Gerontological Advanced Practice Nursing

Nursing Practice Gerontological Practices

Gerontological Advanced Practice Nursing,Advancement in Nursing,Literature Review in Nursing and Outcomes, GAPN Role and Quality of Nursing Care,How ANPs Evaluate Nursing Success,How GAPN Evaluate Nursing Issues,All-inclusive Care for the Elderly (PACE),Benefits of GPNs, Needs of APN.

Gerontological Advanced Practice Nursing

    Over the last 3 decades, research examining the proliferation of Advanced Practice Nurses (APNs) has demonstrated that APNs improve quality of care, increase patient and staff satisfaction, while being cost effective across health care settings (Feldman, Ventura, Crosby, 1987; Master et al., 1987; Miller, SK, 1997; Naylor, Brooten, et al., 1999; Ramsay, McKenzie, & Fish, 1982; Sox, 1979; Spitzer et al., 1974).

Advancement in Nursing

    During the late 1960s to 1970s graduate nursing programs began developing specialties in gerontological nursing. GAPN is an umbrella term referring to Geriatric Nurse Practitioner (GNP) or Gerontological Clinical Nurse Specialist (GCNS). 

    Currently there are nearly 4,000 certified GNPs and over 1,000 certified GCNSS (American Association of Colleges of Nursing, 2004). GAPN subgroups presently require gerontological-focused graduate education. Traditionally, GCNS roles include educator, researcher, practitioner, manager, and consultant. 

    In addition to the GCNS roles, GNPs have the ability to conduct advanced health histories and physical assessments make diagnosis, and prescribe appropriate medical treatments-including pharmaceuticals within a collaborative agreement with a physician. Scopes of practice for both vary between states. 

    Literature demonstrates more similarities between nurse practitioners (NPs) and clinical nurse specialists (CNSS) than differences. Nursing leaders are currently debating role integration (Fenton & Brykczynski , 1993; Soehren & Schumann, 1994, Lincoln, PE, 2000).

Literature Review in Nursing and Outcomes

    The literature reported APNs favorably influence health care outcomes such as: mortality, morbidity, length of stay, functional status, mental status, stress level, and patient satisfaction, burden of care, and cost of care. 

    Overall, studies demonstrated consumer acceptance and satisfaction with NPs, physician comparative quality of care, increased productivity, cost savings, saved physician time, effective management of both preventive and chronically ill care, and improved patient education (Feldman et al., 1987; Naylor , Munro, & Brooten, 1991).

GAPN Role and Quality of Nursing Care

    The GAPN role impacts the quality of care in long-term care (LTC) populations by decreasing hospitalizations, reducing pharmaceutical usage, and improving patient-family-staff satisfaction. GAPNs hold an essential role in reducing restraints in the nursing home population (Evans, LK, et al., 1997). 

    Most notably, the GAPNs provide cost-effective quality care. Using a quasi experimental design, Kane and colleagues (1989) compared data of pre- and post-GNP time periods in 60 nursing homes (30-GNP; 30-control) dispersed throughout eight western states and discovered that GNP provided cost effective care to residents primarily by reducing hospital utilization. 

    Another study, a 1-year retrospective data analysis for 1,077 LTC res idents, compared 414 residents followed by GNP/MD teams and 663 residents followed by MDs alone. Patients of the /MD teams yielded a $72 per resident per month savings (Burl, Bonner, Rao, & Khan, 1998).

How ANPs Evaluate Nursing Success

    GNPs may succeed in nursing home management. Grzeczkowski and Knapp (1988) evaluated a 120-bed nursing home after a GNP became the Director of Nursing. 

    Their findings demonstrated decreased medication usage, lower rates of urinary/respiratory tract infections, decreased utilization of indwelling urinary catheters, and less decubiti. GNPs extensive geriatric education and ability to work well within interdisciplinary teams yielded effective patient care.

How GAPN Evaluate Nursing Issues 

    GAPN education, focused on geriatric issues such as falls, restraint usage, delirium, polypharmacy, and normal versus abnormal physical changes, carves a vital role in acute care management of frail older adults. Often GAPNs anticipate these conditions and provide early intervention. 

    Models of care that have improved hospital care to the elderly include geriatric evaluation teams, Nurses Improving Care to the Hospitalized Elderly (NICHE), Geriatric Resource Nurse (GRN), Case Management (CM), Geriatric Evaluation and Management (GEM) units and Acute Care of the Elderly (ACE) units. GAPNs have been integral members of these models of care.

    A retrospective analysis of nursing home patients admitted to an acute care facility demonstrated a mean decrease of 2.78 (p < 0.05) days in length of stay when care involved a GNP (Miller, SK, 1997). Naylor and colleagues (1999) went further than evaluating "in-house" statistics.     

    Their randomized clinical trial included 363 patients (186 control; 177 intervention) with follow-up data collection up to 24 weeks posthospital discharge. In the intervention group, GAPNS were responsible for comprehensive discharge planning and maintaining a home follow-up protocol. 

    Examples of the outcome measures were hospital readmission, recurrence or exacerbation of the index hospitalization diagnostic-related groups (DRG), comorbidity, cumulative days of rehospitalization, functional status, depression, and patient satisfaction. 

    The findings at 24 weeks posthospital discharge demonstrated that GAPN patients experienced fewer hospitalization days, yielding a Medicare savings of almost $600,000. Other findings: functional status, depression scores, and patient satisfaction, were similar in both study groups. 

    Case studies of older adults living at home describe the accessible, comprehensive, accountable, continual, and collaborative care delivered by GNPs (Burns- Tisdal & Goff, 1989). Alessi and colleagues (1997) studied 414 home care clients (215-intervention and 199-control). 

    The intervention group had GNP-performed geriatric assessments (CGAs) annually for 3 years, along with quarterly follow-up visits. The authors examined the GNP's health care recommendations given to clients and proposed that repetitive reinforcement and the GNP-patient relationship contributed to achieving patient adherence to therapies. This warrants further investigation.

All-inclusive Care for the Elderly (PACE)

    The Program of All-inclusive Care for the Elderly (PACE), developed in San Francisco known as On Lok in 1971, focuses on health and social day services to enable frail older adults to remain in the community. PACE's model requires GAPNs in the interdisciplinary team. PACE programs now exist in nine states providing cost effective quality care with a reduction in institutional care use (Eng. Pedulla , Eleazer, McCann, & Fox, 1997).

Benefits of GPNs

    GNPs provide effective ambulatory care. McDowell, Martin, Snustad , and Flynn (1986) performed a retrospective review of 800 patients comparing GNPs' care to two internal medicine board-certified physicians with geriatric experience using polypharmacy and functional status as comparison measurements. GNPs provided high-quality, cost-effective care. 

    Another study (Mahoney, DF, 1994) compared medication usage of NPs and MDs; Three geriatric vignettes designed by GNPs, geriatricians, and geriatric pharmacists were presented to 373 MDs and 118 NPs. Analysis of the MDs and NPs was discussed and it was discovered that NPs used fewer drugs. 

    The NP sample was not specifically limited to GNPs; family and adult nurse practitioners were included in the sample. Geriatric experience and prescribing experience proved to be significant factors affecting appropriate prescribing. Mahoney proposed that gerontological education for APNs and Family Nurse Practitioners (FNPs) would ensure proper pharmaceutical usage for the elderly.

Needs of APN

    Meta analysis methods have allowed researchers to examine conflicts in the data and deduce clearer and more conclusive findings. Often lacking in the literature is a clear presentation of APN preparation and specialty. Future research needs to be rigorous with attention to:

(a)conceptual definitions sensitivity of outcome measures, study of care delivery processes not solely on the provider, relationship between the process and outcomes of care.

(b) measurement of variables.

(c) APN educational backgrounds.

(d) methodology-more blind randomized trials with attention to internal and external validity (Brown, SA, & Grimes, 1995).