring skilled nursing care, but geron-tological nurses may also function in the area ofhealth promotion to help older adults maintainindependence for as long as possible.

Assisted LivingAs older persons continue to age, it is likely thatcommon disorders associated with the agingprocess may interfere with their ability to care forthemselves. Assisted living facilities (ALFs), a bur-geoning option for older adults, provide an alterna-tive for those older adults who do not feel safe livingalone, who wish to live in a community setting, orwho need some additional help with activities ofdaily living (ADLs). The ALF may be connectedwith a long-term facility or care network, or may befree-standing. For those units that are part of alarger facility, residents who find themselves in needof greater assistance may then progress to the nextlevel of care. The drawback of a free-standing facil-ity is that older adults whose condition worsens andwho need greater assistance may need to pay extrafor that assistance, depending on the terms of theircontract. Some may even need to find an alternatefacility that provides a higher level of care than thatprovided by their ALF.

The typical resident in an assisted living facilityhas a private room or apartment (with a variety ofdesigns available for different costs). All rooms will

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FIGURE 1-2 Assisted living facilities aid older people with activities of daily living.

SOURCE: © Comstock Images/Alamy Images.


have some type of kitchen or kitchenette and pri-vate bathroom with shower. The rest of the spaceincludes a bed or bedroom, living area, and closetspace. Older adults who enter an ALF often selltheir homes and plan to spend as long as possibleliving with minimal assistance.

Assisted living facilities generally providehealthy meals, planned activities, places to walkand exercise, and pleasant surroundings whereadults can socialize with others in a safe and pro-tected environment. Walking paths, aviaries, work-out rooms, beauty salons, community gatheringrooms, chapels, and game rooms are part of manyassisted living facilities.

Foster Care or Group HomesFoster care and/or group homes are for those olderadults who can do most of their ADLs, but mayhave safety issues and require supervision withsome activities such as dressing or taking medica-tions. Foster or group homes generally offer morepersonalized supervision in a smaller, more family-like environment than a traditional nursing homeand, depending on state regulations, may belicensed to provide such services. Some personsoffering this service have a small number of eldersinside their existing home, whereas others havepurchased a larger dwelling for this purpose (see

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Figure 1-2). This type of setting provides an alter-native to nursing home care for some older per-sons. Although nurses may own and operate agroup home, there is no requirement that a personhave a health care background to do so, nor is therea requirement that a nurse’s services be available,so persons should take care to investigate the facil-ity prior to placement of a loved one. Social work-ers can usually provide good information aboutlocal foster or group homes.

Green House ConceptEndorsed by the Centers for Medicare & MedicaidServices, the Green House model, as conceived bygeriatrician Dr. William Thomas (Thomas, 2004), isbecoming an increasingly popular alternative totraditional long-term care facilities. The first GreenHouses were constructed in Tupelo, Mississippi, in2003. Now that an intensive evaluation has docu-mented their success, Thomas has teamed up withthe Robert Wood Johnson Foundation to replacemore than 100 nursing homes nationwide withclusters of small, cozy houses, each housing 8 to 10residents in private rooms, with private bathroomsand an open kitchen.

The primary purpose of the model is to serve asa place where elders can receive assistance andsupport with activities of daily living and clinicalcare without that assistance becoming the focus oftheir existence. Caregivers in Green Houses areempowered to provide individualized care to olderadults who retain control over daily activities, inshort, creating an environment that is a home.

Adult DaycareAdult daycare or day services provide anotheravenue for older adults who are unable to remainat home during the day without supervision. Theseservices are often used by family members who arecaring for older parents or loved ones in their ownhome, but who may work during the day and wishto have their relative safely cared for in theirabsence. This is an excellent alternative to institu-tionalization. “Adult day services are community-based group programs designed to meet the needsof functionally and/or cognitively impaired adultsthrough an individual plan of care. These struc-tured, comprehensive programs provide a variety ofhealth, social, and other related support services ina protective setting during any part of a day, but less

BOX 1-3 Research Highlight

Aim: This study described what caring meant for geriatric nurses.

Methods: Parse’s phenomenology was used to survey 30 nurses in Taiwan who worked on medical-surgical units caring for older adults. The nurses were asked open-ended questions about themeaning of caring in providing care to the elderly.

Findings: The researcher concluded that, for geriatric nurses, the meaning of caring included severalconcepts: deliberation, concern, tolerance, sincerity, empathy, initiative, and dedication. The authorsuggests that caring for the elderly should be natural and not superficial in order for the elderly tofeel cared for.

Application to practice: Geriatric nurses in this study demonstrated the meaning of caring in several dis-tinct ways. Core moral and ethical values appeared in their descriptions of the meaning of caring forolder adults. Nurses may improve their care of older adults by attending to these core conceptsrelated to caring. Gerontological nursing education may benefit by including more about caring theory.

Source: Lui, Shwu-Jiaun. (2004). What caring means to geriatric nurses. Journal of Nursing Research, 12(2), 143–152.

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than 24-hour care” (National Adult Day ServicesAssociation, 2008).

Adult daycare programs may be sponsored by avariety of different organizations including churches,hospitals, health care systems, or the local YMCA.Centers provide socialization, planned outings,nutritional meals, and therapeutic activities thatwould appeal to older adults with moderate physi-cal and/or mental decline. All functions are super-vised by qualified personnel. Services are offeredonly during the day, often from 6 a.m. to 6 p.m. (ornormal business hours) with an emphasis on recre-ation and some health promotion. Some programsoffer weekend hours. Costs vary depending on thesponsoring agency.

SUMMARYGerontological nursing is a specialty practice thatfocuses on the unique needs of older adults andtheir families. It builds on the theories and founda-tions of nursing practice, with application of agrowing body of literature generated by geronto-logical nursing scientists. Caring for older adults isinfluenced by many factors, one of which is recog-nizing one’s own attitude about aging. It is impor-tant with the aging of today’s population that allnurses should have basic gerontological nursingconcepts and principles taught in their undergrad-uate programs. With the growth of the older pop-ulation, more nurses specializing in gerontologywill be needed. Gerontological nurses practice inalmost all settings and there are emerging subfieldsof this specialty that offer promise of future rolesfor nurses who care for older adults. Nurses shouldexplore the multiple career options in this exciting,creative, and innovative field of gerontologicalnursing.

Case Study 1-2

The Brokowskis are a close-knit family of fivewhose grandfather, Papa B., has been living withthem in their home since he was widowed 10 yearsprior. Papa B. is 88 years old and has recently beendiagnosed with Alzheimer’s disease in the earlystage. The family is having increasing difficultysupervising Papa B. and feels it is no longer safe forhim to be at home alone. Both parents in the fam-ily work, and the three children are in high schoolduring the day. The family wishes to keep Papa B.at home, but do not know what possibilities thereare in the community to help them.

Questions:1. What services might the Brokowski family use

to help them keep Papa B. at home? Do theseservices seem feasible at this time?

2. As Papa B.’s condition worsens with the pro-gression of Alzheimer’s disease, what otherservices discussed in this chapter might benecessary at various points in time?

3. What assessments would a nurse need to makein order to determine the best placement forPapa B.? Given the history of this family, whatrecommendations for the future might be made?Which interdisciplinary team member could pro-vide additional information to the nurse and thefamily about community services?

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Summary 23

Critical Thinking Exercises

1. Do this exercise with another student as a partner. Close your eyes. Picture yourself as an 85-year-old. Note your appearance, sights, sounds, and surroundings. Open your eyes and describe yourself at85 to your partner. Then discuss how your mental image of yourself as an older person might have beeninfluenced by your family history, grandparents, and perceptions about aging.

2. Go to a local card shop and browse. Look at the birthday cards that persons might buy for someonegetting older. What do they say about society’s attitudes toward aging? Do the cards you read pointout any areas that we stereotype as problems with advancing age?

3. Complete this sentence: Older people are . . .List as many adjectives as you can think of. After making your list, identify how many are negative andhow many are positive descriptors. Think about where your ideas came from as you did this exercise.

4. Check out the Web site at www.consultgerirn.org. How could you use this Web site to enhance yourknowledge about the care of older adults? What services are available through the Web site?

5. Look at the list of competencies for gerontological nurses in Table 1-2. How many of these competen-cies do you feel you meet at this point? Make a conscious effort to develop these skills as you gothrough your career.

6. Visit a local nursing home that offers various levels of care. Call ahead of time to arrange a tour froma nurse and ask questions about the services they offer to older adults.

Personal Reflections

1. How do you feel about aging? Do you dread getting older, or look forward to it? Do you seeadvanced age as a challenge or something to fear?

2. Have you ever cared for an older adult? If so, what was that experience like? How do you feelabout caring for older adults in your nursing practice?

3. What do you think about nurses who work in nursing homes? Have you ever considered a careerin gerontology? What are the positives you can see about developing expertise in this field ofnursing?

4. Have you ever seen ageism in practice? If so, think about that situation and how it could havebeen turned into a positive scenario. If not, how have the situations you have been in avoideddiscrimination against older adults?

5. Which of the settings for gerontological nursing practice appeal to you most at this time in yourprofessional career? Is there any one setting that you can see yourself working in more thananother? Do you think this will change as you progress in your career?

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Lui, S-J. (2004). What caring means to geriatric nurses.Journal of Nursing Research, 12(2), 143–152.

Meiner, S., & Lueckenotte, A. (2006). Gerontologic nursing.St. Louis, MO: Mosby.

Mezey, M. (2005). About us. Retrieved December 25, 2005from http://www.geronurseonline.org

National Adult Day Services Association. (2008). RetrievedOctober 12, 2008, from http://www.nadsa.org/

Norton, D. (1956, July 6). The place of geriatric nursing intraining. Nursing Times, 264.

Quadagno, J. (2005). Understanding the older client. Boston:McGraw-Hill.

SeniorHousingNet. (2008). Finding senior housing and care.Retrieved July 3, 2008, from http://www.seniorhousingnet.com/seniors

SeniorOutlook.com. (2008). Glossary of senior housingterms. Retrieved July 3, 2008, from http://www.senioroutlook.com/glossary.asp

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