Gerontological Nursing at the Heart of Effective Care for the Elderly

May 2013Kate Darby Rauch

In Caroline Stephens’ ideal world, frail nursing home residents would be a rare sight in emergency rooms (ERs), rather than the frequent visitors they are today. Many of the reasons for their ER visits are potentially preventable and can be safely managed without the trip to the hospital – a far safer, more comfortable option, says Stephens.

Stephens, who joined the faculty at UCSF School of Nursing last year, conducts research on how to improve medical care systems to minimize the need for frail older adults to make these disruptive trips to the hospital. She’s compelled to share and build her knowledge with future nurses, so they too can have an effect on geriatric care.

“I’ve always been passionate about engaging, educating and empowering nurses and other providers to better understand and address the complex physical and mental health needs of older adults,” she says.

Early Caregiving Experience

Caroline Stephens Stephens believes nurses are ideally positioned to take the lead on geriatric care management because, “We have a holistic approach versus a disease-oriented approach.”

Too often, she says, medical care of the elderly focuses on treating an illness without carefully considering the patient’s overall comfort, strength, function, cognition or even wishes. Doing so can be especially tricky in the care of older adults with cognitive impairment, including those in nursing homes, because many of these patients can’t express details about what’s bothering them.

In many cases, dialing 911 or heading to the nearest ER is the most prudent option. But this is where the insights from a gerontological nursing perspective – that sense of a whole person – can make a marked difference. Stephens uses a deeply personal anecdote to illustrate her point.

She became familiar with the world of chronic disability at age 6, when her mother was permanently institutionalized for mental illness and, later, dementia. Then, while Stephens was in middle school, her father developed early-onset Alzheimer’s; by high school, she was the caregiver for both of her parents.

As her father’s condition declined and he was institutionalized, Stephens was struck by how often he wound up in the emergency room for “acute confusion,” after becoming agitated by an undiagnosed urinary tract infection.

“Instead of determining and addressing the underlying medical cause for his behavior change, the nursing staff often sent him to the emergency department on a 5150,” she says, referring to the California law that allows a qualified officer or clinician to involuntarily confine a person with a mental disorder who is a danger to himself and/or others. “Invariably, eight hours later my father would return to the facility more confused, disoriented and agitated, with new orders for antibiotics, psychotropic medications and physical restraints.… Each trip would hasten his decline.”

Stephens feels both of her parents’ primary medical needs were buried under their cognitive and behavioral issues, leading to medical complications that could have been prevented or treated earlier if caregivers were better trained in working with cognitively impaired patients.

“I soon realized that…many vulnerable individuals might be able to avoid serious functional and cognitive decline if the system [hospitals, nursing home, emergency care] was able and incentivized to appropriately meet their complex care needs,” she says.

From the Personal to the Professional

After earning her PhD in gerontological nursing and health policy at UCSF School of Nursing and completing two postdoctoral fellowships in the field, Stephens was hired as an assistant professor in 2012. A licensed gerontological nurse practitioner and geropsychiatric advanced practice nurse, she’s also cared directly for frail elders in many settings, from home to nursing home to hospital.

“I try to infuse a strength-based versus a deficit-based approach,” Stephens says. “With aging, this means rather than a ‘Wow, they can’t walk, they can’t eat, they can’t XYZ,’ I turn this on its head to focus on what people can do. How can we channel their strengths and maximize their quality of life?”

She thinks of the nursing home resident with dementia who was labeled as problematic for his night wandering – he’d spent his career as a nighttime security officer and couldn’t adjust to the mandatory bedtimes. Instead of forcing him to sleep with medication, Stephens devised a plan for him to join the night nurse on rounds “making” a security check, complete with clipboard and badge. “He loved his ‘new job’ – it gave him a sense of meaning and purpose. He felt important, not unwanted.”

And there was the retired hospital clerk, also with dementia, who was bothering nursing home staff with her insistence on helping. Stephens arranged for her to volunteer officially three days a week, reporting for duty at 9 a.m. for an assignment of tasks. “By focusing on her strengths and desires to be helpful, we were able to reduce the conflict with the staff, and her mood and behavior improved.”

Recently awarded a UCSF Clinical and Translational Science Institute (CTSI) KL2 scholarship, Stephens is currently investigating how to use technology to access clinical expertise and improve care coordination remotely.

Her past research includes studies on emergency department use by nursing home residents (published in Gerontologist), transitional care challenges of rehospitalized veterans (Population Health Management), care coordination for cognitively impaired older adults (Home Health Care Services Quarterly) and transitioning cognitively impaired patients from hospital to home care (American Journal of Nursing). In all of these situations, the nurse’s role is essential.

“At almost every step in the care of both of my parents, there was a nurse at the core of the team who really made the key difference,” Stephens says. “When I was making extremely difficult end-of-life decisions for my father, it was a gerontological nurse practitioner who guided me through that challenging process – a gift for which I am eternally grateful.”

Caroline Stephens' work has been funded by, among others, the National Hartford Centers of Gerontological Nursing Excellence Patricia G. Archbold Scholars and Claire M. Fagin Fellows programs and the VA National Quality Scholars Fellowship program.