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Geriatric nursing audit
Geriatric .Nursing Audit The authors offer a tool they've tested. It's not perfect, they say, but it has promise. PATRICIA GATHERS NADINE JOHNSON KATHLEEN MAGILL CLAIRE MAHONEY We work with older adults in an /tcute-care setting, the Montefiore Hospital and Medical Center. Our geriatric unit, established in 1975, provides elderly patients with intensive physical and psychosocial rehabilitation in order to return them to the community in the best possible health. The unit receives patients through a nursing outreach program that screens elderly inpatients for their rehabilitation potential. A geriatric nurse clinician, working with other consultants in aging, provides inservice orientation, continuing education, and clinical consultation in the unit. Montefiore's patient population is among the most elderly of any large medical center. According to the 1970 census, the over-65 age group comprised 12 percent of the population of New York City as a whole but 21 percent of the population in the district surrounding Montefiore(1). Many of these persons are at high risk because they are over 75, live alone, have low incomes, or are in poor health. A 1971 national study found that 14 percent of the population over age 65 who lived at home were functionally impaired Patricia Gathers, R.N., A.A.S.; Nadine Johnson, R.N., M.S.N.; Kathleen Magill, R.N., Ed.D; and Claire Mahoney, R.N., B.S.N., were members of the Geriatric Project Committee, Montefiore Hospital and Medical Center, Bronx, N.Y. With the help of other colleagues they developed the audit described here.
(that is, unable to m a n a g e a c t i v i ties of daily living)(2). These findings, coupled w i t h the fact that 75 percent of t h e p a t i e n t s hospitalized on our m e d i c a l service were over age 60, p r o m p t e d M o n t e fiore's Task Force on G e r i a t r i c s to recommend, in 1977, t h e development of a model p r o g r a m "'to prevent or delay unnecessary or premature institutionalization." Prevention would be a c c o m p l i s h e d by functional assessments, identification of elderly at risk, follow-up, continuity of care, and o u t r e a c h , as well as by documenting n e e d s and evaluating services g i v e n ( 3 ) . The geriatric unit supervisor, senior nurse, and nurse clinician worked with a nursing p r o j e c t t e a m to explore the impact o f g e r i a t r i c nursing care on patients. A n immediate problem that:we e n c o u n t e r e d was the identification o f a b o d y of discrete geriatric n u r s i n g knowledge. Nursing gerontology, or the scientific study of n u r s i n g c a r e of older adults, is indeed a y o u n g discipline(4). In England, in 1965, Norton specified two d i s t i n c t categories of geriatric nursing practice: rehabilitation and chronic c a r e ( 4 ) . The American Nurses' Association's Standards of G e r o n t o l o g i c a l Nursing Practice were h e l p f u l in exploring practice(5). W e agreed with the beliefs about t h e aged stated by Brunner and o t h e r s ( 6 ) . We were especially i n t e r e s t e d in their description of significant characteristics of the older patient, which represented m a n y o f t h e critical process elements we c o n s i d e r in our geriatric nursing u n i t . In reviewing the nursing l i t e r a t u r e , however, we discovered little on geriatric nursing audit. We looked at each step o f the nursing process to d e t e r m i n e what results we would like to a u d i t in our patient care tecords. To b e t t e r define the assessment, p l a n n i n g , and
implementation phases of the nursing process, we developed a geriatric nursing history assessment and care plan for hospitalized patients. Drawing on our group's experience and the expertise of others, we then designed the hospital retrospective geriatric nursing audit tool that is shown on page 196. By pulling together semi-acute, rehabilitative, chronic care, and other criteria, the tool reflects the needs of our hospitalized patients. Problems in Development
Our first problem in pilot testing the geriatric audit was in selecting a study sample. We quickly discovered that we did not have a discrete population of elderly patients to study; all patients in the geriatric nursing unit had been admitted first to other units. We decided, however, to compare nursing outcomes in a group of patients who were transferred to, and discharged from, the geriatric unit with a group of patients who were admitted to other units and assessed as eligible for transfer to the geriatric unit but, for various reasons, were not admitted there. Our second problem was the lack of an available pool of patients, due to inadequate collection of data about patients who had been hospitalized previously in the geriatric unit, or been eligible for it. Our audit sample size was, therefore, much smaller than anticipated and not truly random. Two nurses independently attempted to retrieve data from the selected patient records, using the geriatric audit criteria. Some criteria were retrievable and some were not, and some criteria were open to various interpretations. For instance, does a "geriatric problem identified" mean that the patient was assessed for a specific common aging problem but was
Geriatric Nursing May/June 1981 195_
found not to have that problem? Or does it m e a n that the patient actually has or had a geriatric problem that the nurse was able to assess? m " y e s " or " n o " answer to I t e m 1 on the tool could have different interpretations. For this reason, our data results showed poor interrater reliability on several of the criteria. O u r documentation system does not require geriatric functional assessment in the discharge s u m m a r y
~1 ~
196 Geriatric Nursing May/June 19gl
note. This h a m p e r e d our a t t e m p t to c b m p a r e patient outcomes in terms of functional abilities for the two patient groups. T h e audit criteria did not correspond directly to the items cued into our nursing discharge s u m m a r y sheet, and so, for the most part, were not measurable. W e also found that the maintenance of specific functions is difficult to m e a s u r e unless there are ongoing assessment notes that verify continued integrity of function.
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Audit T e s t Benefits
Despite the problems, the audit was useful. F r o m it, we identified 9 deficiencies in our initial criteria, which would be modified in future studies 9 elements that needed strengthening in terms of ongoing functional assessment for admission to the geriatric unit and for discharge of the older patient 9 and the possibility of adding
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these strengthened criteria to our new documentation system, now in the developmental stage. Both positive and negative findings, as well as omissions in charting the nursing process, raised m a n y questions about our system for nursing orientation and education, care delivery, charting, and evaluation. As a result of the audit pilot study, our committee recommended better staffing to match
patient needs with the required numbers of nursing staff. W e suggested expanded continuing education, revisions in the hospital documentation system, further refiner ment of our assessment tool, and trials of the geriatric audit with older patients throughout the hospital. T o some extent, these recommendations are currently being followed. Geriatric nursing inservice sessions for all staff are offered in
the geriatric unit and in the medical and specialty nursing areas. Revised criteria for geriatric unit admission and a new nursing d o c u mentation system are undergoing pilot study. Our geriatric unit has been expanded from four to seven beds, so we now have more patients to include in our study of the new admission criteria and charting system. Since more than 75 percent of the patients in our medical service
X
Geriatric Nursing Max/June 1981 197
are 60 or older, we will soon be testing many of the revised criteria as a part of a generic, medical-nursing, retrospective audit that is relevant to our population. Any tool must, of course, be valid and reliable for the specific patient population it tests or a u d i t s . Valid criteria for Montefiore m a y not be valid in other geriatric settings. Once the body of gerontological and geriatric nursing is clearly identified by scholars and practi-
tioners, it may be possible to develop an audit tool that will be reliable and valid for use with the aged in multiple settings. In the meantime, we present this section of our audit tool in the hope of stimulating an exchange of questions and experiences among hospital colleagues. Although geriatric nursing care audit is young, it is an essential tool to help confirm the importance of nursing care to the elderly.
References 1. New York City, Office for the Aging. Cor~
munity Planning District Profiles (Based o1970 Census). N.Y., Sept. 1974. " n 2. Bell, W. G. Community Care for the elderlyan alternative to institutionalization" Gerontologist 3 (Pt. I): 349-354 Aut '73" 3. Ibid., p. 25. ' " 9 4. Gunter, L. M., and Miller, j. C. Toward a nursing gerontology. June 1977. Nurs.Res. 26:209, May5. American Nurses" Association. Standards of
Gerontological Nursing Practice
'J
No. GE-2) Kansas City, Mo., 1976ev" (Publ. 6. Brunner, L. S., and others. Text~.^~- icaI-Surgtcal" Nursing. 2d r ~'~'~'rmla.,~Med-j B Lippincott Co., 1970, pp. 41-57.
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198 Geriatric Nursing May/June 1981
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(that is, unable to m a n a g e a c t i v i ties of daily living)(2). These findings, coupled w i t h the fact that 75 percent of t h e p a t i e n t s hospitalized on our m e d i c a l service were over age 60, p r o m p t e d M o n t e fiore's Task Force on G e r i a t r i c s to recommend, in 1977, t h e development of a model p r o g r a m "'to prevent or delay unnecessary or premature institutionalization." Prevention would be a c c o m p l i s h e d by functional assessments, identification of elderly at risk, follow-up, continuity of care, and o u t r e a c h , as well as by documenting n e e d s and evaluating services g i v e n ( 3 ) . The geriatric unit supervisor, senior nurse, and nurse clinician worked with a nursing p r o j e c t t e a m to explore the impact o f g e r i a t r i c nursing care on patients. A n immediate problem that:we e n c o u n t e r e d was the identification o f a b o d y of discrete geriatric n u r s i n g knowledge. Nursing gerontology, or the scientific study of n u r s i n g c a r e of older adults, is indeed a y o u n g discipline(4). In England, in 1965, Norton specified two d i s t i n c t categories of geriatric nursing practice: rehabilitation and chronic c a r e ( 4 ) . The American Nurses' Association's Standards of G e r o n t o l o g i c a l Nursing Practice were h e l p f u l in exploring practice(5). W e agreed with the beliefs about t h e aged stated by Brunner and o t h e r s ( 6 ) . We were especially i n t e r e s t e d in their description of significant characteristics of the older patient, which represented m a n y o f t h e critical process elements we c o n s i d e r in our geriatric nursing u n i t . In reviewing the nursing l i t e r a t u r e , however, we discovered little on geriatric nursing audit. We looked at each step o f the nursing process to d e t e r m i n e what results we would like to a u d i t in our patient care tecords. To b e t t e r define the assessment, p l a n n i n g , and
implementation phases of the nursing process, we developed a geriatric nursing history assessment and care plan for hospitalized patients. Drawing on our group's experience and the expertise of others, we then designed the hospital retrospective geriatric nursing audit tool that is shown on page 196. By pulling together semi-acute, rehabilitative, chronic care, and other criteria, the tool reflects the needs of our hospitalized patients. Problems in Development
Our first problem in pilot testing the geriatric audit was in selecting a study sample. We quickly discovered that we did not have a discrete population of elderly patients to study; all patients in the geriatric nursing unit had been admitted first to other units. We decided, however, to compare nursing outcomes in a group of patients who were transferred to, and discharged from, the geriatric unit with a group of patients who were admitted to other units and assessed as eligible for transfer to the geriatric unit but, for various reasons, were not admitted there. Our second problem was the lack of an available pool of patients, due to inadequate collection of data about patients who had been hospitalized previously in the geriatric unit, or been eligible for it. Our audit sample size was, therefore, much smaller than anticipated and not truly random. Two nurses independently attempted to retrieve data from the selected patient records, using the geriatric audit criteria. Some criteria were retrievable and some were not, and some criteria were open to various interpretations. For instance, does a "geriatric problem identified" mean that the patient was assessed for a specific common aging problem but was
Geriatric Nursing May/June 1981 195_
found not to have that problem? Or does it m e a n that the patient actually has or had a geriatric problem that the nurse was able to assess? m " y e s " or " n o " answer to I t e m 1 on the tool could have different interpretations. For this reason, our data results showed poor interrater reliability on several of the criteria. O u r documentation system does not require geriatric functional assessment in the discharge s u m m a r y
~1 ~
196 Geriatric Nursing May/June 19gl
note. This h a m p e r e d our a t t e m p t to c b m p a r e patient outcomes in terms of functional abilities for the two patient groups. T h e audit criteria did not correspond directly to the items cued into our nursing discharge s u m m a r y sheet, and so, for the most part, were not measurable. W e also found that the maintenance of specific functions is difficult to m e a s u r e unless there are ongoing assessment notes that verify continued integrity of function.
~
I
I ~.
X
t
Audit T e s t Benefits
Despite the problems, the audit was useful. F r o m it, we identified 9 deficiencies in our initial criteria, which would be modified in future studies 9 elements that needed strengthening in terms of ongoing functional assessment for admission to the geriatric unit and for discharge of the older patient 9 and the possibility of adding
~
!
~
x
x
)<
I
X
these strengthened criteria to our new documentation system, now in the developmental stage. Both positive and negative findings, as well as omissions in charting the nursing process, raised m a n y questions about our system for nursing orientation and education, care delivery, charting, and evaluation. As a result of the audit pilot study, our committee recommended better staffing to match
patient needs with the required numbers of nursing staff. W e suggested expanded continuing education, revisions in the hospital documentation system, further refiner ment of our assessment tool, and trials of the geriatric audit with older patients throughout the hospital. T o some extent, these recommendations are currently being followed. Geriatric nursing inservice sessions for all staff are offered in
the geriatric unit and in the medical and specialty nursing areas. Revised criteria for geriatric unit admission and a new nursing d o c u mentation system are undergoing pilot study. Our geriatric unit has been expanded from four to seven beds, so we now have more patients to include in our study of the new admission criteria and charting system. Since more than 75 percent of the patients in our medical service
X
Geriatric Nursing Max/June 1981 197
are 60 or older, we will soon be testing many of the revised criteria as a part of a generic, medical-nursing, retrospective audit that is relevant to our population. Any tool must, of course, be valid and reliable for the specific patient population it tests or a u d i t s . Valid criteria for Montefiore m a y not be valid in other geriatric settings. Once the body of gerontological and geriatric nursing is clearly identified by scholars and practi-
tioners, it may be possible to develop an audit tool that will be reliable and valid for use with the aged in multiple settings. In the meantime, we present this section of our audit tool in the hope of stimulating an exchange of questions and experiences among hospital colleagues. Although geriatric nursing care audit is young, it is an essential tool to help confirm the importance of nursing care to the elderly.
References 1. New York City, Office for the Aging. Cor~
munity Planning District Profiles (Based o1970 Census). N.Y., Sept. 1974. " n 2. Bell, W. G. Community Care for the elderlyan alternative to institutionalization" Gerontologist 3 (Pt. I): 349-354 Aut '73" 3. Ibid., p. 25. ' " 9 4. Gunter, L. M., and Miller, j. C. Toward a nursing gerontology. June 1977. Nurs.Res. 26:209, May5. American Nurses" Association. Standards of
Gerontological Nursing Practice
'J
No. GE-2) Kansas City, Mo., 1976ev" (Publ. 6. Brunner, L. S., and others. Text~.^~- icaI-Surgtcal" Nursing. 2d r ~'~'~'rmla.,~Med-j B Lippincott Co., 1970, pp. 41-57.
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198 Geriatric Nursing May/June 1981
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