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Rethinking Teaching Nursing Homes: Potential for Improving Long-Term Care

Correspondence: Address correspondence to Ethel L. Mitty, EdD, RN, Hartford Institute for Geriatric Nursing, New York University College of Nursing, 246 Greene Street, New York, NY 10003-6677. E-mail: em7{at}nyu.edu

	Abstract

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To meet the special needs of and provide quality health care to nursing home residents, the health care workforce must be knowledgeable about the aging process. Health professionals are minimally prepared in their academic programs to care for older adults, and few programs have required rotations in geriatrics. Teaching nursing homes (TNHs) have shown promise as sites for the preparation of a health workforce to care for older adults in nursing homes as well as improvement of quality outcomes. This article reports on the process and recommendations of a TNH summit of experts in geriatric education and practice as to the feasibility of developing a sustainable and replicable TNH model that would prepare a professional workforce knowledgeable about and prepared to work in long-term care. The TNH summit identified characteristics of partnerships between academia, nursing home(s), and other stakeholders that would constitute a successful TNH collaboration. Goals of a TNH partnership between service and academia include interdisciplinary education and practice, research and dissemination of evidence-based practices, and benchmarks of a nursing home professional learning environment.

Key Words: Education • Practice • Collaboration • Teaching nursing homes • Health care workforce

Despite the need for improved care and clinicians knowledgeable about the aging process, nursing homes are experiencing a decrease in the number of professional nursing staff and are hampered by a shortage in geriatrics-prepared providers. Only one third of nursing students in baccalaureate nursing programs have a required course in geriatrics (Berman et al., 2005). Although programs in geriatric medicine, nursing, and geropharmacy all require nursing home placements with preceptors (Mezey, Mitty, & Burger, 2005), the length and breadth of these clinical rotations is extremely variable within and across professions.

In the 1980s, teaching nursing homes (TNHs) were promoted as a means to improve the preparation of a health workforce knowledgeable about geriatric care, to foster research, and to improve resident outcomes. Two TNH models, one funded by the National Institute on Aging and the second by the Robert Wood Johnson (RWJ) Foundation, established substantive linkages between academic medicine and nursing programs and nursing homes nationally. Outcomes from TNHs showed promise in terms of expansion of geriatric curriculum, research, and improved resident outcomes.

Over the past 15 years, some schools of nursing and medicine have maintained TNHs. Yet there has been little recent exploration as to whether TNHs can potentially expand research training opportunities in the health professions and substantially contribute to improved resident outcomes. This article describes the process and the recommendations of a summit of experts in geriatric education and practice as to the feasibility of developing a sustainable and replicable TNH model that would prepare a health care professional workforce knowledgeable about and prepared to work in long-term care.

	Background: TNHs

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In 1981, the National Institute on Aging TNH model sought to bring geriatrics into mainstream medical education and thereby infuse long-term care with intellectual vigor and create an environment for medical research focused on frail residents of nursing homes (Small, 1988). The multisite, multidisciplinary approach of National Institute on Aging TNHs increased research and contributed to improved resident outcomes (Fretwell & Katz, 1985; Schneider, Ory, & Aung, 1987).

In the RWJ TNH program, between 1982 and 1987, 11 university schools of nursing and nursing homes created affiliations, the purpose of which was to influence registered nurse and advanced practice nursing student (nurse practitioners and clinical nurse specialists) competence, faculty research, and resident health outcomes. Evaluation showed that the RWJ TNHs significantly improved undergraduate and graduate students' attitudes toward older adults and strengthened geriatric curriculum clinical experiences, faculty preparation, and research as compared with the typical use of nursing homes for circumscribed student rotations (Mezey, 1989; Mezey, Lynaugh, & Cartier, 1988). The RWJ TNHs significantly enhanced or stabilized resident outcomes (activities of daily living) as compared to those of residents in six matched nursing homes without academic affiliations (Mezey & Lynaugh, 1989; Shaughnessy, Kramer, Hittle, & Steiner, 1995). A 7% decrease in hospitalizations of residents within 3 months of admission and reduced per-patient cost of care were attributed to TNH involvement of nurse faculty, nurses, and nurse's aides in care planning (Shaughnessy et al., 1995).

Over the past 15 years, there have been sporadic reports of TNHs. Eight years after funding ceased, 7 of the 11 original RWJ TNH schools of nursing maintained all or some TNH components (Mezey, Mitty, & Bottrell, 1997). Other academic nursing programs have implemented aspects of a TNH model (e.g., Texas Tech University has a geriatric center on its campus, and the University of Washington has a multilevel geriatric facility). Some geriatric medicine fellowship programs maintain TNHs (e.g., the Division of Geriatric Medicine at Emory University has a continuing care retirement community). In Missouri, the state agency responsible for nursing home surveys and certifications collaboration with the University of Missouri School of Nursing to provide onsite clinical consultation has yielded improvements on clinical outcomes (e.g., pressure ulcers, range of motion, dehydration, depression; Rantz et al., 2003).

TNHs are sustained where they enhance the core mission of the academic setting and the home. The sustained RWJ TNH sites provide faculty with research opportunities in urinary incontinence, sleep disorders, and falls. TNH homes use faculty to improve standards of resident care and help gain market share and outside funding. The nursing home collaborating with Texas Tech University secured state funding to conduct mandated training of certified nursing assistants. Because they provide educational opportunities for staff, TNHs diminish turnover. Where sustained, TNHs promote a positive image of nursing homes in the academic setting and in the community.

The importance of these factors in sustaining TNHs is evident in results of a questionnaire returned by 35 self-identified TNHs (17 nursing homes and 18 academic programs; Mezey, Mitty, & Burger, 2005). Responding TNHs represented urban/suburban for-profit and not-for profit homes with a wide range of clinical services (e.g., subacute, dementia, hospice). In academic nursing TNHs, the number of faculty certified in geriatrics (M = 2.4), required geriatric courses (57%), schools using nursing homes for student rotations (86%), and geriatric faculty holding joint appointments (mean value 1.6), all exceeded the national average (Berman et al., 2005). In 64% of schools, faculty in the home conducted research and provided gerontological educational programs. TNH homes had lower turnover of nursing leadership and staff and more advanced practice nurses and nursing and medical directors certified in geriatrics than the national average (Mezey, Burger, et al., 2005). TNH home staff had access to the school libraries (67% of homes) and faculty appointments (56%), staff made joint facility and academic presentations at state and national meetings (67%), and homes and academic programs received joint funding for research (44%), all factors known to be associated with high staff retention.

Thus, TNHs may offer an advantage over current methods of geriatric training and efforts to improve care. They might help reverse the decreasing number of students applying for programs in geriatric nursing and geriatric medicine (Kovner, Mezey, & Harrington, 2002), create more attractive sites for faculty practice, help better manage the care for the growing numbers of short-stay postacute and rehabilitation residents, counteract the decreasing number of registered nurses in nursing homes (Harrington, Swan, & Carrillo, in press), better address ongoing quality improvement initiatives (Lucas et al., 2005; Rantz et al., 2004), and implement the growing movement to achieve culture change in nursing homes (Grant & Norton, 2003).

	The TNH Summit

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In March 2005, 38 experts in geriatric education and practice (chosen from experts and identified leaders in education, practice, administration, and long-term-care quality oversight; see Appendix for participant list) met in New York City to discuss the value of a TNH model and to identify factors that would promote feasibility, sustainability, and replicability. Participants, who received publications on TNHs and a summary of extant TNHs, were asked to consider (a) stakeholders critical to achieving successful TNHs, (b) likely barriers, (c) evidence-based research support of TNHs, and (d) how TNHs might advance national and state regulatory/monitoring/health policy agendas. Summit participants were asked for their critique of and feedback on the TNH summit Executive Summary and goals and principles within 3 months of the summit.

	TNH Summit Outcomes

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TNH summit participants enthusiastically endorsed TNHs and consistently identified key aspects of the professional practice environment of long-term-care facilities and academic settings necessary to establish TNHs. Participants identified a need for research to describe the congruency of competencies of health care disciplines in geriatrics, and the extent to which academic programs preparing health professionals use nursing homes to meet these competencies.

Summit participants clearly differentiated TNH homes and academic programs from the typical relationship that now exists between most academic settings and nursing homes (i.e., student clinical placement on a specific unit ranging from 2 to 14 days in one semester). The eight goals of a TNH/Learning Collaborative/Learning Partnership articulated at the summit (see Table 1) focused on the reciprocal nature of potential TNH outcomes for academia and nursing homes such that a "culture of learning" would pervade and guide both organizations. Participants saw TNHs as vehicles for transforming the perceptions and images of nursing homes in academia and the community, as exemplary places for quality of care and quality of life that promotes interdisciplinary education and practice and person-directed care (Weiner, 2003), as settings in which to test and disseminate evidence-based practices, and as the ideal sites in which to build the workforce needed for the future.

	Principles and Actions of a TNH/Learning Collaborative/Learning Partnership

TOP Abstract Background: TNHs The TNH Summit TNH Summit Outcomes Principles and Actions of... Appendix References

Summit participants identified three characteristics as essential to future TNH viability. First, they envisioned TNHs as consortia of nursing homes and academic centers. Second, they saw TNHs as encompassing an interdisciplinary approach rather than focusing on one discipline (Page, 2004). And third, participants saw the success of future TNHs as highly dependent on the use of information technology both in the home and in the academic setting. Participants identified the fact that nursing homes lag considerably behind hospitals and academic settings in the use of electronic medical records and staff access to e-mail and the Internet as a barrier to TNH implementation.

TNH summit participants addressed factors to be considered in creating the best fit between nursing homes and academic professional schools, including material resources, the organization's mission and ethos, performance and quality improvement systems, and innovation and research experience. A TNH requires stable leadership and understanding of the unique decision-making processes of the respective clinical domains and sensitivity to time and workload distribution. Teaching and learning flow across and between the academic setting and the home. TNHs have a responsibility for dissemination of their activities to encourage broad adoption of best practices as standard practice throughout the long-term-care industry.

In relationship to nursing homes, TNH homes need to evidence a "climate of learning," openness to innovation, clarity as to mission and goals, administrative commitment for staff to attend educational sessions (including payment for replacement staff), introduction of evidence-based protocols and procedures, and incentives to encourage staff to achieve professional certification. TNH homes need to provide students with access to a continuum of diverse acute and long-term services (e.g., hospice, short-term rehab, dementia unit, and services for residents with differing levels of functional and mental status). TNHs need to commit to good regulatory standing (e.g., state survey findings) and formal recognition for excellence (e.g., Magnet status, Joint Commission for Accreditation of Healthcare Organizations [JCAHO] accreditation; Lucas et al., 2005), sufficient and well-prepared clinical staff (e.g., nursing, rehab, social services), strong medical staffing patterns (American Geriatrics Society and American Association for Geriatric Psychiatry, 2003; American Medical Directors Association, 2003a, 2003b), use of advanced practice nurses, and low staff turnover.

Similarly, TNH academic settings need to evidence clarity as to academic mission in relationship to practice. In many academic programs, practice takes a backseat to education and research and carries less weight in considerations for promotion and tenure. Academic settings also need to value interdisciplinary education, practice, and research. TNH academic units need sufficient numbers of undergraduate and graduate students, faculty prepared and/or certified in geriatrics, geriatric programs, and a history of joint nursing home/academia collaborations. Barriers include lack of faculty prepared in geriatrics; the time involved to build and maintain collaborative relationships; and lack of administrative and financial support, which can be tenuous if dependent on outside funding or changes in academic and clinical priorities.

Next Steps for TNH Implementation
Outcomes from the RWJ TNH program, anecdotal evidence from extant TNHs, and the goals and principles of TNHs articulated by summit participants speak to the feasibility of the TNH model and suggest that TNHs could help transform perceptions about nursing homes, which are currently seen as milieus with low expectations as to training sites and as to their ability to provide for the quality of life of residents (Kane, 2003). As places for interactive learning that enhances the competencies of staff, students, and faculty, TNHs could help achieve quality of care and quality of life for nursing home residents and have a substantive impact on the long-term-care professional workforce.

Developing a long-term relationship between academia and nursing homes requires planning and board, senior faculty, and administrative leadership. The emerging philosophy of resident-directed care (or culture change; National Citizens' Coalition for Nursing Home Reform, 2006) is an opportunity for academia and nursing homes to develop a robust evidence-based and ethical framework to view and balance older adults' safety needs and their right to self-determination.

Historically, TNHs have been located in the nonprofit nursing home sector. Only 28% of U.S. nursing homes are nonprofit, and these homes tend to have more staff, which is the key to quality care (Harrington et al., 2007). Beginning relationships between academic settings and for-profit chains (e.g., the University of Pennsylvania School of Nursing and Genesis Health Care) may evolve as models for expanding such relationships.

TNHs are uniquely positioned to promote models of interdisciplinary education, practice, and research critical to preparing the future long-term-care workforce. Although summit participants identified interdisciplinary collaboration as a cornerstone of TNHs, health care professional education and practice remains singularly insular (McCallin, 2001). The Hartford Geriatric Interdisciplinary Team Training program (Fulmer et al., 2003) might serve as one platform for reexamining interdisciplinary training; and the Wellspring model (Stone et al., 2002), whereby advanced practice geriatric nurses consult with several nursing homes, might be expanded to include other disciplines and academic settings. The collaborative approach exemplified by the National Institutes of Health initiative National Consortium to Transform Clinical Research might also serve as a model for TNH development. The 12 participating academic centers seek to promote the conduct of clinical research and its efficient and quick dissemination to reach residents (National Consortium to Transfer Clinical Research, 2006). Through interdisciplinary initiatives, TNHs could become academic and clinical hubs for ongoing educational and translational research efforts in long-term care.

In summary, summit participants' analysis hopefully will stimulate further discussion and initiate testing as to the potential of TNHs to contribute to quality care of residents and quality education of the geriatric workforce.

	Appendix

TOP Abstract Background: TNHs The TNH Summit TNH Summit Outcomes Principles and Actions of... Appendix References

 
Teaching Nursing Home Summit Participants

Polly Bednash, PhD, RN, FAAN

American Association of Colleges of Nursing

Claudia Beverly, PhD, RN, FAAN

University of Arkansas for Medical Science

Marie Boltz, MSN, NHA, PhD(c)

New York University

Patricia Burbank, DNSc, RN

University of Rhode Island

Elizabeth Capezuti, PhD, RN, CRNP, FAAN

New York University

Diane Carter, RN, MSN, CS

American Association of Nurse Assessment Coordinators

Annemarie Dowling-Castronovo, RN, MA, GNP

Rutgers, The State University of New Jersey

Lois Evans, PhD, RN, FAAN

University of Pennsylvania

Ellen Flaherty, PhD, APRN, BC

Village Care of New York

Irene Fleshner, Senior Vice-President

Genesis Health Care

Elinor Fritz, RN, MS

New Jersey Department of Health & Senior Services

Roberta Greene, PhD, MSW

University of Texas

Charlene Harrington, PhD, RN

University of California San Francisco

Nancy Hooyman, PhD, MSW

University of Washington

Mark Kator, President and CEO

Isabella Geriatric Center

Robert Kennedy, MD

Maimonides Medical Center

Mary Jane Koren, MD, MPH

Commonwealth Fund

Katie Maslow, MSW

Alzheimer's Association

Pat Maxon, LMSW

The University at Albany

Phillip McCallion, PhD, ACSW

The University at Albany

Hope Miller, RN, MS

Isabella Geriatric Center

Joseph Ouslander, MD

Emory University

Douglas Pace, BS, LNHA

National Commission for Quality Long-Term Care

Elyse A. Perweiler, MPP, RN

New Jersey Institute for Successful Aging

Barbara B. Phillips, DNSc, CNS, GNP-BC

National Conference of Gerontological Nurse Practitioners

Mark Poher, RN, MS

Community Hospital of Dobbs Ferry & Michael Malotz Skilled Nursing

Joanne Rader, MN, RN, FAAN

Oregon Health Sciences University

Susan Reinhard, PhD, FAAN

Rutgers, The State University of New Jersey

Karen Schoeneman, BS, MPA

Centers for Medicare & Medicaid Services

Cindy Shemansky, MEd, RNC, LNHA, FNGNA

National Gerontological Nurses Association

Mary Tellis-Nayak, RN, MSN, MPH

MyInnerView

Ana M. Valadez, EdD, FAAN

Texas Tech University Health Science Center

Nancy Watson, PhD, RN

University of Rochester

Jeffrey West, RN

Quality Improvement Organization–Washington State

Joan Levy Zlotnik, PhD, ACSW

Institute for the Advancement of Social Work Research

	Footnotes

 
This project was conducted under a contract from the Health Resources and Services Administration.

¹ Hartford Institute for Geriatric Nursing, New York University College of Nursing, New York.

Decision Editor: William J. McAuley, PhD

Received for publication February 15, 2007. Accepted for publication June 7, 2007.

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