ASSISTED LIVING COLUMN

Ethel Mitty

The NICHE Geriatric Resource Nurse Model: Improving

the Care of Older Adults with Alzheimer’s Disease

and Other DementiasJosh Allen, RN, and Jackie Close, RN, MSN, GCNS-BC

There are an estimated 5.3 million Americans

with Alzheimer’s disease, and as the popula-

tion ages, that number is expected to reach

7.7 million by the year 2030.1 Older adults

with Alzheimer’s and other dementias are

3.1 times more likely to have a hospital

stay than those without the condition.1 The

Nurses Improving Care to Healthsystem El-

ders (NICHE) geriatric resource nurse (GRN)

model is a proven framework to prepare acute

care hospital registered nurses to care for

this special population of older adults. This

article addresses the NICHE/GRN model and

its implementation at Palomar Pomerado

Health. (Geriatr Nurs 2010;31:128-132)

There are an estimated 5.3 million Americanswith Alzheimer’s disease, and as the populationages, that number is expected to reach 7.7 millionby 2030.1 Older adults with Alzheimer’s and otherdementias are 3.1 times more likely to have a hos-pital stay than those without the condition.1 Theneed for geriatric education among hospital nurs-ing staff is great. Only recently have schools ofnursing begun teaching formal programs in geri-atrics; most nurses have had little or no trainingin geriatric care. Nursing staff need to recognizethat care for the older adult patient is very differ-ent from that for other adult patients. The desireto improve staff knowledge and practice in geriat-rics through enhanced continuing education isa major impetus behind the adoption of NursesImproving Care to Healthsystem Elders (NICHE)at many hospitals. The NICHE geriatric resourcenurse (GRN) model is a proven framework to pre-pare acute care hospital registered nurses to carefor this special population of older adults. This

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article addresses the NICHE/GRN model and itsimplementation at Palomar Pomerado Health.

Background

Most older adults with Alzheimer’s and otherdementias also suffer from 1 or more seriousmedical conditions: coronary artery disease,26%; diabetes, 23%; chronic obstructive pulmo-nary disease, 15% (see Table).1 Coexisting medi-cal conditions as well as other high-riskpotentially acute issues (e.g., falls, medicationside effects, etc.) contribute to the prevalenceof hospital stays in this population.

These statistical realities are a picture of thechallenge facing acute care nurses and othercare staff in America’s hospitals—namely, tocare effectively for the acute conditions pre-sented by older adults with Alzheimer’s and otherdementias while managing the behavioral andother manifestations related to cognitive impair-ment. Any older adult being cared for in an emer-gency department or other hospital setting islikely to experience physical discomfort, over-stimulation, and an unfamiliar environment, allwhile facing physiological and psychologicaldemands. For a person with Alzheimer’s diseaseor other dementia, this is a potentially disastroussituation that could quickly lead to severe behav-ioral disturbances and acute decompensation,such as agitation, aggression, refusal of care,and other manifestations.

Acute Care Challenges

Providing quality patient care for hospitalizedolder adults is challenging. Older adults are at

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Table.Medical Conditions Coexistingwith Alzheimer’s Disease andOther Dementias

Medical Condition

Percentage with

Alzheimer’s Disease

or Other Dementia

Hypertension 60%

Coronary heart disease 26%

Stroke – late effects 25%

Diabetes 23%

Osteoporosis 18%

Congestive heart failure 16%

Chronic obstructive

pulmonary disease

15%

Cancer 13%

Parkinson’s disease 8%

higher risk for iatrogenic complications, the mostcommon being adverse drug reaction, which oc-curs in 20% to 25% of hospitalized older adults.Older adults are also more predisposed to othercomplications such as delirium, falls, and urinaryincontinence. It is especially difficult when thepatient is suffering with Alzheimer’s disease orother dementia. The acute care environment iscomposed of many mini-environments (aspects,systems): physical plant, staff, communication,assistive devices, and safety issues. The ‘‘label’’is the same but the context is vastly differentfrom an assisted living community/residence ornursing home. Therefore, responding to the chal-lenges may require an approach unique to hospi-tals and other acute care settings.

Most hospitals, especially emergency depart-ments, are filled with noise, people, excessiveactivity (‘‘commotion’’), and smells. The environ-ment can be overwhelming, especially for anolder adult with Alzheimer’s disease or otherdementia. Overstimulation and unfamiliar sur-roundings, both of which are common in acutecare, can lead to agitation.2 Therefore, one ofthe first steps for a hospital seeking to improvecare of older adults with Alzheimer’s disease orother dementias is to modify the environmentwith an emphasis on finding ways to createcalm and minimize overstimulation. This maybe accomplished by finding a room that is awayfrom busy nurses’ stations, adjusting lighting tocreate a sense of calm, and reminding staff to

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reduce noise when possible. These interventions,however, must be balanced with the need tosupervise the patient adequately during his orher hospital stay.

A calm and compassionate demeanor canmake the difference between a successful inter-action with a cognitively impaired older adultand a situation that leads to a behavioral out-burst. Unfortunately, workload demands reducethe time available to employ this approach—that is, to ‘‘be there’’ with the patient. As manyas 83% of acute care registered nurses (RNs)reported an increase in the number of patientsassigned to them during the previous year; only34.4% believe that there are enough RNs to pro-vide high-quality care.3 Nurses feeling this typeof pressure are unlikely to feel they can spendan extra few minutes with a cognitively impairedpatient. Burdened with guilt and frustration ofnot being able to care properly for their patients,nurses become dissatisfied; they burn out andmay leave the profession. The benefits of teach-ing how to create those ‘‘special minutes’’ canbe significant for both the nurse and the patient.

NICHE/GRN

A program of the Hartford Institute for GeriatricNursing at New York University College of Nurs-ing, the goal of NICHE is to achieve systematicnursing change that will benefit hospitalized olderpatients. The Nurses for Improving Care forHealthsystem Elders (NICHE) program developedthe GRN model—one of several NICHE models de-signed to help hospitals improve clinical care andoutcomes of hospitalized older adults.

The GRN model was developed in 1981 with thegoal of improving the geriatric knowledge and ex-pertise of the bedside nurse.4 NICHE describesthe model as ‘‘an educational and clinical inter-vention model that prepares staff nurses as theclinical resource person on geriatric issues toother nurses on their unit.’’ It identifies theprovision of excellent bedside nursing to hospital-ized older adults and the development of a corpsof nurses armed with the clinical competenciesto meet the needs of older adults, among others,justifies implementation of the GRN model ina hospital setting.5 Statistically significant im-provement in nurses’ perceptions of caring forthe acutely ill older adult has been demonstratedat four NICHE sites using the GRN model.5

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The NICHE program provides tools and re-sources to increase geriatric nurse competenceas well as health care system principles, processes,and structures that support continued learning andthe application of specialized knowledge intopractice.6,7 Resources provided by NICHE includethe technical support of a major university’snationally renowned geriatric program, as well asthe expertise of NICHE providers who take partin an ongoing collaborative to share resourcesand experiences. Also provided by NICHE isa combination of materials and services designedto cultivate a new way of thinking and caringfor the elderly at their institutions and stimulateand support a 3-phase implementation process:assessing gaps and needs in geriatric care, planningand implementing interventions to address thosegaps, and evaluating the effectiveness of thoseinterventions.

Palomar Pomerado’s Experiences

Palomar Pomerado Health is California’s larg-est health care district, serving nearly a halfa million people in San Diego’s North County.Covering more than 800 square miles, withits trauma center serving a 1,440-square-mileregion, the district encompasses significant geo-graphic, ethnic, and age diversity, from affluent,suburban cities to very poor rural communities.Senior citizens are highly represented in severalcommunities. More than one third of PalomarPomerado’s hospital admissions in 2006 were pa-tients aged 65 and older. Clearly, there was a needfor specialized care of hospitalized older adults.

The care of older adults requires an interdisci-plinary approach, and nurses play a central rolein coordinating that care. There is sufficientevidence that nursing models specific to care ofthe elderly improve outcomes and decreasescosts. Within Palomar Pomerado Health, severalRNs expressed an interest in becoming trainedas geriatric resource nurses after they were ex-posed to the model by the geriatric clinical nursespecialist. They understand that it takes a greatdeal of expertise to properly ‘‘nurse’’ the olderadult patient.

The NICHE Geriatric Institutional AssessmentProfile (GIAP) is a self-completed survey forhospital staff designed to assess 4 institutionalparameters: 1) attitudes regarding the institu-tion’s care of the older adult patient; 2) knowl-

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edge of institutional guidelines for care of theolder adult patient; 3) knowledge of best practiceof 4 common geriatric syndromes: sleep distur-bances, pressure ulcers, incontinence, and useof physical restraints; and 4) Perceived institu-tional strengths and barriers to best practice forcare of older adults. It was administered onlinein January 2008 with a 40% return rate from the1200 RNs in the organization. Data from theGIAP showed the following:

� Of respondents, 19.2% believed that almost noolder adult patients had a continuing careplan. However, hospital records reflect that60% of older adults have a continuing careplan. Nurses’ perception varies widely from re-ality. This kind of result indicates perceptionproblems that could hamper improvements.

� Nurses scored high in their attitudes about pres-sure ulcer management, but they scored lowerin their knowledge of the same. This was usedas a springboard for education in the area ofpressure ulcer prevention and management.

� Nurses also scored high in their attituderegarding restraint management, but theirknowledge score was lower. Subsequentrestraint education proved successful becauseof their positive attitude.

Discussion

Comparing knowledge versus attitude scores,and the gap between, revealed a knowledge–attitude disconnect that in turn presented anopportunity for improvement. This also indicatedareas in which nurses want to provide best prac-tices but lack the knowledge to do so. The GIAPalso provides a baseline against which tomeasure the effectiveness of quality improve-ment efforts related to nurse-sensitive outcomes.

The implementation of the NICHE philosophywith the Geriatric Resource Model of Nursingfollows the American Nurses Association (ANA)Gerontological Standards of Care8 and aims toimprove nurses’ abilities to understand the demo-graphic changes and health policy context thatmandate improved care to the hospitalized olderadult:

� Recognize the physiological and psychologicalchanges associated with aging;

� Recognize the attributes of aging that affectassessment;

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� Assess mental and physical function in theolder adult;

� Identify older adult patients at risk for poorhospital and postdischarge outcomes;

� Preserve functional capacity of older patients.

In addition to these objectives, nurses shouldbe able to improve their ability to assess riskfor, prevent, and manage certain syndromes com-mon to the hospitalized older adult such as uri-nary incontinence, medication side effects,physical and pharmacological restraints, pres-sure ulcers, depression, and sleep disorders.

A NICHE pilot class was first held in July 2008and was followed by another class of 42 RNs inNovember 2009. Education spanned two 8-hourdays. Content included attitudes about aging,functional decline, normal changes of aging, sen-sory changes and communication, polypharmacy,depression, dementia, and delirium, elder abuse,nutrition, palliative care, finances, fall preven-tion, family caregiving, mealtime difficulties andnutrition, and hands-on experiential learning tofocus our efforts on learning how to best carefor the older adult patient. Our clinical goals areto increase the safety, satisfaction, and comfortof our older adult patients experiencing an acuteillness using evidence-based best practices. Westrive to improve functional status, decrease falls,increase patient satisfaction, decrease pressureulcer rates, and help increase quality of sleep.

Some of the barriers to becoming a geriatricresource nurse are the time it takes out of one’sschedule to attend the required 2 classes. Thiswas addressed by giving the interested nursesplenty of notice to arrange their schedules. Thereis no monetary reward for becoming a geriatric re-source nurse; however, there is much professionalpride in doing so. We hold bimonthly NICHEupdates for the GRNs. Discussion for the next 3months are pharmacology (i.e., cardiac medicationand how it affects the elderly), nutrition, and socialwork/case management issues with our elderlypatient population. The nursing resource for theGRN is a geriatric clinical nurse specialist.

Conclusion

Palomar Pomerado also benchmarks with theCollaborative Alliance for Nursing Outcomes(CalNOC) and the National Database of NurseQuality Indicators for pressure ulcer and fallrates. Changes in the electronic medical record

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will include the Confusion Assessment Methodtool for identifying delirium and treating soonerfor better results. We are joining with our com-munity partners such as assisted living, skillednursing, and long-term care facilities to improveour transfer process.

Another important project Palomar PomeradoHealth is involved in is the North County SanDiego Dementia Consortium. Composed of a vari-ety of community members working with pa-tients with dementia, the sole purpose of thisgroup is to establish standards of care for cogni-tive health and contribute at the community- andcounty-level toward the overall health and well-being of cognitively impaired seniors. Althoughin its infancy, the consortium is ready to pilota tool for use in the transfer of dementia patientsto give the receiving facility all the pertinent in-formation needed for a seamless transition.

The Clinical Care Extender program is made upof college students with an interest in entering themedical or nursing field. They volunteer their timein 4-hour increments at our hospitals, and theirprimary role is ambulating safely the older adultto decrease functional decline while hospitalized.This is successful because the patients enjoythe company, and they are getting out of bed; fur-thermore, the students have a true hands-oninteraction.

Our acute rehabilitation unit has volunteersthat read to the patients and talk about currentevents to keep our patients in the here and now.They will play cards or just sit quietly at the bed-side to keep the patient company.

Hospital care will continue to be challenged bya rapidly expanding population of older adultswith Alzheimer’s disease and other dementias.These older adults depend on hospitals to treatacute exacerbations of coexisting medical condi-tions that are often unrelated to the cognitive im-pairments. However, although they may beclinically unrelated, the effects of cognitive dete-rioration and behavioral manifestations canprove to be one of the biggest obstacles to effec-tively managing the individual’s acute condition.The NICHE/GRN model is a success story; every-body wins: older adult, nurse, hospital system,and assisted living community.

References

1. Alzheimer’s disease facts and figures. Chicago:

Alzheimer’s Association; 2009.

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2. Behaviors: what causes dementia-related behavior like

aggression, and how to respond. Chicago: Alzheimer’s

Association; 2005.

3. Stanton MW, Rutherford MK. Hospital nurse staffing and

quality of care. Research in Action Issue 14 (AHRQ Pub.

No. 04-0029). Rockville, MD: Agency for Healthcare

Research and Quality; 2004.

4. Nurses Improving Care for Healthsystem Elders: history.

2008. Available at www.nicheprogram.org/about/history.

Cited January 8, 2010.

5. Nurses Improving Care for Healthsystem Elders: models.

2008. Available at www.nicheprogram.org/about/models.

Cited January 8, 2010.

6. Fulmer T, Mezey M, Bottrell M, et al. Nurses Improving

Care for Healthsystem Elders (NICHE): nursing outcomes

and benchmarks for evidence-based practice. Geriatr Nurs

2002;23:121-7.

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7. Mezey M, Capezuti E, Fulmer T. Older adults: their current

and future health needs. Nurs Clin North Am 2004;39:8-20.

8. Congdon J. Scope and standards of gerontological nursing

practice. 2nd ed. National Gerontological Nursing

Association, National Association of Directors of Nursing

Administration in Long Term Care, National Conference

of Gerontological Nurse Practitioners, American Nurses

Association.

JOSH ALLEN, RN, is President and CEO of Care and

Compliance Group, Inc., Wildomar, CA. JACKIE CLOSE,

RN, MSN, GCNS-BC, Palomar Pomerado Health, San

Diego, CA.

0197-4572/10/$ - see front matter

� 2010 Mosby, Inc. All rights reserved.

doi:10.1016/j.gerinurse.2010.02.006

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