Specialty Association Accomplishments: Exemplars of Activities and Products

American Association of Critical Care Nurses 

One of the earliest associations to participate in this project, the American Association of Critical Care Nurses (AACN; www.aacn.org) became involved at an auspicious moment. The 66,000-member association had recently conducted a study of critical care nurses that yielded some worrisome results with regard to perceptions of older adult patients. The study, conducted in 2000, asked critical care nurses whether they cared for geriatric patients, and about 70% of members did not identify geriatric patients in their population group. However, when asked about their patients’ actual ages, most were indeed taking care of very old patients.

“We validated this result through other methods and found that critical care nurses do not identify their practice with the word ‘geriatric,’” says Justine Medina, RN, MS, director of professional practice for the AACN and a geriatric nurse. “For them, ‘geriatric’ meant patients in long-term care or those who were not acutely ill.”

Without seeing their patients as older adults with specific needs, says Ms. Medina, the association’s members risked missing symptoms and syndromes that they should be looking for. At that point, the AACN began an all-out effort to embed content about age-related changes and how they affect care that critical care nurses provide to critically and acutely ill patients. As part of that effort, the AACN launched a monthly series of newsletter articles on geriatric issues in critical care. When applying for grant funding through NCA, the association concluded that its priority was to look at whether certification questions for critical care nurses adequately addressed age-related competency. To validate that conclusion, it conducted another job analysis study and found that critical care nurses were caring for a higher percentage of people aged over 65 than under 65 years—even more than in the previous study. This change in the patient population requires an important perceptual shift among the membership, says Ms. Medina.

Using its NCA grant, the AACN hired experts to write new questions for its certification exam to reflect older-adult issues. Ms. Medina reports that items are performing extremely well in testing knowledge and implied competence in caring for older patients. These results are congruent with the AACN’s examinations in which the items are based on the synergy model that says nurses’ competence must be driven by the needs of patients.

According to Ms. Medina, AACN has successfully used “covert” methods to infuse geriatric material within the content it produces on the needs of its patients, recognizing members’ reticence to acknowledge older adults as geriatric. To highlight older people separately, she says, is antithetical to their approach. The AACN provides evidence-based, free online resources such as the Practice Alerts, written by specialty researchers and geared toward practical applications.

“We looked at areas where evidence-based research has not been applied, and in our Practice Alerts we make very clear what the evidence is and what the practice should be,” says Ms. Medina.

For example, there is evidence to support the discontinuation of using blue food coloring in tube feeding to identify placement, but the practice has not changed. Practice Alerts have also addressed the case of ventilator-assisted pneumonia, for which geriatric experts in critical care have recommended a change in practice. It is recommended that the head of the bed for patients with ventilators should be elevated 30 degrees to prevent the occurrence of ventilator-associated pneumonia, but this does not happen universally. The Practice Alerts delve into clinical topics such as these and include references and resources; they also provide information highly specific to older patients. The association is currently studying whether these alerts have had effects in units where they are being used.

The AACN has infused geriatrics into its communication with members in a number of other ways. Of 200 topics presented at a recent conference, 30% had content that addressed care of the older adult. The association was asked to present its work with the certification exam at a Geriatric Society of America meeting in 2004 and received support from NCA to implement a Nurse Competence in Aging Award.

Looking toward the future, the AACN will continue to look for opportunities to bring expert care for geriatric patients into the realm of acute and critical care nursing—whether through annual meetings, publications, or its Web site. The organization is also seeking opportunities to work with other organizations to help them replicate the success that AACN has had.

“We have fully integrated it into our everyday processes,” says Ms. Medina. “If we can help others in any way, we would be willing to do so.”

American Society of PeriAnesthesia Nurses 

The American Society of PeriAnesthesia Nurses (ASPAN; www.aspan.org) was in the first cohort of associations to join NCA, in May 2003. The 13,000-member association represents nurses who practice in all phases of preanesthesia and postanesthesia, ambulatory surgery, and pain management. At least half of the patients cared for by perianesthesia nurses are older adults, and many ASPAN members have expressed concern about the rapid changes that have taken place in the health care system and the effects on their patients.

“Our members express concern about the potentially devastating effects on geriatric outcomes when patients are rushed out of the hospital,” says Jennifer Allen, MSQSM, RN, CPAN, Geriatric Specialty Practice Group coordinator for the ASPAN.

With a 2-year grant from NCA, the ASPAN focused on its continuing-education program. This coincided with a needs assessment that revealed a significant need for advanced knowledge of geriatric pain and comfort management. A panel of perianesthesia experts in the field of pain and comfort developed the ASPAN Geriatric Advanced Perianesthesia Competency in Pain and Comfort (GAPCPC) Learning Module, which was subsequently tested for reliability and validity.

To determine the level of member education necessary to complete the module, the association first developed a study of members’ geriatric competency around pain and comfort. A pretest was administered to more than 385 participants recruited from among members attending a national conference and through advertising. Following that pretest, a learning module was distributed to the study participants, followed by a posttest, which was completed by 252 participants.

According to a report on the study’s highlights, by Myrna Mamaril, MS, RN, CPAN, CAPA, “over 83% of perianesthesia nurses who completed the learning module scored higher on the posttest.” Of the 3 components—geriatric physiology, pain, and comfort management—comfort management (the Kolcaba Comfort Care Module that provided one part of the framework for the ASPAN GAPCPC learning module) showed the greatest improvement of score on the posttest. Moreover, there was no significant difference among the posttest results related to one’s years of perianesthesia nursing experience, age, education, or certification. However, there was a significant difference depending on where the nurses practiced. Postanesthesia nurses scored higher on the pretest in the pain-management section than did perianesthesia nurses from ambulatory surgery, preoperative assessment, or preoperative units. There was greater than a 65% return rate on the posttests, which was phenomenal, says Ms. Allen. The educational module used in the posttest phase will be disseminated if a continuation grant is received.

The key driver of the ASPAN’s geriatric offerings is the Geriatric Specialty Practice Group, a 40-member body that Ms. Allen coordinates. Established in 2003, the group has established a geriatric presence at national meetings through preconference and concurrent continuing-education sessions. It also contributes information to the new geriatric page on the association’s Web site (www.aspan.org/geriatricresources.htm) as part of the Web Fellow program and publishes its own newsletter.

Beginning in 2002, the association substantially reorganized its approach to geriatric content in the bi-monthly Journal of PeriAnesthesia Nursing, and, as of 2007, has published 15 articles that deal with the geriatric patient, and 3 of those articles—on managing acute postoperative pain, osteoporosis, and medication usage in the elderly patient—are continuing-education offerings. In December 2004, the entire journal was focused on geriatrics.

The newsletter Breathline, which alternates publication months with the journal, has featured 14 articles related to the older adult since 2003. One member published the article “Nursing Considerations in the Geriatric Surgical Patient: The Perioperative Continuum of Care” in Nursing Clinics of North America.1

The Geriatric Specialty Practice Group has published 8 newsletters, which direct members to useful information from ASPAN and other organizations. Anesthesiologists, surgeons, and ASPAN members have contributed to this newsletter, which features articles on topics such as communicating with older people who are ethnically diverse.

“We have conducted a total of 8 geriatric seminars, and for 2 years, we have used NCA funding to give a geriatric competency award to an ASPAN member. Our members have been very positive about our focus on the older adult,” says Ms. Allen.

Emergency Nurses Association 

With 35,000 members, the Emergency Nurses Association (ENA; www.ena.org) is one of the larger specialty nursing associations. Many ENA members have expressed interest in learning more about the special needs of older adults and in improving their competencies in providing high-quality nursing care to the geriatric population. Currently, 15% of all emergency department (ED) visits are by persons aged 65 and over, and it is projected that by 2020, this percentage will increase to more than 20% of all ED visits.2 In fact, the trend has already been observed. Between 1993 and 2003, a greater increase in the ED visit rate has been reported among older patients than among any other age group.3 The ENA Injury Prevention Institute/EN CARE Director Pierre Désy, MPH, explains that, with the aging of the population, ED nurses must adjust their practices to meet the special needs of the aging population.

Emergency nurses need to be aware of a particularly wide array of changes that occur during the normal aging process. Normal results of lab tests are often different in people over 65, and when ill, older patients may present with different signs and symptoms than younger people. Patients with urinary tract infections, for example, may appear to have acute confusion, and patients with depression—a common and often undiagnosed condition—may have a series of somatic complaints. The common denominator is this: Most practicing nurses did not learn about these differences while in nursing school.

Indeed, fewer than 1% of practicing nurses have taken a geriatric course in nursing school, and fewer than 3% of advanced practice nurses overall are certified in geriatrics. Prior to NCA, the ENA looked at this constellation of factors and decided to address them. It formed a small committee and began drafting a position statement on care of the older adult.

It was the association’s participation in NCA that spurred a much more intensive commitment to educating its members on geriatric issues. Mr. Désy’s personal efforts have made an important difference in infusing geriatrics into the organization’s communication with its members, and he has become the liaison to the committee that was formed.

The most significant of ENA’s achievements has been the development of the Geriatric Emergency Nurse Education, or GENE, course, for which the association used its original NCA grant. To develop the course, ENA created a 5-member committee from among members interested or experienced in geriatric nursing. After multiple meetings and outside research, the committee came up with a curriculum, which was first introduced as an 8-hour classroom session at the association’s annual conference in San Diego in October 2004. The course has evolved into a full, Internet-based, self-education program, enabling many more members to take the course without the financial burden of travel or time away from work. To date, approximately 600 nurses have completed the course, which provides continuing-education credits.

ENA has conducted pre-and posttests of the GENE course, revealing several concrete findings. Three months after taking the GENE course, ED nurses advanced in their ability to provide geriatric care in assessment of patients relative to environment (26.6% of nurses), ADLs (31.8% of nurses), functional status (29.8% of nurses), depression (29.1% of nurses), delirium (42% of nurses), dementia (39.9% of nurses), nutritional status (31.5% of nurses), end-of-life care (23.5% of nurses), and appropriate referrals for services (20% of nurses). Moreover, 3 months postcourse, there was a significant increase in the number of geriatric protocols established in EDs where the nurses had completed the course work (21.1%), compared with baseline (11.5%).

ENA has implemented a series of additional activities to enhance the geriatric knowledge and skills of its members. Chief among them is the completion of the position statement it had begun prior to NCA. The statement makes plain the imperative for emergency nurses to understand the uniqueness of older adults:

Compared with younger patients, “it is known that elderly patients are more likely to present to the emergency department with illnesses of higher acuity levels, to have longer lengths of stay, to arrive by ambulance, to be admitted to an intensive care unit, to be admitted to the hospital, and to require more staff time and resources.”4, 5 It is also known that “older adults are less likely to inappropriately seek ED care for minor complaints.”6

The statement emphasizes the need for multidisciplinary collaboration among the health care team; geriatric nursing education for members; awareness of how changes in aging affect assessment, interventions, and discharge decisions; recognition of elder abuse; and other important issues. ENA has also developed a special-interest group for geriatric nurses and instituted a Web Fellow program under the auspices of the education department. Through the latter, the association has integrated geriatric components throughout its Web site. For example, a section on falls prevention appears under the Injury Prevention Institute/EN CARE portion of the Web site. The association’s geriatric content can be accessed at www.ena.org/nursing/geriatric. Finally, ENA is currently completing a CD-ROM on safe medication use for older adults and is developing brochures on nursing best practice, as well as materials that nurses can give to older adults at discharge.

Mr. Désy emphasizes that although members’ views and knowledge about older adults are slowly changing, awareness has been raised across the board. Moreover, although only a small percentage of association members have taken the GENE course, those nurses who have taken the course are bringing change to their hospitals. Mr. Désy adds that the funding attached to project participation and the close involvement of geriatric experts were crucial factors in its implementation. For the future, a top priority of the association is to promote and disseminate the GENE program, getting more nurses—including nonemergency nurses—to take the course.

Infusion Nurses Society 

Having an awareness of the changes that occur in aging is critical for infusion nurses, according to Kathy Walther, RN, BSN, CRNI, education manager for the 6,000-member Infusion Nurses Society (INS; www.ins1.org). Because INS recognizes that members care for many older adults—in hospitals, long-term care, and, home care—it has integrated geriatrics throughout the 9 core competencies that its educational programs and CRNI (Certified Registered Nurse Infusionist) certification examination follow. Through a 2-year grant from NCA, the association was able to expand and diversify its geriatric educational offerings. It also revised the INS Standards of Practice in 2006, expanding Standard No. 3, which focuses on the older-adult patient.

Standard 3.1, for example, states: The nurse providing infusion therapy for older adults shall have specific knowledge and technical expertise with respect to this population.

Standard 3.2, for example, states: Clinical management of older adults shall be established in organizational policies and procedures and shall be according to applicable standards of practice.

The most important difference between older and younger adults to an infusion nurse is the percentage of the body that is made up of fluid. Whereas a 40-year-old woman’s body is made up of 60% fluid, the body weight of an 80-year-old female is only 33% fluid. That signals a need to assess for fluid and electrolyte imbalances.

“Unfortunately, low potassium in the elderly can look like dementia,” says Ms. Walther. “In less than 4 hours, an elderly person can become dehydrated.” Beyond knowing what kinds of fluids to give, nurses must find the correct vascular access device and use the correct gauge size for the kind of therapy that is indicated.

The INS’s revised Practice Criteria state that the nurse providing infusion therapy should have validation of demonstrated competency in 11 discrete areas, including anatomy and physiology related to older adults; complexity of the management of this population with respect to systemic changes that affect the older adult’s response to infusion therapy; and interaction with older adults at various stages of physical, cognitive, and psychosocial development and impairment, together with awareness of socioeconomic considerations.

The first project INS undertook with its NCA grant was to work with the American Nurses Association on creating the manual Policies and Procedures for Infusion Nursing of the Older Adult, published in 2004. That manual addresses issues such as the dangers of giving certain drugs to older patients through peripheral catheters.

The INS’s bimonthly Journal of Infusion Nursing has focused specifically on geriatrics several times, and members have had the opportunity to attend many sessions on infusion nursing and older adults at the society’s 2 annual meetings. The society’s newsletter INS Newsline includes a section on clinical concepts in infusion therapy and recently included an article with a geriatric focus.

The augmentation of geriatric content among INS materials has been championed especially by the education department, whose manager, Kathy Walther, has been a geriatric specialist for 25 years; Ms. Walther wrote the chapter on geriatrics for the educational manual Infusion Therapy in Clinical Practice.7 In addition, the INS’s National Council on Education, a volunteer committee whose members serve 2-year terms, seeks geriatric experts to speak at meetings, write abstracts for conferences, and contribute content to the organization’s publications and Web site.

INS members’ focus on geriatrics is growing, says Ms. Walther. “Members have seen our articles and know we’re a resource. They are coming to INS to expand their base of knowledge because they’re realizing that better outcomes with older patients are possible.” For example, she adds, “They’re understanding that if you prehydrate a patient before you put in a PICC (peripherally inserted central catheter), then outcomes are better. They’re becoming more aware not to give certain irritant and vesicant medications, such as Vancomycin, through a peripheral catheter because of the potential for extravasation.”

Ms. Walther receives hundreds of e-mails each week from members all over the world, and at least 30 to 40% are geriatric-related, she says.

Oncology Nurses Society 

Like a number of other nurses’ associations, the 35,000-member Oncology Nurses Society (ONS) had already taken initial steps to enhance the information it provides about older-adult care to its membership when it joined NCA. Taking part in a formal partnership, however, spurred the organization to start thinking about older adults in a much more active way, according to Jan Kinzler, corporate relations manager in ONS’s business development department.

The first step, in 2004, was to develop a joint position statement with the Geriatric Oncology Consortium on cancer care in the older adult. The Consortium is a multidisciplinary heath care organization that seeks to counter age-based disparities in cancer research, education, and treatment. Indeed, although cancer is a disease that is often associated with older people, false notions about older adults, even among experienced nurses, can compromise the care they receive. The position statement acknowledges the unique needs of older adults; aims to sensitize people to the devastating effects of ageism in cancer care, public policy, research, and education; and offers guidelines for ensuring proper and equal access to care for older adults. The position statement was distributed widely among ONS members.

Says Ms. Kinzler, “In pain management, the way you treat older adults with cancer is different from the way you treat younger adults. For example, there are physiologic changes with age that affect pain, and people may have comorbidities that compound the effects of cancer treatment.”

To further its communication with its membership in this area, the ONS developed the book An Evidence-Based Approach to the Treatment and Care of the Older Adult with Cancer, which won second place in the 2006 American Journal of Nursing Book of the Year Award competition in the Gerontological Nursing category. Highlighting new frontiers in the field of oncology, the book covers the physiology of aging, screening issues, pharmacologic issues, nutrition, symptom management of pain, sexuality, spiritual and palliative care, and cancer survivorship.

The ONS Education Department has worked closely with geriatric leaders within the organization to plan programs that address the needs of the elderly. As its commitment to improving older-adult awareness has expanded, ONS had integrated care of older adults into its national meetings. One precongress workshop featured the session “Geriatric Cancer Care across the Continuum—Using the ‘Evidence’: Where We Are and Where We Should Go.” The session addressed the ONS’s positions as the population of older people grows and educated participants in how to integrate research into their practice in geriatric oncology. At the following fall meeting, 2 geriatric-related sessions were held: “Competent Pain Management in Cancer Care for Older Adults” and “Babyboomers Come of Age: Challenges in Caring for the Older Adult with Cancer.” These sessions also were posted as online modules for a period of time.

Rounding out the ONS’s efforts to draw its members into older-adult-related activities, a gerontology-oncology focus group was created. Its members have been involved in updating the organization’s older adult Web page; have written articles for the Clinical Journal of Oncology Nursing on pain, chemotherapy, and problems facing older people with cancer; and have met at national meetings to update and share information.

According to Ms. Kinzler, ONS members themselves have become more sensitive to older adults through the combined effect of the position statement, meetings, and journal articles, and the organization’s Web site.

“We are seeing that they really pay attention to how they provide care, use research, and use resources that address the older adult,” she says.

Preventive Cardiovascular Nurses Association 

Recognizing that cardiovascular disease is the No. 1 killer of adults worldwide, the 2,500-member Preventive Cardiovascular Nurses Association (PCNA; www.pcna.net) focuses on cardiovascular-disease risk reduction to reduce death and disability. Although the association represents nurses who work with people across the lifespan, the majority of its members’ efforts relate primarily to older adults.

The PCNA had, before the NCA project, produced a series of geriatric-education resources. Yet it credits NCA with helping to focus its efforts in terms of more substantial integration of geriatric specific education into its existing materials.

The association in 2002 launched Get Tough on Angina, a multiple-component campaign, supported through an unrestricted grant from Cardiovascular Therapeutics, to raise awareness among the public and professionals about causes, treatments, and quality of life for persons living with chronic stable angina. The campaign includes a comprehensive “how-to” kit containing a patient handbook, educational materials, 2 CD-ROM PowerPoint presentations, a comprehensive training syllabus, script, and instructions on how to implement a 4-part educational series and 1-hour community seminar about living with chronic stable angina. This kit is provided free of charge to health care professionals who want to offer educational seminars in their communities or who want to conduct the educational series for their patients.

It was to build on this work that the PCNA entered its relationship with NCA. Its board first took the opportunity to evaluate all of the association’s products in terms of their specific emphasis on aging, looking beyond nursing-education materials to the enduring patient-education materials that the association produces. An active committee was formed to ensure that issues important to the care of the geriatric patient were integrated into all products developed by PCNA.

“We took on the commitment that, where appropriate, all of our educational programs and products will have a special focus on the elderly,” says Kathy Berra, past president and current member of the PCNA board and clinical director of the Stanford Heart Network.

PCNA has produced a number of specific products that focus specifically on the older adult. One project that was directly influenced by NCA was a special issue of the Journal of Cardiovascular Nursing that focused on cardiovascular-disease risk reduction in the elderly.

“Over the past 10 to 15 years, as our population continues to live longer, there has been concern and controversy over whether the medical therapeutics that we apply to 40- and 50-year-olds are safe in 80- and 90-year-olds,” says Ms. Berra. “The scientific community is addressing that question, so we wanted to bring this important focus to our members. We aspire to help our older patients not only live longer but live healthier lives with excellent quality of life.”

The PCNA has created several older-adult-related components that are permanent features of its national conference held annually. The PCNA includes a specialty abstract category related to older adult cardiovascular care—an opportunity that has attracted much interest. The organization has also included an annual workshop or keynote presentation on care of the elderly.

Through the NCA Web Fellow program, the PCNA has appointed a board member who oversees the clinical and policy-related geriatric content posted on the association’s Web site. Forms and evaluation tools are downloaded directly from the Hartford Institute’s Web site.

“To me, the next generation of thought is: how do we define the older adult?” asks Ms. Berra. “The elderly are not a homogeneous group but are widely diversified. Their needs are as varied as their age, their culture, their health status, and their socioeconomic status. The future holds much promise for continued improvements in the way we understand the process of aging, thus making the care of our aging population more challenging as well as more successful. PCNA considers it a real privilege to work with the NCA and the many important professional nursing organizations to improve the lives of the elderly in this country and worldwide.”

More information about these associations’ products and other NCA association products is available online at www.ConsultGeriRN.org in the “Specialty Practice” section.