“Nurse Clinician” – A New Model for Comprehensive Geriatric Nursing

By: Juergen Bludau MD*, Georgann Weissman MPS, MS, ARNP**

*Chief and Director of Geriatric Clinical Services, Division of Aging, Brigham & Women’s Hospital

Harvard Medical School, Boston, Massachusetts, USA

Member of the Scientific Council, Gerontological-Economic Research Organization (GERO), Kreuzlingen, Switzerland

**Consulting HQ, Sole Proprietor, West Palm Beach, Florida

Adjunct Faculty, Florida Atlantic University, Boca Raton, Florida

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Many countries around the globe are affected by the “graying trend” of their populations. Although the reasons for the significant increase in the aging of the populations may vary because of the historic and political developments in different countries, the consequences are ultimately the same. The following world maps illustrate the predicted percentage rise in people age 60 and older from 1999 to 2050 in various countries. Of note are the large increases in China, Russia, Asia, Australia, North and South America, and Europe.

These dramatic changes in the age structure of the population will require many different approaches unique to each country. There is, however, one universal requirement and that is an urgent need to establish better public health systems for the older segment of the population, which has very different medical needs than their younger counterparts. More often than not, Care not Cure should direct the healthcare delivery to these patients. This makes the role of the nurse paramount in the care of the older adult. While medicine as a whole has made great advances as a result of improvements in medical care, public health, and new medicines and technology, improvements in “basic” nursing have not been as robust. This deficit is especially evident when it comes to the care of the elderly. Careful attention to geriatric nursing education and training can improve eldercare, which has been demonstrated by programs such as the NICHE study (Nurses Improving Care to Health System Elders) and others.[1]

For a number of reasons, geriatric medicine has concentrated on the use of multi- and interdisciplinary team approaches. The literature is filled with articles describing the benefits and effectiveness of interdisciplinary team approaches in the care of frail, elderly patients.[2, 3] In particular, the GEM (Geriatric Evaluation and Management) model at Veterans Administration (VA) medical centers, and the PACE (Program of All-inclusive Care for the Elderly) model come to mind.[2, 4]

While these are all excellent models, it is our opinion that in reality they can only work in settings such as the VA system, major teaching hospitals, and nursing homes affiliated with academic institutions. We do not think that the interdisciplinary team approach is feasible in ordinary hospitals, doctor’s offices, or nursing homes. It is not a question of effectiveness but rather of applicability of this concept in the “real” world, where financial constraints are a major stumbling block or clustering by disease takes priority. In fact, we think that geriatricians are unrealistic in their attempt to improve geriatric care, as long as we only emphasize such models. In the meantime, the care of older patients is far below many quality standards. This is especially evident in the community setting, where patients receive inappropriate care for a variety of diseases commonly found in the elderly, such as heart disease, falls, and diminished mobility and pneumonia.[5]

An up-close examination of the “classic” interdisciplinary team consisting of nursing, physical and occupational therapists, and a social worker shows that it is often the nurse or nurse practitioner who is the focal point of the team. In fact, studies have shown that both in nursing homes and hospitals the nurse practitioner–physician collaboration is the most effective part of the larger team.[6,7] The Evercare program, started in 1987 by two nurse practitioners, now serves more than 65,000 Medicare and Medicaid recipients across the country and is a good example of how nurse practitioners providing additional primary care over and above that provided by physicians can improve care for the elderly.[8]

It is our experience that many nurse practitioners – and nurses – often take on the roles of the therapists as well as the social worker. It is not our intent to cast aspersions on the skill of the hard-working people in these professions. Rather, our position is one of practicality, logistics, and economics, all of which must be considered. The fact is that nurses or nurse practitioners can perform some of the tasks handled by therapists and social workers quite effectively. Nurses typically integrate knowledge and skills from other disciplines: e.g., in helping patients eat, nutritional knowledge is used to assist patients in selecting healthy foods they can tolerate, while physical therapy skills are applied if the patient needs help with transfers and ambulation.

Keeping in mind that many nurses already regularly perform tasks that go beyond the purview of traditional nursing, we propose to educate a new “multi-task” nurse we call the Nurse Clinician. This nurse will be able to perform the most common occupational, physical, and speech therapy interventions and will also be capable of addressing aspects of care that in the U.S. are now handled by social workers. Educated to approach the patient from a truly holistic perspective, Nurse Clinicians can offer a well-rounded foundation that incorporates knowledge and skills from medicine and nursing, as well as familiarity with and easy access to ancillary resources. This unique approach to geriatric nursing and medical care is practical, innovative, economically sound, and can easily be integrated into hospitals and other settings where elders receive care. The Nurse Clinician model develops an efficient and clinically competent approach to eldercare in a reasonably short period of time. However, in certain circumstances, especially if the patient or the psycho-social situation is complicated, therapists and social workers will certainly need to become involved, and Nurse Clinicians should be attuned to these situations and encouraged to seek the expertise of these individuals.

These Nurse Clinicians would be particularly suited for home care, community centers, and, of course, in nursing or assisted-living facilities. They could also improve the care of elderly patients both in acute-care hospitals and doctor’s offices. Because they would be nurses not nurse practitioners, they could not prescribe or medically treat patients. Their principle function would be to make sure that elderly patients in these various settings receive the best possible care and the necessary support and follow-up. Their strength would lie in their assessment skills of the older patient and their ability to relay this information to the treating physician, together with specific suggestions as to appropriate nursing care. They could supervise other nurses and ancillary helpers, evaluate the progress of the therapy, and identify complications early, while simultaneously focusing on the maintenance of function in these patients. In addition, their knowledge of medicine and of the patient’s care would enable them to provide close caregiver contact and support.

We believe these specially trained nurses could play an integral role in countries that do not yet have or are currently developing a nurse practitioner model and are in need of an efficient and less costly eldercare system in the near term. The cost and time required to establish a nurse practitioner training program, which in the U.S. currently consists of an average of 40 credits beyond the bachelor’s degree, may be prohibitive for large-scale implementation in many countries. In general, educating nurses is an expensive endeavor because of the number of faculty needed to provide supervision during students’ clinical work. And once the program is in place, training usually takes several years to complete.

The following table compares the current geriatric model of interdisciplinary care with our proposed universally applicable model of geriatric nursing care.

  Interdisciplinary Model Nurse Clinician Model
Advantages Group of healthcare providers who perform tasks independently but coordinate their efforts One designated caregiver who knows patient very well and close nurse/physician collaboration and communication
Disadvantages Number of team members can be overwhelming and coordination and communication difficult Need for other healthcare members to be called to assist with care when necessary
Settings Major academic medical centers or large medical institutions only Community and long-term-care settings, private practice and hospitals

Although certainly not limited to China, Nurse Clinicians could be particularly useful in that country, where the population is not only exponentially increasing in number but also in age. It would be unrealistic to expect a country such as Chin or other countries to first develop the extensive nursing education programs required for nurse practitioners (as is currently in place in the U.S.), before starting to tackle the complex medical and social needs of an aging society.

In November 2005, we presented the first detailed overview of the Nurse Clinician model during a one-day workshop at the International Nursing Conference, Health-Culture-Nursing, Fudan University, Shanghai. The presentation and ideas put forth were well received, and we will likely be returning to China later this year.

It is our opinion that a 5-day course would be sufficient to begin educating nurses in the principles of good geriatric care required for Nurse Clinicians. (See the addendum that follows for a brief description of the proposed curriculum.) It would be taught by a nurse practitioner and a geriatrician using PowerPoint presentations, small group sessions, and case-study discussions. This intensive, week-long course would provide a good base, but additional courses and follow-up would also be integral to training Nurse Clinicians.

We believe that the Nurse Clinician model is a practical, easily implementable approach to better serving the fast-growing elder population in many countries. With a minimum of cost and a very focused training program, nurses can gain the skills needed to provide the holistic care so many elders need but currently do not get. Drawing upon an existing resource – nurses –seems a logical step in addressing the large-scale deficiency in basic geriatric care that confronts much of our society.

ADDENDUM: Five-day model for Nurse Clinician curriculum

Using a five-day model, here is what we envision.

Day One: The morning session would include registration, introductions, and a pretest of geriatric knowledge, with emphasis on the differences between older versus younger patients. In the afternoon, general principles of geriatric medicine, such as differences in disease, disease presentation, and management would be discussed from the medical point of view and followed by the nursing perspective. At the end of each day, a case will be presented that will include the points discussed during that day.

Day Two: The focus will be on the functional assessment as the centerpiece of geriatric medicine, both from a medical and a nursing perspective. Participants will learn the ADL/IADL assessment tools. Particular emphasis will be placed on the assessment of mobility as it pertains to the prevention and identification of risk factors for falls. Furthermore, the concept of “Change in Condition” will be emphasized as it refers to a change in function. In the afternoon session, the most commonly used physical and occupational therapy modalities will be discussed and practiced among the participants. A case discussion would conclude the day.

Days Three and Four: Both will start with an extensive review of body systems and the most commonly found diseases in the elderly. There will first be a medical description of the pathophysiology and the specific signs and symptoms of these diseases in the elderly patient. This will be followed by the appropriate nursing assessment and therapy. During these discussions, great emphasis will be placed on the nurse–physician interaction, with the idea being that both the nurse and the physician are clinicians in their own right and therefore need a good working relationship. Case discussions will not only include specific patients, but also several scenarios depicting various nurse–doctor interactions. The skin, immune, and endocrine systems will be discussed first, followed by an afternoon of cardiac disease presentation and management.

Day Four: The renal and gastrointestinal systems will be discussed in the morning followed by the neurological and musculoskeletal systems in the afternoon.

Day Five: In the morning, the topic of dementia, the types and different presentations, and the common treatment approaches will be presented. In the afternoon, dementia and its common presentation as delirium in the acute-care setting will be discussed in great detail. Special emphasis will be placed on the consequences of delirium, such as changes in behavior and lack of cooperation, increased risk for dehydration and falls, and the resulting caregiver distress. Both medical and nursing interventions will be described. The reason for this detailed discussion is the fact that delirium frequently complicates the hospital stay of an elderly patient, and the correct identification of this is crucial for appropriate treatment. The afternoon will conclude with a post-test, review, and wrap-up. Certificates of attendance will be issued at that time.

References:

  1. Mezey M, Kobayashi M, Grossman S, et al. Nurses improving care to health system elders (NICHE). JONA Oct 2004; 34(10):451-457.
  2. Burns R, Nichols LO, Martindale-Adams J, Graney MJ. Interdisciplinary geriatric primary care evaluation and management: two-year outcomes. J Am Geriatr Soc. Jan 2000; 48 (1): 8-13.
  3. Sommers LS, Marton KI, Barbaccia JC, Randolph J. Physician, nurse, and social worker collaboration in primary care for chronically ill seniors. Jun 2000; 160 (12): 1825-1833.
  4. Mui AC. The Program of All-Inclusive Care for the Elderly (PACE): an innovative long-term care model in the United States. J Aging Soc Policy. 2001; 13 (2-3):53-67.
  5. Wenger NS, Solomon DH, Roth CP, et al. The quality of medical care provided to vulnerable community-dwelling older patients. Ann Intern Med. 2003; 139 (9): 740-747.
  6. Aigner MJ, Drew S, Phipps J. a comparative study of nursing home resident outcomes between care provided by nurse practitioners/physicians versus physicians only. J Am Med Dir Assoc. Jan-Feb 2004: 5 (1):16-23.
  7. Lambing AY, Adams DL, Fox DH, et al. Nurse practitioners’ and physicians’ care activities and clinical outcomes with an inpatient geriatric population. J Am Acad Nurse Pract. Aug 2004; 16 (8): 343-52.
  8. Kane RL, Flood S, Bershadsky B, Keckhafer G. Effect of an innovative Medicare managed care program on the quality of care for nursing home residents. Gerontologist Feb 2004; 44 (1): 95-103.

 

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