1. The Efficacy of Elderly Caring Among Nurses<br />By: Reynario Cabezada Ruiz Jr.<br />REVIEW OF RELATED LITERATURE AND STUDIES<br /> “The present challenge is not adding years to one’s life, but rather to improve the quality of an extended life span.”<br />(Deluane and Landner, 2004)<br />As a growing individual and a nursing student, one may have preconceived ideas about caring for older adults. True to the Filipino culture and its being a family oriented living, these ideas are influenced by one’s observation of one’s family members, friends, neighbors and media and their own experience on older adults. This universal phenomenon called aging has some type of meaning, whether or not people have taken the time to consciously think about it. <br />The Old and Ageism<br />The impact of change is constant and permanent to every life form. This change is commonly measured by time which is a concrete determinant of showing age. Aging as a topic involves a variety of dimensions involving evident changes in physical, mental, psychosocial and spiritual aspect of a human person. The human person measures its life by the laps of living time, of how long one has lived his life. Objectively, aging is observed more by the physical change it produces, much of which is getting an old age.<br />Long life, this has been a quest during the past, many of which did not succeed to realize the secret of its longevity. Before the 1900, men lived a life expectancy of 47, and relatively only few people reach the age of 50. Factors of this short life expectancy are much to be blamed to the health status of aging population. Until in the last centuries, great strides were made in medicine, sanitation, hygiene and control of infectious diseases. People have learned to live life longer, with life expectance reaching 75 years or even more, but are still trying to learn how to live well (Deluane and Landner, 2004).<br />Mary Kalfoss and Liv Halvorsrud (2008) of Diakonova University College studied the Important Issues to Quality of Life (QoL) Among Norwegian Older Adults: An Exploratory Study where the concluded that All importance issues were found to be moderate to highly important for older adults with the exception of sex life. Highest mean importance was given to the ability to perform ADL activities, ability to move around, sensory abilities, health, and home environment. There are significant differences in the importance given to various aspects of QoL by younger old and older old and for women and men. Similarly, there are differences in areas of importance for those partnered and not and for persons hospitalized and not hospitalized. Understanding what is important to older adults’ QoL can help nurses in setting priorities in policy and treatment strategies for ageing populations. Future application of the importance questions could facilitate understanding and recognition of importance issues in subgroups of older adults. Further research is needed to assess how the importance ratings vary in other elderly populations and cultures.<br />Many young people today, especially in western countries, have little personal contact with older family members such as grandparents; also health care providers usually see only older people who are acutely or chronically ill and hospitalized or live in a long term care setting (Hogstel, 2010). Older adults are being stereotyped as being ill, bald, hard of hearing, forgetful, rigid, grumpy or boring simply on the basis on their age and regardless of their competencies and individual characteristics. The way people view aging and older adults is often a product of the environment and experiences to which people are exposed. Ageism or the negative attitudes towards aging of ten arise in the same way from negative past experiences (Mauk, 2010).<br />Getting older is a natural process but many would try to resist it. So when does old age begin? The most obvious measure of age is a person’s chronological age, or the exact age of a person from birth. According to the National Institute of Aging in 2000, ages ranging 65 to 74 years are classified as young old, 75 to 84 as old, 85 to 94 as old-old and 95 and older are the elite-old or the chronologically gifted. In 2003, approximately 36 million people in America are at the age of 65 and older, this is according to the American Association of Retired Persons (AARP). As the fastest-growing segment of the population, the number of adults over the age of 65 is projected to be approximately nine million in the year 2030.<br />Successful aging can be defined as the enjoyment of health and vigor of the mind, body and spirit into middle age and beyond (Wagnild, 2003). Nowadays, the graying of baby boomers demands an enormous impact on health care in this century especially to nurses requiring them to increase their sensitivity to and understanding, of the needs, requirements and the capabilities of the older adults. <br />Theories of Aging<br />Theories of aging attempts to completely embrace and explain all the many facets of change and two of them are popular to us. The Biological theories address the physical changes of aging one of which is the Stress Theory suggests that irreversible structural and chemical changes occur in the body as a result of stress throughout the life span and that individuals must learn to adapt to these changes. The Cross Linkage Theory describes the deterioration of tissues and organs as the cause of loss of flexibility and functional ability that occurs with aging. The Somatic Mutation Theory takes a similar cellular level approach in stating the changes in DNA that are not repaired lead to the replication of the mutated cell, which brings about decreased cellular functioning and loss of organ efficiency. The Programed Aging Theory states that life span is determined by heredity and that internal genetic clock is responsible for the rate at which an individual develops, ages and eventually dies (Deluane and Landner, 2004).<br />Psychosocial theories on aging present the position that many factors in addition to genetics contribute to the aging process. The Disengagement Theory posits that as individual ages, they inevitably withdraw from the society and the society withdraws from them in a process of separation. The Continuity Theory suggests that an individual’s values and personality develop over a lifetime and that goals and individual characteristics will remain constant throughout life; an individual thus learns to adapt to changes and will tend to repeat those reactions and behaviors that brought success in the past. The Activity Theory proposes that an individual’s satisfaction with life depend on involvement in new interests, hobbies, roles and relationships. Volunteering is one way that many retirees stay connected to the community. In addition to providing social connection, volunteer activities provide a daily routine, a way to make a contribution and a sense of being needed (Deluane and Landner, 2004).<br />Perspectives of Caring<br />There are numerous theoretical concepts relative to caring in nursing. Some of the major ideas were postulated in Watson’s theory of human caring where she had her major concepts such as caring is central to nursing practice, the emphasis of caring is on the dignity and worth of individuals, each person’s response to illness is unique, caring is demonstrated interpersonally and caring involves a commitment to care and is based on knowledge (Watson, 1991).<br />According to Leininger (2002), caring is the essence of nursing, caring is universal occurring in all culture, caring behaviors are determined by and occur within a cultural context. Benner (2001) stated that caring is central to all helping professions, caring is the foundation of being, people and interpersonal concerns are important, caring is communicated through actions, problem solving is a major component of caring and that advocacy is caring.<br />In the Nursing Circles of Care, Core and Cure as the central concepts of Lydia Hall’s theory (1964), care alludes to the “hands-on”, intimate bodily care of the patient and implies as comforting, and nurturing relationship. While intimate physical care is provided, the nurse and the patient develop a close relationship representing teaching and learning aspect of nursing. <br />Along with the different roles of gerontological nurses, caring is a main component that connects the nurse to the recipient of service. A study by Lui, Shwu-Jiaun in 2004 described what caring meant to geriatric nurses. The researcher concluded that for geriatric nurses, the meaning of caring included several concepts: deliberation, concern, tolerance, sincerity, empathy, dedication and initiative. The author suggests that caring for the elderly should be natural and not superficial in order for the elderly to feel cared for.<br />Gerontology and Geriatrics<br />Quality of life is gaining more emphasis in today’s aging society and the trend is in fact for people to live longer and healthier lives. Outlook and adaptation contribute to the high quality of life enjoyed by many older adults today. Although many people over 65 have some kind of chronic health problem, most have found ways to keep these ailments from interfering with their enjoyment of life. Older people accept a certain amount of declining health as a normal, expected part of aging, but do not allow health issues to interfere with the vigorous pursuit of enjoyment. In a study in 2003 conducted by S.J. Loeb, S. Frankstern, S.H. Guelner and L.W. Poon titled “Supporting Older Adults Living with Multiple Chronic Conditions” they found out that chronicity was a highly personal experience for the older adults. Seven major categories of coping strategies were determined: relating with healthcare providers, medicating, exercising, changing dietary patterns, seeking information, relying on spirituality and religion and engaging in life. This study provided a view of coping strategies from the client perspective. It revealed what older adults do every day as they live with multiple chronic conditions.<br />Statistics show that the majority of nursing career will include caring for older adults. As Mathy Mezey, director of the John A. Hartford Foundation Institute for Geriatric Nursing at New York University, stated, “the population of older Americans is exploding, Geriatric patients are not one subgroup of patient but rather the core business of health systems (Mezey, 2005). Providing quality care to elders requires knowledge of the intricacies of the aging process as well as unique syndromes and disease conditions that can accompany growing older.<br />The Alliance for Aging Research (2002) reports that the average older adult has three chronic medical conditions. Consequently, more nurses are needed to care for the increasing number of older adults with chronic illness.<br />Gerontology is a broad term used to define the study of aging and/or the aged. This includes the biopsychosocial aspects of aging. Under the umbrella of gerontology are several subfields including geriatrics, social gerontology, geropsychology, geropharmachology, financial gerontology, gerontological nursing, and gerontological rehabilitation nursing and etc. Geriatrics is often used as a generic term relating to the aged, but specifically refers to the medical care for the aged. For this reason many nursing journals and texts have chosen to use gerontological nursing instead of geriatric nursing. Gerontological nursing then falls within the discipline of nursing and the scope of nursing practice. It involves nursing advocated for the health of older persons in all levels of prevention. Gerontological nurses work with healthy elderly persons in their communities, acutely ill elders requiring hospitalization and treatment and chronically ill or disabled elders in long term care facilities, skilled care, home care and hospice (Mauk, 2010).<br />The scope of practice for gerontological nursing includes all older adults from the time of “old age” until death. Gerontological nursing is guided by standards of practice. It is commonly assumed that any nurse can take care of older adults. However, with the increasing population of older adults there has been an increase in the amount in specialized geriatric nursing knowledge needed to care for this population. Not only are more nurses needed to care for older adults, but nurses competent in the care of older adults will be needed to meet the enhanced needs of the older population. Rosenfeld, Bottrel, Folmer and Mezey (1999) report that “Today, a nurses’ typical client is an older adult,” and “It behooves the nursing community to ensure that every nurse graduating from a baccalaureate nursing program has defined level of competency in the care of eldrly.<br />Gerontological nursing like other nursing specialty has defined roles in a given setting. In the role of caregiver or provider of care, the gerontological nurse gives direct, hand-on care to the older adults in a variety of setting. Older adults often presents with atypical symptoms that complicate diagnosis and treatment. Thus the nurse as a care provider should be educated about disease processes and syndromes commonly seen in the older population. This may include knowledge of risk factors, signs and symptoms, usual medical treatment, rehabilitation and end of life care (Mauk, 2010).<br />Ann Gallagher and colleagues conducted a research in 2007 in titled “Dignity in the care of older people – a review of the theoretical and empirical literature.” The paper critically reviews the theoretical and empirical literature relating to dignity and clarifies the meaning and implications of dignity in relation to the care of older people. If nurses are to provide dignified care clarification is an essential first step. The group reviewed a range of theoretical and empirical accounts of dignity and identify key dignity promoting factors evident in the literature, including staff attitudes and behaviour; environment; culture of care; and the performance of specific care activities. Although there is scope to learn more about cultural aspects of dignity the researchers know a good deal about dignity in care in general terms. As a conclusion the researchers argue that what is required is to provide sufficient support and education to help nurses understand dignity and adequate resources to operationalize dignity in their everyday practice. Using the themes identified from our review we offer proposals for the direction of future research.<br />An essential part in nursing is teaching. Gerontological nurses focus their teaching on modifiable risk factors and health promotion. Many diseases and debilitating conditions of aging can be prevented through lifestyle modifications such as healthy diet, smoking cessation, appropriate weight maintenance, physical activity and stress management. Nurses have the responsibility to educate the older adult population about ways to decrease the risk of certain disorders such as heart disease, cancer and stroke; the leading cause of death for this group.<br />Geronlogical nurses act as managers during everyday practice as they balance the concerns of the patient, family, nursing and the rest of the interdisciplinary team. Nurse Managers must be skilled in leadership, time management, building relationship, communication and managing change. Nurse managers may supervise other nursing personnel.<br />As an advocate, the gerontological nurse acts on behalf of older adults to promote their best interests and strengthen their autonomy and their decision making. Advocacy may take many forms including active involvement at the political level or helping to explain medical or nursing procedures to the family members on a unit level. Nurses may also advocate for patients through other activities such as helping family members choose the best nursing home for their beloved ones or listening to family members vent frustrations about health problems encountered. Whatever the situation, gerontological nurses must remember that being an advocate does not mean making decisions for older adults but empowering them to remain independent and retain dignity even in difficult situations.<br />The appropriate level of involvement of nurses at the baccalaureate level is that of research consumer. Gerontological nurses must remain abreast of current literature, reading and putting into practice the results of reliable and valid studies. Using evidence-based practice, gerontological nurses can improve the quality of patient care in all settings.<br />Evaluation and Efficacy of Care<br />Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values. Health care that is evidence-based and conducted in a caring context leads to better clinical decisions and patient outcomes. Gaining knowledge and skills in the EBP process provides nurses and other clinicians the tools needed to take ownership of their practices and transform health care. Key elements of a best practice culture are EBP mentors, partnerships between academic and clinical settings, EBP champions, clearly written research, time and resources, and administrative support. (Fineout-Overholt E, 2005)<br />While there is a extensive development to improve the care of the elderly especially in the bulk of theoretical knowledge in gerontological nursing, experts are also aware that there is a need for evaluation and constant monitoring of its results in the clinical nursing practice.<br />Evaluating care involves determining the client’s progress toward achievement of expected outcomes. Effective planning is essential if evaluation is to be effective. In other words, the planned outcomes are the yardsticks by which effectiveness of therapies are being evaluated. If there are no stated expectations of care, how can progress be measured? <br />The purposes of evaluation include determining the client’s progress or lack of progress toward achievement of expected outcomes, to determine the effectiveness of nursing care in helping clients achieve the expected outcomes, to determine the overall quality of care provided and to promote nursing accountability.<br />The nurse who successfully evaluates nursing care uses a systematic approach that ensures thorough, comprehensive collection of data. Evaluation is an orderly process consisting of steps such as establishing standards, collecting data, determining goal achievement, relating nursing actions to client status, judging the value of nursing interventions, reassessing the client status and modifying the plan of care (Deluane and Landner, 2004).<br />Evaluation is performed at the individual and institutional level. Organizational evaluation examines the overall ability of the agency to deliver quality care. Evaluation can be classified according to what is being evaluated: the structure, the process, or the outcome. Structure evaluation is a determination of the health care agency’s ability to provide services offered to its client population. Process evaluation is the measurement of nursing actions by examination of each phase of the nursing process. Outcome evaluation is the process of comparing the client’s current status with the expected outcomes. This type of evaluation examines all direct care that affects the client’s currents health status. Outcomes evaluation focuses on the change sof the client’s health status (Kozier et al., 2004).<br />A Survey of the Quality of Nursing Care in Several Health Districts in South Africa by Leana Uys and Joanne Naido in 2002 revealed that The average scores on the different aspects varied from 11% (for nursing records) to 73% (for management of chronic diseases). Specific problems became evident. In one district three out of four hand-overs between shifts of nurses scored less than 50%. In all three districts the use of protective gear scored low (43%). While the average score for management of chronic illnesses were high at 73%, the blood pressures of only 23% was within the target range, and the blood sugar of only 38% of patients were controlled. Patient satisfaction averaged 72% across the three districts. They also conclude that study has pointed to a number of problems in the quality of care given by nurses in three health districts in South Africa. It has highlighted specific problems in each district and also general problems across all three districts. Some of these problems might be amenable to training and education. However, other management strategies also seem to be indicated. Regular monitoring and feedback to nursing teams, monitoring meetings in the format of perinatal mortality review meetings, and special incentives for higher quality might be considered.<br />Recently there has been emphasis by the nursing profession on evaluating outcomes. Nurse researchers (Moorhead, Johnson and Maas, 2004) at the University of Iowa have developed classifications of client outcomes, the Nursing Outcomes Classification (NOC). The NOC provides a standardized language that can be used to measure the effects of Nursing practice on client outcomes. The NOC outcomes which are used extensively in the United States and other countries are constantly undergoing research to validate application to the clinical practice. Just as the North American Nursing Diagnosis Association (NANDA) and the Nursing Interventions Classification (NIC) are continuing to develop a standardized nursing language relative to diagnosis and intervention, the NOC is striving toward a similar goal of standardized language for classifying nursing outcomes. The NOC can be used to enhance decision making in the clinical practice and research. “Analysis of outcomes may lead initiatives for quality improvement” (Charters, 2003).<br />In a study by Gudmundsdottir, Delaney, Thoroddsen and Karlsson in 2004, “Translation of and Validation of the Nursing Outcomes Classification Labels and Definitions for Acute Care Nursing in Iceland”, revealed that 181 of 260 NOC were perceived as being relevant to clients in the critical care areas. The Icelandic version of the NOC survey is a comprehensive tool that can be used for critical care nursing research. NOC outcomes are applicable to clients in acute care settings in Iceland.<br />The Nursing Outcomes Classification taxonomy focuses on function, physiology, psychosocial aspects, health knowledge and behavior and perceived self-health and family health. The NOC system, which defines over 330 client outcomes that are sensitive to nursing interventions, allows nurses to evaluate client status over time. The NOC (2004) also listed selected outcomes relevant to safety maintenance for an elderly client being cared for in the home. Few of which are namely the description of fall prevention measures, description of risk reduction measures, description of home safety measures, description of emergency procedures and description of community safety risks. Strengthening the links between nursing interventions and client outcomes will benefit not only clients, but nursing as well. Having solid evidence that documents the effectiveness of nursing care on client outcomes will influence political and financial decisions relative to nursing.<br />Bibliography<br />Book References<br />Benner, P., (2001) Form Novice to Expert: Excellence and Power in the Clinical Nursing Practice, (Com. Ed.), Upper Saddle River, New Jersey: Prentice-Hall<br />Burns, N. & Grove, S., (2007) Understanding Nursing Research: Building an Evidence Based Practice (4th ed.). Singapore: Elsevier Pte Ltd<br />Daniels, R. (2005) Nursing Fundamentals, Caring and Clinical Decision Making. 2 vols., Dermak a Division of Thomson Learning<br />Deluane, S. & Lancher P. (2006). Fundamentals of Nursing: Standards and Practice (3rd ed.). Singapore: Delmar Learning a Division of Thomson Learning<br />George, J. (1995) Nursing Theories: Base for Professional Nursing Practice (4th ed.). London: Appletton and Lange a Simmon and Schuster Company<br />Kozeir, B., et al., (2004). Fundamentals of Nursing: Concepts, Process and Practice (7th ed.). New Jersey: Pearsan Education South Asia Pte Ltd<br />Leininger, M (2002) Transcultural Nursing (3rd Edition), New York: McGraw-Hill<br />Mauk, K., (2010) Gerontological Nursing: Competencies for Care (2nd Edition) Bartlett Publisher, LLC<br />Moorhead, S., Johnson, M., and Maas, M., (2004) Nursing Outcomes Classification (NOC) (3rd Edition) St. Louis MO: Mosby<br />Mosby’s Pocket Dictionary of Medicine, Nursing and Health Professions (5th ed.). (2006) Singapore: Mosby Incorporated<br />Nocon, F., et al. (2000) General Statistics Made Simple for Filipinos (2008 reprint) Philippines: National Bookstore<br />Pearsan, J., et al. (2003) Human Communication. NY: McGraw-Hill Companies<br />Polit, D. & Beck (2008) Nursing Research: Generating and Assessing Evidence for Nursing Prcatice (8th ed.). Philidelphia: J. B. Lippincott Company<br />Potter, P. & Perry, A. (2005) Fundamentals of Nursing (6th ed.). St Louis, Missouri: Mosby Incorporated<br />Wallace, M., (2008) Essential for Gerontological Nursing. Springer Publishing Company LLC<br />Watson, J., (1999) Nursing: Human Science and Human Care. Boston: Jones and Bartlett; Denver Colorado<br />Internet Sources<br />http://books.google.com/books?id=QSGrakunwA0C&printsec=frontcover&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=true (Retrieved August 17, 2011)<br />http://www.biomedcentral.com/1472-6955/3/1<br />http://www.biomedcentral.com/1472-6955/7/11<br />http://creativecommons.org/licenses/by/2.0<br />Journals<br />Lui, Shwu-Jiaun., (2004) What Caring Means to Geriatris Nurses. Journal Nursing Research<br />Mary Kalfoss and Liv Halvorsrud (2008) Important Issues to Quality of Life Among Norwegian Older Adults: An Exploratory Study Diakonova University College, Linstowsgate 5, 0166, Oslo, Norway Published online 2009 August 20. doi: 10.2174/1874434600903010045<br />GUdmundsdottir, F., Dekaney, C., Thoroddsen, A., and Karlsson T. (2004) Translation of and Validation of the Nursing Outcomes Classification Labels and Definitions for Acute Care Nursing in Iceland, Journal of Advanced Nursing<br />Loeb, S. J., Frankstern, Guuelner, S. H., Poon, L. W., (2003) Supporting Older Adults Living with Multiple Chronic Conditions, Western Journal on Nursing Research <br />Related Studies<br />Abrito III, S., et al. (2007) Quality of Nursing Care and Patient’s Satisfaction: Proposed Seminar, Unpublished Thesis, Nursing Research, University of Cebu-Banilad<br />Naidoo, J., and Uys, L., (2004) A Survey of the Quality of Nursing Care in Several Health Districts in South Africa, School of Nursing, University of Natal, Durban, South Africa BMC Nursing 2004, 3:1doi:10.1186/1472-6955-3-1, <br />Ruiz, R. Jr., (2010) Patient’s Satisfaction on the Nursing Services at Severo Verallo Memorial District Hospital, Unpublished Thesis, Nursing Research, University of Cebu-Banilad<br />Ann Gallagher, Sarah Li, Paul Wainwright, Ian Rees Jones and Diana Lee (2008) Dignity in the care of older people – a review of the theoretical and empirical literature. BMC Nursing 2008, 7:11doi:10.1186/1472-6955-7-11<br />