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Journal of Community Health Nursing Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hchn20

Expanding Community Health Nursing Roles to Meet Health-Care Needs of Frail Elderly An Adult Learning Model Sondramae Couser , Barbara A. Moehrlin , Caroline Deitrich & Lauralee Hess Published online: 07 Jun 2010.

To cite this article: Sondramae Couser , Barbara A. Moehrlin , Caroline Deitrich & Lauralee Hess (1990) Expanding Community Health Nursing Roles to Meet Health-Care Needs of Frail Elderly An Adult Learning Model, Journal of Community Health Nursing, 7:1, 3-13, DOI: 10.1207/s15327655jchn0701_1 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0701_1

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JOURNAL OF COMMUNITY HEALTH NURSING, 1990, 7(1), 3-13 Copyright @ 1990, Lawrence Erlbaum Associates, Inc.

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Sondramae Couser, MA, MS, and Barbara A. Moehrlin, RN, M S Santa Clara County Health Department Carole Deitrich, RNC, MS, GNP, a n d Lauralee Hess, RNC, MS, A N P University of California

'The increased training needs for community health nurses (CHNs) working with frail elderly offer a variety of challenges in staff development. Santa Clara County addressed these challenges with an innovative model, and geriatric assessment skills building program presented to 40 CHNs. The model uses a team teaching approach, a preceptorship and adult learning theory, making it readily adaptable to a variety of community health settings.

The growing population of elderly persons in the United States is significantly influencing health-care planning. Increased longevity, shorter hospital stays, stringent regulations on eligibility for home-care services, and the presence of one or more chronic diseases in individuals over age 65 are some of the factors being considered by CHNs in official agencies caring for frail elderly in community settings (Skipwith, 1984, p. 652). Traditionally, the CHN role of "generalist" provides a variety of services including health assessment, counseling, education, information and referral, and case management. In recent years, this role has been expanded to meet new challenges in a number of health program areas including communicable disease control and maternal child health. Similar role diversification and expansion is needed to plan nursing services for the elderly population. One CHN director in a large county health department, where the generalist CHNs function in 16 different health program areas, addressed this challenge through a model staff development program. The director organized a committee to facilitate a workshop to "focus on changes" in community health nursing services for elderly clients. The workshop was attended by a number of CHNs interested in this population and motivated to enhance the current gerontology services. The workshop format utilized a creative approach to program planning. Two new projects were proposed: (a) nurseRequests for reprints should be sent to Barbara A. Moehrlin, RN, MS. Santa Clara County Health Department, 2220 Moorpark Avenue, San Jose, CA 95128.

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managed health promotion programs for well elderly, and (b) expanded services to frail, homebound elderly. Recommendations for the latter program included suggestions for additional training of the nurses to increase skills in areas of physical and mental status assessments and utilization of community resources specific for elderly clients. Acting on the recommendations of the workshop participants, the nursing director requested the geriatric specialist and staff developer to prepare a proposal for program change and training. Emphasis was placed on utilization of existing resources including the expertise of the existing specialized geriatric team. This team, Geriatric Assessment Information and Need (GAIN), is staffed by a geriatric specialist, two social workers, and one CHN. An analysis of current strengths and weaknesses of the generalist CHN staff for meeting nursing needs of frail elderly was summarized. Specific suggestions about training needs were elicited from interested staff, and investigation of resources for teaching staff about the aging process, health assessment, and community resources specific to the target population was carried out. A proposal was presented to the nursing director. It emphasized an educational approach which included a formal class in health assessment of the elderly, a rotational preceptorship with the GAIN team, and monthly educational programs focusing on utilization of community resources and case management strategies. The department agreed to fund the initial training and commit staff time for 12 CHNs to participate. This training opportunity was opened to the entire community health nursing staff. The 12 volunteers who were selected represented staff from six district offices. Six of the 12 were designated as "primary" participants, 6 as backup participants. It was planned that all participants would complete the formal training course in health assessment and attend monthly educational programs for 1 year. Only the primary participants would complete the preceptorship. During the preceptorship rotation, a "float" CHN was provided to cover the CHN's district office work. Each participant was given a binder to collect resource materials, health assessment handouts, and other related information acquired during the training. %O instructors were selected from several who were interviewed for the formal health assessment class. These instructors were chosen on the basis of their community health nursing background and ability to focus on assessment of clients in the home setting. A training team consisting of the staff developer, the geriatric specialist, and the two hired instructors was formed to develop program content. Program content was divided into three areas: (a) health assessment, to be taught by the hired instructors; (b) preceptorship training; and (c) monthly educational meetings, both coordinated by the geriatric specialist.

THEORETICAL FRAMEWORK

Knowles's (1984) Adult Learning Theory was used as a basis for this educational experience. Use of the theory took advantage of three essential features required for

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learning: establishing a climate for learning, facilitating the proactive versus reactive learning, and creating a learning experience based on needs perceived by the learner. A climate for learning is established when students feel the faculty take a personal interest in them and respond to them with warmth and respect. There is dialogue between students and faculty that reinforces the students' competencies and builds a peer relationship. This is, of course, easier to accomplish in a small group and because none of the classes exceeded 14 students with 2 faculty, it was easy to give individualized attention. A climate for learning is supported further by regular and frequent "give and take" with faculty. Because each faculty person was in clinical practice in addition to teaching, it was easy to share experiences, problems, and suggestions for intervention in a reciprocal manner. In this way, the faculty was at once an expert and a peer. Furthermore, the faculty, already experienced with adult learners, held the philosophy that a nurse in practice is already a skilled professional and the additional knowledge and skills offered through this educational experience serve to develop and highlight existing competencies. This feature was implemented by asking the students to present patient problems as they related to class content each week. This reinforced the didactic learning and also encouraged dialogue with faculty and the other nurses. According to Knowles, the proactive learner, or the one who takes initiative in the educational process, usually learns more, retains it longer, and makes use of the learning longer than the reactive or passive learner. In other words, the student participates in the process rather than being merely "stuffed" (i.e., a mere receptacle for information). Although the instructors did their share of "stuffing," to which the amount of content covered in 40 hr can attest, they were very conscious of the need for practice and integration. The patient presentations and discussion helped to keep the student active and searching for solutions to immediate problems. The skills lab, too, offered practice time and opportunity for immediate feedback. The third feature of Knowles's (1984) theory useful in this context-that learning is best when it is based on the perceived needs of the learner-required little faculty intervention. The number of older adults for whom the CHNs were assuming responsibility was escalating and the nurses themselves were quite articulate about the need for added knowledge and skill to handle the many problems of this population. Self-direction, then, was easily built in as a result of this self-assessment. Moreover, the nurse's own experience of success when applying the new learning acts as a stimulus to continue practicing the new skills. In this process the individual is motivated by such internal incentives as the desire to achieve and the need for esteem, in addition to the need to know new information to practice successfully. With such a perspective, tests or grades were not necessary. The practicality and immediate usefulness of the experience served as adequate motivation for quality performance, and evaluation was intended to allow the student to assess his or her own progress as well as give feedback to faculty.

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DESCRIPTION OF THE CURRICULUM The course, Health Assessment of the Older Adult, was an adaptation of a health assessment course at the University of California-San Francisco (UCSF) designed for nurse practitioners. Faculty revised it to reflect the special needs of older adults in a community setting and the special skills of the CHNs who were carrying out the assessment. Assessing clients at home requires that nurses are skilled in relating to and examining clients outside the traditional hospital or clinic setting. The home environment can be a much more challenging setting in which to perform even a routine cardiovascular exam. Frequently clients are reticent about being examined in their home as are the nurses reluctant to perform examinations, often feeling it is intrusive to clients. Older adults tend to adapt to their disabilities and frequently minimize symptoms that may require further evaluation. It is not uncommon for the older adult to have multiple problems requiring a thorough history and physical. In addition, the client's age and physical stamina may require that the exam be performed over a number of home visits. This allows the nurse to develop a trusting relationship with the client. Therefore, the CHN is in an ideal position to identify problems and ensure that older clients receive appropriate attention and services. Furthermore, preserving and promoting function and preventing disabilities are always leading goals in the care of older adults. Some information can be gained through routine questioning and other data is best gleaned through observation of the client performing daily routine activities. This is a unique feature of in-home assessment and one of the features that makes it so valuable. Many health-care providers have been misled about the patient's condition with only the opportunity to view them in the hospital or clinic setting. In teaching CHNs assessment skills, the faculty identified those areas of the physical exam which could be easily performed in the home and which provided the most relevant information concerning the client's health status. It was also important to consider the equipment required and level of skill necessary to perform the examination. Thus, the course content focused on developing history-taking skills, including psychosocial and functional assessment; understanding age-related changes and common medical complaints; developing physical assessment skills of the skin, respiratory, cardiac, abdomen, and neurological systems as well as the mental status examination. Content areas which were believed to be more appropriate for the clinic or office setting included the genitalia and fundoscopic exams, and certain parts of the ear, nose, and throat exam requiring the use of the otoscope.

CONTENT AREAS Normal changes of aging served as an embarkation point in the course. Demographics and attitudes towards aging and older people were covered here. Because the nurse is not separate from the forces of society, the instructors considered it important to make explicit the possible consequences of ageism on the older adult client and how that experi-

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ence may affect the older person's response to the nurse or to health care in general. Normal changes of aging covered both physiological and psychosocial aspects of aging and paved the way for the psychosocial and physical assessment that followed. Having set the stage for assessing the older adult, history taking was emphasized as a foundational skill. The student was expected to build on existing skills and experience to obtain histories that were more complete, more specific and to communicate these findings effectively, orally, and in writing. This was the first step in assuming greater responsibility for patient-care management by obtaining adequate data and communicating it in an organized and knowledgeable way to physicians and other health-care providers. This emphasis arises out of a belief that being certain of one's knowledge base is a significant step in building confidence and promoting assertive behavior. Functional assessment was emphasized early in the course because it forms the basis for health assessment in the home. A functional assessment provides relevant information about the clients' cardiovascular, respiratory, musculoskeletal, neurological, and mental status as well as their ability to carry out all the activities of daily living necessary to function optimally. It is almost a truism held by those providers who have witnessed the value of the functional assessment that it is impossible to tell how the client is doing based on a problem list alone. Knowing that a client has chronic obstructive pulmonary disease (COPD), for instance, tells the nurse nothing about the level of function in the immediate environment or what intervention may improve function even in the absence of change in the medical condition. Although the course followed a systems approach, the problem of falling in the older adult population was selected as a final topic and a means of integration of the entire course. Because the assessment of falling requires consideration of the client's mental status, psychosocial situation, functional status, and multisystem factors, it was an appropriate topic with which to conclude.

SKILLS DEVELOPMENT

n o - h r labs for skills development followed immediately after the lecture content regarding cardiac and peripheral vascular, respiratory, neurological, and the abdominal assessment classes. Faculty provided check lists for each system and students were expected to perform the exam on one or more of their colleagues. Tho faculty were always available throughout each skills lab to first demonstrate the skill and then circulate among the students to provide assistance, encouragement, and feedback. Each person was expected to perform the exam satisfactorily with the faculty using the lab checklist as a guideline. This structured approach facilitated performance by making expectations specific. Furthermore, the atmosphere of exploration was preserved by providing feedback about areas on which the student should continue to work rather than simply passing or failing. We believe that the skills lab experience is an invaluable tool which builds the

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nurse's confidence for practicing these skills with clients. This is a supervised simulation of a client encounter that affords the opportunity to develop the psychomotor skills associated with handling the equipment, and allows the student the experience of being both the examiner and the examinee. Not to be minimized, is the simple truth that, when actually confronted with a client, it really is not the first time the nurse has ever done the exam.

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PRECEPTORSHIP TRAINING

The preceptorship comprised a 20 hr a week, 8-week rotation. Preceptors included the geriatric specialist, social workers, and a CHN from the GAIN team. This component of the training enabled the CHNs to practice newly acquired health assessment skills, develop decision-making abilities with multiproblem frail elderly clients, learn resources specific for the target population, and differentiate the commonly overlapping roles of social workers and CHNs. During the preceptorship, specific attention was given to experiences with other resources including time spent with Adult Protective Services, the Public Guardians Office, The Court Investigation Unit of the Superior Court, Licensed Home Health Agencies, and Mental Health Services. MONTHLY EDUCATIONAL MEETINGS

Monthly meetings were coordinated by the geriatric specialist to present community resources, and discuss case management techniques for the frail elderly population. Speakers were chosen from community agencies. Their presentation related to a variety of health topics, nursing concerns, social needs of aging clients, and services available in the community. Field trips were taken to some agencies to promote comfort, familiarity, and coordination with the extensive network of service providers. Presentations were also directed at expanding nursing knowledge and experience in areas of social service. These included detailed information on financial assessments and the various social and legal resources necessary for complete assessment of the elderly client. The success of the program led to an additional commitment of monies. This included outside funding from the local Area Agency on Aging (AAA) enabling their own CHN staff to also participate in this educational opportunity. A total of 36 county CHNs and 2 agency staff completed the three programs. EVALUATION OF EDUCATIONAL PROGRAM

Informal evaluation was conducted throughout the training by the participants, the faculty, the agency nursing director, and the program planning staff. Based on the initial feedback, the health assessment course which originally consisted of 30 didactic hr and 8 hr of skills development was modified. Hours were expanded to 40

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for the didactic portion and 10 for skill development. The additional hours were based on needs expressed by the first group of students at the close of the course and on observations made by faculty and project administrators. It was agreed that extra hours were necessary for skill development in cardiac and respiratory assessment. Because the CHNs encountered many patients whose cognition was impaired, the mental status exam was often a key feature of the overall assessment process and was an area which warranted more time. Later in the course, dementia itself was included along with its assessment and some management strategies. Additional didactic hours were also added for psychosocial assessment, functional assessment, and changes of aging. Most important for overall learning and integration was the addition of time for client review. This consisted of 1 hr at the start of each class where students presented clients whom they had seen in the course of their work. This was an opportunity to discuss how they had practiced their new skills during the week and what success or difficulty they encountered, while at the same time promoting consultation with their peers. Moreover, it allowed faculty the opportunity to assess progress and facilitated student-faculty dialogue. The students' final clinical evaluation was based on a complete client work-up which the student was to perform with a patient in his or her case load, write it up in the designated format, and give a 10 min presentation of the client to the class on the last day. Feedback and discussion followed and problem solving and consultation were encouraged. This process also afforded the student the opportunity for self-evaluation.

EVALUATION OF CHN PERFORMANCE

Twenty-one of the first 25 participants trained were asked to complete a four-page questionnaire adapted from one used by the faculty in another study (UCSF, 1986). This questionnaire utilized Likert scales and forced choice situations to address four areas of interest to the faculty and program staff: (a) demographic information including the participants' educational level, number of workshops in gerontology completed in the past 5 years, and the number of elderly clients currently being followed in the caseload; (b) questions directed at information about specific activities performed by the nurse in assessing and caring for frail elderly clients prior to and after completion of the training program; (c) information about the participants' perception of the newly acquired skills on client function and status; and (d) perceived satisfaction and confidence of the participants in working relations with clients and physicians. The results were impressive! All participants had at least a Bachelor of Science (BS) degree in nursing and held a public health nurse certificate issued by the State of California. The study showed 57% of the participants entered the training program with less than 10 hr of training in gerontology during the past 5 years, 33% had less than 20. Only 1 participant, a nurse with a Master of Science

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GERONTOLOGY PROGRAM CHN ASSESSMENTS FREQUENCY OF PERFORMANCE

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SPECIFIC NURSING ASSESSMENTS PRIOR TO TRAINING

AFTER TRAINING

l=RARELY 2=SOMETIMES 3-OFTEN 4=ALW4YS

FIGURE 1 CHN assessments.

(MS) degree in community health nursing focusing on gerontology, had over 30 hr of training. All participants reported increased frequency in taking a health history, performing a physical examination, conducting a mental status examination, assessing known health problems, and evaluating financial status of clients after completing the training program (see Figure 1). Greater confidence and comfort level in utilizing referral and consultation resources including public guardians, adult protective services, clinics, Council on Aging, medical doctors, home health agencies, and Department of Social Services was reported. About 80% of participants believed the new skills enhanced their ability to improve physical function, mental status, and comfort levels of the clients. A similar percentage of participants reported enhancements in client psychological and cognitive function (see Figure 2). All participants acknowledged some enhancement in social skills of clients as a result of the training. However, the survey indicated this area had the least amount of perceived change. This might be related to an absence of formal training on this particular topic or that CHNs entered the training with considerable skills and information in the social aspect of care from their generalist activities and therefore reported only minimal changes as a result of the training program. Seventy-five percent of participants believed clients were hospitalized less. Ninetyfive percent reported some or great improvement in medication management. The majority also perceived decreased risk of falling down and improved coping for families as a result of applying skills learned through the training program (see Fig-

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ure 3). Most participants reported improvements from some to a great extent in their relations with physicians, ability to accommodate elderly clients in the case load, and the community image of the nurse (see Figure 4).

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DISCUSSION

Although the findings from analysis of the questionnaires are limited by the selfreport nature of this study, they point to important areas of community health nursing pratice and client effectiveness which are in need of further evaluation. The participants' perceptions of improved nursing practice in several areas can have wide-spread implications for both the nurse and the client. Improvements in frequency of assessment skills allows the CHN to develop greater expertise in this program area and enables him or her to provide more comprehensive evaluation of clients in the home situation. This, in addition to perceived improvements in professional relations, community image, and ability to accommodate more elderly clients in the case load not only has potential for meeting the emerging needs of this population but also may contribute positively to the nurses' self-confidence, motivation, and professional self-esteem. The potential impact of improvements in client status, comfort level, and psychological well-being can have far reaching implications for maintaining frail elderly in the community setting. In addition to the benefits to the clients themselves, the improvements may serve as reinforcers to families and caretakers enabling them to cope more effectively and to continue supporting client-

GERONTOLOGY PROGRAM PERCEIVED EFFECTS ON CLIENTS % CHNs REPORTING

80

1

1

SOCIAL

LEVEL

LITTLE

SOME

GREAT

FIGURE 2 Perceived effects on clients' medical/funct~onalstatus.

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GERONTOLOGY PROGRAM PERCEIVED EFFECTS ON CLIENTS % CHNs REPORTING

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70

LESS

WGED

LITTLE

OF FALLS

SOME

1GREAT

FIGURE 3 Perceived effects of CHN's intervention.

GERONTOLOGY PROGRAM PERCEIVED EFFECTS ON CHNs % CHNs REPORTING *O

0

ACCOMODATE ELDERLY

LITTLE

SOME

COIIIINITY IM6E

GREAT

FIGURE 4 Perceived effects on CHN's case management role

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oriented goals. If controlled studies were conducted supporting findings of improved medication management, decreasing hospitalization, and reducing risk of falling, the economic impact could be very significant in support of prevention programs. We believed that the educational approach which utilized adult learning models was central to the program's success. In addition to acknowledging the existing skills of the trainees, opportunity was provided for participants to apply their new knowledge in actual situations through the preceptorships with the geriatric specialist and social workers. Administrative staff is currently looking at this model as a blueprint for role expansion in other health program areas.

REFERENCES Knowles, M. (1984). The adult learner A neglected species (3rd ed.). Houston: Gulf Publishing. Skipwith, D. (1984). Major community health problems of the older adult. In M. Stanhope & J. Lancester (Eds.), Community health nursing: Process and practice for promoting health (pp. 648-665). St. Louis, MO: Mosby. University of California-San Francisco. (1986). GNP collabomtive evaluation project survey. San Francisco: Author. (Partially funded by W. C. Kellog Foundation.)

Expanding community health nursing roles to meet health-care needs of frail elderly. An adult learning model.

The increased training needs for community health nurses (CHNs) working with frail elderly offer a variety of challenges in staff development. Santa C...
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