Welcome to the Nursing Outlook Blog – “3 Questions” – Timely Interviews with Thought Leaders in Nursing and Health Care Policy

Last year, NURSING OUTLOOK featured a special issue on Gerontological Nursing: Development of the Science, Education and Practice. Early this year, Nursing Outlook published: “Carpe diem: Nursing making inroads to improve mental health for elders” (Evans, Beck & Buckwalter), a summary of the accomplishments of the Academy’s Geropsychiatric Nursing Collaborative (GPNC), a Hartford-funded project. Here, all three authors expand on their points of view and the lessons learned from the project and the evolving specialty of geropsychiatric nursing.

We invite commentary that is thoughtful and provocative! Join the online dialogue!

Veronica D. Feeg, PhD, RN, FAAN
Editor/Moderator

Evans, L., Beck, C. & Buckwalter, K. (2012). Carpe diem: Nursing making inroads to improve mental health for elders. NURSING OUTLOOK, 60, 2, 107-108. 

Cornelia Beck, PhD, RN,FAAN

Louise Hearne Chair in Dementia & Long-Term Care

University of Arkansas for Medical Sciences


Question 1.  “Why is it important that geropsychiatric nursing (GPN) be integrated into other specialty programs?”

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I think it’s very important because we find that people often don’t just have a mental illness. They often have that along with another chronic illness. For example depression and diabetes commonly co-occur. The cost of caring for diabetic with depression is much higher than the cost of caring for an older adult with diabetes without depression. So, even people who don’t consider themselves mental health psychiatric nurses have a need to understand the relationship between the mental health illnesses like depression and anxiety and other chronic conditions.

Now, I think the same is also true if we look at Alzheimer’s disease. For example, people who have Alzheimer’s disease are often cared for by people from other specialties – even let’s say, a women’s health nurse practitioner might be caring for an older woman who has Alzheimer’s disease and some other chronic condition. We know from all lot of work that the cost of caring for someone with Alzheimer’s disease, if we just look at Medicare claims alone, is about three times as high as people with other diseases. I think it’s not because they’re sicker but it’s because often practitioners who are caring for them don’t take into consideration all of the issues that are going on with the other chronic diseases and the co-occurring mental illness. So, the person doesn’t get the kind of treatment and care that’s needed. It’s also probably also true for family nurse practitioners who may be caring for even children and their grandparents and knowing about the mental health issues of the older adult who might be a grandparent and how that plays with the rest of the family care.

I think that one of the reasons it’s a particularly important for all nurses to have some knowledge about geropsychiatric nursing – about mental illness in older adults – is because in each of their practices they are going to be caring for people who not only have physical illness but also have some kind of psychiatric illness or mental health issues. With the baby boom generation coming up, they are seen to be higher risk for depression and anxiety disorders and substance abuse disorders – more so than people who were born before World War II. So as we see the baby boomers coming more into health care, all nurses and nurse practitioners need to have the knowledge to address those mental health care needs of that population.

Lois K. Evans, PhD, RN, FAAN

van Ameringen Professor in Nursing Excellence, Emerita

University of Pennsylvania School of Nursing

Question 2. “What have you learned from this project about the importance of networking and collaboration?”

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Well I think that in the middle of the project and certainly in retrospect, we recognized that we would never have been able to accomplish even a miniscule amount of the goals that we did accomplish without using our contacts, our professional networks and taking advantage of opportunities as they arose during the course of this particular project. We had started out with a very ambitious goal to improve the mental health of older Americans by preparing nurses at all levels to provide some geriatric mental health. It was fortuitous that we set the goal that broadly. We set two particular strategies: one was to develop some competencies in geriatric mental health for nurses, and then to develop or make available curriculum materials that faculty could use to actually help nurses learn how to provide mental health services for older people. But by having the goals so broad – improve the mental health of older Americans by nurses, we actually could take advantage of all sorts of opportunities that occurred over the project. So maybe I’ll just share a few that come to mind, because I think there are lessons to be learned in it.

Once we recognized that we couldn’t do it all – we are three: Cornelia Beck, Kitty Buckwalter and myself – who had planned this project with the John A. Hartford Foundation and housed it at the American Academy of Nursing because we wanted it to be seen as a national nursing project, not something that was closely aligned with one school or one particular setting but one that could be more national in scope, similar to how the Hartford Building Academic Geriatric Nursing Capacity (BAGNC) project has been running at the Academy until recently.

We housed it there and we had collaboration of certainly the three of us, and we came from three different schools representing three of the Hartford Geriatric Centers of Excellence in the country. (There are now nine of them that Hartford supports). We came from Arkansas, Iowa and the University of Pennsylvania. Each of us had some expertise with a history of expertise in research and teaching with some practice in geriatric mental health. But we knew that we couldn’t just among ourselves to do everything – so we really reached out early on by developing a national task force that was pulled together to help develop the competency statements for this project. Now, we couldn’t even do that by ourselves. One of the things we did early on was to review the status of competencies and program competencies for nurses in all the different fields that actually work with older adults. We were overwhelmed by how many there are, who writes them, the fact that none of them are sequentially done in the same timeframe – some got done in 92 and some and 96 and 02 and some in 08.  There was no clarity about when they would be revised or what the schedule was for that sort of thing. We also recognized that it was not timely to think about preparing competencies for a whole new field – geropsychiatric nursing – and I’ll spend a minute just saying about that.  The problem is that it is an area of practice that probably has two strikes against it at least. One of them is that it’s focused on mental health which still has a lot of stigma in our country in the general population, but also certainly among nurses. The second area of stigma is that it’s about old people. So put both of those together and it’s been very difficult to recruit nurses to train in that area to practice in that area etc.

We realized that the timing was short to be able to prepare the cadre of health providers in all the mental health fields that are going to be needed to care for the rapidly increasing elderly population where the estimate is that about one in 5, 20% of people in late life do have mental disorders or mental health problems that require service. At the moment we are woefully under-prepared in terms of just the sheer numbers of providers who have any training in geriatric mental health. Nursing is probably the lowest group for that because we have never had a specialty area proclaimed – there’s no certification exam for it etc. So we said that the best thing to do is to really figure out how to infuse this knowledge and skill set into the preparation of all nurses who are ever going to touch older people. That model was one that had been used by the Hartford Institute of Geriatric Nursing, housed at NYU, in trying to really make geriatrics be a more prominent component of undergraduate and graduate education. They recognized that probably 80% of hospital patients are over the age of 65, and most homecare patients and in many other settings are in fact elderly, but hardly any nursing schools had geriatric course. There were few geriatric nurse practitioner or geriatric CNS programs in the country. The notion was: we really need to get that kind of content and skill set in the hands of all nurses not just a handful. So we use that same kind of model and said let’s see if we can write competency enhancements for all of the programs that prepare graduates to work with adults, therefore with older adults. In our case we chose entry-level including associate degree and baccalaureate level graduates.  And then we looked, at the time there was still an adult health program (this was in 08), adult health, geriatrics, psych mental health, family health, women’s health and acute care were the areas that we targeted because they all care for older adults.

We pulled together a selective group through our networking – who did we know, who had practice expertise, educational expertise from across the country. We represented all the regions of the country, we represented diversity in terms of practice backgrounds, people who were essentially educators, undergraduate and graduate levels. We made sure we had gender diversity and ethnic racial diversity on the team. We tried to cover all of our bases, but again, putting together that committee or task force together, we reached out to our network to identify who were key people. That group worked diligently over a two-day period with materials we had already pulled together for them, to lay out what the essence of these competencies would be.

Again we had reached out of the process to someone who from the AACN, Joan Stanley, who had lead the process of competency development for a lot of the graduate programs when they were looking at how to infuse geriatrics into those graduate program competencies. She had a well-developed process that had been funded by HRSA. We consulted with her about how to go about doing this in a way that would be consistent and would therefore have credibility in what we were doing. She agreed to serve with the director of AACN on our national advisory panel. Beyond that, we used our national advisory panel which was also was a group of people deliberately representing credentialing, education, accreditation and practice, and other kinds of arenas where a lot of work is going to develop geriatrics in the country. That group has really served us very well to identify opportunities, trends and things that were happening before we knew it that might be ways that we could collaborate to further our cause in this project without having to reinvent wheels. I think that was another goal that we had – that we really didn’t have the resources (the time, the money, the personnel) to be able to reinvent wheels. It was too costly to do. We really needed to take advantage of opportunities as they came along and to piggyback onto projects that were already being developed and implemented that related to geriatrics infusion, helping people to recognize that infusion of geropsych was a part of infusion of geriatrics.

People just hadn’t thought about it, but when we brought it up to them they were very willing to have us work side-by-side to add value to the products that they were already producing. A couple of examples of those are: the Hartford Institute of Geriatric Nursing together with the American Association of Colleges of Nursing were preparing a series of geriatric cases – case studies that could be used for teaching core competencies around good geriatric care. It had not occurred to them to have any that related to mental health. But when we talk with the leaders of that project, they saw right away the value doing that and were very willing to add two new cases that related to geriatric mental health.

With our network, mostly capitalizing on people we knew including some alums from the Building Academic Geriatric Nursing Capacity (BAGNC) program, the pre- or post- doctoral training program that Hartford had supported over the years, we were able to help some people produced to wonderful case studies. One of them relates to mental health function in primary care, primarily for nurse practitioners, and the second one was geared toward the clinical nurse specialist and it had to do with confusion in the acute care setting. Those were really well done. They are posted on the NYU web site and I believe you can get to them from AACN, and you can also get to them from our postings on POGOe, which is Portal of Geriatric Online Education. That’s an example of collaboration. The timing was right, we learned that they were into this project. We said – “what about a having a couple of mental health ones?…great!…can you get them done in this time frame?…” and now they’re out there for people to use.

Our second one was one of our representatives on the advisory panel was a leader in the National League for Nursing at New York, and she had been a leader in establishing a new program called ACES [Advancing Care Excellence for Seniors] that had to do with teaching geriatric nursing to their generic students at any level – associate degree, bachelor’s degree. And when we learned about that project, the leader said “is there any way that you can review what we’re doing and make sure that we have all the key concepts from the geropsych project embedded in this project?” So we were able to facilitate that being done. So those cases are enriched with geropsych as a result – again timing, connections and helping build awareness for these opportunities to enrich what was already being produced.

And a third one is all the work that was being done by AACN and the Hartford Institute to help prepare faculty for integrating geriatrics into their education program included a set of webinars on examples of how to go about reviewing one’s curriculum, selecting material, how to find material etc. We proposed to them “what about one on geropsych?” – we were trying to get the word out (we had notified the deans of all the schools, making a lot of presentations, we published articles, we were trying to make as many people aware of this as possible, but it takes a long time for the word to get out for people to use it). They were very happy to use it in their final webinar that was focused on infusing geropsych into the curriculum as a the component of geriatric care. That got done this past fall and is available. A lot of people participated in it while it was live but the recording is available on line for people to access as well. It’s a really important way of getting the word out.  Again, timing, collaboration and networking as a way to get those things to happen.

We have collaborated in addition with the nine Hartford Centers. We engaged them in thinking about how to help their own faculties infuse geriatric mental health into their curricula and we involved the alumni from the pre-doc and post-doc programs. There are quite a large number of them now who do have an interest and background mental health. That group has been very eager to participate is now beginning to assuming some leadership nationally for promulgating the information, doing some of the talks at national meetings, helping keep/update materials that are already posted on the website etc. So were really happy about that.

One other that I can think of – we were planning to produce a video that would highlight the work and thinking of some of the national leaders in geropsychiatric nursing. We really did not have enough resources within this particular project grant to be able to do a videography of some sort. But then we learned about one of our colleagues from Penn State who had actually produced a number of videos, short video clips that were being used to try and interest young nurses in the field of geriatrics. In the process of making the videos, they had a lot of clips that just went onto the cutting floor – and so we said “do you have any pieces from those video clips that might be mended together in a way to make a coherent story about geropsych?”  because all four of the persons that we wanted to showcase on the film had been interviewed for those videos. So we worked with the professional staff at Penn State and they were able to do it. We wove the story – now we have this video for a very modest amount of money and the videotape has been circulated broadly and free online for use. Another example of how as we knew people and things that were happening, and people would tell us “did you know about this or that”? We had filters on our glasses and [filtered] anything about mental health and aging for this project, this opportunity, these new things that were happening.

I guess the last thing I would really want to mention is the opportunity that really showed itself in the publishing of the Consensus Model document, which did happen in late 2008 when we were already finishing up the first year of the project. That Consensus Model – by making the decision that nursing at the graduate level would focus on six populations, four of which dealing are adults and therefore would include older adults that the gero and adult health populations would be merged into one group. But that every of the other four groups (women’s health, psych mental health, family health nursing) all because they were dealing with older adults in their adult population, they all had to have some geriatrics both didactic and clinical learning experiences in their curriculum. Now that requirement was brand new. Many of these programs may have a lecture or two on something related to older people. But to acknowledge that they are actually the major provider of geriatric care, because we don’t have that many geriatric specialists in the country, it now means that they are recognized and are scrambling try this get more content and clinical opportunities for their students. One of the things that consensus document did was to open up the pressure at the credentialing level and accreditation level to say “Now that you have to have geriatrics, geropsych is part of that. Let’s see how we can help you with meeting these new requirements.”

So that is how we’ve sold this stuff. We also sold it by saying “it really is infusing; it really is enhancing what you’re doing; it’s not completely changing what you’re doing but helping you have a broader lens to know some of the specialist information about geriatric care that is so important.” As we’ve worked with a range of people, we’ve been able to have either members of our secondary team or those that we know who are experts, appointed to the competency revision groups or panels that have been put together early on by AACN when they were developing what the adult gero – the new fused program – would look like. We were able to have a geropsych person on both the NP panel and the CNS panel and the same for the gero-adult acute care groups. So the first one was focused on primary care and the second set was focused on acute care. So the views of our geropsych people were infused into those two documents. We were also able to have that level of participation in the revision of the baccalaureate competencies as well. Then when NONPF (National Organization of Nurse Practitioner Faculties) was working on how to make the last three (the women’s health, psych mental health and family nurse practitioner) competencies fit with the new Consensus Model, we were able to have input into those as well.

We’re hoping that the whole area of mental health, as the Affordable Care Act – however it comes forward – everyone is talking about the need for more integrated care. Certainly, mental health needs to be integrated into primary care, community care, acute care etc. and geriatrics needs to be integrated into all of those areas as well.  I think our timing is right for having something available and building awareness of the country both in nursing and outside of nursing about the importance of this field and we obviously could not have done all of that in a short four-year period with just the three of us. The networking, the collaboration and the timing, I think, gave us opportunity to take advantage of all that came forward to move towards our goal of helping to improve the mental health of older Americans – [and]it has been a fabulous, fabulous road to be on for these four years.

 

Kathleen “Kitty” Buckwalter, RN, PhD, FAAN

Professor Emerita, University of Iowa College of Nursing

Question 3.“What do you think the future holds for geropsychiatric nursing GPN?”

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Well I’m very optimistic about the future of geropsychiatric nursing. I think there are a lot of indicators over the last few years and good promise for continued growth and enhancement of geropsychiatric nursing in the future. Some of those indicators include the number and quality of Building Academic Geriatric Nursing Capacity (BAGNC) alumni, whom I believe are the largest subgroup of the alumni organization and who are actively engaged in the preparation and presentation of papers in the area of geropsychiatric nursing. [They] have been helping us to develop case studies, for example, that we can post on the Portal of Geriatric Online Education – or POGOe – for use by others as they infuse geropsychiatric content into all levels of nursing education. We also see with support from the Hartford Foundation the continued growth in the number of pre-and postdoctoral students and fellows who are prepared to do research in the area of geropsychiatric nursing and who will become faculty to teach others about the needed content.

There is also growing national attention to the issue of mental health and substance abuse in older adults. In particular, there will be an Institute of Medicine (IOM) report forthcoming  [Released:July 10, 2012] – the official title is the Committee on Mental Health Workforce for Geriatric Population. This report is really an outgrowth of the 2008 Retooling for an Aging America report that highlighted the need for more and better trained practitioners. In this case, the report focuses on workforce issues for the mental health and substance abuse needs of older adults. So that will be exciting and the Institute of Medicine reports generally have high impact and garner the attention of funders and Congress. So we are looking forward very much to that report.

Our geropsychiatric nursing collaborative (GPNC) and, as you know, with the support from the University of Arkansas, the University of Pennsylvania (in particular Cornelia Beck and Lois Evans from those institutions) and myself here at the University of Iowa, have really accomplished a lot in the past four years [in terms] of increasing visibility of the field of geropsychiatric nursing. We’ve developed and revised brochures that can be used on the “Hill.” We’ve published a number of articles about geropsychiatric nursing in both the periodic peer-reviewed literature and book chapters. We’ve made presentations around the country – most recently at nursing educator conferences, and with the NLN – but also at interdisciplinary meetings such as the Gerontology Society of America. We have convened a joint mental health and aging workgroup at the American Academy of Nursing. While not officially one of the interest groups of the Academy, it is comprised of members from both the mental health and aging special interest groups. They have been active and will continue to outlive the GPNC work.

We also have provided technical assistance to schools of nursing that were interested in infusing geropsychiatric nursing content into their curriculum. And other indicators to me include – I was the editor of the Journal of Gerontological Nursing up until January 2012 for 13 years – and over that 13 year period, I noted a marked increase in both the number and quality of submissions and publications relevant to geropsychiatric nursing. The same thing could be said for the other journal, Research in Gerontological Nursing, that I established four years ago [that] is primarily a research journal whereas JGN is primarily clinical in orientation. But, the high number and extraordinary quality of research articles with geropsychiatric nursing focus has also been very heartening.

Finally, there are two other areas – the growth of evidence-based practice protocols – those coming out of the Hartford Institute of Geriatric Nursing at NYU, and from our Hartford Center of Geriatric Nursing Excellence at the University of Iowa. This will really help to translate the evidence base in geropsychiatric nursing into a usable palatable form for use by clinicians in a variety of acute care, long-term care and community-based settings. (Not that all of the evidence-based protocols produced by the Hartford Institute or the Iowa Hartford Center are geropsych focused, but a high percentage of them are very relevant to geropsychiatric nursing).

The final note I would like to make is that – coming back [just] yesterday from the Midwest Nursing Research Society (MNRS) – I was so impressed again with the quality and quantity of symposia and papers and student posters with geropsychiatric nursing themes. All of these indicators suggest to me that we’re in good shape in terms of the future of the field. But of course, we still face a number of challenges for the future. The challenges include [that] we’re still dealing with a very fragmented and uncoordinated system, especially for older adults with chronic illnesses, mental health and substance use problems.  We’ve got to adapt our acute-care models of care delivery and change them to a more chronic care model. And, despite the recent advances, there are still an insufficient number of nursing faculty with adequate geriatric mental health preparation – and we still need more geriatric mental health content in curricula at the undergraduate and graduate levels.

It still remains a challenge in terms of adequate leadership in the field of geriatric nursing in general but geropsychiatric nursing particular. There are advances in this realm as well. For example, the Geriatric Nursing Leadership Academy sponsored by Sigma Theta Tau and a number of the recipients/participants in that Academy have been interested in geropsychiatric nursing. So, whether they’re from nursing home or acute-care roles, their leadership will serve us all well.

We know a number of other things that happened outside of the work of the collaborative that will foster our work and continues to do so in the near future. One of those is with the advent of the minimum data set 3.0, which came on the scene in October of 2011, there really is marked improvement in the areas of cognitive assessment, mood, routines and activities that are mandated for nursing homes, where many persons with cognitive, functional, and mental health impairments reside. Also we are excited about the proposed APRN regulatory model, the Consensus Model for APRN regulation, licensure, accreditation, certification, and education, because we see with the advent of this Consensus Model, the specialty of geropsychiatric nursing certification is now a possibility. Although full implementation of the proposed model nationally isn’t expected until 2015, work can begin on specialty certification in the field.

Finally a number of the strategic plans of NIH institutes, including NINR, NIMH, and NIA, are very friendly with regard to geropsychiatric nursing. So we are hopeful that as we prepare more better- qualified researchers especially at the postdoctoral level and beyond, they will be able to take advantage of funding opportunities from foundations as well as NIH institutes. We continue to face (a) challenges in the area of tackling mental health disparities in the older adult; (b) the need to systematically demonstrate a cost benefit of mental health nursing services for this population; (c) and to adapt an evidence-base for applications in new settings of care such as prisons and homeless shelters where many older adults with mental health and substance use issues reside.

It’s exciting to think about new service delivery models and setting of care, the research that people with training and interest in geropsychiatric nursing will be able to conduct, and the future emphasis on translation of that research into practice. Still, we need to prepare more nurses with geropsychiatric expertise and who focus, not just on those people who have impairments already, but on health promotion and disease prevention. We still need to develop that critical mass of nurses with the knowledge and skill to provide mental health care to older adults and potentially certifying them in the field.