Elders use healthcare services three times more often than any other age group, mainly because of their higher incidence of acute and chronic disease. Among elderly persons in the United States, 87% have chronic illnesses. By current estimates, patients older than age 65 occupy more than half of hospital beds and nearly 60% of critical-care beds. Also, elders have longer hospital stays than younger persons (7.8 days vs 5.4 days).

Unfortunately, hospitalization increases certain risks in older adults, including hospital-acquired infections, fall-related injuries, and pressure ulcers. As you probably know, Medicare no longer reimburses costs related to these incidents. Therefore, clinical and programmatic initiatives must address the projected growth in health services by our aging population.

Although nurses are the primary caregivers for hospitalized and vulnerable elders living in the community, most aren’t prepared in geriatric, family-centered, or culturally competent care. According to a national survey of baccalaureate nursing programs, required geriatric content in baccalaureate curricula has improved in the last 8 years or so. But only since 1997 has geriatric content been integrated into the curriculum in a significant way, so most practicing nurses haven’t benefited from this content. Also, many nurses have little formal preparation in culturally appropriate and culturally sensitive care, including attention to patient and family values and cultural differences—despite increasing evidence of the interactions between culture and health. For example, cultural factors may influence the likelihood of a person using health-promotion and disease-prevention practices.

Family-centered model

The family-centered approach to healthcare delivery redefines the relationships between consumers and health providers. It hinges on the belief that the family significantly influences an individual’s health and well-being. (See the box below.)

Family-centered care was first implemented nationally for hospitalized children with special healthcare needs. Since 2001, the Institute for Patient- and Family-Centered Care has implemented programs focused on hospitalized elders and their families. In organizations with these programs, leaders must promote an organizational culture that values collaboration with family members in delivering care to hospitalized elders.

Danbury Hospital’s family-centered geriatric care program

Danbury Hospital in Danbury, Connecticut (part of the Western Connecticut Health Network) has implemented a family-centered geriatric care nursing program to address multiple issues, including:

• increased population of elders hospitalized for chronic and acute health conditions
• general lack of knowledge and skills among nursing staff regarding culturally competent and family-centered geriatric care
• perceived need for programs that focus on nurse empowerment and retention.

The program was funded by a grant from the Department of Health and Human Resources’ Comprehensive Geriatric Education Program. The overall goal is to prepare nursing staff, including registered nurses (RNs) and nursing assistants, to provide culturally competent and family-centered geriatric care. We developed a comprehensive continuing education program for staff on all inpatient units that admit elderly patients; we also prepared home-care and public-health nursing staff from the Visiting Nurse Association. Content areas in our continuing education (CE) programs for RNs and nursing assistants included geriatric, family-centered, and culturally competent care.

The curriculum included a four-part session based on the care model developed through the Institute for Patient- and Family-Centered Care. (See www.ipfcc.org.) The Geriatric Educational CE Series for RNs includes nine geriatric sessions based on curricula of the Hartford Institute for Geriatric Nursing (HIGN)—specifically, the Best Nursing Practice Protocols Geriatric Resource Nurse (GRN) core curriculum and the ” Try This” curriculum. (See the box below.)

The hospital held a cultural competency workshop and five CE sessions on cultural issues among the elderly to prepare RNs in culturally competent care for elders and their families. Preparation of nursing assistants included an 8-hour workshop on geriatric care, the four-part family-centered program, and a workshop on developing cultural sensitivity.

Goals and outcomes

Our goals were to develop a community of nursing staff committed to excellence in family-centered and culturally competent geriatric care who support each other in creating a culture of learning. We measure nursing staff, patient, and family outcomes for each project component, including:

• nursing staff knowledge and skills in geriatric, family-centered, and culturally competent care
• nursing staff turnover
• nurse-sensitive patient outcomes
• patient and family satisfaction with care.

For RNs, we measure certification rates, turnover rates, geriatric knowledge, and cultural awareness, knowledge, and competence. For nursing assistants, we measure changes based on attendance at the geriatric, family-centered care, and cultural awareness workshop sessions, knowledge of geriatric care, cultural awareness, and turnover rates. Additional project outcomes include measures of changes in nurse-sensitive patient outcome variables (falls, pressure ulcers, and restraint use) from baseline quarterly through each year of the project, and patient and family satisfaction rates through each project year.

Outcomes for our program are consistent with state and local health department goals.

• Our fall incidence has decreased from 2.6% to 1.4%.
• Our pressure-ulcer incidence has declined from 3.4% to 2.7%.
• RN turnover rates have dropped from 7.1% to 4.9%.

In addition, pretest scores for RN participants averaged 69%; posttest scores, 82%. Pretest scores for nursing assistants averaged 80%; posttest scores, 94%. Among nursing assistant participants, 19% have been promoted to the next level on the career ladder. As of January 2013, 42 RN participants had achieved American Nurses Credentialing Center gerontological nursing certification. (All RNs who go through this program are able to sit for the ANCC certification exam in generalist gerontological nursing.)

Because our program integrates geriatric, family-centered, and culturally competent care, it provides an innovative approach to preparing nursing staff to care for hospitalized, home-bound, and community-based elderly patients and their families. We anticipate it will better prepare our nursing staff and empower them in their own professional development—an outcome we believe will lower our RN and nursing assistant turnover.

When they wrote this article, the authors were staff employees or consultants for Danbury Hospital in Danbury, Connecticut. Moreen Donahue is senior vice president of patient care services and chief nursing officer at Western Connecticut Health Network in Danbury (which includes Danbury Hospital). Meredith Wallace Kazer is an associate professor at Fairfield University School of Nursing in Fairfield, Connecticut. Lisa Smith is director of nursing education at Danbury Hospital. Joyce J. Fitzpatrick is the Elizabeth Brooks Ford Professor of Nursing at the Frances Payne Bolton School of Nursing at Case Western Reserve University in Cleveland, Ohio.

Selected references

Boltz M, Capezuti E, Fulmer TT, Zwicker D, O’Meara A, eds. Evidence-Based Geriatric Nursing Protocols For Best Practice. 4th ed. New York: Springer Publishing; 2011.

Gilje F, Lacey L, Moore C. Gerontology and geriatric issues and trends in U.S. nursing programs: a national survey. J Prof Nurs. 2007;23(1):21-9.

Institute for Patient- and Family-Centered Practice. Advancing the practice. http://www.ipfcc.org/resources/getting_started.pdf. Accessed February 9, 2013.

Kurtzman ET, Buerhaus PI. New Medicare payment rules: danger or opportunity for nursing? Am J Nurs. 2008;108(6);30-5.