Over the last 20 years, hospitals in the United States have become increasingly focused on the Magnet Recognition Program® (MRP), a national initiative honoring hospitals that have achieved the highest possible standards of excellence in nursing and patient care. The process of designating outstanding health care facilities as Magnet hospitals first began in the early 1980s during yet another international nursing shortage. Even though many hospitals were struggling to fill their nurse staffing needs, it was apparent that a few facilities were somehow unaffected by the shortage. An investigation of these hospitals, sponsored by the American Nurses Association (ANA) identified 14 key standards and qualities that truly set these facilities apart from the crowd.
As a result, ANA—through its credentialing body, the American Nurses Credentialing Center (ANCC)—developed what is now known as the Magnet Recognition Program. This program recognizes hospitals, medical centers and health systems which, like a powerful magnet, have the ability to attract and retain more registered nurses and other health care workers. Most importantly, the Magnet recognition is more than just an award: It is a systematic approach to the ongoing pursuit of excellence in patient care.
More recently, medical centers within the Department of Veterans Affairs (VA) have decided to join their private sector peers in the pursuit of this coveted recognition. Of the 155 VA medical centers (VAMCs) in the U.S., only three have earned the Magnet designation. The first was James A. Haley Veterans’ Hospital in Tampa, Fla., followed by the Michael E. DeBakey VAMC in Houston, Texas, and most recently, Portland (Ore.) VAMC in 2007. The medical center where I am employed, Overton Brooks VAMC in northwest Louisiana, has also decided to join the ranks of these prestigious facilities by pursuing Magnet status.
One of the criteria for Magnet recognition is that at least 20% of all direct care staff nurses hold a current nursing certification in their area of specialty. Simultaneously, there is also a national initiative within the VA’s Office of Nursing Services (ONS), encouraging certification by at least 25% of a VA facility’s direct care nursing staff.
Certification is the formal recognition of a nurse’s specialized knowledge, skills and experience that promote optimal health outcomes. It is documented by successful completion of a national standardized certification exam and adherence to practice standards identified by a professional nursing organization in a defined clinical area. It represents a benchmark and indicator of increased clinical knowledge and experience, analogous to board certification in other disciplines. Nursing certification is not a routine competency expected of all nurses practicing within a certain specialty (e.g., CPR training).
Benefits of Certification
For VA hospitals, the benefits of certification are exponential to the organization, the individual nurse and, most importantly, to the veterans we care for. Certified nurses are more competent, accountable and confident in their practice. Moreover, studies have shown that certified nurses practice in a manner that is most likely to improve patient outcomes.1 Other research has revealed that three out of four patients are much more likely to select a hospital employing a high percentage of certified nurses.2
Furthermore, nurses who hold a certification report higher levels of empowerment, which is a characteristic associated with job satisfaction and intent to stay in their current position.3 High percentages of certified nurses are found in facilities that have a reputation for recruiting and retaining the best nursing talent—for example, 26.4% of nurses in Magnet hospitals are certified.4
For the individual VA nurse, becoming certified in your competency area can:
• validate your knowledge and expertise;
• build confidence in your professional ability;
• demonstrate that you meet high national standards;
• demonstrate your dedication to nursing as a profession;
• provide opportunities for career advancement;
• validate you as a credible resource for your colleagues and patients; and
• promote personal growth and satisfaction as a professional nurse.
Nursing certification is reflective of the Veterans Health Administration (VHA)’s current transformational performance measure to distinguish VA facilities as learning organizations, charged with creating an integrated and synergistic educational environment for all staff. In addition to the MRP, certification is used as an indicator of nursing excellence in other national health care recognition programs, including the American Association of Critical-Care Nurses (AACN) Beacon Award for Critical Care Excellence and the National Institute of Standards and Technology (NIST)’s Malcolm Baldridge National Quality Award.
Don’t Overlook LPNs
In general, hospitals’ efforts to increase their number of certified nurses have usually concentrated on professional nurses (RNs). But this overlooks the important role licensed practical nurses (LPNs) play in the VA health care system. Therefore, our medical center, in recognition of our LPNs’ system-wide contribution to patient care, is also including this group in our initiative to increase certification among all direct care nurses.
Table 1:National LPN/LVN Certifications Approved by the VA Office of Nursing Services Practice Area: Long-Term Care Certification Name: CLTC (Certified in Long-Term Care) Certifying Body: National Association for Practical Nurse Education and Service (NAPNES) Web Site: www.napnes.org Practice Area: Gerontology Certification Name: GC (Gerontology Certified) Certifying Body: National Federation of Licensed Practical Nurses (NFLPN) Web Site: www.nflpn.org
Overton Brooks VAMC currently employs approximately 75 LPNs serving in various areas, such as our primary care and specialty clinics, medical-surgical and mental health units, community-based outpatient clinics and community health nursing. In most instances, the LPN is working as a team member led by the RN. However, on many occasions the LPN is directly assigned to a specific provider, such as a physician or advanced practice nurse. This expanded role remains within the LPN’s designated scope of practice, in support of the veteran’s plan of care.
Several nursing associations and certifying boards, such as the Society of Urologic Nurses and Associates (SUNA) and the National Board for Certification of Hospice and Palliative Nurses (NBCHPN), offer various types of certifications for LPNs/LVNs. However, the VA Office of Nursing Services only recognizes two specific certifications offered by the National Association of Practical Nurse Education and Service (NAPNES) and the National Federation of Licensed Practical Nurses (NFLPN). The VA-approved certification offered by NAPNES is in long-term care (LTC) and the NFLPN certification is in gerontology. (See Table 1.)
The average age of a veteran at Overton Brooks VAMC is 60, and this near-geriatric population is increasing within the VA health care system in general. Therefore, it will be extremely beneficial for VA hospitals to have a pool of talented gerontology nurses on staff. For this reason, and in the absence of an LTC unit within our facility, we concentrated our efforts on the certification in gerontology offered by NFLPN.
This certification evaluates competency in four specific domains:
1. Phases of the Nursing Process: Gathering information regarding the patient; identifying the patient’s health needs and selecting appropriate goals of care; designing a strategy to achieve the goals established for the patient; initiating and completing actions necessary to accomplish goals; and determining the extent to which the goals have been achieved.
2. Areas of Patient Needs: Provision of coordinated and goal-oriented care; evaluation of patients’ basic physiological care; psychosocial, coping and adaptation needs of the patient; and developmental changes that occur in older persons.
3. Critical Thinking Skills: Identifying, gathering, discriminating and prioritizing data collection; discovering and then discerning the nature of relationships between concepts; determining how and why concepts are related; developing a process for establishing goals; and using problem-solving to achieve patient-specific outcomes.
4. Gerontology-Specific Topics: Nursing of elderly patients with physical and psychological disorders; special issues in gerontological care; foundations of gerontology; and promoting health and wellness in the geriatric patient.
Case Study: How We Did It
As the Magnet program director (MPD) for Overton Brooks VAMC, I was responsible for spearheading the LPN certification efforts. First, we sent out a call for participation to all LPNs within our medical center. The purpose of this initial call was to determine the number of LPNs who might be interested in certification, and in attending a dedicated review session to prepare for taking the gerontology certification exam. The LPNs were informed that all materials would be supplied by the medical center, the review session would be held on a Saturday and the test would be given at our facility, once again on a Saturday.
Answering this call for participation were 15 LPNs with varying levels of experience, employed in a variety of inpatient and outpatient settings. The LPNs were then asked to sign a letter of commitment acknowledging their individual willingness to attend the Saturday review session and the Saturday test. These were not scheduled workdays, and participating LPNs who worked on Saturdays were to use vacation time or request these days as scheduled days off. Unfortunately, this decreased the size of our participant group from 15 to 12. Even so, we moved forward with our initial plans to increase the number of certified LPNs.
Our next step was to obtain funding for the certification project. Initially, the project was discussed with nursing leadership, who viewed the certification in gerontology as a continuing education opportunity. Subsequently, the proposal was presented to the medical center’s executive leadership group, who determined that this very worthwhile professional development activity was appropriate for funding through continuing education funds. This enabled us to order the materials we needed.
Education Resources, Inc. (ERI) sponsors the certification testing and credentialing offered by the NFLPN. ERI has a long history of assisting practical nurses with various types of educational opportunities. The paper/pencil examination may be administered at the place of employment for LPNs or at an approved testing facility. Hence, the test was administered at our hospital and I served as the proctor.
ERI provided a review DVD, test booklet, pencils and proctor verification forms for each participant. They also provide each LPN participant with a diagnostic report, listing on the national LPN registry and individual certificates (for those who pass the exam).
When the DVD review materials arrived, my next job was to evaluate them to determine their adequacy in preparing our LPNs for this examination. I was qualified to do this because I have experience in working with practical nursing schools and NCLEX-PN® and -RN® preparations, and I hold an advanced degree in public health education and a doctoral degree in health policy. I also have more than 15 years experience in curriculum design, development and evaluation.
My initial review of the materials determined that further enhancement would be beneficial to this LPN group. Therefore, I developed our own additional review materials, including over 300 PowerPoint slides covering topics such as normal aging changes (physical and emotional), major disease processes affecting the elderly, and test-taking strategies. Additionally, the DVD was transcribed verbatim to a hard-copy format to facilitate adult learning.
Gerontology Certification Costs Certificates, diagnostic results, test fees and DVD review materials for 12 LPNs: $1,800.00
Reproduction of review materials developed by MPD: $ 72.00
12 binders for the review materials: $ 36.12
Total: $1,908.12
As with any review course, it’s important to know your audience. Standardized review courses are generally tailored to a large audience. That’s why it’s so crucial to determine if the majority of your group members are functioning at the same knowledge level prior to conducting a group review.
In early May 2008, we conducted the review session with our 12 LPN participants. It lasted six hours, with three 15-minute breaks. Participants were encouraged to bring beverages and light snacks to the session; however, lunch was not provided.
The LPN group returned later that month to write a 105-item certification exam. They had two hours to complete the exam, though most were finished within one hour.
When ERI sent us the examination results, they arrived at my office in individual sealed envelopes to ensure confidentiality. In turn, the LPNs were notified that the results were available. Individually, each one came to my office, received their envelope and anxiously reviewed their results. Nearly all of the participants—11 out of 12—successfully passed the certification exam and are now proudly identified as certified LPNs in gerontology, holding the LPN, GC [Gerontology Certified] designation.
Cost-Effective and User-Friendly
The cost to our medical center was minimal. As itemized in Table 2, the estimated total cost was around $1,900. I volunteered a total of 12 hours of my time for the review session and the test proctoring.
In conclusion, this certification strategy has proven to be a worthwhile professional development opportunity involving a successful collaboration between direct care nurses, medical center leadership and our facility’s Education and Training Service, which provided financial resources. The benefits to our facility and our LPNs are evident. The group certification enabled us to:
• increase the professional role of the LPN;
• improve career advancement opportunities for these nurses;
• help LPNs meet their personal and self-improvement goals; and
• provide an avenue for LPNs to highlight their special skills and talents in gerontology.
We have rewarded each newly certified LPN with a within-grade step increase. The next phase of the project will be to replicate this user-friendly approach to group certification with other licensed nursing staff (RNs and advanced practice nurses), as well as unlicensed staff (nursing assistants and health care technicians). Our VAMC is well on its way to obtaining 20-25% certification among its direct care nurses—the first step in our journey toward achieving Magnet recognition. n
References
1. Cary, A.H. (2001). “Certified Registered Nurses: Results of the Study of the Certified Workforce.” American Journal of Nursing, Vol. 101, No. 1, pp. 44-52.
2. American Association of Critical-Care Nurses and AACN Certification Corporation (2003). “Safeguarding the Patient and the Profession: The Value of Critical-Care Nurse Certification.” American Journal of Critical Care, Vol. 12, No. 2, pp. 154-164.
3. Piazza, I.M., Donahue, M., Dykes, P.C., Griffin, M.Q., and Fitzpatrick, J.J. (2006). “Difference in Perceptions of Empowerment Among Nationally Certified and Noncertified Nurses.” Journal of Nursing Administration, Vol. 36, No. 5, pp. 277-283.
4. Shirey, M.R. (2005). “Celebrating Certification in Nursing: Forces of Magnetism in Action.” Nursing Administration Quarterly, Vol. 29, No. 3, pp. 245-253.
As a registered nurse and lawyer with training in medical bioethics, Gloria Ramsey, JD, BSN, RN, knew a lot about end-of-life planning. Yet as her mother lay dying in a hospital after suffering a stroke, Ramsey’s knowledge didn’t save her from distress when it came to making final medical decisions for her.
“I will always remember [how my stomach dropped] when the attending physician asked me the question,” she recalls.
Fortunately, Ramsey knew her mother’s wishes and had the support of family members. But what about others, she wondered, who didn’t have a medical background or family to back them up? Today the question fuels her mission to educate minorities about the importance of planning for end-of-life care in advance—before they suffer a serious illness or become incapacitated.
Although most Americans believe patients should have the right to direct their medical treatment at the end of life, less than a quarter of the general population has completed advance directives. And Americans of color are even less likely to have expressed their wishes in writing.
There are two kinds of advance directive documents: a health care power of attorney (also known as a health care proxy), which identifies the person whom patients select to make medical decisions for them if they cannot speak for themselves, and living wills, which spell out patients’ preferences for end-of-life medical treatment, such as the right to refuse life-prolonging care.
“[Advance directives] help avoid the worst thing that can happen—family members left to make agonizing choices because they don’t know what the person wanted,” says Kathy Brandt, MS, vice president of professional leadership, consumer and caregiver services for the National Hospice and Palliative Care Organization (NHPCO). “If you don’t choose for yourself, the choice will be made for you.”
Removing Cultural Barriers
Nurses can make a profound difference by educating patients about the importance of end-of-life care planning. And when it comes to closing the gap of advance directive disparities, minority nurses can play a key role because they bring to the table cultural knowledge and understanding that helps establish trust in communities of color.
Gloria Ramsey, JD, BSN, RN
“Nurses are on the front lines,” says Paul Malley, president of Aging with Dignity, a nonprofit organization in Tallahassee, Fla., that promotes better care for people facing the end of life. “These are questions people feel comfortable asking a nurse.”
Minorities are less likely to complete advance directives for a variety of reasons, including a lack of access to culturally and linguistically appropriate information. Mistrust of the health care system, misperceptions about advance directives and difficulties in understanding medical terminology can also create barriers. Given the long history of racism in this country, some older African Americans suspect they will get inferior medical treatment if they complete advance directives. Many of them have not forgotten the infamous 1932-1972 Tuskegee syphilis experiment, in which 399 African American men with syphilis were misled by researchers and were not given the treatment they needed; 128 died of the disease or related complications as a result.
Ramsey, who has conducted research on African Americans’ perspectives on end-of-life planning, says that some black Americans don’t complete advance directives because they believe their families will know what to do when the time comes. Others view end-of-life treatment planning as giving up hope, or giving up on God. African Americans who do complete advance directives tend to request more aggressive life-sustaining treatment than whites.
In the Chinese culture, talking about death is taboo, and Western concepts of end-of-life care, such as hospice, may be unfamiliar to patients who are immigrants from mainland China. Some Chinese elders may have the fatalistic belief that advance end-of-life planning cannot change the future, according to NHPCO, whose Caring Connections outreach program offers informational resources on end-of-life issues developed specifically for Chinese American and Latino populations.
In focus groups with Latinos, NHPCO found that most participants were unfamiliar with the idea of advance health care planning. There were also linguistic misunderstandings about certain terms, such as “caregiver,” which in the Latino community implies a professional role rather than one undertaken at home by family members. Some Latinos have not heard of hospice and may equate it with nursing homes, which have a negative connotation because they go against the traditional cultural belief that it is the family’s responsibility to care for their sick and elderly relatives.
Still other barriers stem from legal red tape. Each state has its own advance directive laws, and some states require advance directive documents to be notarized in the presence of a lawyer. This can be a problem for minorities who live in low-income or rural communities where there is little or no access to notaries and legal services.
“Although the advance directive laws were written with good intentions, they have created hurdles that are insurmountable for many patients,” says Rebecca Sudore, MD, assistant professor of medicine at the University of California, San Francisco.
Simplifying Advance Directives
In a study published in the June 2008 issue of the Journal of the American Geriatrics Society, a team of researchers headed by Sudore recommended that oral advance directives, based on patients’ discussions with doctors, be made legally binding in all states. The study also emphasized the need for health care professionals and policymakers to facilitate opportunities for discussion about advance care planning in minority communities.
Anna Terrell, MSN, RN, BC
Of the 173 subjects who participated in the study, the majority (73%) were persons of color, and 31% had less than a high school education. The researchers found that subjects who had talked with family, friends or health care professionals about their end-of-life care preferences were more likely to take the next step and complete a written advance directive. Especially in communities where there is distrust of the health care system, says Sudore, the emphasis should be on getting people to think and talk about end-of-life planning rather than looking only at whether they have signed the legal documents.
She also stresses the need for advance directive documents that are easy-to read, easy-to-understand and culturally and linguistically appropriate. In a previous study, Sudore’s research team found that patients in California overwhelmingly preferred a simplified advance directive form to the standard form used in the state. The simplified version, which Sudore created with input from health literacy experts, patients, social workers, nurses and attorneys, uses short sentences, large type and helpful graphics that illustrate the text. Of the 205 people recruited for the study, 40% had limited literacy and 30% spoke only Spanish. Participants were able to complete greater portions of the simplified form, and almost three-quarters said they preferred it. Six months later, 19% of the group assigned to the simplified form had completed an advance directive for their personal use, compared to only 8% of those who were given the standard form. The simplified form, which is written at a fifth-grade reading level, is now legally valid in California and is available in English, Spanish, Chinese and Vietnamese.
Online Resources Nurses and nursing associations can participate in National Health Care Decisions Day (NHDD), an annual initiative held each April to encourage Americans around the country to talk about their future health care decisions and complete an advance directive. The NHDD Web site, www.nationalhealthcaredecisionsday.org, contains educational resources, ideas for community outreach activities, promotional materials and links to national and state-specific information, including copies of advance directives. The Center for Practical Bioethics’ Caring Conversations® consumer education initiative (www.practicalbioethics.org) offers a free advance care planning guidebook to help families share meaningful conversations while preparing to make decisions for end-of-life care. The guide, which includes advance directive documents, is available in English, Spanish and Braille. Aging with Dignity, www.agingwithdignity.org, provides information and resources for end-of-life care planning, including free copies of Five Wishes, an easy-to-understand advance directive available in 20 languages. Caring Connections, www.caringinfo.org, a program of the National Hospice and Palliative Care Organization, offers a variety of free downloadable resources, include state-specific advance directives and consumer education brochures in English, Chinese and Spanish. Key Topics on End-of-Life Care for African Americans, www.iceol.duke.edu/resources/lastmiles/index.html, an “electronic book” published by the Duke Institute on Care at the End of Life’s Initiative to Improve Palliative Care for African Americans, is a collection of papers presented at the Last Miles of the Way Home conference in 2004, the first national conference focusing on end-of-life care issues in the African American community. The Chinese American Coalition for Compassionate Care, www.caccc-usa.org, provides educational resources and advance directive forms in Chinese and English. Free copies of the simplified California Advance Health Care Directive developed by Rebecca Sudore, MD, of the University of California, San Francisco are available in English, Spanish, Chinese and Vietnamese from the Institute for Healthcare Advancement (IHA), www.iha4health.org. Bulk copies can be ordered by contacting IHA at (800) 434-4633 or [email protected]. What Y’all Gon’ Do With Me? The African American Spiritual and Ethical Guide to End of Life Care by Gloria Thomas Anderson, LMSW, can be ordered from her Web site, www.hearttones.com, or by emailing her directly at [email protected]. The Web site www.DoYourProxy.org offers a free online tool that helps people quickly and easily create a health care proxy and/or a living will.
Other organizations have also been working to make advance directives simpler. In 1998, Aging with Dignity introduced Five Wishes, an easy-to-use advance directive written in plain language. The document includes a health care proxy and lets people state their preferences regarding the kind of medical treatment they want or don’t want, how comfortable they want to be and what information they want their loved ones to know.
“It asks all the right questions and doesn’t make any assumptions about where someone is coming from,” Malley says. Five Wishes is valid in 40 states, and it can be used as a helpful guideline in states where the document does not meet legal requirements.
Two years ago, Aging with Dignity launched the 500,000 Wishes campaign, an outreach program designed to raise awareness of the need for advance care planning in minority communities. Funded by a $200,000 grant from the United Health Foundation, the campaign translated Five Wishes into 20 languages—including Arabic, Hindi, Hmong, Somali and Korean—and offered them for free. So far 250,000 have been distributed to individuals, community organizations, hospitals and hospices nationwide—halfway to the campaign’s goal of reaching a half million minority Americans. “Having this type of document available in so many languages is a first,” Malley says.
“It’s written in a positive and loving light,” says Leslie Piet, RN, MA, CCM, a nurse case manager in Bel Air, Md., who distributes Five Wishes to her patients. In some cases, she reads it aloud to patients. A passionate advocate for end-of-life planning, Piet was prompted by the 2005 Terri Schiavo right-to-die case to host a “living will party” for her family and friends. People gathered to discuss end-of-life choices and complete the Five Wishes document.
“[In our society,] we plan for bringing our children into this world. Now we need to get into the mindset of preparing for transition from this world,” she says. “When good end-of-life care is done well, patients and their families tend to be at greater peace.”
Positive Messages
To reach people from a variety of cultures, education about advance directives must be framed in a positive way, Piet emphasizes. “It’s not about the things you don’t want. It’s about what you do want.” Most health care facilities are required by the federal Patient Self-Determination Act of 1990 to inform patients about their health care decision-making rights and ask if they have completed an advance directive. But too often this communication with patients becomes a checkbox item.
“It needs to be about more than policy and procedure,” says Anna Terrell, MSN, RN, BC, a retired nurse in Kansas City, Missouri. “It takes some time to sit down with patients and discuss end-of-life care.”
Before her retirement, Terrell educated nurses on advance care planning, served on her hospital’s ethics committee and worked with the Center for Practical Bioethics in Kansas City to learn more about African Americans’ experiences with end-of-life care. She developed a script to use with hospital patients during the admission summary process and tailored it to each patient’s needs, always mindful of their cultural and religious backgrounds.
“You have to be culturally knowledgeable about how to introduce the subject,” she says. “Many African Americans believe that if you bring up the subject of end-of-life care, you’re trying to rush the death.”
Misunderstandings can occur when doctors and nurses don’t consider the issue from their patients’ perspectives. Gloria Thomas Anderson, LMSW, a social worker in Kansas City, recalls how one of her elderly family members became upset and had to be restrained after a nurse asked if she had completed an advance directive.
“She interpreted that to mean that the hospital staff was trying to put her in a nursing home,” Anderson says. “She had avoided medical treatment for over 20 years, because she feared doctors and hospitals.”
After her relative calmed down, Anderson explained that the purpose of the document was not to put her away or to take things from her, but to make sure her family knew her wishes if she were not able to speak for herself. The woman agreed to complete an advance directive, giving one of her adult children power of attorney over her health care needs.
Anderson, who researched end-of-life care for her master’s thesis in 2006, received a grant from the Women’s Council at the University of Missouri-Kansas City to create and produce the booklet What Y’all Gon’ Do With Me? The African American Spiritual and Ethical Guide to End of Life Care. She is now partnering with Kansas City Hospice in a joint effort to distribute the booklet as a free educational resource for African Americans in the Kansas City area. This fall, Anderson will introduce an accompanying outreach training kit that health educators and organizations can use with the booklet to increase awareness of end-of-life issues in the black community.
Forming Coalitions, Building Trust
Sandy Chen Stokes, MSN, RN
Collaborating with other health care professionals and organizations can help nurses make an even bigger difference in closing advance directive knowledge gaps in minority communities. Three years ago, Sandy Chen Stokes, MSN, RN, a public health nurse in El Dorado County, Calif., founded the Chinese American Coalition for Compassionate Care to address the lack of linguistically and culturally appropriate end-of-life care information available to California’s Chinese community. Today the coalition includes more than 50 organizations (including NHPCO), provides training for Chinese-speaking volunteers and family caregivers, and offers advance directives, booklets and other educational resources in Chinese and English.
Less than 1% of Chinese Americans have completed advance directives, Stokes says. In focus groups with Chinese American health consumers, the coalition found that many families did not have adequate information for making informed medical decisions at the end of life, and most believed their choices were limited to either aggressive life-sustaining measures or simply “giving up.”
The coalition’s future plans include developing training for health care professionals, expanding its speakers’ bureau and partnering with additional U.S. and international organizations.
“My hope is that [what we are doing in the Chinese American community] can become a model program for other minority groups,” says Stokes.
As part of her research into African Americans’ attitudes about advance care planning, Gloria Ramsey partnered with a large African American church in Harlem, where she provided education on end-of-life issues and advance directives. Ramsey, now an associate professor at the Uniformed Services University of the Health Sciences Graduate School of Nursing in Bethesda, Md., was on the faculty at New York University at the time. She soon realized that even when nurses share the same ethnicity and culture as the community they’re working with, they must still establish trust and credibility before their outreach efforts can succeed.
“Although I am an African American, and the community saw me as African American, I still had to work hard at gaining their trust,” she says. “I had to show that I had no ulterior motives.”
The church was already receiving numerous requests a month to participate in research projects, and it had recently had a bad experience with another researcher. In situations like this, Ramsey advises, “it is imperative to have a local champion, a key person who can [serve as a gatekeeper].”
She partnered with the parish nurse, who acted as a liaison with the pastor and church members. Ramsey also immersed herself in the community by attending services every Sunday and volunteering with the church’s health ministry. She was careful about how she introduced her project. The parish nurse warned her not to use any language about death and dying, for instance.
Ramsey earned the trust of the congregation, although she hit a roadblock early on when she distributed a bulletin insert mentioning organ donation, a question that’s part of the New York advance directive document. The board of trustees, concerned that she was trying to get something from church members through the back door, requested a meeting. Ramsey addressed their concerns and explained her intentions, and the project moved forward.
But she says in hindsight she would not have brought up organ donation so soon without first providing education to put the issue in perspective.
Ramsey conducted focus groups and used that input to design a comprehensive, multifaceted health education program for the church. It included information on health risks, healthy living, spirituality and health, grief and bereavement, and advance care planning, using Five Wishes. She also shared her own story of making end-of-life decisions for her mother, which brought the issue home to church members on an emotional level. Suddenly she was perceived as not just an academic but also a loving daughter confronting the challenge of carrying out her mother’s wishes.
Today Ramsey continues to think of her mother as the inspiration for her work. “This was her last gift to me,” she says. “By sharing my story with communities of color, I am able to empower them.”
America is a graying society. According to the 2000 U.S. Census, 35 million people in this country are age 65 and older, and there are 9.2 million Americans age 80 or older. These numbers are expected to rise dramatically over the next 20 years as the country’s 80 million baby boomers hit retirement. In fact, the 65-and-older population is expected to increase nearly 80% by 2025.
When this tidal wave of elderly Americans hits, will our health care facilities be ready to care for them? As the severe national nursing shortage drags on, many experts are concerned that the answer will be “no.” For example, a study recently published in Nursing Economic$ raised the alarm that the nation’s supply of cancer nurses is likely to fall far short of the number needed to meet the demands of the baby boomers as they age.
The rapid growth of the “senior boomer” population is creating an urgent need for nurses in a variety of specialties, from cancer to Alzheimer’s—and RNs with specialized skills and training in geriatric health will be in particularly high demand.
“Gerontology is the field that is going to have the greatest need for nurses in the future,” predicts Mireya Guzman, RN, MSN, MHSA, who works at the Health Foundation of South Florida. “People are living longer, many resources that weren’t always available to the elderly are becoming more available now and more invasive procedures are being performed on elderly patients. This specialty will continue to grow.”
Because the U.S. population is not only getting older but also becoming more ethnically and culturally diverse, she adds, there will be a critical demand for more minority gerontology nurses who can help meet elderly patients’ need for culturally competent care.
“I don’t think belonging to the same ethnic group as the patient necessarily means you will provide better care,” says Guzman, who is of Cuban descent. “Some nurses who work with a minority population are able to develop a sensitivity to that group’s cultural needs, regardless of their own ethnic background. But I do think it’s nice to have, for example, some Hispanic nurses in the field, because other nurses can learn from them and increase their awareness of cultural issues that affect Hispanic patients’ health needs.
“Research has demonstrated that when we get ill, we regress to our roots,” she continues. “Sometimes people become more dependent when they get sick, and they may feel a stronger need to rely on their familiar cultural traditions.”
For example, Guzman explains, while North American culture emphasizes independence, Hispanic culture is more family-oriented. “When a Hispanic person has to make a decision, what their family thinks is very important,” she notes. “When you get older, that tradition not only stays with you, but can become stronger. Now that they are physically weaker, they will place tremendous value in what their children say. The children are really expected to be there for the older relative and provide that support.”
Aging Parents, Changing Needs
This approach to caring for elderly family members holds true in other minority cultures as well, according to Carmen Galang, RN, PNSc, a Filipino American nurse who is a lecturer at California State University, Long Beach, and the team leader for an undergraduate course on gerontological nursing. In her own case, Galang took a leave of absence from her educational pursuits, and later from a teaching position, to take care of her ailing parents.
Throughout her education, Galang has done aging-related research; she also has extensive clinical experience in the care of elderly patients in community, home health and hospital settings. After her father became ill, she decided to look at how other cultures deal with this situation, focusing first on Mexican Americans. Many people from this culture, Galang learned, prefer to care for their elders at home rather than placing them in a nursing home or other facility. “Sometimes additional relatives come over [from Mexico] to help out,” she adds.
But Victoria Berbano, RN, BSN, MHA, vice president of case management for VitalCare America in Orange County, Calif., which manages long-term care for patients who are in acute care facilities, believes this pattern is beginning to change as more minority baby boomers struggle with their “sandwich generation” responsibilities of caring for both their own children and their aging parents.
“I never used to see Koreans or Filipinos being admitted to long-term care, because Asians usually take care of their elderly parents at home,” reports Berbano, who is Filipino. “But now there are a lot of Asian Americans who, like myself, are baby boomers who work full time and are not able to take care of their older moms and dads. I am definitely seeing more Asians in long-term care than I used to see 12 years ago.”
Many African-American communities are also underserved in the area of elder care, says Tonya Boyd, RN, MS, CS, a nurse at the Hebrew Rehabilitation Center for the Aged in Boston. She feels that a stronger representation of minorities in geriatric nursing might encourage older people of color to seek care more quickly.
“African Americans are usually reluctant to seek care until a disease process has progressed to a point where the treatment might be difficult,” she explains. “The African- American patients we do get here seem to respond better to me than to my [white] counterparts. They tend to be more open with me.”
Gwen Huddleston, RN, BSN, an African-American nurse who works at Hurley Medical Center in Flint, Mich., echoes that assessment, adding that it’s important for elderly black patients to feel comfortable with their nurses because these patients often lack knowledge about medications and other care options available to them. “People say we are all alike but our cultures are very different,” she maintains. “If you grew up in a [minority] community, you can sometimes see it better. There is a close bond and you can’t take that bond away. Black patients, especially the very old, sometimes listen better to people who are like them. They didn’t grow up in a community that was white–they came up in a black community.”
Special Skills for a Special Population
While many of the nurses interviewed for this article feel there is good representation of minorities in gerontological nursing, this was not always the case. Sarah Myers, RN, PhD, nursing clinical coordinator for Geriatrics and Extended Care at the Atlanta Veterans Administration Nursing Home Care Unit, part of the VA Medical Center, remembers having few role models when she was growing up. As a youngster in Georgetown, S.C., Myers used to watch TV shows like “Dr. Kildare” and “Marcus Welby, MD.”
“One factor that influenced me to become a nurse was the noticeable absence of African-American health professionals on television, in the local health department and in the doctors’ offices in my hometown,” she recalls. Helping her mother care for her great-grandmother, who lived to be 115, and her grandmother, who died at 98, also shaped her decision and led to her interest in geriatric nursing.
Older people, says Myers, represent a population of untapped wisdom. “This is a population that has suffered significant losses,” she points out. These can include the death of a spouse, loss of a body part or function, loss of income and the loss of significant others, be it children, siblings or friends. “I can’t think of any population–other than veterans–that has suffered so many losses, sometimes all or most of them occurring at the same time,” she continues.
In addition, the elderly population presents nurses with significant and complex health care challenges. “They require a health professional with specialized skills,” Myers notes. “Gerontology is a specialty and there is a knowledge base that nurses must have to work with these patients.”
For starters, nurses need to know normal aging. “You need to know what happens to someone as they get older, so that when you see something that deviates from that, you will know it is not normal,” Myers says. “These specialized skills relate to issues such as pain management, wound management, prevention and management of bed sores, and nutrition.” Research shows that a significant number of patients suffer weight loss in long-term care settings as well as hospitals, she adds.
Career paths for gerontological nurses are not just limited to working in hospitals and nursing homes. Community health, home health care, public health, senior centers, clinics and hospices all offer opportunities for nurses who specialize in this field. All of these settings, experts agree, will have high demand for nurses over the next 20 years.
With today’s health care economics dictating shorter and shorter hospital stays, Galang adds, more elderly patients are receiving nursing care at home and in outpatient settings. “There will be a lot of [jobs opening up] in home health, nursing homes, extended care facilities and boarding care. Nurses in this field have lots of opportunities.”
Gerontology Goes to School
Although gerontological nurses of color are not a rarity in the clinical setting, their presence is severely lacking when it comes to teaching this specialty. “In academia there are very few of us,” says Galang. “I think we need more gerontology faculty who are minorities. They could share their own experiences and culture with students, to help them learn to be more culturally sensitive.”
Stronger gerontology curricula at the nation’s nursing schools would be helpful as well, Myers believes. “The care of older people is changing so much, even in areas like pain management, nutrition, weight loss and elder abuse,” she emphasizes. “If you look at current curricula, some of these things need to be added.”
Myers is currently working as a consultant for Tuskegee University on a program to enhance students’ knowledge within this field. The university recently earned a major grant from the John A. Hartford Foundation, which has helped the school incorporate more gerontology into its nursing curriculum.
Another historically black nursing school, the Department of Nursing at Winston-Salem State University School of Health Sciences, has been nationally recognized by the American Association of Colleges of Nursing (AACN) for its innovative baccalaureate curriculum in gerontological nursing. The program has included courses held in low-income community housing projects where the students had the opportunity to work directly with elderly residents.
Other schools whose gerontology programs have been cited as exceptional by AACN include Pennsylvania State University School of Nursing, University of Nebraska Medical Center College of Nursing and Sacred Heart University Nursing Programs and Physical Therapy Program in Connecticut.
A Booming Need for Researchers
Gerontological research is still another area where minority nurses can find rewarding careers and make a difference in improving health care for the elderly. There are several organizations that fund such projects nationwide, including The National Institute on Aging, one of the National Institutes of Health.
“There are many subjects [in gerontology] that need to be explored, including behavioral research,” Galang stresses. “Right now there is lot of money available for doing research on the elderly. I think it is in anticipation of the aging baby boomers.”
Saun-Joo Yoon, RN, PhD, an assistant professor at the University of Florida, Gainesville, College of Nursing, was one of approximately a dozen gerontology nurses from the Southern region who spent time this past summer participating in New York University’s John A. Hartford Institute for Geriatric Nursing program.
“We met renowned gerontology scholars and researchers who became our mentors,” she says. The institute’s goals include fostering successful gerontological research programs with significant implications for practice, assisting in the refinement of a program of significant research, honing nurses’ research skills and helping them gain a competitive edge in obtaining funding for their projects.
Yoon is a published researcher who has presented her findings at a number of conferences. In 2001, she published a paper on the use of oral dietary supplements among older women. She is currently doing a similar research project, but has narrowed her topic down to focus on older African-American women. She is also working on another project involving use of the supplements glucosamine and condroitin for older people with osteoarthritis.
A native of South Korea, Yoon says her interest in gerontology research is a result of several factors. “In America, the minority population is steadily increasing, and they are aging as well, along with the white Americans,” she explains. “The new Census shows that the elderly Hispanic, African American and Asian populations are increasing both in number and age. We definitely need to have a better understanding of these populations’ health needs as they grow older.”
Historically, Yoon says, the older generation of minorities has been reluctant to participate in research studies because of their memories of negative experiences in the past, such as the infamous Tuskegee syphilis study, which from 1932 to 1972 allowed African-American men with the disease go untreated. Today, she still finds it difficult to recruit minority participants for certain studies, because of lingering mistrust and misconceptions about the research process.
“I try to utilize the best possible ways to include minorities in research,” Yoon comments. “Their participation will provide valuable information, which will, in turn, provide better health care.”
Giving and Getting Back
Whether your passion is scientific investigation, caring for patients or educating the next generation of nurses, these roads converge in gerontological care. “If you like seniors and you like to teach, this field is as wonderful as it is rewarding,” Huddleston concludes. “I love working with these people. I am hoping to retire in the next few years and this is a perfect closure to my nursing career. It has been a great opportunity for me.”
“You get the chance to meet new people, as well as their families and loved ones,” adds Carmen Stephens, RN, a Mexican-American elder care nurse at La Mesa Care Center, a long-term care and rehab center in Yuma, Ariz. “To work in this field, you need passion and compassion for the elderly, and what you get back is the chance to know you made a difference in someone’s life. The greatest reward is when you put a smile on an elderly person’s face.”
Next Steps
Want to learn more about careers in gerontological nursing, research opportunities and health issues affecting the elderly? Here are a few good places to start:
National Gerontological Nursing Association
7794 Grow Drive
Pensacola, FL 32514
(800) 723-0560
www.ngna.org
Administration on Aging
U.S. Department of Health and Human Services
330 Independence Avenue, SW
Washington, DC 20201
(202) 619-7501
www.aoa.gov
The National Institute on Aging
Building 31, Room 5C27
31 Center Drive, MSC 2292
Bethesda, MD 20892
(301) 496-1752
www.nia.nih.gov
John A. Hartford Foundation Institute for Geriatric Nursing
New York University
Division of Nursing
246 Greene Street
New York, NY 10003
(212) 998-9018
www.hartfordign.org
New nursing technology has opened endless opportunities for superior care, says Susan R. Stafford, R.N., B.S.N., M.P.A., M.B.A., Associate Chief Nursing Officer of Nursing Informatics at the Cleveland Clinic Stanley Shalom Zielony Institute for Nursing Excellence. The Zielony Institute oversees the practice and education of more than 11,000 nurses in all aspects of the Cleveland Clinic health system, including inpatient, outpatient, rehabilitation, and home care fields. “From recently introduced innovations to those that are on the horizon, enhanced technology gives nurses the ability to integrate so we can focus on delivering quality, safe, world-class care,” Stafford says.
Nurses have always been information managers at the center of a wheel, according to Patricia Abbott, Ph.D., R.N., associate professor and Co-Director of the World Health Organization/Pan American Health Organization Collaborating Center for Nursing Knowledge, Information Management, and Sharing at The Johns Hopkins University Schools of Nursing and Medicine, and chair of the 11th International Congress on Nursing Informatics in 2012. Everybody touches base with the nurse to get the latest information on a patient, says Abbot. “We’ve always had technology in our lives.”
“Our students come in with every piece of technology known to man hooked on their belt. Sometimes it’s like Jeopardy—we’ve got the answer; now what’s the question?” Abbott says. “We’ve got the technology; now show me how to apply it.” Abbott says the younger generation was raised with technology, impacting the way they communicate and conceptualize. “It’s fundamentally changing the way you think and your belief networks,” she says. “What’s happening is a lot of people are starting to look at this and see they have to adapt or leave.”
As U.S. Secretary of Veterans Affairs General Eric Shinseki once said, “If you dislike change, you’re going to dislike irrelevance even more.”
What follows are some of the top trends in nursing technology today, from the macro-level, government-funded changes to the little gadgets you might soon find in your hand.
Nursing informatics
Nursing informatics is a growing field that supports nursing processes through technology, including telehealth, home health, ambulatory care, long-term care, education/research, acute care, outpatient settings, software development, and work flow redesign.
“Technology has been growing and work has been done for 40 years, but people didn’t know about informatics education and it was not that widely available,” says Bonnie Westra, Ph.D., R.N., F.A.A.N., associate professor and Co-Director of the International Classification of Nursing Practice Research and Development Center for Nursing Minimum Data Set Knowledge Discovery at the University of Minnesota School of Nursing. She says she’s suddenly seeing informatics classes that previously attracted three people grow into classes of 25. “Now programs are crawling out of the woodwork,” says Westra, also co-chair for the Alliance for Nursing Informatics (ANI).
The Healthcare Information and Management Systems Society (HIMSS) 2011 Nursing Informatics Workforce Survey reported that nurse informaticists play a critical role in the implementation of various clinical applications, including clinical/nursing documentation and clinical information systems, computerized practitioner order entry (CPOE), and electronic health records (EHR). The 2011 data also suggests a substantial increase in salary for nurse informaticists, which is up 17% from 2007.
Kathryn H. Bowles, Ph.D., R.N., F.A.A.N., associate professor of nursing at the University of Pennsylvania School of Nursing, says there are a few programs in the United States for nurses holding a master’s or Ph.D. She added the American Medical Informatics Association (AMIA) is doing a lot of work to promote nursing and medical education in nursing informatics, and the Technology Informatics Guiding Educational Reform (TIGER) Initiative is transforming informatics.
The TIGER Initiative aims to identify information/knowledge management best practices and effective technology to help practicing nurses and nursing students make health care safer, effective, efficient, patient-centered, timely, and equitable. “Nurses are out doing 50%–80% of all care in the globe, and many times they are in the field or in the bush,” Abbott says. “As technologies have gotten smaller, powerful, and more mobile, if we combine a huge workforce with more powerful technologies, we are enabling nurses, birth attendants, and midwives to practice better. When you do that, you improve care to an entire community.”
Telehealth
Telehealth promotes lower-cost health care through mobile communication and video. Laptops, tablets, and smartphones offer video conference capabilities that allow face-to-face visits without travel costs and complications, and provide vital signs and medical history for remote diagnosis and monitoring.
“Telehealth provides specialty services on the turn of a dime without the patient being shipped off to another facility,” Westra says. Telestroke robotics is one example, where practitioners use robotic technology to manage stroke victims in remote areas. Telehealth also is being used for psychiatric consults in prisons, a less expensive and equally effective treatment option.
Abbott worked on a National Institutes of Health–funded study involving implementing telehealth services for minority patients suffering from congestive heart failure. The program placed telehealth monitors in patient homes for remote monitoring, allowing patients to Skype with nurses regarding their health concerns. “Some of my patients are geriatric African American folks with heart failure, and they don’t have transportation, and they might be in the only occupied house in an area of burned-out homes,” Abbott says. Telehealth also can be a lifeline for entire communities, scaling up knowledge levels of community health workers in low-resource areas without a formally trained nurse on site.
“We know there are not enough doctors to go around, and also not enough nurses,” Abbott says. “In reality, when you start looking at the large provider groups that exist around the world, you look at ways you can reach and teach. Many of these folks, both nationally and internationally, cannot travel to the bricks and mortar model of a school to get additional training.”
Mobile technology
Gartner Inc., a Connecticut-based information technology research and advisory company, says mobile health, or mHealth, is one of the top 10 consumer mobile applications for 2012. According to the 2009 American Academy of Nurse Practitioners (AANP) Membership Survey, 60% of respondents indicated they used a PDA or smartphone in clinical practice. Applications do not require a large, up-front investment and are simple to download. Health diaries, medication reminders, exercise tips, and applications to track food intake, pain levels, and sleeping habits are helping people monitor their own health.
Cell phones facilitating mHealth are proving to be powerful tools in the Latino and African American communities, particularly with illegal aliens afraid to participate in a formal health care system. Abbott says she’s involved in a movement surrounding texting for health, in which nurses reach out to minority populations with health tips and reminders concerning maternal health, HIV/AIDS, and drug addiction. The National Healthy Mothers, Healthy Babies Coalition text4baby’s Hispanic Outreach program, for example, supports mothers by providing 140 characters of health information and resources to a pregnant woman’s cell phone.
“They don’t have home phones—a lot don’t even have a home—but they have a cell phone,” Abbott says. “We are getting messages to them about appointments and medication refills. We let them text in questions or problems they have because they won’t come to the clinic. It’s a way to reach people through something so many people have these days.”
Over the past two years, the University of San Diego’s Hahn School of Nursing and Health Science has required an iPod Touch for incoming RN pre-licensure students. Instead of carrying multiple books to clinical sites, the iTouch provides clinical reference tools and pharmacology manuals with the tap of a finger.
“They find that having those clinical reference tools available to them very quickly while seeing patients is easier than having to look something up in a book,” says Karen Macauley, D.N.P., F.N.P.-B.C., Director of the Simulation and Standardized Patient Nursing Laboratory and clinical associate professor. The school developed an nTrack application for the iTouch with Skyscape Medical to help students document clinical experiences in hospital sites. Once they graduate, students can compile the data into an e-portfolio for potential employers.
“We decided to require it because it forces students to really embrace technology,” Macauley says. “Once they get into the hospital sites, you’re really looking at the best evidence-based practice and how to apply it to their clinical practice. Without having something at their fingertips to look at right away, they are at a loss.”
Another mobile tool growing in popularity is the electronic tablet. “The whole iPad application, how it will affect patient teaching and patient interaction, will be huge,” Westra says.
Abbott says mobile technology is especially important for nurses, who are incredibly mobile themselves. “We are running from bed to bed to bed, from unit to unit to unit, from clinic to clinic to clinic, from house to house to house,” Abbott says. “Records never seem to go with us, which has caused a lot of errors, redundancy, and wasted effort. Now when you put mobile technology in a nurse’s hand or in her pocket, it allows her to do her job, help her patient, right at the patient’s side instead of running back to the nurses’ station and grabbing a chart or looking on a computer.”
Mobile technology can also be a lifeline for remote nurses in “frontier environments” with less than seven people per square mile, Abbott says. A mini clinic with connectivity enables nurses to provide more services, find the help they need when they need it, and quickly connect through Skype with a specialist to find an answer.
Electronic health records
The federal government set aside $27 billion for an incentive program, as part of the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, to encourage hospitals and providers to adopt electronic health records systems (EHR). Policymakers continue to work toward establishing a Nationwide Healthcare Information Network to standardize EHRs, which would provide a seamless exchange of data among physicians, hospitals, laboratories, pharmacies, and other health care organizations.
At the Cleveland Clinic, electronic documentation includes computerized provider order entry (CPOE), nursing care documentation, medication dispensing and administration, and results reporting. The technology improves access to patient information at the point of care and enhances the ability to benchmark, monitor, audit, and report quality measures while offering quality data to support nursing-led research.
The Cleveland Clinic has been implementing EHR technology in stages over the past six years. The most recent implementation was the ICU nursing documentation with device integration. With this implementation, vital signs go directly from the cardiac monitor at the bedside into the EHR.
At the University of Pennsylvania, Bowles’ is examining decision making supported by information technology to improve care for older adults. Her ongoing study, funded by the National Institute of Nursing Research, focuses on the development of decision support for hospital discharge referral decisions. Using an electronic record, patients are asked a series of questions, ranging from their ability to walk to whether they have a caregiver available at home. Through statistical analysis of the answers and information already contained in the EHR, clinicians can make an informed decision regarding a patient’s needs. “Decision support, in general, is a new phenomenon,” Bowles says. “As we start using electronic records, more and more patient data will be available electronically and more developed to remind clinicians of the right thing to do.”
In May 2010, the Office of the National Coordinator for Health Information Technology (ONC) estimated an additional 50,000 health information technology workers will be needed over the next five years to satisfy meaningful use criteria. Abbott is the principal investigator on a HITECH grant to create a six-month, non-degree program for the unemployed to be qualified to build, upgrade, and maintain the implementation of health information technology programs, including EHR systems, at hospitals and clinics.
eICU
Centralized monitoring of intensive care units in remote areas is the health care delivery of the future. FHN Memorial Hospital in Freeport, Illinois, is collaborating with the University of Wisconsin e-Care team of intensivist physicians and critical care nurses in Madison, Wisconsin, on eICU care. Small microphones and cameras in each ICU patient room provide a constant link to the e-Care team at UW Hospital. Patient vital information, including heart rate, blood pressure, medications, and test results, are monitored in the FHN ICU and shared in real time with the e-Care team.
If a patient’s condition suddenly changes, the FHN physician and nurses can touch a button and activate a two-way visual and audio link for an immediate consultation with e-Care specialists.
Social media
The Mayo Clinic health guide used to be the go-to guide at everyone’s bedside. But the introduction of social media has both patients and caregivers logging onto sites like WebMD and Patients Like Me for health information, advice, and forums to share experiences.
A 2008 Edelman Health Engagement Barometer found the Internet has become the “new second opinion.” Patients with a diagnosis are barely out of the exam room door before typing status updates on their smartphones and searching for support groups via social media.
Many nurses have taken to Facebook and Twitter to promote accurate medical information to help the general population make healthy lifestyle choices, as well as to promote their profession.
Virtual reality simulations
Imagine being in the operating room and making a devastating decision that risks the life of a patient. Now imagine being given a do-over and figuring out the best way to proceed.
Such is the scenario in Second Life, a 3D virtual world becoming popular in nursing education. Westra says universities are buying islands and creating communities in which students develop avatars and run through different scenarios to see the consequences of their decisions. She’s even seen a virtual theater set up where students in their avatar personas can “attend” an author interview on a virtual theater stage. “It’s a chance to have people practice skills and make decisions and study consequences and not kill patients,” Westra says.
Radio frequency identification
Radio frequency identification (RFID) has been traditionally used for tagging equipment, but it’s starting to replace bar coding for patient identification. Westra says she is seeing RFID in nurseries to prevent kidnappings and tagging breast milk to ensure it goes to the right baby. Alzheimer’s units are using it as well to monitor patients prone to wandering.
Experimentally, it also is showing up in operating room equipment. A wand with an RFID reader is replacing X-rays to pick up any sponges or instruments left in patients before they are sewn up. Another experimental use is with intubating patients to check placement rather than using X-ray.
Judy Murphy, R.N., F.A.C.M.I., F.H.I.M.S.S., Vice President of Information Technology for Aurora Health Care in Wisconsin and co-chair of ANI, says RFID is a lot like Global Positioning System (GPS), but added there isn’t a lot of penetration of the technology at this point due to the expense. But it may be something more institutions turn to down the road.
Smart pumps
Almost every IV these days is connected to a smart pump integrated with a computer that handles drug infusion calculating. Computerized infusion pumps with dose error reduction systems were developed to alert nurses if a programmed fusion dosage exceeds the hospital’s best practice guidelines.
Some organizations are integrating the pumps with EHRs, allowing physicians to enter information electronically and pass it along via computer to the pump, Murphy says.
Cleveland Clinic is rolling out new IV digital smart pumps designed specifically for high-volume medication infusions. This imitation will be completed and fully implemented in 2012. The Clinic will also be using new smart syringe pumps and smart pain pumps.
Wireless voice-over-IP phones
Through wireless voice-over-IP phones—voice carried over Internet protocol networks—nurses can be more easily reached when they are caring for patients in various rooms throughout a unit. This technology eliminates the need for unit secretaries to make announcements over a loudspeaker. The phone, according to the Cleveland Clinic, helps with noise control, improves efficiency in communication between staff and patients, and streamlines processes.
Electronic patient tracking boards
Similar to wireless voice-over-IP phones, electronic patient tracking boards facilitate ease of communication and coordination of patient care with a quick status display of current activity on a unit. A combination of wireless communication, barcode, and Internet technology, electronic patient tracking boards are replacing white boards in many settings.
Cleveland Clinic first used patient tracking systems in the emergency department and operating room areas. In 2010 the hospital system rolled out a new patient tracking board system to all of the main campus inpatient units.
Electronic patient tracking boards, according to Stafford, decrease the need for phone calls or meetings to find information about patients as they are coming and going. The systems give nursing units a one-stop shop for critical information on patients. A nurse, for example, can easily see if patients are at risk of falling or need extra precautions in isolation.
Point-of-care technology
Point-of-care technology offers access to patient records, labs, medication information, and even second opinions, all from the patient’s bedside. A wireless network and computer allow nurses to access and receive a wide array of information without leaving the patient’s side.
Wireless point-of-care glucometers, for example, submit blood glucose results to the electronic medical record as soon as the clinician checks a patient’s blood sugar level. This technology offers completed reporting and documentation immediately upon the docking of the wireless device into its cradle. The information transaction can also be sent into the electronic medical record.
Workstations on wheels are also used for bedside and point-of-care documentation and information retrieval. Cleveland Clinic has one workstation on wheels for each caregiver working a shift on a nursing unit, providing instant access to a patient’s medical records at the bedside. The Cleveland Clinic finds the system helps nurses confirm all patient information is accurate, including medical history and medications, and improves patient safety for medication administration.
Web-based self-scheduling
Cleveland Clinic is also rolling out a new Web-based self-scheduling platform for all caregivers. The system offers nursing caregivers convenience and flexibility through the ability to select shifts based on competencies. Nurse managers can now spend less time filling shifts and making phone calls. This technology is relatively new and still uncommon among most health systems, but it is a growing trend and anticipated to be coming to more health systems over the next few years.
“We look at the opportunities that are possible because of technological advancements,” Stafford says. “The common thread is that many of these advancements were developed to help nurses give the patient a positive experience. An enhanced patient experience is very valuable, creating a healing environment that contributes to overall positive patient outcomes.”
While all of this technology is meant to create efficiencies, improve outcomes, and ease the workload, Macauley says it all comes down to how medical professionals communicate with each other. The future of medical technology lies within professionals and students who will embrace it and create a system that lowers health care costs by reducing redundancy.
“Those people who leave the program in technology are thinking out of the box on using mobile devices and mobile technology and looking at ways of being innovative in using technology we’re all exposed to,” Macauley says.
As the youngest and first Asian American president of AARP (formerly the American Association of Retired Persons), Jennie Chin Hansen, RN, MS, FAAN, embodies the changing face of this important advocacy organization and its 40 million members, one-third of whom are baby boomers.
Hansen, who is 59, was elected to her two-year term as AARP’s president in May 2008, bringing with her a wealth of expertise in health care and aging issues. According to her official AARP bio, she teaches nursing at San Francisco State University, holds an appointment as senior fellow at the University of California San Francisco’s Center for the Health Professions and is a past president of the American Society on Aging.
Hansen also spent nearly 25 years as executive director of On Lok, Inc., a not-for-profit family of organizations providing community-based health care and other social services for seniors in culturally diverse California communities. On Lok was the prototype for PACE (Program of All-Inclusive Care for the Elderly), which was signed into federal law in 1997, making this Medicare/Medicaid program available in all 50 states.
“I think I am probably the first nurse in this position [of AARP president] in 25 years,” Hansen says. “It is a tremendous honor and a tremendous responsibility.”
Hansen grew up in Boston, the daughter of parents who were immigrants from China. “Being very bicultural—my first language was Chinese—I bring [to AARP] a mindset that is able to [understand and work well] in a diverse, complex community,” she says. “There are many ways to look at life and living. I think [having a multicultural background] allows you that perspective, because you realize that you are always moving in multiple communities.”
In an extensive interview with Minority Nurse in early March, Hansen discussed several health care-related AARP initiatives and her goals for her presidency. Here are some highlights of that conversation.
Q: During the course of your nursing career, you went from community nursing to rural nursing to being a nurse advocate. How have these roles helped you in your current position at AARP?
I think one of the things you learn [in community nursing] is that when you are [working] outside of an institution, such as a hospital, people look at health and well-being a little differently. I think I am quite grounded in understanding the professional knowledge that we bring but also how people want and use information to maintain their well-being or to address their illness. That approach applies in rural health as well.
Growing up in a Chinatown community, I learned that you need to understand core values and help people view what is important in their lives. When you do that, it really informs how you help do community building or do advocacy. It is not something that is [done] top down. It is really about what matters to people at the living edge, as I call it. So you need to bring [everything] together in ways that make sense from a policy perspective, but it also has to make sense to people whose lives are directly affected by policy.
Q: What led you to AARP and your current position?
When I was president of the American Society on Aging, one of our board members was the [then] director of AARP’s Andrus Foundation, so we were colleagues. He was interested in recruiting members for [the foundation’s] board who would bring a different point of view that would help both the foundation and AARP itself begin to think more broadly.
I was actually brought in as an independent member of the board [in 2000] to add to the mix of what the core board offered. From that, I became part of the AARP affiliated family and was then invited to apply for a position on a larger AARP board.
Q: When you became AARP’s new president last year, you highlighted three core themes: the roles medications play in older people’s health; fall prevention; and encouraging important conversations about such issues as end-of-life preferences. Why those three themes?
It relates back to AARP’s current Divided We Fail joint initiative (www.DividedWeFail.org), which focuses on bringing the country together [to develop bipartisan solutions] for ensuring affordable, quality health care for all Americans, and also long-term economic security. This [initiative is a partnership between] the business community, the labor community and AARP, along with other independent organizations.
Since I am a nurse, I am focusing a little bit more on the health side, but [my approach also involves] showing how [health care] ties in to economic security, both for individual people and the country. We need to make these issues tangible and not political, bringing it down to specifics that regular people can do something about, regardless of [which political party is in power]. These are three themes that I think people can relate to.
People over 45 years old take, on average, at least four medications apiece. Medications are an important part of our daily lives. When we do not take them correctly, it costs money and it creates [health care] quality problems. The theme of medication is an important one to me. If people go into the hospital and then go home and do not take their medication correctly, they end up back in the hospital.
The second point was about falls. One in three people over the age of 65 will likely fall in a given year. This is the biggest cause of injury for older people. Half of the people [in this age bracket] who break a bone will die within the following year.
Half the falls that happen to older people happen in their own homes. This is an example of how we can use evidence-based practice [to create practical solutions]. The evidence from the Centers for Disease Control and Prevention tells us that there are simple things people can do to prevent falls from happening: make sure there are better light bulbs, that there are not slippery rugs in place, that electric wires are not crossing areas where people walk. They can also learn to do some exercises that strengthen trunk balance and prevent falls.
These are well-known strategies that involve little or no cost. So this is an area where we can use proven research and apply the [data] in our daily lives to enhance the quality and safety of living and save money.
The third theme is about how much money both individuals and the country spend on the last year of life for people. Oftentimes it doesn’t produce the quality or value that people really wanted. We spend more money on health care during the last six months of life than we do in our entire lifetime. Is that really the best use of our precious resources?
We need to focus more on having conversations [with loved ones about end-of-life care planning] because we all know how much angst occurs when a loved one goes into the hospital. Often family members have not had those conversations about the important changes that happen as we age. We need to bring our families together and have some of these conversations at a time that is not an emergency, because only in America do people think death is an option.
Q: How much support has there been for the Divided We Fail platform and how has it manifested itself?
Our core partners include the Business Roundtable, the National Federation of Independent Business and the Service Employees International Union. In addition to the big players, we have more than 100 independent groups that have joined in to pledge their support as well. On the legislative side, nearly 360 members of the last Congress have signed the pledge or written a letter of support on [the initiative’s] behalf.
[This year] we will host more than 50 events in nearly every state to educate the public about the contemporary issues of what is going on in health care reform and economic security. Part of this will be done through the globalization of town hall meetings, especially during this first Congressional recess, so that constituents and their lawmakers can really connect and discuss [these issues] directly. We will collectively present to the lawmakers the 1.6 million pledges that have been signed by people across the country, asking for this above-partisanship focus by our policymakers.
There are three particular policy areas we will focus on:
The first is access to health insurance coverage. We will try to build on the existing employer-based system while also thinking about other ways to provide coverage for people who are currently not insured. We all have a personal responsibility to make sure we have some good choices and participate in coming under the health care umbrella.
Second, we are looking at improving health care affordability, value and outcomes. Part of this includes a focus on preventive care programs, which again emphasizes the personal opportunity and responsibility people have.
Also, we need to address how poorly advanced our health care system is in the area of technology. We are focusing collectively on that to make sure the electronic highway system of communication will be built to help improve the quality of care and decrease health care costs.
We also need to make sure that the system rewards evidence-based care—in other words, not just [doing something] because somebody thinks it’s the best way, but [because it’s based on proven clinical evidence].
We need to make sure that care is coordinated. Older people who have multiple chronic diseases see anywhere from 10 to 14 doctors a year. We want to make sure that more effort is put into place to ensure that one doctor doesn’t inadvertently prescribe something that [will cause a negative interaction] because [they don’t know that] another doctor is treating that person with a different medication. Coordination of care is so important to make sure we are aligned together for good outcomes.
The third area is increasing quality and efficiency and making sure that we think about it from a patient-centered standpoint, so that the patient is not shunted around from place to place and the delivery of care is smoother and well-coordinated on behalf of that individual
[We also need to] compare the effectiveness of different treatments. Sometimes medication may be more effective than surgery. This kind of research really needs to be done and promoted and used. Divided We Fail [calls for] increasing comparative effectiveness in all parts of the health care system and making sure that the public [can access and understand] this information.
We do know there is a lot of money in the health care system—over $700 billion every year, according to the Congressional Budget Office—that is not being used well. Beyond the need for new money, there is money in the system already that can be better used on behalf of coverage and on behalf of quality.
Q: Another joint initiative AARP is involved in, along with the AARP Foundation and the Robert Wood Johnson Foundation, is the Center to Champion Nursing in America (www.championnursing.org), which is addressing the nursing shortage as well as the shortage of nursing faculty. Last month the Center, in collaboration with the Health Resources and Services Administration (HRSA) Division of Nursing and the Department of Labor (DOL), convened a national Nursing Education Capacity Summit, which brought together teams from nearly all 50 states to discuss solutions to the nursing shortage. What came out of that summit?
What we are doing is aligning all the efforts [across the country, including sharing] of some of the best practices that have been implemented in some of the states. We have states that have signed up to [share information] at the ground level about what some of the best practices are and facilitate the forming of coalitions to bring that about [on a national level].
We are bringing together [representatives from DOL and business], because [they are stakeholders too; we have to] make sure we have a nursing workforce. And we are also bringing in other foundations [that are concerned with aging issues] to try to make sure that not only are we [increasing the number of] nurses in general but also addressing a particular need for nurses to know about [the health care needs of older people] and the complexity of those needs, such as having multiple chronic diseases. This follows on the heels of the [2008] Institute of Medicine report Retooling for an Aging America: Building the Health Care Workforce.
This initiative is also helping to support [health care-related provisions in] the
current economic stimulus bill to make sure that not only is the government
funding nursing education but also education for all [the many] health professionals that are going to be needed for elder care in the future.
So the summit helped bring all of these efforts together to say that this is a national problem and we need advocacy, practice and new ways to think about the care of older people in America.
Q: What are the goals of the Center to Champion Nursing in America?
One of its objectives is to help support the infrastructure for increasing the number of nursing faculty. Without more faculty, thousands of people get turned away [from nursing schools, because there are not enough nursing educators to teach them].
The second goal is the whole aspect of retaining nurses. This especially speaks to people who are middle-aged nurses. Are there ways in which we can help in retention of existing, practicing nurses?
Number three is the ability to advance nurses further into leadership roles, so that they can help represent our profession throughout larger organizations and foundations [that can help shape health policymaking]. We are the largest health care workforce in America. There are nearly 3 million nurses in America right now [compared to] about 750,000 physicians. The contribution and voice [of nurses] to help shape where health care is going to be in the future is an important part of having nurse leaders embedded in the country.
Q: Even though there are 3 million nurses, people of color are very underrepresented in the RN workforce. In your personal opinion as a minority nurse, what can be done to attract more minorities into nursing?
I think having nurses of color as faculty , but there also has to be a focus on providing [more] educational opportunities for [future minority] nurses, such as [bridge programs] that align community college programs with baccalaureate programs. Many students who are immigrants or people of color might find it easier to start with a community-college level of access, so we need to ensure that there is an open pipeline that can lead them to more advanced nursing credentialing, such as bachelor’s and master’s degrees. Some people may find that starting with a BSN program is prohibitive economically. So it may well be that [putting more emphasis on] community colleges as a beginning venue, especially in large urban areas, might be one opportunity to increase the pool of [minority] nurses.
Given [America’s] diversity and the known health care disparities, it is so important to have a workforce that reflects the population.
Q: President Obama’s Health Summit is happening this week. The president is proposing a $634 billion down payment on health care reform. What are your thoughts about what is happening at that summit right now?
One great thing is that all the input and constructive thinking is open and on the table, so we know we agree to these core principles and that there are many ways to approach this. The openness to different ideas that may be delivered is extremely promising. We are recognizing that the need for health care reform is a problem for the whole country, not for one party or another, not for one sector or another. I think if we are able to hold that [inclusive, non-partisan] tone, some give and take will occur. The bottom line is that we have to protect the country’s economic security, and that is so tied to health care security. We have to spend the money, invest in it, but spend it well.
The fact that insurance companies and businesses, as well as advocacy groups [are all coming together and] saying we are committed to change is a very different space to be in than we had back in 1993-94, which was the last attempt at health care reform.
Q: Is there anything else you’d like to add?
This is such an important opportunity for minority nurses and students to become active in thinking not only about the clinical care we give and the research that is in our field, but about the economics, politics and policy issues. It is a time when we need to raise our own bar in understanding both how we fit into the picture and how we can lead the country.
