In 2008 the newly endorsed national Consensus Model for APRN Regulation: Licensure, Accreditation, Certification, and Education (LACE) specified that the certified nurse practitioner (CNP) must be educated and practice in at least one of six population foci: family/individual across the lifespan, adult-gerontology, pediatrics, neonatal, women’s health/gender-related, or psych/mental health. Prior to development of the consensus model, there were separate adult and gerontology nurse practitioner programs. This change may seem on the surface to have been a big loss to the field of geriatrics, but in truth it is an enormous gain. In 2008, for example, only 137 students in 62 programs became geriatric nurse practitioners as compared to 1,171 students in 145 programs who became “adult” nurse practitioners. Even though “geriatrics” was not their explicitly stated area of specialization, adult CNPs were seeing almost as many older patients as geriatric specialists. Merging these specialty areas puts geriatrics right where it should be--in the mainstream of nursing, where the vast majority of students can gain competence in caring for older adults.
Following the decision to educate nurses to care for the combined adult-gerontology population, several stakeholders have come together to facilitate this transition. The Gerontology Primary Care Nurse Practitioner (NP) Competencies, generously supported by the John A. Hartford Foundation and developed in collaboration with the American Association of Colleges of Nursing, the Hartford Institute for Geriatric Nursing at New York University, and the National Organization of Nurse Practitioner Faculties, are an important step forward in response to the 2008 LACE revisions. Not only did we want to have the general LACE framework and competencies, but we also wanted to develop a specific set of expectations and outcomes for adult-gero nurse practitioners who train to become primary care providers.
A national panel of experts developed the competencies to help guide the merging process. The panel combined the expertise of adult and gerontology nurse practitioners in acute and primary care settings as well as education. As we start a new academic year, I anticipate that many nursing programs are reviewing their curriculum—with some trepidation--to be sure they are meeting these new competencies. Yet, despite the short time we have with students, I am confident that with good communication and working systems between adult and geriatric faculty, we can all meet the new expectations. As developed, the competencies simply provide the road map to assure we cover all of the critical components necessary for entry-level nurse practitioners who will be working with adult patients of every age.
One of my favorite examples of how the competencies serve as a guide and reminder to address the critically important differentiation between care of young, middle-aged, and older adults is how they address health promotion, particularly screening. The Health Assessment competency reads as follows:
These competencies describe the role of the adult-gerontology primary care NP in terms of health promotion, health protection, and disease prevention. The adult-gerontology primary care NP employs evidence-based clinical practice guidelines for screening activities, identifies health promotion needs, provides anticipatory guidance and counseling to address environmental, lifestyle, and developmental issues.
What this means is that all advanced practice nurses need to know and understand how to thoughtfully use and apply screening guidelines to those on the older end of the aging continuum. Older adults should not be screened with the same guidelines as younger or middle-aged adults. Borrowing from the approach used in gerontological nurse practitioner programs, education further stresses the available evidence, or lack thereof, for screening in adults with life expectancies that may be less than 10 years and or for those who are simply greater than 65 years of age. While individuals can still make choices about whether or not to undergo tests such as mammography, it is critical that advanced practice nurses do not promote needless, futile, and even dangerous screening to their older patients. The competency reminds us to address this full spectrum of care needs and care decisions.
Having participated in the merging of our adult and gerontological nurse practitioner program at the University of Maryland, I appreciate the many challenges that arise in terms of weighing content and time and providing students with all the material needed to graduate, pass certification exams, and practice safely as entry-level providers. We did not have the benefit of the competencies at the time we revised our program. I believe the competencies can help others make some of those difficult decisions around what might need to be cut from a lecture or what might need to be highlighted repeatedly.
Let us also get the big, old white elephant on the table: the competencies can make sure we do not put forth programs that are gero-light! Nursing programs working on merging their gero and adult programs should consider each competency carefully and how they can address the continuum of aging in a single lecture/class or course. As we developed these competencies, we enjoyed many wonderful conversations around important issues and content that students would need to understand, such as environmental safety and sexuality from the teen years to those 100 years of age and older. Thus not only can we cover the material, but we can do it in a way that is fun and stimulating for the learner!
So, again thank you to the John A. Hartford Foundation for being willing to support this endeavor and to the many organizations and individuals who gave their time to the development of the competencies. I encourage us all to use these competencies as an opportunity to teach all adult-focused advanced practice nurses to provide exemplary care to all older adults in our country.
Barbara Resnick, Ph.D., CRNP, FAAN, FAANP, is Professor of Nursing at the University of Maryland School of Nursing.