Ethel Mitty

Nurses Improving Care to Health System Elders (NICHE): implementation of best practice models.

Nurses Improving Care to Health System Elders (NICHE) is a comprehensive program that hospitals use to foster system-wide improvements in the care of older patients. The authors report on a survey of 103 NICHE hospitals to determine perceptions of the NICHE program, the adoption of NICHE models and protocols, and the educational outcomes, policy changes, and benchmarks related to care of older patients established by the participating NICHE hospitals.

Medication Adherence is a Partnership, Medication Compliance is Not

Medication adherence is a complex phenomenon. As individuals assume greater responsibility for, and participation in, decisions about their health care, teaching and supporting adherence behaviors that reflect a persons unique lifestyle are the essence of a clinician-patient partnership-and it is a perfect fit with assisted living communities and nursing practice. The notion of compliance is an outdated concept and should be abandoned as a clinical practice/goal in the medical management of patient and illness. It connotes dependence and blame and does not move the patient forward on a pathway of better clinical outcomes. This article discusses the differences between compliance and adherence, identifies purposeful and unintentional reasons for nonadherence, and describes assessment tools for adherence, medication effect, and self-management capacity. Drawing on the scholarly work of others, we introduce a model for medication adherence, the ACE-ME Model: assessment, collaboration, education, monitoring, and evaluation. This model draws on the strengths and science of nursing and engages nursing participation in the continuing evolution of adherence strategies. For purposes of clarity in discussing these concepts, we use the word patient in this article rather than the word resident-that is, the older adult living in an assisted living community.

Decision-making capacity to execute a health care proxy: development and testing of guidelines.

OBJECTIVE: To evaluate the reliability and validity of guidelines to determine the capacity of nursing home residents to execute a health care proxy (HCP).

Suicide in Late Life

Late-life suicide is a persistent threat and a reality from which no one emerges unscathed. Family members and significant others feel guilty and inconsequential. Assisted living residence staff is demoralized. The residents feel frightened and confused. Although constituting only 13% of the population in the United States, older adults accounted for 18% of suicide deaths in the later 1990s. There is at present a national strategy for suicide prevention among youth under 19 years and adults aged 65 years and older. The assisted living community that fosters independence and self-determination can be, simultaneously, an environment in which the warning signs of suicidal ideation and self-destruction can be missed. This article discusses risk factors of suicide, the association of depression with suicide, basic screening tools, and supportive actions.

Healthcare professional training: a comparison of geriatric competencies.

Health professionals specializing in geriatrics are a unique but scarce resource who nevertheless play a critical role in shaping the care of older adults. An interdisciplinary didactic and clinical training milieu would have the potential to maximize training opportunities for geriatric healthcare professionals. The fact that little is known about the concordance between discipline‐specific geriatric competencies hampers the creation of interdisciplinary geriatric training opportunities. Discipline‐specific geriatric experts compared the geriatric competencies specified by geriatric‐certifying bodies of five healthcare professions: dentistry, medicine, nursing, pharmacy, and social work. Overlap and differences in geriatric competencies across disciplines are presented, and opportunities and barriers to interdisciplinary geriatric education are discussed.

ADVANCE DIRECTIVES: Older Adults with Dementia

The benefits and risks for older adults with dementia executing advance directives are discussed. Salient issues related to decision-specific capacity and models for advance planning and end-of-life decisions by cognitively impaired older adults are presented.

The teaching nursing home program: Enduring educational outcomes

T h e 5-year, Teaching

Iatrogenesis, frailty, and geriatric syndromes.

5 million Nursing Home Program (TNHP), which was funded by the Robert Wood Johnson Foundation from 1982-87, sought to improve the quality of clinical care in nursing homes, create an environment supportive of the education of undergraduate and graduate students and nursing home staff, and promote clinical research. Cosponsored by the American Academy of Nursing, the TNHP established linkages between 11 schools of nursing and 12 nursing homes. An underlying assumption of the TNHP was that the involvement of schools of nursing in nursing homes and the introduction of highly skilled nurses into nursing homes would improve standards of patient care, improve the recruitment and retention of qualified staff members, and contribute to the more effective use of physicians and nurses. Clinical appointments in the nursing home for qualified faculty and faculty appointments for qualified nursing home nurses was a key aspect of the TNHP. Expected desirable effects were that (1) fac-

Nursing delegation and medication administration in assisted living.

Older adults are at risk for iatrogenesis, especially if they are frail and have 1 or more geriatric syndromes. Iatrogenic events do not occur only in acute care; in nursing homes they affect 65% of residents annually. It is therefore likely that they are occurring in assisted living communities, though perhaps called by another name. Most commonly, iatrogenesis is an adverse drug event or reaction. Knowing more about the characteristics of frailty and the contributing factors to geriatric syndrome(s), assisted living nurses can be better prepared to monitor, detect, describe, and communicate an iatrogenic event or outcome. This article describes the signs and symptoms of atypical presentation of illness that can mask or are associated with iatrogenesis. Evidence-based assessment instruments are suggested for each geriatric syndrome.

Nursing Homes as a Clinical Site for Training Geriatric Health Care Professionals

Assisted living (AL) residences are residential long-term care settings that provide housing, 24-hour oversight, personal care services, health-related services, or a combination of these on an as-needed basis. Most residents require some assistance with activities of daily living and instrumental activities of daily living, such as medication management. A resident plan of care (ie, service agreement) is developed to address the health and psychosocial needs of the resident. The amount and type of care provided, and the individual who provides that care, vary on the basis of state regulations and what services are provided within the facility. Some states require that an RN hold a leadership position to oversee medication management and other aspects of care within the facility. A licensed practical nurse/licensed vocational nurse can supervise the day-to-day direct care within the facility. The majority of direct care in AL settings is provided by direct care workers (DCWs), including certified nursing assistants or unlicensed providers. The scope of practice of a DCW varies by state and the legal structure within that state. In some states, the DCW is exempt from the nurse practice act, and in some states, the DCW may practice within a specific scope such as being a medication aide. In most states, however, the DCW scope of practice is conscribed, in part, by the delegation of responsibilities (such as medication administration) by a supervising RN. The issue of RN delegation has become the subject of ongoing discussion for AL residents, facilities, and regulators and for the nursing profession. The purpose of this article is to review delegation in AL and to provide recommendations for future practice and research in this area.