As at most U.S. hospitals, about half of John Muir Health’s patients are 65 or older. To better serve geriatric patients, the East San Francisco Bay Area-based health system has focused on changing staff perceptions about aging and boosting nurses’ knowledge about older adult patients’ needs. One way the health system has done this is by joining the national NICHE (Nurses Improving Care for Healthsystem Elders) program.
The Hartford Institute for Geriatric Nursing, which is part of the New York University College of Nursing, developed NICHE to make systemwide changes in nursing care to benefit older hospitalized patients. More than 225 hospitals in the United States and Canada participate in the program.
NICHE is one of the neatest things we have done, says Pat Davis, RN, BSN, MS, NEA-BC, director of professional practice at John Muir Medical Center’s Concord campus. Many of our patients are seniors. They deserve a special focus, and we are able to do that with the NICHE program.
People’s care requirements change as they age. The co-morbidities increase, and it becomes a complex patient to care for in our fast-paced healthcare environment, which is not always user friendly for a person with sensory deficits and multiple illnesses, says Mary Spear, RN, MSN, GNP, a geriatric clinical educator at John Muir Medical Center’s Walnut Creek campus.
Arlene Phillips, MA, manager of John Muir Senior Services, adds that the health system aims to become more elder friendly. Physicians and staff from both acute-care hospitals — 259-bed Concord and 324-bed Walnut Creek — developed a three-year plan to implement various older-adult services, including NICHE.
Hospitals that participate in NICHE can avail themselves of clinical protocols, organizational tools, staff development programs, and other guidance for improving the care of older adults.
NICHE provides wonderful resources with evidence-based protocols, Spear says.
In July, John Muir Heath used a tool called the Geriatric Institutional Assessment Profile, available through NICHE, to assess its readiness to implement the NICHE program and provide a foundation from which to move forward. The health system was able to compare its results with other facilities on a range of areas, such as skin care, restraint use, incontinence, and sleep issues, as well as on attitudes and perceptions about caring for older individuals.
We actually scored higher than the national mean in a number of areas, which means we are already doing a pretty good job with our geriatric patients, but we want to achieve excellence, Davis says.
However, John Muir Health nurses reported they do not always know what person can make decisions on behalf of some older adults, and expressed concern about legal issues.
It’s sometimes frustrating to have a patient who is confused or argumentative, and [the nurses] want to make sure they have the tools to best care for those patients, Spear says. This gives us a direction and a charge where we want to go.
Educators will develop a plan to address those concerns, including programs that explain the difference between delirium and dementia and how to respond appropriately, and programs that assess fall risk.
The health system’s senior services department has already developed an experiential training program about age-related sensory changes for new nurses, nursing assistants, and other health system staff. The program focuses on best practices for relating to older adults.
It’s very well received in terms of ‘aha!’ moments, Spear says. It’s eye opening to them to see what the patients deal with day to day.
It Takes a Team
John Muir Health will establish a geriatric interdisciplinary team, which will create geriatric plans of care by tailoring NICHE templates. Nurses will be able to review those and other care plans in the electronic medical record system and select accordingly.
An existing outpatient geriatric coordinator program, which is staffed by social workers and serves 1,200 high-risk patients annually, complements NICHE. John Muir Health also will continue to offer biannual interdisciplinary geriatric professional development seminars for the community and staff. The health system plans to pursue collaboration with other NICHE facilities on the West Coast.
NICHE has broadened our emphasis and provides the clinical training to nurses, and that translates to [better] overall patient satisfaction, Phillips says. It’s strengthening our overall emphasis on services to older adults.
The Right Tools
John Muir Health expects to create a geriatric resource nurse program within the next year or two and eventually establish a medical/surgical unit that focuses on acute care of the elderly. NICHE offers guidelines and strategies to implement both programs, which have proven successful around the country. Spear also hopes more health system nurses pursue geriatric certification, in addition to certification in their clinical specialties.
Through having geriatric resource nurses and certification, we would see the quality of care of our older adult patients improve, Spear says. She adds that she expects improved patient care would not only enhance patient satisfaction but also nurse satisfaction, because nurses would have the tools to care for these patients.