Respecting the Stories of Our Patients' Lives: NICHE Designation

January-February 2016



Andrea Eberbach
Everyone has a story to tell. Patients' medical histories, symptoms and diagnoses commonly relay stories to their health care providers. But looking beyond the medical to see the human element, the real stories of patients' lives, becomes even more important for a vulnerable patient population, a group that includes adults who are 65 years and older.


Here is an example: An immigrant married couple in their 90s, Johanna and Pieter (names changed for privacy purposes), lived in separate long-term care facilities because Johanna needed skilled nursing for high-level care. She had suffered a stroke and also had a history of dementia; Pieter, her husband of more than 50 years, resided in assisted living.

Johanna was admitted to the senior adult unit at Mercy Health Saint Mary's with a urinary tract infection. On the same day, Pieter was admitted with dangerously low blood pressure. During a visit to see her parents, one of the couple's three daughters told the nursing staff, "Whenever Mom is on the decline, Dad starts to falter, too. The same goes for him — when one experiences decline, the other follows suit."

In the hospital, Pieter was alert, but Johanna was confused. Staff members thought that if they could bring the two together, it would reduce confusion for Johanna. Pieter was too weak to travel within the unit, so the nursing staff brought Johanna on visits to Pieter. When she walked in and saw her husband, Johanna would light up. She spoke to him in their native Dutch and immediately reached out to hold his hand. Staff couldn't understand a word they were saying, but the love needed no translation.

Mercy Health Saint Mary's staff cared for Johanna and Pieter for four days, during which many visits between the two were arranged. Physical and occupational therapy for both patients was coordinated in Pieter's room. Pieter had a pacemaker implanted to control his heart rate, and Johanna's infection cleared up. In the meantime, Mercy Health Saint Mary's case managers collaborated and arranged for the couple to be discharged to a long-term care facility that provided different levels of care, so Johanna and Pieter no longer had to live apart. Learning and respecting their stories was crucial to their health, not to mention their happiness.

Every day in our country, 8,000 Americans turn 65, according to AARP. By 2030, senior adults are projected to represent 20 percent of the U.S. population. Such a significant number has many health care organizations like Mercy Health Saint Mary's in Grand Rapids, Michigan, a member of Trinity Health, turning to evidence-based practices and protocols to ensure they possess the appropriate tools, training and knowledge to care for senior patients with dignity, respect and clinically sound methods.

To create not just a staff and department but an entire hospital tuned into the senior adult story requires continuous dedication and effort. Mercy Health Saint Mary's began such an undertaking in 2009 with the initial goal of earning designation as a NICHE hospital, which would take 15 months.

NICHE, which stands for Nurses Improving Care for Healthsystem Elders, is an international program designed to help hospitals improve the care of adults 65 years and older. The program is based at the New York University College of Nursing in New York City.

"NICHE offered us the structure to complete an organizationwide assessment throughout our hospital and begin the journey to change processes and practices to improve care for seniors," said Liz Murphy, MSBA, RN, NEA-BC, FACHE, vice president and chief nursing officer at Mercy Health Saint Mary's. "Our local team at Mercy Health Saint Mary's believed that we needed to assure we had this level of physical facility and evidence-based practices for all of senior patients across Mercy Health Saint Mary's, regardless of where they enter or receive care."

Mercy Health Saint Mary's created an interdisciplinary steering team of leaders that included physicians, nurses, therapists, clinical pharmacists, social workers and support staff. This committee developed an analysis of the organization's current state, opportunities, strengths and weaknesses around geriatric care. The committee also conducted a survey throughout Mercy Health Saint Mary's to gauge staff perception and knowledge of geriatric nursing. The survey identified areas that would require additional education in order to achieve optimal outcomes for senior adult patients. Additionally, the steering team collaborated with NICHE on strategies.

These efforts resulted in Mercy Health Saint Mary's earning NICHE designation in August 2010.

While its NICHE designation process progressed, Mercy Health Saint Mary's also was preparing to open a new senior adult unit, a 32-bed acuity-adaptable inpatient unit focused on caring for patients 65 years or older with a medical diagnosis.

At that time, data analyses showed that across Trinity Health, nearly half of the patients who are admitted to the hospital are older than 65. Since this age group has unique needs, some of which include sight, balance, or different reactions to medications or unfamiliar places, the unit's construction and the education and training of the staff were tailored to best support those 65 or older.

Led by physician champion James Passinault, MD, some of the training and preparation for the unit's specialized care and culture involved the collaboration of an interdisciplinary team, on-site training sessions led by a national expert, and nursing and hospital leadership's attendance of the NICHE Leadership conference in 2010.

The senior adult unit's evidence-based design principles included all private rooms, soft lighting, noise-absorbing materials, recliners, non-glare and slip-proof floors, convenient grab bars and an inviting color scheme. The unit opened for patients in early 2011, but even before then, it was determined that a clinical nurse leader (CNL) would be a valuable asset.

Enter Bridget Graham, MSN, RN-BC, CNL, one of 17 Saint Mary's nurses who earned her master's degree as a clinical nurse leader in 2010. To be accepted into the program funded by Trinity Health, these CNL hopefuls were interviewed and selected by hospital leadership to ensure they had certain qualities and skill sets required of a clinical nurse leader.

Starting her nursing career at Mercy Health Saint Mary's in 2004, Graham had first worked in the intermediate care unit and then neurology. She quickly proved herself as a leader, as she began working as a charge nurse and then advancing to become a nurse supervisor.

"While I was in school for my master's, I had no idea I would be called to care for the senior adult," Graham recalled. "I figured I would continue working in my current unit, in neurology."

However, Mercy Health Saint Mary's nursing leadership envisioned that the CNLs would bring a fresh perspective to a new environment with their roles, and would not necessarily be working in the departments where they had previously worked.

With Graham's experience in intermediate care and neurology, caring for the geriatric population seemed like a logical next step for her career as a clinical nurse leader.

"I could apply many of the skill sets I had acquired while still being challenged by learning something new, the field of gerontology," she said.

Graham recently marked five years' tenure as the senior adult unit's CNL and has earned her board certification in gerontology. She is one of Mercy Health Saint Mary's more than 70 nurses board-certified in gerontology, including those who work in surgery, intensive care, oncology and neuroscience, and 25 other nurses on the senior adult unit with Graham.

The evidence-based materials provided by NICHE have assisted Graham in many ways on the senior adult unit, including the initial and continual hiring processes.

"After we hire staff for our unit, we prepare them with NICHE materials available to us as a NICHE-designated system. These assessment tools are validated and reliable, so we use them to train our staff to being able to care for this level of patient. Many of our hires for this unit's opening in 2011 came from a medical/surgical unit, so they needed much training," said Graham. "We interviewed them individually to see if they each had a passion for caring for this type of patient and ability to meet the needs of the senior adult. You can teach the skills, but you can't teach the passion for caring for this patient population."

Within a year of being hired to this unit, all patient care assistants are required to complete a Geriatric Resource Nurse (GRN) model from NICHE.

"Caring for these patients requires a specialized skill set and level of compassion, one that isn't necessarily needed when caring for a 20-year-old," said Graham.

Mercy Health Saint Mary's staff has adopted the GRN model from NICHE throughout the organization, since patients 65 and older are located throughout the hospital, not just in the senior adult unit. The emergency department is another extremely important unit for senior adult care — many times it is where a senior's hospital visit starts. Fully 45 percent of Trinity Health patients who are admitted through the emergency department are 65 years or older. Located on the ground level of the Hauenstein Center on Mercy Health Saint Mary's campus in Grand Rapids, the emergency department was opened in early 2009. During its planning phase, emergency response personnel, nurses, physicians and patients were consulted on how to create a department that would better meet the needs of those working in, being treated in, and even those visiting the department.

Special attention was paid to details that would make the senior adult as comfortable as possible. Physical amenities include clocks placed in every room to help orient patients to the time, non-skid floors, audio and sight enhancement equipment as needed, ambient lighting, private rooms, extra-thick mattresses and warm blankets. An in-department pharmacist is available during the department's peak hours to better care for the senior adult. The emergency department staff uses the Confusion Assessment Method, a model provided by NICHE, for delirium screenings on all patients over 65 years of age who are being admitted to the hospital.

Perhaps even more important than high-quality, in-hospital care for the senior adult is preventing their admission in the first place.

Thanks to NICHE principles and guidelines, 12 nurses from the Mercy Health Saint Mary's Senior Adult Unit are presenting seminars for the staff of local long-term facilities. Centered on caring for the dementia patient, the goals of these seminars are to reduce hospital admissions from long-term care facilities and to prevent agitated behaviors within the dementia population.

"As a NICHE-designated facility, we are taking the effective measures for our patients outside the hospital walls, and through collaboration with these long-term care facilities to provide quality, evidence-based care for all people who need it, we hope to prevent future hospital stays and increase quality of life for seniors in our community," said Graham.

In February 2014, Mercy Health Saint Mary's achieved NICHE Exemplar status. At the time, Mercy Health Saint Mary's was one of fewer than 30 hospitals in the nation that had earned Exemplar status, the highest of four possible program levels. It required a rigorous self-evaluation of the current state and future goals of the NICHE program at Mercy Health Saint Mary's. The NICHE organization recognized Mercy Health Saint Mary's for incorporating NICHE principles and introducing the geriatric nurse model throughout the entire organization, as well as for achieving outcomes such as better length of stay, a better admission rate and outperformance in nursing-sensitive indicators, such as falls, pressure ulcers and bloodstream infections.

The senior adult unit has implemented many direct learnings from NICHE, with one of the favorites being the therapeutic activity closet, filled with activities for patients, available to staff 24 hours a day.

"This closet is designed for three different levels of cognitive impairment," said Graham. "Before we had the closet, there were no easy methods to soothe patients who were agitated."

All that has changed. Today, staff can go into the closet, easily spot the appropriate section of cognitive impairment for their patient within the closet and select an activity or toy that will help soothe their patients.

"This closet gives us options to help our patients," said Graham.

One such patient who now had options was an agitated elderly woman. Due to her severe cognitive impairment, the nurse selected a baby doll for the patient from the closet. The patient immediately fell in love with the doll and named him after her father. When hospital staff came into her room, rather than being agitated as she had previously been, she simply introduced them to her baby doll, explaining where he had gotten his name.

"I have never seen her so calm," the patient's son told Graham later. "Can she keep this baby doll?" The staff agreed, and the patient was discharged, with her doll, back to her long-term care facility.

"This therapeutic activity closet is one of the things from NICHE that we can't always measure, but we see firsthand how it helps our patients, families and staff," said Graham.

D'ANNA SPRINGER is the clinical services manager of the senior adult unit and KRISTY TODD is the director of professional practice and development, both at Mercy Health Saint Mary's in Grand Rapids, Michigan.

Respecting the Stories of Our Patients Lives-NICHE Designation

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