References
Institute of Medicine (2003). Health professions education: A bridge to quality.
Barton, A., Armstrong, G., Preheim, G., Gelmon, S.B., & Andrus, L.C. (2009). A national Delphi to determine developmental progression of quality and safety competencies in nursing education. Nursing Outlook, 57, 313-322.
Washington, DC: National Academies Press.
doi:10.1016/j.outlook.2009.08.003
Page, J. B., Kowlowitz, V., & Alden, K. R. (2010). Development of a scripted ongoing case study focusing on delirium in older adults. Journal of Continuing Education in Nursing, 41, 225-230. doi: 10.3928/00220124-20100423-05
Centers for Disease Control and Prevention. (2011). Home and recreational safety. Falls among older adults: An overview. Retrieved from www.cdc.gov/
Reese, C. R. (2010). ACES Case #1: Millie Larsen. Developed by the National League for Nursing, Simulation Team Advancing Gerontological
homeandrecreationalsafety/falls/adultfalls.html
Education Strategies (STAGES). Retrieved from www.nln.org/facultydevel-
Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell,
opment/facultyresources/aces/millie.htm
P., & Warren, J. (2007). Quality and safety education for nurses. Nursing
Starkweather, A. R., & Kardong-Edgren, S. (2008). Diffusion of innovation: Embedding simulation into nursing curricula. International Journal of Nursing
Outlook, 55, 122-131. doi:10.1016/j.outlook.2007.02.006
Education Scholarship, 5(1), 1-11. Retrieved from www.bepress.com
Attaining Baccalaureate Competencies Nursing Care
of Older Adults Through Curriculum Innovation
A N N M A R I E P. M A U R O , M A RY T. H I C K E Y, D O N N A E . M C C A B E ,
N
EW NURSES JOINING THE WORKFORCE ARE FACED WITH
PAT I E N T
INCREASED
PAT I E N T
DEMOGRAPHICS, AND THE
AC U I T Y,
for
CHANGING
COMPLEXITIES
OF A
To advocate effectively for geriatric patients with multifaceted needs, nursing students must develop competence in managing data from multiple sources, making clinical decisions, and collaborating effectively with the interprofessional team. Integrative teaching methods that contextualize learning — case studies, simulation, and clinical experiences — are needed to develop in students the clinical reasoning skills necessary to care for aging patients (Benner, Sutphen, Leonard, & Day, 2010). The transformation of nursing education to meet the demands of growing numbers of geriatric patients in an ever-changing health care environment requires faculty development, curriculum redesign, and opportunities for student reflection and experiential learning (American Association of Colleges of Nursing [AACN] & Hartford Institute for Geriatric Nursing [HIGN], 2010; Benner et al.). The New York University College of Nursing has more than 60 full-time faculty and more than 120 adjunct faculty, with approximately half teaching in the undergraduate program. Faculty development workshops and ongoing training help ensure that geriatric competencies are integrated into the baccalaureate curriculum. For example, undergraduate clinical faculty are required to complete two HIGN online education modules on how to best incorporate care of the older adult into clinical teaching. Simulation training and support for on-campus clinical faculty is provided, and adjunct faculty are paid to attend development activities that offer continuing education hours. Moreover, course coordinators make site visits, as needed, to evaluate, guide, and support clinical faculty. This article reports on decisions made in the process of curriculum redesign and describes briefly the innovative integrative teaching
AND
EMERSON EA
strategies used to develop competencies in clinical decision-making and patient-centered, evidence-based, culturally competent care of older adults in diverse settings.
DYNAMIC HEALTH CARE ENVIRONMENT.
Planning the Curriculum Redesign The need to integrate
baccalaureate geriatric competencies for our students and develop methods to meet educational demands was identified based on the emerging literature, feedback from clinical partners, and an understanding of the complex health care needs of older adults. Curriculum revision began in spring 2010; course development and evaluation are ongoing. The revision was guided by resources from the AACN (2008) and the AACN and HIGN (2010), as well as Quality and Safety Education for Nurses (QSEN) competencies (Cronenwett et al., 2007), Purnell’s Model for Cultural Competence (2002), and Healthy People 2020 objectives (US Department of Health & Human Services [HHS], 2011a). A literature review yielded no definitive method to incorporate older adult care in the curriculum. Some programs developed stand-alone courses, while others integrated concepts focused on the unique needs of the older adult across curricula (Berman et al., 2005; Forbes & Hickey, 2009; Hickey, Forbes, & Greenfield, 2010; Scott-Tilley, Marshall-Gray, Valadez, & Green, 2005). Our faculty chose to change from a stand-alone course to an integrated program. The first step was to determine what concepts were essential for baccalaureate graduates by developing multiple crosswalks that compared our program outcomes, course descriptions, and learning outcomes to competencies outlined in the literature. Faculty teams were organized to work on the crosswalks for various courses. The results were brought to the full baccalaureate faculty for discussion. Curriculum gaps and redundancies were identified, new course
May / June 2 0 1 2 Vo l . 3 3 N o . 3 1 8 7
Innovation
CENTER
descriptions were written, and enhanced learning outcomes were developed. Content was streamlined to include essential quality and safety concepts, the most common acute and chronic health problems, the best available evidence, and the use of technology. The first step was to revise support courses in health assessment and promotion (HAP), pathophysiology, and pharmacology to incorporate geriatric competencies. For example, HAP now has a focus on functional status; pharmacology addresses medication safety for elders and the risk of side effects, adverse reactions, and toxicity; and pathophysiology discusses physiologic changes associated with aging. The traditional medical-surgical nursing and stand-alone geriatric courses were transformed into Adult and Elder Nursing (A&E) I, II, and III, with updated descriptions and learning outcomes to enhance competencies in providing quality, safe nursing care to older adults. A&E I introduces gerontologic care, including concepts of frailty, geriatric syndromes, and atypical signs and symptoms of acute and chronic illnesses. Content includes the promotion and maintenance of functional ability, fall prevention, skin BSused Competencies care, and nutrition; unfolding case studies are to highlight these concepts. Students develop clinical competencies in older adult care and utilize online, evidence-based assessment tools from the HIGN Try This® series. (See Table.) The Transformation of Courses
Our A&E II course focuses primarily on patient responses to acute illnesses. Again, the unique clinical presentation and increasingly complex health care needs of older adults are emphasized. Students learn to become more aware of assessment findings in patients, including subtle changes in mental status or low-grade fever, which may be early signs of dehydration, hypovolemia, urinary tract infection, or sepsis. Priorities are emphasized using clinical examples, unfolding cases, and NCLEX-RN® type questions. QSEN competencies are cultivated for care of an aging population with increasingly complex problems, such as heart failure, the most common cause for hospital admission among patients age 65 or older (HHS, 2011b). These QSEN competencies include knowledge, skills, and attitudes related to geriatric patient-centered care, teamwork and collaboration, evidence-based practice, quality improvement, safety, and informatics (Cronenwett et al., 2007). For instance, discharge planning, medication reconciliation, patient and caregiver teaching regarding symptoms, and follow-up care instructions for older adults are accentuated in an A&E II didactic case and simulation scenario of heart failure. This is followed by an indepth Integrative Seminar II discussion of a faculty-led case. for Older A&EAdults III addresses1 the most complex geriatric syndromes and issues in acute, long-term, and community-based care. Topics include the three Ds (dementia, delirium, and depression), end-of-life care, frailty, and iatrogenesis. Simulated
Tab le . E x am p le s fr om th e Har tf or d In st itu te f or Ger iatr ic Nu r s in g, New Y or k Un iver si ty , Co lleg e of Nu r sin g, Tr y Th is ® A sse ssm en t T o ol s Try This ® Series Title T. Fulmer, M. Wallace, 2012: Fulmer SPICES: An Overall Assessment Tool for Older Adults http://consultgerirn.org/uploads/File/trythis/try_this_1.pdf M. Wallace, M. Shelkey, 2007: Katz Index of Independence in Activities of Daily Living (ADL) http://consultgerirn.org/uploads/File/trythis/try_this_2.pdf D. M. C. Doerflinger, 2007: Mental Status Assessment of Older Adults: The Mini-Cog http://consultgerirn.org/uploads/File/trythis/try_this_3.pdf L. Kurlowicz, S. A. Greenberg, 2007: Geriatric Depression Scale (GDS) http://consultgerirn.org/uploads/File/trythis/try_this_4.pdf E. A. Ayello, 2012: Predicting Pressure Ulcer Risk http://consultgerirn.org/uploads/File/trythis/try_this_5.pdf E. Flaherty, 2007: Pain Assessment for Older Adults http://consultgerirn.org/uploads/File/trythis/try_this_7.pdf D. Gray-Miceli, 2007: Fall Risk Assessment for Older Adults: Hendrich II Fall Risk Model http://consultgerirn.org/uploads/File/trythis/try_this_8.pdf E. J. Amella, 2007: Assessing Nutrition in Older Adults http://consultgerirn.org/uploads/File/trythis/try_this_9.pdf
D e script io n Assesses common syndromes of the elderly requiring nursing intervention: S leep Disorders; P roblems with Eating or Feeding, I ncontinence, C onfusion, E vidence of Falls, S kin Breakdown Assesses functional status as a measurement of the client’s ability to perform activities of daily living independently. Tool consists of three-item recall and the Clock Drawing Test; can be used to detect dementia quickly in various settings. Assesses registration, recall, and executive function. The Short Form GDS consists of 15 questions; developed from questions on the Long Form GDS. Discusses Braden Scale for Predicting Pressure Sore Risk in six areas: sensory perception, skin moisture, activity, mobility, nutrition, friction/shear. Describes commonly used pain intensity scales for older adults: the Numeric Rating Scale (NRS), Verbal Descriptor Scale (VDS), and Faces Pain Scale-Revised (FPS-R). Used in the acute care setting to identify adults at risk for falls. Discusses the Mini Nutritional Assessment (MNA®) used to identify adults >65 years at risk of malnutrition.
Note: These resources are available at www.hartfordign.org/Practice/Try_This/ and http://consultgerirn.org/resources.
1 8 8 N u r s i n g E d u c a t i o n Pe r s p e c t i v e s
learning experiences consist of complex patient scenarios with multiple comorbidities. one noteworthy scenario involves a patient with alzheimer’s dementia experiencing an acute decompensation who transitions from long-term care to an acute care setting. Students must communicate with the patient, family, and the interprofessional team; coordinate care; and manage physical and psychological needs. thoughts and feelings regarding older adults with cognitive impairment are discussed during debriefing. to better promote clinical decision-making and integrative thinking, three sequential seminars are taken concurrently with each a&E course. the new integrative Seminar (iS) i, ii, and iii courses support learning in the a&E courses and other simultaneous classes. Each iS section combines a&E clinical groups (total 24 students) to form a learning community. these seminars use an unfolding case study format, along with student-generated cases from actual clinical patients. as the majority of patients in our clinical sites are over 65 years old, students primarily explore cases involving older adults. Best practices in quality, safety, teamwork, and informatics are infused into each of the seminars, with a focus on the needs of the older adult in acute, long-term care, and community settings. Faculty facilitate the integration of concepts and discussion of clinical experiences. iS students critically appraise their clinical learning through reflection logs, which most often address their experiences caring for older adult patients. all iS iii cases address nursing care of the older adult. one unfolding case, in particular, highlights many of the competencies required to provide safe, appropriate care. it involves a hospitalized older adult with mild cognitive impairment who sustained an injury after a fall. issues are raised regarding functional capacity loss, medication safety, and psychosocial concerns about discharge planning. Students examine what went wrong or what could have been prevented. Collaboration with the patient, family, and interprofessional team is incorporated in the discharge planning. Creation of the Integrative Seminars
Learning outcomes are leveled across the a&E courses from beginning proficiencies to more advanced competencies in: utilizing knowledge from the arts and sciences, information integration from multiple sources, patient-centered care, health promotion, disease prevention, cultural competence, teamwork, interprofessional collaboration, professional comportment, and advocating for quality, safe care for adults and older adults with increasingly complex acute and chronic health problems. Students use evidence-based geriatric assessment tools to identify physical, cognitive, affective, functional, and social issues, such as the Fulmer SpiCES assessment tool for identifying common syndromes of the elderly requiring nursing intervention. (See table.) Links to the Hartford websites are posted for each course, enabling students to use the most up-to-date, evidence-based resources to care for older adult patients. Innovative Integrative Teaching Strategies
integrative didactic strategies to develop clinical decision-making skills and to contextualize learning for an aging population with complex health needs are used. these strategies include Socratic questioning, clinical examples, unfolding cases, critical thinking exercises with nCLEX-rn style questions using audience response technology, virtual patients, and podcasting. our inventive a-B model alternates 50 percent high-fidelity simulation with 50 percent traditional clinical in acute or long-term care agencies. this a-B model provides students with standardized, intensive, simulated learning experiences to develop the competencies required to care for elderly patients with complicated needs in an ever-changing health care environment. Students use personal digital assistants (pdas) or smart phone technology applications using free software, such as epocrates (www.epocrates.com/mobile/) and Micromedex (www.micromedex.com/mobile/), to help plan patient care. these resources are particularly valuable for the nursing care of older adults who are at great risk for overdosage, drug interactions, side effects, and adverse events. Summary this new curriculum promotes up-to-date, evidence-
based plans of care for older adults in acute care, long-term care, and community settings. Geriatric-specific content is a curricular thread and strong focus. Students have responded positively to the many opportunities they have to learn about the unique needs of older adults in multiple settings. Fortunately, we have several geriatric nurse practitioners on faculty along. our students observe experts who are committed to promoting safe, quality, compassionate care to older adults in action on a daily basis. About the Authors The authors are faculty at the New York University College of Nursing, New York, New York. Ann Marie P. Mauro, PhD, RN, CNL, CNE, is clinical associate professor, senior clinical faculty associate in the Hartford Institute for Geriatric Nursing and Curriculum Committee chairperson. Mary T. Hickey, EdD, WHNP-BC, is clinical associate professor. Donna E. McCabe, DNP, APRN-BC, GNP, is clinical assistant professor and senior clinical faculty associate in the Hartford Institute for Geriatric Nursing. Emerson Ea, DNP, APRN-BC, CEN, is clinical assistant professor and senior clinical faculty associate in the Hartford Institute for Geriatric Nursing. For more information, contact Dr. Mauro at
[email protected]. References American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Washington, DC: Author. American Association of Colleges of Nursing & Hartford Institute for Geriatric Nursing (2010). Recommended baccalaureate competencies and curricular guidelines for the nursing care of older adults: A supplement to the essentials of baccalaureate education for professional nursing practice. Retrieved from www.aacn.nche.edu/geriatric-rsing/AACN_Gerocompetencies.pdf
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Innovation
CENTER strategies. Journal of Professional Nursing, 26(4), 214-222.
Benner, P., Sutphen, M., Leonard, V., & Day, L. (2010). Educating nurses: A call for radical transformation. Stanford, CA: Jossey-Bass.
doi:10.1016/j.profnurs.2010.03.001
Berman, A., Mezey, M., Kobayashi, M., Fulmer, T., Stanley, J., Thornlow, D., &
Purnell, L. (2002). The Purnell Model for Cultural Competence. Journal of
Rosenfeld, P. (2005). Gerontological nursing content in baccalaureate nurs-
Transcultural Nursing, 13(3), 193-196. doi:10.1177/10459602013003006
ing programs: Comparison of findings from 1997-2003. Journal of
Scott-Tilley, D., Marshall-Gray, P., Valadez, A., & Green, A. (2005). Integrating
Professional Nursing, 21(5), 268-275.
long-term care concepts into baccalaureate nursing education: The road to
Cronenwett, L., Sherrwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell,
quality geriatric health care. Journal of Nursing Education, 44(6), 286-290.
P., et al. (2007). Quality and safety education for nurses. Nursing Outlook,
US Department of Health and Human Services. (2011a). Healthy People
55(3), 122-131. doi:10.1016/j.outlook.2007.02.006
2020 objective topic areas and page numbers. Retrieved from
Forbes, M. O., & Hickey, M. T. (2009). Curriculum reform in baccalaureate
www.healthypeople.gov/2020/topicsobjectives2020/pdfs/HP2020objec-
nursing education: Review of the literature. International Journal of Nursing
tives.pdf
Education Scholarship, 6(1), Article 27. doi: 10.2202/1548-923X.1797
Medicine competencies in a baccalaureate curricular revision: Process and
US Department of Health and Human Services. (2011b). Technical appendix: Heart failure. Retrieved from www.hospitalcompare.hhs.gov/staticpages/for-professionals/poc/technical-appendix.aspx
Engaging Students
in Clinical Reasoning When Caring for Older Adults ME L I S S A J . G E I S T
O
NE
H E A LT H
CARE
SETTING
FRAUGHT
WITH
R I S K S F O R E R R O R A N D I N J U RY TO T H E O L D E R
P O P U L AT I O N
IS THE
EMERGENCY
D E PA R T M E N T
(ED).
Older adults experience more adverse events while in the ED, and after discharge, when compared with other age groups (Aminzadeh & Dalziel, 2002). Tang, Stein, Hsia, Maselli, and Gonzales (2010) reported 17.5 million visits by older adults to EDs in 2007. The distinct physiological and psychosocial developmental changes that older adults experience profoundly affect the provision of safe, competent, and holistic nursing care. (See Figure 1.) When physiologic and psychosocial changes are not appropriately addressed, errors in management and poor outcomes may ensue. New graduate nurses tend to struggle when managing elderly patients, especially if they have not received appropriate training while in nursing school. In response to the need to include older adult-focused content in a baccalaureate nursing curriculum, a faculty member at Tennessee Technological University Whitson-Hester School of Nursing collaborated with an adult health/gerontology nurse practitioner to design a Legacy Cycle that engages students in challenge-based learning. The Legacy Cycle approach is a product of the National Research Council and a multi-institutional biomedical engineering education initiative funded by the National Science Foundation (Bransford, Brown, & Cocking, 2000). A strong research foundation for the application of Legacy Cycle modules exists in other disciplines.
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AND
KELLIE KAHVECI
Biomedical engineering educators have found Legacy Cycles to be effective tools for training students to think efficiently and creatively (Brophy, 2003; Martin, Rivale, & Diller, 2007; Pandy, Petrosino, Austin, & Barr, 2004). The Legacy Cycle approach is easily adapted for educating nursing students as they develop critical thinking, collaboration, and communication skills. Modules on topics such as emergent care of myocardial infarction, acid-base balance, and transitioning clients from parenteral to oral anticoagulant therapy were designed by the author and have been implemented as both graded assignments and as formative assessment tools. This Legacy Cycle is not currently graded. Rather, it serves as a formative assessment by providing ongoing evaluation of nursing students’ ability to synthesize multiple pieces of data and prioritize findings concerning the care of older adults. Since the implementation of Legacy Cycles and other guided instructional design strategies (Bransford et al., 2000), the nursing program has achieved an NCLEX-RN® pass rate consistently greater than 95 percent. Anecdotally, students and employers report superior clinical reasoning and safe decision-making when compared with new graduates from comparable programs. The Legacy Cycle Design A Legacy Cycle makes use of a contextually based “challenge” followed by a sequence of instruction where the students offer initial predictions (“Generate Ideas”), gather information from multiple sources (“Multiple Perspectives”), integrate the knowledge gathered
