Geriatric Nursing
Volume 31, Issue 2 , Pages 81-83, March 2010

A Big Welcome to our NICHE Hospitals

Article Outline

 

I am thrilled to take this opportunity to send out a big welcome to our NICHE (Nurses Improving Care to Healthsystem Elders) hospitals and nurses working in these sites who will now receive Geriatric Nursing on a regular basis. As was noted with our initiation of the Acute Care Column 2 years ago, we are dedicated to improving care to older adults across all settings and see acute care at the core of the care continuum. Older adults are admitted to acute care facilities at rates as high as 3 times those of younger individuals.1 The focus of these admissions is geared toward addressing acute medical problems such as infection; fracture; acute cardiac, pulmonary, or neurological event; or metabolic disorders. Medical stabilization may be challenging with treatment for the admission problem, causing an exacerbation of comorbid problems or delirium. In addition, 40–60% of older adults lose some functional ability while hospitalized, with declines occurring as early as the second day of hospitalization.2 Although difficult, it is critical to prevent functional decline and associated adverse events such as falls, pressure ulcers, and infections during the course of the hospital stay.

Recognition of the challenges associated with care of older adults in the acute care setting is not new to nursing. In 1982, as a geriatric nurse practitioner, I took a position as the clinical specialist in medicine in an acute care setting with the focus of that position being on improving care to older adults on the multiple medical/surgical units in that site. Twenty-plus years ago, nursing management recognized the need for a specific focus on aging to increase the knowledge and skill of the nursing staff, along with other members of the interdisciplinary team. It is exciting to think that there are now national programs, specifically NICHE, to facilitate the improvement in care we provide to older adults during acute care admissions.

So what or who is NICHE? NICHE, or “a niche,” has been defined as a special area of demand for a product or service. Certainly, this is a suitable name for a focus on care of older adults in acute care as it is a special area of demand for a product or service! Started in 1992, NICHE has evolved into a national geriatric program that includes more than 300 hospitals in more than 40 states, as well as parts of Canada. It is a program of the Hartford Institute for Geriatric Nursing at New York University College of Nursing (NYUCN), and its goal is to improve the quality of care provided to older adult patients in the acute care setting. NICHE has been implemented in both teaching and nonteaching hospitals, with bed size ranging from 50 to 800+. NICHE designation demonstrates that a hospital has an organizational commitment to care of older adults and assumedly improving or optimizing the care received in their institution.

NICHE is built on the premise that the bedside nurse plays a pivotal role in influencing the older adult's hospital experience and outcomes, through direct nursing care, as well as the coordination of interdisciplinary activities.3 Accordingly, a central focus is on improving the geriatric-specific skills and competencies of individual nurses and other staff members. The geriatric resource nurse (GRN) model is foundational to a NICHE program.4 GRNs are staff nurses who receive competency-based training and are mentored by advanced practice nurses in the care of the hospitalized older adult. GRNs act as peer consultants on clinical issues, provide education to patient care associates, and take part in quality improvement initiatives. 3 Implementation of the NICHE model is supported by the competency-based,14-module GRN training program, the 1-module Introduction to Gerontology series providing sensitivity training for all hospital staff, and the 6-module Geriatric Patient Care Associate training program. Instructor guides provide testing tools, resources, and operational guidelines to assist with the practical aspects of implementation and evaluation of all staff development programs.

Although improving the competency of individual clinicians is critical, the care environment needs to be aging-sensitive to support their effectiveness.5, 6 Systemic factors that are critical include institutional values that support the rights of older adults as core consumers, geriatric-specific resources for staff and patients and their families, and tools and practices that foster interdisciplinary collaboration.7 NICHE's guiding principles address these dimensions and provide a framework for organizations to use in program planning and evaluation. The specific tools that NICHE hospitals use include evidence-based interdisciplinary protocols, management strategies, and operational policies to meet the specialized needs of older patients. An online knowledge center provides ongoing educational support to clinicians and managers at all levels.

Although the process of becoming a NICHE site is fairly straightforward, it does require an organizational commitment, including careful attention to startup activities.8 NICHE faculty provide consultation to help hospitals create steering committees and prepare for startup, including defining roles, particularly the role of the person designated as NICHE Coordinator. The steering committee is an interdisciplinary group comprising clinicians, administrators/managers, and staff educators. Its functions are to conduct strategic planning, guide quality initiatives, and make sure there is continuity in the NICHE coordinator role. The NICHE leadership training program, an online interactive course, provides the opportunity for new NICHE teams to learn from mature NICHE sites. The NICHE Planning and Implementation Guide provides a blueprint for startup, and includes activities such as developing a vision for geriatric care, internal evaluation, building a business case, defining measures, and developing a 2-year action plan.

NICHE implementation begins by completing the Geriatric Institutional Assessment Profile (GIAP), a reliable and valid tool that assesses the geriatric institutional milieu. The GIAP is an online survey that evaluates staff knowledge and attitudes toward older adults and the organizational strengths and barriers to providing an aging-sensitive environment. The GIAP is used to establish priorities for staff education and policy/practice modification.7, 9 The next step for NICHE sites is to “pilot” the GRN model and interdisciplinary protocols on a select unit. The lessons learned from the experience on that unit are then applied to other units and can include specialty and critical care units.10 NICHE operational strategies and tools complement the protocols and training and address clinical issues (e.g., fall prevention), staff development (e.g., nurse certification campaign), marketing, the business case for improving geriatric care, and more. The GIAP as well as other measures, clinical and organizational, can then be evaluated on an ongoing basis.

NICHE designation means that a hospital is part of a national movement to improve geriatric care in the hospital setting. NICHE is a collaborative community. Clinicians, educators, and managers engage with NYUCN faculty to identify and develop resources on an ongoing basis, and to take part in NICHE research. NICHE sites also share innovations and “lessons learned” through ongoing listserv dialogue, national and regional conferences, webinars, and discussion boards. Involvement with a geriatric–intensive community has spawned innovations such as functional mobility programs, relationship-based care initiatives, and delirium/dementia identification projects. NICHE hospitals report improvements in staff perception of the care environment,5 patient and nurse satisfaction, job performance, clinical outcomes, and financial outcomes.8, 10, 11, 12, 13 NICHE Coordinators and other staff are supported by NYUCN faculty to publish and to present their work at national conferences.

The success of NICHE hospitals is attributed to the following unique characteristics of the program:

•An empiric basis: a model of geriatric care (the GRN model) tested and proven effective at hospitals around the country;

•An internal assessment of a hospital's geriatric strengths and weaknesses that drives startup and ongoing program evaluation;

•Evidence-based, interdisciplinary resources and tools that are field tested and aligned with regulatory and Magnet Standards;

•A systemic approach to planning, implementation, and evaluation.

Currently, NICHE is funded through a 5-year grant from Atlantic Philanthropies (Principal Investigator: Liz Capezuti, codirector of the Hartford Institute for Geriatric Nursing at NYU/NICHE Faculty Director) to expand educational programs and resources for participating hospitals and accelerate the spread of evidence-based practice throughout the country. Additional information can be obtained at www.nicheprogram.org. I would also recommend you consider attending the annual NICHE Conference in Baltimore, Maryland, April 21–23. This year's theme is “Interdisciplinary Paths to Improved Geriatric Care.” The meeting will focus on the critical role that collaboration across disciplines plays in the quality of care of older adults. Clinicians, administrators, and researchers will present evidence-based, interdisciplinary approaches to promote positive outcomes and experiences for hospitalized older adults.

So again I welcome our NICHE nurses and truly look forward to how Geriatric Nursing can continue to reach nurses in all settings to optimize care provided to older adults. Moreover, I am certain that we can learn much by sharing ideas and effective interventions from one site of service to the next. In geriatrics, more so than in other clinical areas, older adults are treated for similar medical problems in all types of settings—hospitals, at home, acute management of problems in long-term care settings, and chronic care management in acute care sites. So welcome NICHE sites, share your knowledge and experiences. Likewise, those of you in long-term care, home care, and outpatient practices or elsewhere, share what you have learned, experienced, and tested!

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Acknowledgment 

I acknowledge Marie Boltz, PhD, CRNP, Practice Director for NICHE, for providing me with her insight on NICHE and her wonderful description of the program.

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References 

  1. Landefeld CS. Improving health care for older persons. Ann Int Med. 2003;139:421–424
  2. Rosenthal MB. Nonpayment for performance? Medicare's new reimbursement rule. New Engl J Med. 2007;357:1573–1575
  3. 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;23:121–127
  4. Capezuti E, Boltz M, Fulmer T. The geriatric resource nurse. In:  Capezuti E,  Siegler E,  Mezey MD editor. The encyclopedia of elder care. 2nd ed. New York: Springer Publishing Company; 2008;p. 361–362
  5. Boltz M, Capezuti E, Bower-Ferres S, et al. Changes in the geriatric care environment associated with NICHE. Geriatr Nurs. 2008;29:176–185
  6. Kim H, Capezuti E, Boltz M, et al. The relationship between nursing practice environment and quality of geriatric care in hospitals. West J Nurs Res. 2009;31:480–495
  7. Boltz M, Capezuti E, Bowar-Ferres S, et al. Hospital nurses' perceptions of the geriatric care environment. J Nurs Scholar. 2008;40:282–289
  8. Pfaff J. The geriatric resource nurse model: a culture change. Geriatr Nurs. 2002;23:140
  9. Boltz M, Capezuti E, Kim H, et al. Test–retest reliability of the GIAP (Geriatric Institutional Assessment Profile). Clin Nurs Res. 2009;18:242–252
  10. Fletcher K, Hawkes P, Williams-Rosenthal S, et al. Using nurse practitioners to implement best practice care for the elderly during hospitalization: The NICHE journey at the University of Virginia Medical Center. Crit Care Nurs Clin North Am. 2007;19:321–337
  11. Lopez M, Delmore B, Young K, et al. Implementing a geriatric resource model. J Nurs Admin. 2002;32:577–585
  12. Guthrie PF, Edinger G, Schumacher S. TWICE: A NICHE program at North Memorial Health Care. Geriatr Nurs. 2002;23:140
  13. Lee VK, Fletcher KR. Sustaining the geriatric resource nurse model at the University of Virginia. Geriatr Nurs. 2002;23:128–132

PII: S0197-4572(10)00086-8

doi:10.1016/j.gerinurse.2010.02.002

Geriatric Nursing
Volume 31, Issue 2 , Pages 81-83, March 2010

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