RN Residency: Transitioning to Geriatrics and Palliative Care Virtual Friday Presentation Purposes 1. Describe an example of an innovative workforce training program that addresses the critical need to build hospital geriatric nursing capacity, and 2. Search if there are other people in the ILN who are interested in this issue and would like to network

RN Residency: Transitioning to Geriatrics and Palliative Care RN Residency: Transitioning to Geriatrics and Palliative Care Edward Coakley, RN, Project Director Susan Lee, RN, Senior Faculty and Evaluator Penny Ford-Carleton, RN, Faculty Connie Dahlin, RN, Faculty Funded by the U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, Division of Nursing, Grant No. D11HP08359

RN Residency: Transitioning to Geriatrics and Palliative Care HRSA Purposes Develop and implement internship and residency program Encourage mentoring and the development of specialties Assure the quality of health care: Improve the knowledge, skills, competencies and outcomes of the health professions workforce.

RN Residency: Transitioning to Geriatrics and Palliative Care Background In 2008, the first of the baby boom generation reaches age 62. Over the next 30 years, the U.S. population over age 62 is projected to double (from about 40 million to about 80 million people), while the working age population increases by just 13 percent. The implications for individuals, labor markets, government and employer provided retirement and health insurance programs, and the overall economy are profound.

RN Residency: Transitioning to Geriatrics and Palliative Care Background Older adults in the U.S. National nursing shortage Lack of geriatric experts Palliative care trends Paucity of innovative care models Wealth of geriatric information on the web Need to develop networks of innovators Increasing inequalities in health care

RN Residency: Transitioning to Geriatrics and Palliative Care Older Adults in the US Geriatrics is the core business of US hospitals, comprising about 50% of hospital visits By 2030, the population of older adults in the US will nearly double (37 million to over 70 million) Older adults have a longer average LOS (6.6 days) than adults below age 65 (5.5 LOS) Older adults are at higher risk for adverse events in hospitals Older adults

RN Residency: Transitioning to Geriatrics and Palliative Care Background: Registered Nurses in the US National nursing shortage. Nurses are aging (average age 46) It is important to retain our nurses. Our highest turnover exists among nurses < 5 years at MGH. We want to retain older nurses who possess invaluable clinical knowledge by creating new roles close to the bedside. Residency programs are effective ways of engaging nurses in new learning and developing new skills.

RN Residency: Transitioning to Geriatrics and Palliative Care

Executive Challenges Increase workforce flexibility Extend workforce longevity Recruit and retain a multi-generational workforce Ensure transfer of clinical knowledge through out the generations Develop multi-generational workforce that delivers innovative patient care

RN Residency: Transitioning to Geriatrics and Palliative Care MGH a NICHE Hospital Started in 1992, NICHE has evolved into a national geriatric nursing program comprising more than 200 hospitals in more than 40 states as well as parts of Canada. A program of the Hartford Institute for Geriatric Nursing at New York University College of Nursing, the goal of NICHE is to achieve systematic nursing change that will benefit hospitalized older patients. The vision of NICHE is for all patients 65 and over to be given sensitive and exemplary care. The mission of NICHE is to import principles and tools to stimulate a change in the culture of healthcare facilities to achieve patient- centered care for older adults.

RN Residency: Transitioning to Geriatrics and Palliative Care Evaluation of Geriatric Capacity at MGH In 2004, MGH became a NICHE hospital. NICHE goals are: –to improve health outcomes for hospitalized older adults –to support clinicians in providing a positive experience for older adults & their families –to improve knowledge, attitudes, and practices regarding care of older adults Geriatric Institutional Assessment Profile (GIAP) Findings suggested that although nurses perceived themselves to be knowledgeable in the care of older adults, scores fell short in some areas. MGH Senior Health, psychiatric CNSs One staff nurse with geriatric certification

RN Residency: Transitioning to Geriatrics and Palliative Care Goals of RNResidency Program 1.to strengthen the nursing workforce by increasing knowledge, skills, and competencies in the specialties of geriatrics and palliative care 2.to improve retention of the RN workforce at MGH by providing career pathways and transitioning to specialties 3.to improve the quality of nursing care to elderly patients and their families

RN Residency: Transitioning to Geriatrics and Palliative Care RN Preceptors Age days of class (48 hrs) 3 days/clinical placement participates in online learning willing to serve as preceptor to RN resident Sep-Dec 2008; 2009 RN Residents Out of school 2 to 5 yrs. 12 days of class (144 hrs) 3 days clinical placement participates in online learning willing to work with preceptor on unit projects Jan-Sep 2009, 2010

RN Residency: Transitioning to Geriatrics and Palliative Care Geriatrics National curricula: John A. Hartford Foundation Use expert faculty from MGH clinical staff Sit for ANCC Geriatric Certification exam Palliative Care National curricula: ELNEC curricula Use expert faculty from MGH clinical staff ELNEC Trained Sit for Palliative Care Certification exam

RN Residency: Transitioning to Geriatrics and Palliative Care National Curricula: John A. Hartford Foundation: essment_tools/ Hartford Institute for Geriatric Nursing End-of-Life Nursing Curriculum (ELNEC) National Quality Forum and National Consensus Project

RN Residency: Transitioning to Geriatrics and Palliative Care Examples of Modules Assessing Cognitive Functioning Depression Delirium Dementia Preventing Falls Assessment of Function Urinary Incontinence Physical Restraints

RN Residency: Transitioning to Geriatrics and Palliative Care Excessive sleepiness Pressure ulcers and skin tears Critically ill elders Age-related changes in health Reducing adverse drug events Family care-giving Mealtime difficulties

RN Residency: Transitioning to Geriatrics and Palliative Care Geriatric Syndromes Term used to capture those clinical conditions in older persons that do not fit into discrete disease categories. Have multiple risk factors. Examples: delirium, falls, urinary incontinence, pressure ulcers, mealtime difficulties. Associated with longer LOS, morbidity, mortality. Predictable and many can be prevented. For nurses who have not been trained in geriatrics, it is crucial to gain knowledge of geriatric syndromes and EBP.

RN Residency: Transitioning to Geriatrics and Palliative Care Palliative Care Prevailing paradigm: reserves palliative care for end-of- life and disregards the needs of the elderly who suffer from chronic illness on a longer, slower trajectory Building on existing palliative care program Merging Critical Care and Palliative Care Cultures in the MICU (RWJF grant) Need more nurses trained in palliative care

RN Residency: Transitioning to Geriatrics and Palliative Care Nursing Care at the End of Life: Overview of death and dying in America, principles and goals of hospice and palliative care, dimensions of and barriers to quality care at EOL, concepts of suffering and healing, role of the nurse in EOL care. Pain Management: Definitions of pain, current status of and barriers to pain relief, components of pain assessment, specific pharmacological, and non-pharmacological therapies including concerns for special populations. Symptom Management: Detailed overview of symptoms commonly experienced at the EOL, and for each, the cause, impact on quality of life, assessment, and pharmacological/non-pharmacological management. Ethical/Legal Issues: Recognizing and responding to ethical dilemmas in EOL care including issues of comfort, consent, prolonging life, withholding treatment; euthanasia, and allocation of resources; and legal issues including advance care planning, advance directives, and decision making at EOL. Cultural Considerations in EOL Care: Multiple aspects of culture and belief systems, components of cultural assessment with emphasis on patient/family beliefs about roles, death and dying, afterlife, and bereavement. Communication: Essentials of communication at EOL, attentive listening, barriers to communication, breaking bad news, and interdisciplinary collaboration. Grief, Loss, Bereavement: Stages and types of grief, grief assessment and intervention, and the nurse's experience with loss/grief and need for support. Achieving Quality Care at the End of Life: Challenge for nursing in EOL care, availability and cost of EOL care, the nurses' role in improving care systems, opportunities for growth at EOL, concepts of peaceful or "good death", "dying well", and dignity. Preparation and Care for the Time of Death: Nursing care at the time of death including physical, psychological, and spiritual care of the patient, support of family members, the death vigil, recognizing death, and care after death.

RN Residency: Transitioning to Geriatrics and Palliative Care End of Year 1 14 RN Preceptors 12 RN Residents Revising curricula, program, competencies Web-based Learning site Placement Sites Focus Groups Certification Exams

RN Residency: Transitioning to Geriatrics and Palliative Care Retooling for an Aging America: Building the Health Care Workforce Institute of Medicine (IOM), Committee on the Future of Health Care Workforce for Older Americans in Jan, 2007 To determine the best use of the health care workforce to meet the needs of the growing number of adults 65 and older