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Celebrating Ten Years of Improving Health Care for Older Adults
Making Best Geriatric Practice
Standard Practice

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Strategy No. 2: Promoting Work Environment Changes

Nurses Improving Care to Healthsystem Elders (NICHE)

To assist hospitals in implementing systemic changes to achieve institutional improvements in geriatric care, the Hartford Foundation provided funding to the NYU Division of Nursing to launch Nurses Improving Care to Healthsystem Elders (NICHE) in 1992. NICHE has since been incorporated into the Hartford Institute for Geriatric Nursing. NICHE focuses on programs and protocols that are under the control of nursing practice; in other words, the areas where nursing interventions have a substantive and positive impact on patient care. Examples include preventing falls, assessing for delirium, assessing cognitive function, assessing pain, and preventing pressure ulcers and skin tears. The NICHE program currently has 198 active sites in 38 states as well as parts of Canada and The Netherlands.

NICHE hospitals use the educational resources of the Hartford Institute for Geriatric Nursing, but the program provides more than just content. "NICHE hospitals want to know how to put programs into place and how to write policies and procedures," says Dr. Capezuti. "It's not about just training one person, but rather how to embed certain practices into the system in a way that is ongoing and self-sustaining." NICHE does not prescribe how institutions should modify geriatric care; rather, it provides the materials and services necessary to stimulate and support the planning and implementation process.

The process usually begins with attendance at the NICHE Leadership Conference, a two-day meeting introducing new sites to the program and providing an overview of the available tools. The faculty of the conference are national leaders in gerontologic nursing, and representatives from mature NICHE sites often participate as well. The next step is the Geriatric Institutional Assessment Profile, a 68-item self-report survey that allows hospitals to assess staff knowledge and attitudes towards older adults and examine institutional barriers and support for quality geriatric care. It also helps identify issues and concerns of staff and provides baseline data that can be used to develop priorities for geriatric nursing care. The questionnaire evaluates knowledge and practice related to four common geriatric syndromes (incontinence, sleep, restraints, and pressure ulcers). The survey is available free of charge, but many hospitals using it contract with the Hartford Institute to analyze the results and provide benchmarks to guide care improvement programs.

To reorganize care of older patients, NICHE promotes two nursing care models. The first is the geriatric resource nurse model. About 12 percent of NICHE hospitals use a second nursing care model, which is an Acute Care for the Elderly unit as a venue to provide tailored services for older patients with complex medical problems. Visit the Hartford Institute for Geriatric Nursing Web site: www.hartfordign.org