Improving Nursing Care for Older Adults

The Senior Adult Unit at Addison Gilbert Hospital is licensed as a mental health unit but also treats subacute medical problems of its population of older adults. Located in in Gloucester, Mass., Addison Gilbert is an affiliate of Northeast Health System (NHS), which has three hospitals along Boston’s North Shore.

The geriatric nursing unit has earned a reputation for exemplary care and is distinguished by its unique approach. Here, the focus is on getting patients out of bed and keeping them active. After being hospitalized, an older adult’s physical and mental condition can decline dramatically. For every day that an older adult remains in bed, it typically takes four days for the patient to return to baseline.

“The more normal the hospital stay can be, the quicker the recovery,” says Mike Tarmey, MS, RN, director of clinical operations for behavioral health, who was deeply involved in developing the Senior Adult Unit.

To help keep them active, patients eat their meals in the dining room, not in bed. The unit’s psychiatrist can often be found sitting among patients there, observing social interaction. Patients wear street clothes and are encouraged to socialize and watch television in a central location.

Holistic programming?art, pet, and music therapy?is offered during the day along with pastoral counseling and open family visitation to keep patients engaged. Medication is used minimally, and patients are restraint-free thanks to an interdisciplinary approach. Unit staff engages family members whenever possible. All of this improves patient function so patients are able to return to their homes as quickly as possible.

This approach makes a critical difference in patient outcomes because it heads off problems before they occur. If a patient’s condition declines, it can quickly snowball, causing an avalanche of complications. Consider this potential scenario: a bedridden patient receives a urinary catheter, which can lead to a catheter-related infection.

The infection causes delirium, associated with acute confusion and behavioral problems, which are then treated with sedating medications. The medications can result in more confusion and falls. Physical restraints are applied to prevent falls. The patient resists the restraints, resulting in the use of more medication to act as a “medication restraint.”

This use of combined physical and medication restraints results in depression, poor nutritional intake, loss of mobility, and skin breakdown. In many cases, implementing best practices for geriatric patient-centered care can prevent this unfortunate downward spiral.

The Next Level

Recognizing the importance of implementing best practices, NHS continued in its journey to provide quality care to older adults. The next level was finding a way to grow the Senior Adult Unit’s legitimacy.

To help accomplish this goal, Shirley Conway, MBA, MSN, RN, BC, director of Geriatric Initiatives, applied to Sigma Theta Tau International, a Nursing Honor Society of Geriatric Leadership Academy in partnership with the Hartford Foundation Centers of Geriatric Nursing Excellence. Conway was one of 16 geriatric leadership fellows from around the country chosen to enter the program and then share what she had learned about geriatric care with her organization.

Conway and her colleagues looked for a comprehensive program that would provide a framework of care for their older patients. That’s when they turned to NICHE?Nurses Improving Care for Healthsystem Elders. NICHE is a program of the Hartford Institute for Geriatric Nursing at New York University College of Nursing. The program provides principles, tools, and resources to promote best practices around the care of older adults.

After a cohort of clinical staff from Addison Gilbert attended their first NICHE annual conference, they decided to move forward with NICHE designation because of the educational resources and framework for providing evidence-based care that the NICHE program offers. The accessibility of the NYU leadership team also played a role in the decision.

“NICHE is interdisciplinary and fit our unit’s care goals and objectives,” Conway explains. “We followed NICHE principles as our guiding light and could adapt the curriculum to meet the needs of our hospitals.”

The Senior Adult Unit became NICHE-designated in May 2007, and the first group of nurses began NICHE training soon after. NICHE designation is awarded when an institution can demonstrate an ongoing commitment to improving the care of older adults by employing evidenced-based practices.

“We completed our first Geriatric Institutional Assessment Profile (GIAP) in 2008,” Conway explains. The GIAP is an instrument that helps NICHE participating hospitals assess their institutional readiness to provide quality care to older adults.

After solidly implanting NICHE principles on the Senior Adult Unit, NHS’ next step was to expand and grow legitimacy in geriatric care by exporting NICHE principles and practices throughout the health system. Using NICHE educational materials and fundamentals as a framework, more than 300 NHS nurses completed a two-day training program that included education in prevention and treatment of geriatric syndromes.

The program is taught by NHS interdisciplinary experts-such as Steven Gillespie, MD, medical director of the Senior Adult Unit; Fay Curtis, MSN, RN, director of Acute Care Services; Melinda Adam, PT, OCS, rehabilitation director; Cheryl Merrill, MS,RN, director of Nursing Practice, Quality, and Education; Daniel F. Newberg, MS, FMSHP, RPh, director of Pharmacy; Jerra Sullivan, MS, RN, wound, ostomy and continence nurse; and Sara Barnum, MS, RN, geriatric clinical educator. At least one nurse in every NHS unit has completed training in providing specialized care to older patients.

“These nurses are now able to act as resources for their coworkers who have not yet completed the classes,” Conway says.

Physicians have also been offered special training through geriatric continuing medical education (CME) programs provided by Dr. Gillespie who is one of a relatively small number of physicians nationwide who is board-certified in adult and geriatric psychiatry. He has been a champion of the NICHE initiative and of improving geriatric care throughout Northeast Health System.

Now, because of this initiative, Addison Gilbert Hospital, Beverly Hospital, and BayRidge Hospital-all NHS affiliates-are among a handful of hospitals in the state to be recognized by NICHE. In August 2009, NHS became a NICHE-designated health system, joining a growing number of health systems committed to providing quality care to older adults.


NHS is unique in that the initiative to implement best practices in geriatric care began with a mental health unit and migrated onto medical-surgical floors within the hospital. Despite the unconventional progression, implementing NICHE principles has yielded impressive results for NHS in several areas.

In the Senior Adult Unit, NICHE training has helped staff reduce patient falls by 50 percent, prevent pressure ulcers, and improve patient and employee satisfaction scores. Medical-surgical units also saw pressure ulcers, length of stay, and discharges to long-term care (versus home) decline.

Some measures are less quantifiable, but no less significant. Leaders at NHS believe their geriatric initiatives have contributed to the vibrancy and financial success of the facility. Dr. Gillespie has noted that many physicians are sending their loved ones to NHS hospitals because they know they’ll receive excellent care.

Another telling indicator is how the attitude of health care providers toward the older patient population has changed as a result of NICHE training.

“The staff now readily understands that providing evidence-based care to older adults is a priority in their practice,” Conway says, adding, “It is now accepted as common knowledge that the majority of our patients are older and that specialized care and knowledge are needed to take care of them.”

Harder to measure is how nursing staff perceptions about caring for older patients have evolved. But Fay Curtis, director of Acute Care Services, knows that they have. A few months after the first NICHE training class, Curtis and Conway invited participants to a lunch meeting to ask these nurses for feedback on the classes and how they could support them in using this new knowledge. One of the attendees was a behavioral health nurse who had observed that more and more older adults were being cared for on her unit.

She was honest in sharing that she did not enjoy caring for them. Her goal in attending the class was to increase her knowledge in this area. She believed that what she had learned not only gave her more understanding about how to provide competent care to older adults, but she now realized that what had made her uncomfortable was her lack of understanding of the issues surrounding older patients and that she had not felt competent caring for them. The class gave her confidence that she could meet the needs of these patients, and she found working on her unit enjoyable again.

For Curtis, feeling that if they had changed even one nurse’s job satisfaction and improved the care she gave her patients, then the program was a success.

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