Helping hospitals serve older patients: Nurse managers find NICHE

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by Barbara Kancelbaum, MSJ

Improving patient care often means seeing it through the eyes of the patient. And that becomes even more crucial if your patients are having trouble seeing the world around them. Some hospitals are experimenting with ways to allow staff members to view the world through the eyes of patients with cataracts.

"More than half of the patients at our hospital are older adults, and they have special needs," says Jane Smeaton, RN, MSOLQ, manager of the medical floor at Waukesha Memorial Hospital in Milwaukee, WI. Since becoming one of the first hospitals to join the national NICHE (Nurses Improving Care for Healthsystem Elders) program in 1999, the facility has taken many steps to serve this need. One includes training sessions where nurses wear vision-distorting glasses to understand what it is like to have cataracts. 

NICHE was developed by the Hartford Institute for Geriatric Nursing at NYU College of Nursing, in New York, NY, to help hospitals provide better nursing care to older adults. The number of hospitalized older adults is growing, yet merely 1% of nurses are certified in geriatrics, and many have had little education targeted about this population. NICHE provides hospitals with educational resources, clinical protocols, and organizational models and tools that they can customize to fill the gaps in nurses' education.

Waukesha elected to join NICHE because staff wanted to use one of its central models, the Geriatric Resource Nurse (GRN) model, in which some nurses are specially trained in geriatric issues and become resources and role models for their colleagues.

"The GRN model was a good fit for our organization because it gave nurses working in med-surg a specialty of their own," says Smeaton. "It's rewarding for them to be recognized for care of the older adult."

Some 115 Waukesha nurses have become GRNs. To do so, a nurse must attend a two-day class, taught by the clinical nurse specialist for the NICHE program. The class provides an overview of issues that particularly affect the older adult, such as dementia, confusion, polypharmacy, and sensory perception. Part of the training involves helping nurses understand how the older adult sees the world, which is when participants experience what it would be like to have cataracts.

After the initial class, GRNs attend monthly meetings where they talk about quality and satisfaction indicators such as falls and pressure ulcers, and discuss how to improve the care of older adults. GRNs are employed on the med-surg, heart care, psychiatry, oncology, and day surgery units. Managers and charge nurses assign older and more complex patients to the GRNs on their units and other nurses are alerted to their availability by their lab coats embroidered with the words "Geriatric Resource Nurse." Waukesha has also trained 59 certified nurse assistants as Geriatric Resource Aides in a one-day conference that focuses mainly on mental and behavioral issues.

The nurse manager's role

Smeaton plays a key role in continually supporting NICHE and advocating for resources to enhance the hospital's care of its older adult patients. She collaborates with the clinical nurse specialist in making educational materials available with the help of the NICHE headquarters in New York. And when it comes to budgeting, she keeps NICHE principles front and center. Smeaton encourages nurses to take the NICHE class and makes sure the budget includes them time to attend, as well as time to attend regular NICHE meetings afterward.

Like Smeaton at Waukesha, North Carolina Baptist Hospital (NCBH), part of Wake Forest University Baptist Medical Center in Winston-Salem, NC, was increasingly aware that the older patients in the 840-bed hospital had special needs. Kathy Long, BSN, Acute Care for the Elderly (ACE) and palliative care manager at NCBH was placed in charge of the hospital's ACE unit in 2000, and she began searching the Web for evidence-based materials to share with the nurses on the unit. She soon found the NICHE Web site, attended a NICHE conference, and immediately sought support to establish a GRN program with a multidisciplinary approach.

Soon after attending a NICHE conference in New York, Long and her staff received an unexpected windfall that helped get the project off the ground. An 89-year-old patient had come to NCBH from Florida because he had been unable to find a hospital to perform an operation due to his age. Following his successful surgery, he gave the hospital $10,000 for geriatric education to thank the hospital for the excellent care he had received. 

Like Waukesha, NCBH now has an active and voluntary GRN program, which has trained 65 nurses in an array of geriatric symptoms and syndromes. Thanks to Long's steadfast promotion of the GRN model within the hospital's Shared Governance councils, these nurses now serve on 18 units, including the ICU, emergency department, and oncology, as well as med-surg, dialysis, and outpatient areas.

Long chairs the NICHE steering committee, which includes nurse managers, a director of nursing, a director of research, a clinical nurse specialist, and a physician. Like Smeaton, she is taking NICHE principles hospitalwide. When the hospital remodels rooms, for example, she asks whether the bed will be elder-friendly, and insists that any printing is dark and large enough to be read by older adults.

Editor's note: Read about the benefits of the NICHE program at both facilities in the second part of this article on Monday. The annual NICHE Leadership Conference orients new hospitals to the program's principles and process of implementation. It will be held in Orlando, FL, in February 2009. To learn more about NICHE and the annual conference, visit