Changes in the Geriatric CareEnvironment Associated withNICHE (Nurses Improving Care forHealthSystem Elders)

Marie Boltz, PhD, RN, GNP, BC, Elizabeth Capezuti, PhD, RN,FAAN, Susan Bowar-Ferres, PhD, RN, CNAA-BC,Robert Norman, PhD, Michelle Secic, MS, Hongsoo Kim, PhD, MPH, RN,Susan Fairchild, MPH, Mathy Mezey, EdD, RN, FAAN,

Terry Fulmer, PhD, RN, FAAN

The aging of the U.S. population has pro-found implications for acute care nursingpractice. NICHE (Nurses Improving Care forHealthSystem Elders) is the only nationalnursing program that addresses the needsof the hospitalized older adult. This sec-ondary analysis examines the influence ofthe NICHE program on nurse perceptionsof the geriatric nursing practice environ-ment and quality of geriatric care, as wellas geriatric nursing knowledge in a samplecomprising 8 acute care hospitals in theUnited States that administered the Geriat-ric Institutional Assessment Profile beforeand after NICHE implementation. Resultswere compared in a sample of 821 and 942direct care nurses, respectively. Control-ling for hospital and nurse characteristics,both nurse perceptions of the geriatricnursing practice environment (P � .0001)and quality of geriatric care (P �.0004) in-creased, but not geriatric nursing knowl-edge (P �.1462), following NICHE imple-mentation. NICHE tools and principles canexert an important influence over the careprovided to older adult patients by increas-ing the organizational support for geriatricnursing. (Geriatr Nurs 2008;29:176-185)

Adults age 65 and older utilize 48% of thenation’s total health care resources andcomprise approximately 60% of all adult

non-obstetric acute care admissions.1 This agingtrend is expected to continue, as the U.S. Ad-ministration on Aging projects that more than20% of the population will be aged over 65 yearsby the year 2030, with the fastest growing seg-ment being those aged 85 and above.2 Compared

with other age cohorts, older hospitalized pa-

Geriatric Nursing, Volu176

tients demonstrate higher acuity, use morehealth care resources, experience more compli-cations, and have longer lengths of stay.3 Theever-increasing number of older adults and thehealth care needs of an aging population make itinevitable that most nursing care in the hospitalwill continue to be delivered to older adults4

and require specialized knowledge of geriatricand aging-sensitive care delivery.5

Experts in the field agree that quality geriatriccare, similar to patient-centered care in general, isevidence based; is individualized to the patient’sneeds, situations, and preferences; and promotespatient decision making.6-8 It is specialized to theolder adult patient in that the evidence base isaging-specific and interdisciplinary in nature andsupports continuity across settings.5,9-11 Essentialcomponents of the nurse practice environmentnecessary to provide quality geriatric care include:1) institutional values that align the rights of olderadults to receive specialized care and the profes-sional autonomy of the direct care nurse; 2) nurseaccess to geriatric-specific resources (materialand human); and 3) institutional practices andprotocols that support interdisciplinary collabora-tion.12

The development of elder-friendly care envi-ronments is hindered by the fact that the major-ity of nurses have received no formal educationregarding the specialized nursing needs of olderpatients13,14 despite evidence that lack of geri-atric education negatively affects quality ofcare.15 Further complicating the problem is thefact that few of the nation’s approximately 6000hospitals have institutional practice guidelines,educational resources, and administrative prac-tices that support best practices care of olderadults.16 NICHE (Nurses Improving Care for

HealthSystem Elders), a program of the Hart-

me 29, Number 3

.

ford Institute for Geriatric Nursing at New YorkUniversity College of Nursing, addresses theseshortfalls and is the only national nursing pro-gram designed to strengthen the geriatric nursepractice environment.17 NICHE provides guid-

Figure 1. Components of the NICHE Tool Kit

ing principles and operational tools to develop

Geriatric Nursing, Volu

and utilize geriatric-specific resources, evi-dence-based clinical protocols and nursing or-ganizational models.18 Figure 1 provides anoverview of the NICHE tool kit.

In single-site studies, NICHE hospitals dem-

onstrate improved clinical outcomes,19-23 rates

me 29, Number 3 177

of compliance with institutional protocols,20,21

cost-related outcomes,21,23 and nurse knowl-edge.20,24,25 NICHE coordinators report that aninstitutional commitment to geriatric care is in-tegral to the successful implementation and sta-bilization of the NICHE program,16 consistentwith studies demonstrating that the nurse prac-tice environment (organizational factors thatconstrain or support nursing practice26) has par-ticular implications for nurse effectiveness andpatient outcomes.26,27 The purpose of this studywas to examine the influence of NICHE in anational sample of member hospitals on selectgeriatric outcomes. We hypothesized that, con-trolling for nurse and hospital characteristics,NICHE implementation would increase nurseperceptions of the geriatric nursing practice en-vironment and the quality of geriatric care pro-vided to older adult patients, as well as increasegeriatric nursing knowledge.

Conceptual Framework

Bandura’s concept of collective efficacy guidedthe measures and analysis for this study. Collec-tive efficacy is defined as “the conjoint capabilitiesto organize and execute the courses of actionrequired to produce given levels of attainment”28

(p. 477). According to Bandura, there are 3 waysto measure collective self-efficacy: the aggregateof each individual’s self-evaluation of his or herpersonal skills; the aggregate of each member’sappraisal of the group’s capabilities, and a mea-sure of performance as a whole. Accordingly, thisstudy evaluated the effectiveness of the NICHEprogram by measuring the change in the followingcomponents of the geriatric care environment: 1)nurse knowledge of geriatric care (a measure ofindividual efficacy); 2) the perception of the geri-atric nurse practice environment (a measure ofgroup capability); and 3) the perception of qualityof geriatric care (a measure of organizational per-formance). Social and structural factors can influ-ence organizational efficacy,28 including the char-acteristics of the setting and the groupcomposition (in this study, nurse and hospitalcharacteristics). Thus, this study examined theinfluence of the NICHE program on 3 measures ofgeriatric-specific efficacy while considering thepotentially additive effects of nurse and hospital

characteristics.

Geriatric Nursing, Volu178

Methods

Design

This study was a secondary analysis of datacollected by the NICHE program, used to assessa hospital’s readiness to implement geriatric in-itiatives. Data from the Geriatric InstitutionalAssessment Profile (GIAP) database, a proxymeasure for the overall quality of care providedto older adult patients, was used. The GIAPserves as a benchmarking tool to assist hospi-tals in identifying gaps in knowledge, specificpractice issues and concerns, and organiza-tional attributes of the hospital relevant to geri-atric care.29 A pre-post, cross-sectional designwas used, examining data before and afterNICHE implementation.

Sites and Participants

The GIAP responses of 8 urban, not-for-profit,acute-care hospitals were examined. The hospitalswere located in the following geographic areas:the Northeast (1), the Southeast (1), the Midwest(1), the Northwest (2), the Southwest (1), SouthCentral (1), and non-mainland United States (1).Four hospitals were members of the Council ofTeaching Hospitals. The hospitals differed insize, 1 with 100-199 beds, 2 with 200-299 beds, 2with 300-399 beds, and 3 with more than 400beds. Payer mix also varied, with the mean an-nual percentage of Medicare and Medicaid dis-charges ranging from 8% to 50% and 3% to 25%,respectively.

The sample was restricted to acute-care, staff-registered nurses in direct care positions whowork with older adults. There were 896 regis-tered nurses in the pre-NICHE implementationgroup (pre-NICHE) and 1028 nurses in the post-NICHE implementation group (post-NICHE).The difference in the number of respondents isrelated to the availability of respondents be-tween the 2 groups and reflects personnelchanges that typically occur on a hospital unit.Nurses from the following units were included:general medical, general surgical, medical/surgi-cal, emergency department, critical care, non-critical care specialty unit (e.g., orthopedic, pul-monary unit), geriatric, and psychiatric. Excludedwere nurses who worked on nonacute (rehabil-itation, ambulatory care, and home care), ob-stetric/gynecologic, and “rotating” units (pre-

NICHE, n � 75; post-NICHE, n � 86), yielding a

me 29, Number 3

study sample of 821 nurses in the pre-NICHEgroup and 942 nurses in the post-NICHE group.The study was approved by the New York Uni-versity Committee on Activities Involving Hu-man Subjects (UCAIHS).

Measurement

The GIAP, which contains 68 major questionsand a total of 152 items, surveys geriatric prac-tice knowledge, care attitudes, and perceptionof the geriatric care environment in the acute-care setting, as well as respondent demographicand professional characteristics.17,29 Two scales

Table 1.Geriatric Institutional Assessment

Construct Concept

The Geriatric Nurse PracticeEnvironment (GNPE) scale

A composite meassociated withgeriatric nursinenvironment: 1regarding oldecapacity for coresource availa

Institutional ValuesRegarding Older Adultsand Staff (GNPE subscale)

Nurse perceptionrights of olderolder adults anmaking, suppoand personal g

Capacity for Collaboration(GNPE subscale)

Nurse perceptionknowledge of ggeriatric protocconflict

Resource Availability (GNPEsubscale)

Nurse perceptionand material recare of older asupport of compatients and fa

Geriatric Nursing Knowledgescale

Knowledge of thnursing managgeriatric syndroincontinence, rdisturbance

Quality of Geriatric NursingCare/Aging-Sensitive CareDelivery scale

Geriatric-specificindividualized cinformed deciscontinuous acr

*Data from Kim et al., 2007.30

†Data from Abraham et al., 1999.29

‡Study database.§Reverse scored.

of the GIAP, the geriatric care environment

Geriatric Nursing, Volu

scale and the knowledge scale, were used forthis study. Psychometric testing of these scalesyielded good internal consistency (� �.60–.94)30 and good interrater reliability (r �.71–.85).31 In the study data set, internal consis-tency ranged from � � .66 to � � .93. Table 1summarizes the constructs, conceptual defini-tions, number of items in each construct, possi-ble ranges, published Cronbach’s alphas, andthen the sample Cronbach’s alphas.Nurse and Hospital Characteristics. Nursedemographic (age, sex, and race/ethnicity) andprofessional data (nurse educational level, years

file Study Scales and Subscales

efinitions

No.

Items

Possible

Range � �‡

of the 3 variablesoncept of the

cticeitutional valuests and staff, 2)ation, and 3)

18 0-72 .93* .89

espect for the, involvement ofilies in decisionurse autonomy

7 0-28 .84* .84

ther disciplines’ic care, use ofnd degree of

3 0-12§ .83* .83

ccess to humanes specific to

and managementcation with

8 0-32§ .90* .89

ssment andt of 4 commonpressure ulcers,

nt use, and sleep

22 0-10 .60† .66

ence-based,at promotes

aking and isttings

10 0-40 .94* .93

Pro

ual D

asurethe c

g pra) instr adulllaborbilitys of radultsd famrt of nrowths of oeriatrols, a

s of asourc

dultsmunimiliese asseemenmes:

estrai

, evidare th

ion moss se

of experience in the profession, the years of

me 29, Number 3 179

experience at the institution, and the primarytype of unit worked on) were extracted from theGIAP. Nurse educational level was defined asthe nurse’s highest nursing degree (diploma, as-sociate, baccalaureate, master’s, or doctorate).The GIAP and the American Hospital Associa-tion Survey32 provided information on the fol-lowing hospital characteristics: teaching status(based on hospital membership in the Councilof Teaching Hospitals), bed size, and payer mix(defined by 2 variables: the percentage of Medi-care discharges and the percentage of Medicaiddischarges). Nurse and hospital structural char-acteristics were used for descriptive purposes,were examined for possible associations withthe outcomes, and were included as covariatesin the model, as indicated.Nurse Perception of the Geriatric Nurse

Practice Environment. The nurse practice en-vironment, a term synonymous with organiza-tional support, encompasses the hospital orga-nizational characteristics that facilitate orconstrain nursing practice.26 Three constructsare associated with the concept of the geriatricnursing practice environment: 1) institutionalvalues regarding older adults and staff, 2) capac-ity for collaboration, and 3) resource availabil-ity. Each of these constructs serves as a dimen-sion or subscale of the geriatric care environmentscale and are more fully described in Table 1.The composite measure of the 18-item geriatricnursing practice environment as well as eachdimension—resource availability (8 items), in-stitutional values (7 items), and capacity forcollaboration (3 items)—were outcome vari-ables, evaluated as the mean value of the itemscomposing each of the constructs.Nurse Perception of Quality of Geriatric

Care. Nurse perception of quality of geriatriccare, another outcome variable, is defined asevidence-based care that is specialized to thecare of older adults and individualized to thepatient’s needs, situations, and preferences.29 Itis operationalized by the 10-item aging-sensitivecare delivery subscale of the GIAP geriatric careenvironment scale30 and evaluated as the meanof the values for each item measured for thisconstruct.Geriatric Nursing Knowledge. Geriatric nurs-ing knowledge, also an outcome variable and aGIAP subscale, was evaluated as the mean ofthe values for each item measured for this con-

struct. It is defined as knowledge of the assess-

Geriatric Nursing, Volu180

ment and management of the following commongeriatric syndromes: pressure ulcers, inconti-nence, restraint use, and sleep disturbance.30

Data Analysis

Before data analysis, imputation methodswere employed. Although multiple imputation33

methods are attractive, they assume all vari-ables to be imputed are multivariately normallydistributed. Although this method is widely usedto impute categorical data, there is a naturalconcern about the consequences of violatingthese assumptions,34 and this introduces biasedestimates of proportions in the database.35 Inaddition, the analyses developed for multipleimputed data sets do not allow categorical vari-ables to be defined in the models because theyassume all imputed variables are normally dis-tributed. Again, the assumption would have tobe made that the categorical variables were con-tinuous in the modeling stage, thus introducinganother layer of bias. Because the database hasmany categorical covariates, single-sample im-putation methods were used. The first step ofthe multiple imputation methods to impute mul-tiple data sets was used and then only a ran-domly selected single sample was used for anal-ysis. This therefore removed the need for use ofthe multiple imputation process and allowed foruse of standard statistical modeling proceduresafter single-sample imputation. It is also impor-tant to point out that imputation was conductedon the item level, not the construct level. Toensure reliability of the data, imputation wasnot conducted for cases in which more than halfof the items in a certain construct were missing(approximately 5% of total cases).

Descriptive data of the nurses in the 8 hospi-tals that implemented NICHE were examined,comparing preintervention to postimplementa-tion. Changes pre- to post-NICHE implementa-tion in the perception of the geriatric nursepractice environment, perception of quality ofgeriatric care, and geriatric nursing knowledgewere examined using a linear mixed effects(LME) model using these variables as the out-comes to be modeled, testing for a relationshipwith the administration time (pre- and post-NICHE implementation). The relationship of po-tential nurse or hospital characteristics (orboth) with the outcomes were explored and

added as covariates to the model when indi-

me 29, Number 3

cated. The nurse characteristic variables in-clude age, gender, race/ethnicity, educationlevel, years of professional experience, years ofexperience at the institution, and type of unitworked. The hospital characteristics includedtype of hospital ownership, hospital bed size,and hospital teaching status. Within the statisti-cal model, the hospital characteristics and nurs-ing staff levels were considered random effectsbecause the levels of the factors within the sam-ple do not exhaust all possible levels for everyhospital/staff. Therefore, they could not be con-sidered fixed, like gender, for example; theywere more appropriately defined as random ef-fects in the model. Analyses were conductedusing SPSS for Windows version 15.0 (Chicago,IL) and SAS software. A P value of �.05 wasconsidered significant for all tests.

Findings

The study hospitals are all not-for-profit, ur-

Table 2.Comparison of Nurse Characterist

Pre-NICHE (

Female* 90 (7Race/Ethnicity*

White 80 (6Black/African American 2 (1Hispanic/Latino 1 (1Asian 13 (1Other 3 (2

Education*Diploma 8 (6Associate 45 (3Baccalaureate 45 (3Master or doctorate 2 (1

Age† 9.7 (4Unit worked*

Medical 10 (8Surgical 9 (7Medical-surgical 27 (2Critical care 21 (1Non–critical care specialty unit 13 (1Emergency department 7 (5Geriatric 5 (4Psychiatric 2 (1Missing 6 (4

Data from: Health Resources and Services Administration

*Percentage (n) values.†Mean (SD).NICHE � Nurses Improving Care for Health

ban sites with diverse payer mixes and geo-

Geriatric Nursing, Volu

graphic locations that conducted the GIAP be-fore and after NICHE implementation. Therewere 821 nurses in the pre-NICHE implementa-tion sample and 942 in the post-NICHE imple-mentation sample. The nurses’ demographicand professional characteristics are similar inthe pre-NICHE and post-NICHE implementers.Table 2 compares the key characteristics of thestudy nurses at both time points to the nationalprofile of nurses.

The sample has less diploma nurses and mas-ter’s or doctorally prepared nurses comparedwith national figures of registered nurses, whichis not surprising given that the nurses were indirect care positions. The majority of nurses ineach group was white and female and had eitheran associate or baccalaureate degree as thehighest level of academic nursing preparation.Comparatively, the average age of 40.0 for bothpre- and post- samples is somewhat youngerthan the national average age of 46.8, which is

Pre- and Post-NICHE

21) Post-NICHE (n � 942) National Profile

92 (867) 94.2

78 (739) 81.83 (28) 4.21 (9) 1.7

15 (138) 3.13 (28) 7.8

7 (66) 25.245 (424) 33.747 (443) 34.21 (9) 13

40 (10.5) 46.8

11 (104)9 (84)

26 (245)19 (179)14 (132)7 (66)5 (47)3 (29)6 (56)

6). 2004 National Sample Survey of Registered Nurses.36

Elders.

ics:

n � 8

39)

59)7)1)08)6)

8)70)65)8)0)

3)5)22)69)10)5)0)9)8)

. (200

System

not surprising given that the sample was re-

me 29, Number 3 181

ost-NIC

stricted to direct care nurses who tend to beyounger than nurses in administrative and otherpositions.36 Additionally, there is more repre-sentation of Asian nurses and fewer nurses whodescribe their race ethnicity as “other” in thestudy sample. These differences are most prob-ably reflective of geographic differences be-tween the study sample and the national sam-ple. Most participants worked in a medical orsurgical unit (or both), and the mean years ofexperience in the nursing profession were 13.1years (SD 9.9) in the pre-NICHE group, and 13.2years (SD 10.4) in NICHE implementers. Themean years worked at the institution was 8.6(SD 7.6) in the pre-NICHE group and 8.1 (SD8.0) in NICHE implementers. Neither nursecharacteristics nor hospital characteristics dem-onstrated a significant association with thenurses’ perception of the geriatric nurse prac-tice environment, perception of aging-sensitivecare delivery, or geriatric nursing knowledge.

Table 3 compares perceptions of the geriatricnursing practice environment, perceptions ofquality of geriatric care, and geriatric nursingknowledge, pre- and post-NICHE implementa-tion. The mean estimated geriatric nurse prac-tice environment scores increased significantlywith NICHE implementation from 39.0 to 41.9 (P

Table 3.Linear Mixed Effects Model: Pre- aGeriatric Nurse Practice Environmof Geriatric Care, and Geriatric Nu

n Administration* t

GNPE 1540 Time 1Time 2 19.7

Values 1634 Time 1Time 2 3.9

RA 1663 Time 1Time 2 45.8

CC 1701 Time 1Time 2 3.8

ASCD 1655 Time 1Time 2 11.3

GNK 1370 Time 1Time 2 1.4

ASCD � Aging-sensitive Care Delivery; CC � Capacity f

� Geriatric Nursing Practice Environment (Composite

NICHE � Nurses Improving Care for HealthSystem Eld

*Admin Time 1: Pre-NICHE implementation; Time 2: P

�.0001). The mean score for institutional values

Geriatric Nursing, Volu182

around care of older adults and staff increasedfrom 15.4 to 17.4 (P �.0001). No statisticallysignificant change in capacity for collaborationor resource availability was found. The meanaging-sensitive care delivery scores (measuringperceptions of quality of geriatric care) signifi-cantly increased from 22.7 to 24.3 after NICHEimplementation (P �.0004). The time of admin-istration (pre- vs. post-NICHE implementation)of the GIAP does not show a statistically signif-icant relationship with geriatric nursing knowl-edge scores (P � .1462).

Discussion

NICHE implementers demonstrated a signifi-cant improvement in the scores measuringnurse perceptions of both the geriatric nursingpractice environment and quality of geriatriccare. Thus, the findings suggest that these sitesdemonstrated a trend toward improvements as-sociated with the stated goal of NICHE, which isto provide organizational tools to modify thenurse practice environment to make it moregeriatric-responsive. This finding is consistentwith the initial pilot testing of the NICHE imple-menters, which demonstrated an increase innurses’ perceptions of improved practice envi-

ost-NICHE Comparisons of the(Composite and Dimensions), Qualityg Knowledge

P Estimated Mean Standard Error

39.0 0.47.0001 41.9 0.44

15.4 0.27.0001 17.4 0.25

15.5 0.21.1100 16.1 0.20

7.5 0.10.1300 7.7 0.93

22.7 0.30.0004 24.3 0.30

4.8 0.30.1462 4.9 0.28

aboration; GNK � Geriatric Nursing Knowledge; GNPE

Institutional Values regarding Older Adults and Staff;

� Resource Availability.

HE implementation.

nd Pentrsin

�

�

or Coll

); IV �ers; RA

ronment related to the care of older adult pa-

me 29, Number 3

tients.17 Study results further demonstrate anincrease in the nurse perception of the institu-tional values related to the care of older adultpatients and staff, a dimension of the geriatricnurse practice environment. This finding is sim-ilar to those of other studies demonstrating thatleadership commitment to the values of bothpatient and nurse self-direction are associatedwith nurse perceptions of an institutional valuesof patient centered care,37,38 promotion of nurseautonomy, and improved patient care deliv-ery.39,40

Among the 3 subscales of the geriatric nursingpractice environment, 2—nurse perception ofresource availability and capacity for collabora-tion—did not significantly increase with NICHEimplementation. The level of implementation(for example, unit vs. institutional-wide dissem-ination) was unknown and most likely variedbetween settings, a limitation of the study. Fu-ture investigation is warranted to examine theeffects of “NICHE doses,” using uniform pro-cess and structure measures that quantifyNICHE implementation.

Nurses perceived an increase in the quality ofgeriatric care with NICHE implementation. Thisfinding suggests that NICHE can be effective inaddressing the issues deemed important byolder adults: competence in nursing staff, sup-port of patient autonomy, and skill in facilitatingpositive discharge planning.6,41-44 The increasein nurse perception of the geriatric nurse prac-tice environment, in combination with an in-crease in aging-sensitivity scores associatedwith NICHE implementation, supports the mainfindings of a previous study that significantlylinked the geriatric nursing practice environ-ment to quality of geriatric care.12 Thus studyresults suggest that NICHE tools and principlescan exert important influence over the care pro-vided to older adult patients by increasing theorganizational support for geriatric nursing.

NICHE implementers did not demonstrate anincrease in geriatric nursing knowledge. Again,it is not known how many of the nurses com-pleting the GIAP were exposed to NICHE train-ing or the extent of that training. Also, the lengthof time between NICHE training/implementa-tion and postevaluation may not have been suf-ficient to effect substantial change in nurse ge-riatric nursing knowledge. This is an area forfuture investigation because the required train-

ing and time frame to effect sustained improve-

Geriatric Nursing, Volu

ment in nurse knowledge of care of older adultpatients is not known. Additionally, further eval-uation of the knowledge scale of the GIAP iswarranted to ensure that questions continue tobe clinically relevant and reflect current evi-dence.

The role of the nurse leader is critical in shap-ing the nurse practice environment. Nurse lead-ers who promote effective collaboration, facili-tate access to resources, and support nurseautonomy are more likely to engender increasednurse work satisfaction45-47 and improved caredelivery.37,48 Accordingly, additional investiga-tion of the practice environment and associatedleadership characteristics of various types ofnursing units (e.g., critical care, emergencyroom, orthopedic unit) is indicated to help buildflexible, adaptable versions of both the AcuteCare of the Elderly (ACE) unit model and theGeriatric Resource (GRN) model20,22,23,25 andinform the development of specialty-specificprotocols and education programs. An addedvalue of examining programs at the unit level isthe potential to develop and test efficiently pilotmodels of funding and evaluation.

Limitations

A threat to internal validity is the time span (9years) of data collection, posing the possibilitythat the demands imposed by external forces(regulatory and reimbursement) may have ex-erted varying influences on the organization ofacute care geriatric nursing at different timeperiods. The reliance on nurse perceptions asthe source of GIAP data and the potential forother unknown factors influencing nurse per-ceptions poses an additional threat to internalvalidity. Examples of other factors that were notmeasured in this study (because of data limita-tions) that could influence nurse perceptionsinclude patient acuity and staffing. Also, thestudy did not include nurses from for-profit hos-pitals and rural areas, limiting the generalizabil-ity of results to those groups.

As stated previously, because of data limita-tions, the study did not address the intensity,consistency, and duration of NICHE implemen-tation. Future research should address issues oftreatment fidelity by standardizing NICHE inter-ventions across study sites and establishingmechanisms of ensuring fidelity. Essential com-

ponents of the treatment fidelity program

me 29, Number 3 183

should include measures that quantify interven-tions, study controls, and treatment adherence,training of NICHE providers, and validation ofskill acquisition in implementing interven-tions.49

The GIAP is used to assess a hospital’s readi-ness for geriatric nursing initiatives by focusingon the institutional milieu supporting geriatriccare. These study findings suggest that NICHEhospitals improve the hospital’s capacity to pro-vide quality geriatric care. However, the GIAP isnot intended to measure clinical effectivenessand thus is limited in its capacity to evaluate anorganization’s geriatric care in a comprehensivemanner. NICHE researchers are currently devel-oping structural, process, clinical outcome, andorganizational outcome measures to be used forboth national benchmarking and evaluation ofNICHE program effectiveness.

In conclusion, despite the fact that the major-ity of hospital patients are older adults and theprimary practice location of the nation’s 2.7 mil-lion registered nurses is the hospital setting,26

limited attention has been paid to the delivery ofgeriatric nursing care by RNs.16 This study dem-onstrates that hospitals that have adapted theNICHE model can modify the nurse practiceenvironment to promote an institutional milieuthat improves the quality of geriatric care. Ad-ditionally, NICHE can be implemented in bothteaching and nonteaching hospitals regardlessof size and payer mix and by nurses with diversedemographic and professional characteristics.

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MARIE BOLTZ, PhD, RN, GNP, BC, is an assistant profes-

sor at New York University College of Nursing, New York,

New York. ELIZABETH CAPEZUTI, PhD, RN, FAAN, is an

associate professor and codirector of the Hartford Institute

for Geriatric Nursing, New York University College of

Nursing, New York, New York. SUSAN BOWAR-FERRES,

PhD, RN, CNAA-BC, is a professor of nursing and nursing

administration, and senior vice president and chief nurs-

ing officer at New York University Medical Center, New

York, New York. ROBERT NORMAN, PhD, is a research

associate professor and director of biostatistics at New

York University College of Dentistry, New York, New York.

MICHELLE SECIC, MS, is president and independent con-

sultant, Secic Statistical Consulting, Inc., Chardon, Ohio.

HONGSOO KIM, PhD, MPH, RN, is an assistant professor

at New York University College of Nursing, New York, New

York. SUSAN FAIRCHILD, MPH, is a NICHE program

evaluator, John A. Hartford Foundation Institute for Geri-

atric Nursing New York University College of Nursing,

New York, New York. MATHY MEZEY, EdD, RN, FAAN, is

a professor and director of the John A. Hartford Founda-

tion Institute for Geriatric Nursing, New York University

College of Nursing, New York, New York. TERRY FULMER,

PhD, RN, FAAN, is dean and the Erline Perkins McGriff

Professor at New York University College of Nursing, New

York, New York.

0197-4572/08/$ - see front matter

© 2008 Mosby, Inc. All rights reserved.

doi:10.1016/j.gerinurse.2008.02.002

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