From Controversy to Win-Win
Several years ago, the American Association of Colleges of Nursing (AACN) came to the Hartford Foundation with unsettling news. The AACN, in partnership with other nursing organizations, had developed a new, national consensus model for regulating the licensure, accreditation, certification, and education (LACE) of advanced practice registered nurses (APRNs), which would, in effect, mean the end of geriatric nurse practitioner programs as they currently exist.
The new LACE guidelines would merge the curricula and certification requirements of the previously distinct specialty of geriatric nursing with the much broader field of adult-care nursing for both clinical nurse specialists (CNSs) and nurse practitioners (NPs). Not only were those professionals who were committed to the field of geriatric nursing apprehensive, but as Rachael Watman, senior program officer at the Foundation, explains, “We were somewhat nervous that the gerontology piece would be watered down in the new curricula. We were concerned it would result in “gero-light” competencies, curricular resources, and certification exams.”
AACN was sensitive to JAHF’s concern. “Hartford had a stake in not wanting these programs to turn out nurses who were unable to provide quality care to older adult patients,” says Joan Stanley, senior director of education policy at the AACN and a co-facilitator in developing the consensus model. “To ensure that they really did provide comprehensive preparation to care for the older adult population, we came to the Hartford Foundation and suggested that we needed to create a set of consensus-based standards and competencies for these new or expanded programs in order to ensure nurses would have the knowledge and skills required in the care of older adults.”
As a result, JAHF requested that AACN submit a formal grant proposal. Hartford made the grant in 2008. The solution seemed a good one, although the transition wouldn’t be easy. For many, especially those already established in gero-nursing specialties, the new model proved difficult to accept, but unfortunately, the old way of doing things had produced disappointing results. “The Foundation had funded an effort to develop NPs in gerontology, but nationally the numbers of APRNs specializing in geriatrics were low and did not keep pace with the demographic need,” says Watman. “With the combination of adult and gero, we know that many, many more nurses will graduate with the skills to care for older adults.”
“We recognized that we were asking a lot of educators and practitioners in merging these competencies for such a broadly defined population,” adds Katherine Crabtree, professor in the Doctor of Nursing Practice Program at Oregon Health & Science University. “However, society’s needs cannot be denied. Nursing as a profession serves society rather than itself. Dr. Crabtree represents the National Organization of Nurse Practitioner Faculties—an important stakeholder in LACE—and co-facilitated the development of the new adult-gerontology competencies with Joan Stanley.
“In the past, much of the care for older adults was provided by adult NPs,” Dr. Stanley explains. “There were many more adult NP programs and graduates each year, and these numbers had grown. So as the population of older adults grew, we felt it was important to make sure that those NPs and CNSs who were caring for this population had the needed competencies.”
The statistics bear out Dr. Stanley’s contention. Annually, only 1.7 percent of all APRN graduates specialize in gerontology, and in the past schools of nursing were not required to incorporate the same depth of geriatric content and clinical experiences into the other NP and CNS curricula—despite the fact that older adults represent the largest population seeking care from APRNs.
To move the project forward, AACN partnered with the Hartford Institute for Geriatric Nursing at New York University to develop two sets of competencies —one for adult-gerontology primary care NPs and another for adult-gerontology CNSs. A third set, for adult-gerontology acute care NPs, is currently under development. As part of the process, AACN invited representatives from practice, education, and certification bodies, as well as other key adult and gerontology areas, to help form the expert and validation panels charged with developing the competencies. Next steps include developing curricular resources and faculty development opportunities to implement the competencies in the classroom. This effort will build on the past success of the AACN’s Geriatric Nursing Education Consortium project.
Many stakeholders seem happy with the results. Today, 46 national nursing entities have endorsed the LACE model,including all major APRN organizations. Phase II of the Hartford-funded project focuses on implementation. “We’re developing faculty materials to help educators implement the new competencies,” says Dr. Stanley. “We are also working with the accreditors and certifiers to ensure that the competencies are used in evaluating programs and graduates, and this work has been going very smoothly.”
“From AACN’s perspective,” continues Dr. Stanley, “we think creating the competencies is an extremely important first step in the implementation of the consensus model because education programs must change and evolve before the rest of the model is implemented. I don’t think everybody is 100 percent onboard yet, but most are beginning to realize that this change opens up new opportunities for APRNs to create various areas of specialization that build on the broad role and population-foci identified in the model.”
In addition, notes Watman, “The value of the competencies transcends nurses. Doctors, nurses, social workers—we all work together and should coordinate care for older adults. We are encouraged that other disciplines have shown interest in these competencies.”
Despite initial misgivings about the new LACE standards that merge the adult and gerontology specialties, it now seems that the addition of the new competencies has made this change a win-win for nurses and older adults alike. In the future, newly educated APRNs will be better prepared to provide appropriate care to older Americans. “In keeping with the National Organization of Nurse Practitioner Faculties’ development of standards for NP education,” says Dr. Crabtree, “these competencies offer a national standard for NPs’ scope of practice, which NP programs, state regulators, and national certifiers can adopt. In doing so, they provide direction for the educational preparation of nurse practitioners to serve the needs of the older adult population. Whether these practitioners become entrepreneurs, direct a medical home, or are employed by health care systems, they will bring new skills to bear on the design and implementation of care delivery.”
