Gerontological Care in Acute Care Settings
Submitted by Mary Kjorven, RN, BsN, MsN
It is well documented in the literature that older adults aged >65 years are high users of hospital services
and remain in hospital longer than younger patients (Ahmend and Pearce, 2010; Ebersole, Hess, Touhy,
Jett and Luggen, 2008; Miller, 2009; Novak and Campbell, 2010; Parke, Ross and Moss, 2004;
Robertson, 2010, Warburton, Parke, Church and McCusker, 2004). This trend is reflected in local
statistics where I practice as a Clinical Nurse Specialist (CNS) in specialized geriatrics; in 2010/2011,
elderly patients (65+) accounted for a significant proportion of the cases treated at the four large hospitals
within Interior Health (IH), British Columbia. The percentage of elder patient encounters to total patient
encounters range from 37% to 51% in these hospitals (Interior Health, 2010).
Not only are older adults high users of hospital services, but the experience of hospitalization significantly
increases risks for this population, including functional decline and loss of physical and mental ability
(Parke, Ross and Moss, 2003; Inouye, 2000; Warburton, Parke, Church and McCusker, 2004) as imposed
bed rest, urinary catheter utilization, excessive environmental stimulation and other characteristics of
acute hospitalization deplete frail elders of already limited physiologic reserves (Ahmed and Pearce,
2010). Elderly patients present in large numbers to Emergency Departments (EDs), often by ambulance,
and end up waiting for days on stretchers in the ED of hospitals which are not equipped to provide an
adequate environment and appropriate care for elders. Problems associated with physical space in ED
departments include overcrowding, noise, limited access to bathrooms, and limited equipment to safely
mobilize; all of these issues contribute to functional decline for the elderly (Kelley, Parke, Jokinen, Stones
and Renaud, 2011). Because of a system that is focused on rescue and prevention of crisis, rather than
attending to basic geriatric principles, the elderly patient is at significant risk of harm (Sloan 2009). Older
adults also experience higher rates of adverse health outcomes after discharge (Aminzadeh and Dalziel,
2002, Parke and McCusker, 2008) and readmission rates of elders >75 years averages 42% (Novak and
Campbell, 2010; Robertson, 2010; Roterman, 2006).
Parke and Brand (2004) describe how the complexity of older adults entering a hospital presents staff and
administrators with significant challenges. “Not only must the care provided respond to an acute
healthcare crisis, it must take cognizance of the developmental phenomena associated with aging and the
likelihood that chronic diseases are present, compounding both diagnosis and treatment” (p. 62). Few
hospitals have practice guidelines, educational resources and administrative practices that support best
practice care of older adults (Mezey, Kobayashi, Grossman, Firpo, Fulmer and Mitty, 2004; Boltz et al.,
2008).
Some hospitals have integrated units which specialize in acute care for elders (ACE units) or short term
geriatric assessment units (GAUs) (Rodriguez, Kergoat, Latour, Lebel & Contandriopoulos, 2003; Del
Giudice et al., 2009; Kay, MacTavish, Moffat and Lau, 1992). While these units provide excellent,
comprehensive assessment and care to elders, the disadvantage is that the care affects only a small portion
of the inpatient geriatric population. In other words, a few seniors receive “Cadillac” care, while the
majority receive usual care. In addition these units are costly to maintain and statistics do not reflect that
the units decrease length of patient stay. Other hospitals have chosen to support interdisciplinary geriatric
teams that serve the hospital as a whole.
In order to optimally care for this patient population in the hospital, acute care nurses require specialized
geriatric knowledge and skills (Parke, Ross and Moss, 2003; Boltz et al., 2008). Despite the fact that
older patients represent the majority of hospital patients, older adults rarely receive this type of care in
part because this type of specialty is not often valued in acute care settings. Nolan and Tolson (2000)
reported findings in the United Kingdom where the “specific needs of older people in general hospital
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wards were not adequately identified or addressed [and describe] restrictive and poorly applied care
practices in which basic aspects of nursing were deficient” (p. 39). Most acute care nurses are not aware
of the Canadian Gerontological Association (CGNA) Gerontological Nursing Competencies and
Standards of Practice (2010), that they represent minimum standards and competencies for nursing care of
this population, or that they apply to their acute care practice; “lack of academic preparation or
certification in geriatric nursing is a pervasive and long-standing problem that is recognized
internationally” (Boltz et al., 2008).
On the other hand, it is widely accepted that nurses require specialized knowledge and skills to care for
other specialized patient populations, for example paediatric, cardiac and/or patients requiring intensive
care. Cheek (2004a) explains this situation in terms of discourse, how certain discourses are given the
stamp of approval and others are absent, marginalized and oppressed. In the health care arena the
challenge is to question “correct or accepted ways of acting and thinking” (p. 1141). These questions
include the way that health care is represented, and “why this representation is the one accepted as
‘normal’ or ‘given’ [and] what are the alternate ways of representing the same reality” (2004b, p. 56).
Possibilities
Opening the discussion of how to do things differently has prompted hospital administrators to espouse to
a patient-and family-centered care philosophy (DiGioia, Embree and Shapiro, 2009; MacDonald, 2010)
and consider elder friendly hospital environments (Parke and Friesen, n.d.; Parke and Brand, 2004). The
hospital where I practice (Kelowna General Hospital) is in the process of adopting some of these
strategies; for example, renovations are underway to implement some of the recommendations for
physical design components for an elder friendly hospital (Parke and Friesen, n.d), including changing the
colors of walls from cooler tones to warm colors which are easier for older adults to see, and painting the
handrails a color that contrasts with the floor and the wall. In addition, a new ED department (slated to
open in 2012) will incorporate a number of designs especially for the aging patient including:
 Technology such as Vocera and integration with Rauland 5 Nurse call which will decrease the need
for overhead paging and thereby decrease noise throughout the department
 Data capacity for future bedside pressure alarm systems and electronic documentation
 Softer lighting with decreased glare; in some areas patients will have the ability at the bedside to dim
or turn lights off
 Natural light maximized where possible
 Larger stretcher bays which can accommodate a family member at the bedside
 Private rooms available in all zones for intimate conversations with patients and families
 Flooring which contrasts to indicate a change in function (reception, main wayfinding)
 Washrooms fully equipped with hand rails and non skid flooring.
In addition to environmental changes, the hospital is also undergoing changes to the interdisciplinary
Geriatric Team, now titled Geriatric Consult and Action Team (GCAT). I am new in the CNS role on this
team. When I communicated my role to my nursing colleagues they automatically assumed that I would
be working in residential care. To most nurses, geriatrics equates to residential care, not acute care.
Therefore, although the role encompasses residential care, community integrated health services and acute
care, I chose to focus initially on acute care at KGH. Although this role was new to me, it was not new to
KGH. The individual previously in the position retired in May 2010; the position was vacant until I
moved into it in November 2010. As well as the CNS, the team consisted of a Physiotherapist, an
Occupational Therapist and (as of June 2010) a Geriatrician. The team has been in operation for over 10
years, however research (Kjorven, 2009, Kjorven, Rush and Hole, in print) revealed that while other
support teams were highly visible within the hospital, the geriatric team was invisible. Nurses either did
not know it existed or did not understand how the team could support their practice.
Therefore, one of my goals in this role is to support the team to not only make gerontological care visible
and valuable in acute care, but to build capacity in front line care providers to optimally care for this
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population. By the time I was hired, work was already underway to enhance the team; funding had been
secured to add a Geriatric Nurse and a Rehab Assistant. Historically the purpose of the team was focused
on screening geriatric patients in acute care for convalescent care; the new purpose reflects an
interprofessional, patient and family centered approach in order to optimize outcomes for the geriatric
patient in acute care. The objectives of the team are to:
 Raise awareness of the impact of geriatric syndromes (Inouye, Studenski, Tinetti and Kuchel, 2007)
and principles of elder friendly culture through role modeling and education;
 Provide consultative services for comprehensive geriatric assessment and care planning to the unit
specific care team;
 Work collaboratively with front line care providers to support and facilitate the implementation of
care delivery that optimize function and maintain patient independence;
 Prevent iatrogenesis frequently associated with acute care hospitalization of the geriatric population.
The direction for the team follows other established, evaluated and validated teams (Parke, Ross and
Moss, 2003; Parke and McCuster, 2008).
As an advanced practice nurse working in a CNS role, I am involved in clinical practice, education and
research and the larger component of my focus is on the patient population and program development
rather than primary care (Fulton, 2011; Roberts, 2009). As part of the redevelopment of the geriatric team
and geriatric program, I am tasked with addressing the recommendations from the Geriatric Services
Review (Interior Health, 2008). This includes developing and implementing evidence based screening
tools to identify at-risk frail elderly patients and clinical guidelines to target geriatric syndromes (Inouye,
Studenski, Tinetti and Kuchel, 2007). I must admit that I have a love/hate relationship with standardized
protocols for this population; I believe this population is better served with individualized, specialized
care. However, I also believe we need a place to start, and I believe identifying those at risk, and
intervening to reduce and manage the risk, is that place.
Conclusion
I believe there is no better time and there are great possibilities to create a cultural shift toward
gerontological enrichment in acute care settings. However, as Parke, Ross and Moss (2003) emphasize,
in order to be successful it “is more than what nurses need to know; it is about how nurses implement
change and go about learning in hospitals” (p. 311). The first step to creating a change according to
Lewin (as cited in Marquis and Huston, 2006) is to unfreeze, to question the status quo and the taken-forgranted practice. Once the dominant hegemony is questioned, room can be made for new possibilities.
Senior management has a role to play in improving hospital experiences for older adults. It is everyone’s
responsibility to make certain our health care leaders are making the right decisions for quality and safety
of all patients, including our most frail.
References can be requested from Mary.Kjorven@interiorhealth.ca
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