However, one Philadelphia hospital strives to be anything but typical when caring for its elderly population, thanks to its nurses.

Music, Activity

Consider a scenario where big band music is infused into a communal area, while rounds of bingo and cards are played. On another day, black-and-white movies are shown while furry visitors greet patients as part of pet therapy.

Lucky for the patients on the receiving end of all that activity at the Magnet-designated Hospital of the University of Pennsylvania (HUP), because the hospital is on track to maximize their function and dignity during their stay.

All of this is the result of a systematic nurse-directed initiative called NICHE (Nurses Improving Care for Healthsystem Elders) designed to enhance care of the elderly. This one-of-a-kind program, already implemented in some hospitals around the nation, is just taking hold at HUP and has required dozens of hours of education for HUP's participating nurses.

In fact, since the official NICHE designation was announced in November, a positive impact has taken hold in the emergency department, surgery and neuroscience/neurology.

"NICHE provides a pathway and blueprint for us to adhere to - and everything is evidence-based," said Thora Warrington, BSN, RN, CNRN, who works on the neuroscience floor and is one of the NICHE geriatric resource nurses.

NICHE & Magnet Compatible

A NICHE designation does not interfere with a Magnet designation. In fact, it works alongside a Magnet designation, according to Warrington. Essentially, NICHE allows each unit to implement different interventions to keep the geriatric population more involved in their own care, at a more highly functional and physically mobile level.

"We learned NICHE married the HUP philosophy and our initiative toward patient- and family-centered care," said AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN, ED clinical nurse specialist and clinical lead for NICHE. "This was not a flavor-of-the-month type of thing. It incorporates sound evidence-based practices but also involves the frontline nurses' ability to translate them into practice."

In addition to fall prevention precautions already taken at HUP, simple changes to the way nurses are practicing enhances care of the elderly. Paul T. Harrington, MSN, MBA, RN, clinical director for surgical nursing and administrative lead for NICHE, describes it as "a full-court press" to get staff to understand the needs of the geriatric population are unique.

Why the Change?

After being introduced to NICHE last year by a colleague with a gerontological background, HUP nurses decided to take on the challenge of entering into NICHE designation. So last April, about a dozen HUP nurses from all staff levels attended a NICHE conference in Baltimore to learn all they could about the program and bring it back to the hospital.

"They were very enthusiastic and thought it was a great opportunity for us to invest in their professional development," said Harrington. "So we signed up and started our journey."

One of the biggest eye-openers for nurses who attended the conference was how much function is lost once elderly patients enter the hospital. "They lose function and maybe only 10 percent is regained," said Barbara Young, BSN, RN, CEN, a staff nurse in the ED who attended the conference.

The reason, Young explained, is as a whole, patients are completely cared for at the hospital rather than encouraged to care for themselves. "We do everything for them: bathe them, help them eat, dress them . but we don't realize we should be encouraging them to do these activities themselves."

That's where the loss of function starts, she added, and where changes in nurses' thinking should occur.

How Change Is Good

After going through education and training, Young has taken what she learned, educated other nurses and techs, and started applying it to the ED. For example, now when elderly patients come through the ED, instead of immediately putting ambulatory patients in a wheelchair and wheeling them from spot to spot, the ED nurses encourage these patients to walk. This helps keep them active and discourages pressure ulcers - a known problem for hospitalized elderly patients and major prevention focus of the NICHE program.

Another step is asking patients to undress right away even though they may not want to. The reason is to assess their skin for areas of tissue breakdown and document any concerns before the patient is put on a stretcher.

Nurses in the ED are also moving the patient from the thin, hard stretcher to a regular bed as soon as possible. "If we can't get them in a bed upstairs right away, then we'll try to put them on a regular house bed [in the ED]," said Young. "We're looking into the development of a redistribution mattress for us [to help prevent pressure ulcers], but that's a long way off," he added. Until then, lower-cost common-sense measures are in place.

A further step the ED is taking is installing ceiling lifts in every exam room as part of the ED's new "no-boost" initiative. This alleviates the need for nurses to lift or boost the patient onto the bed and prevents skin sheering.

Fitting in Time for Fun

NICHE-designed care is not just about medical interventions; it's also about mentally engaging the elderly. For example, in the neurology department, nurses are moving elderly patients out of bed more and involving them in activities like music, bingo and card playing in a nearby conference room. This is not typical for a hospital neurology unit, but nurses have found a social environment helps stimulate thought and interactions.

"We get to know patients better because they share more about themselves when they're getting out of bed. We understand their limitations more fully because we see their degree of interaction, so our care is even better developed," said Warrington. For example, when patients are out of bed they're more likely to say they need to use the bathroom, so it helps with toileting; nurses are noticing fewer incidents of incontinence. There's also a decrease in falls because patients are not alone all day. "It enhances their 'dignity' because it allows them to feel [they are] part of this environment and not just a number," she added.

To further confirm the benefits, neurology nurses conducted a mini interview for patients and families about the activity level with the new initiatives. The feedback was nothing but positive. And the program went from being held 3 times a week to every day. Plus, "patients are in a much more cheerful mood," observed Warrington.

While it sounds like more attention to the elderly would take more time from already time-strapped nurses, NICHE nurses say that it doesn't have to. RNs can delegate using their own staff for some of the initiatives; otherwise, volunteers can be trained to help. And in the ED, techs will be educated and used more, in addition to med student volunteers. "It doesn't have to take more time," said Young. "It's a mindset - a change in perspective and attitude."

Where It's Headed

Although it's still too early for NICHE nurses to tell exactly what advances have been made with patients, more understanding will evolve as the program moves ahead and additional feedback is received from nurses, patients and families. At this point, Young is also in talks with the pharmacy department to evaluate patient med lists and identify medicines that can be harmful for the elderly, so they can, in turn, inform the attending physician.

Papa foresees that every floor of the hospital will have access to a NICHE geriatric resource nurse for consultation as soon as possible. Also, nurses are hopeful of partnering with an inpatient "physician champion" so NICHE initiatives are understood at all levels. Additionally, Papa plans to publicize NICHE projects nurses have completed to inspire others to do more.

"[NICHE] is really a wonderful way to ensure care the elderly receive is world class," said Papa. "To me, it's most exciting to engage that frontline nurse because this is something they really understand and it's in their language; they're the ones who drive it."

Christine McLaughlin is a frequent contributor to ADVANCE.