NICHE HISTORY

 

Dr. Terry Fulmer, Dean of the NYU College of Nursing, initiated the Geriatric Resource Nurse (GRN) model in 1981 at Boston’s Beth Israel Hospital. The unit-based GRN nurses provided consultation to other staff nurses regarding specific geriatric clinical syndromes. Anecdotal staff feedback indicated that this was a very successful approach to improving care of the elderly by creating standard protocols for common geriatric problems and enhancing the expertise of staff nurses. (1)

 

As part of the Hartford Foundation’s Hospital Outcomes Program for the Elderly (HOPE) multi-site initiative, Dr. Fulmer and colleagues adapted the Geriatric Resource Nurse model within a geriatrician-led care team at Yale New Haven Hospital. (2)

 

References

(1)   Fulmer, T. (2001). The geriatric resource nurse: A model of caring for older patients. American Journal of Nursing, 102, 62.

(2)   Inouye, S.K., Acampora, D., Miller, R.L., Fulmer, T., Hurst, L.D., Cooney, L.M. Jr. (1993).  The Yale Geriatric Care Program: a model of care to prevent functional decline in hospitalized elderly patients. Journal of the American Geriatrics Society. 41(12),1345-1352.

 

Based on the success of the models developed in the HOPE program, the John A. Hartford Foundation provided funds in 1992 to New York University (NYU; Drs. Terry Fulmer and Mathy Mezey) and the Education Development Center, Inc. (EDC) to field-test the nursing care models in the broader hospital community. The HOPE field-test project thus became known as Nurses Improving Care for Health System Elders (NICHE) and aimed to create a better care environment for the hospitalized elderly patient by improving nursing practice. An advisory board of geriatric nursing experts helped to develop protocols to guide nursing practice in the assessment, prevention, and management of four conditions/interventions that lead to functional decline and other complications among the hospitalized older adult patient: pressure ulcers, incontinence, sleep disorders, and the use of physical restraints.

 

These protocols served as the basis for the Geriatric Institutional Assessment Profile (GIAP), an instrument designed to help hospitals analyze the needs of their elderly patients and determine gaps in geriatric care provision. The GIAP format was based on the Decisions Near the End of Life model for bioethics developed by staff at EDC and the Hastings Center. Click here to read more about the GIAP.

 

In order to locate sites to implement the newly developed nursing standard of practice protocols and the GIAP, and to present the HOPE nursing models, NICHE staff convened four workshops linked to national professional nursing meetings reaching more than 250 nurses. At these conferences, staff solicited proposals from hospitals around the country to participate in the implementation and evaluation of NICHE activities. Twenty-three hospitals applied to participate. Four sites were selected to field-test the NICHE tools and processes. They represented a diverse mix of staffing structures and administrative priorities, as well as geographic regions and an urban-rural-suburban client base. These sites were:

• The University of Virginia, Charlottesville, Virginia,
• North Iowa Mercy Health Center, Mason City, Iowa,
• University of California, Davis Medical Center, Sacramento, California, and
• Methodist Hospital Of Indiana, Inc. Indianapolis, Indiana

The evaluation documented improvements by surveying staff before and during the implementation of NICHE regarding their perceptions of geriatric care and using quality assurance, risk management, and human resources allocation data from the four NICHE sites.

In addition, the evaluation examined the processes by which sites were able to achieve these outcomes, the characteristics and elements of strategies across sites critical to success and the barriers and disincentives that affected NICHE implementation. Through semi-structured telephone interviews with key field-site staff and site visits, including individual and focus-group interviews with hospital staff, the details of how NICHE works became more defined. The following organizations joined the original four field-test sites: Bassett Health Care, Baystate Medical Center, Charleston Area Medical Center, Barnes Jewish-Christian Health System, and New Rochelle Hospital Medical Center. (3)

 

The findings from these field tests resulted in the NICHE Tool Kit that includes the following:

· The NICHE Planning and Implementation Guide

· Effective nursing care models, a variety of nursing approaches to care implemented and tested around the country that can reorganize nursing care to more efficiently and effectively meet the special needs of acutely ill elders. These include the Geriatric Resource Nurse (GRN) model and the ACE (Acute Care for Elders) models.

· Action plan worksheets to help key staff devise a plan for improving geriatric care based on gaps identified through assessment

· Revised Geriatric Institutional Assessment Profile (GIAP)

· Expanded clinical practice protocols that reflect the standards of nursing practice on 13 important geriatric syndromes

 

Reference

(3) Fulmer, T., Mezey, M., Bottrell, M., Abraham, I., Sazant, J., Grossman, C., et al. (2002). Nurses Improving Care for Healthsystem Elders (NICHE): nursing outcomes and benchmarks for evidence-based practice. Geriatric Nursing, 23 (3), 121-127.

Since 1996, NICHE has been an integral program of the Hartford Institute for Geriatric Nursing. Among the many accomplishments during this period include expansion of the NICHE Tool Kit and NICHE Resources. Examples include:

· An Annual Conference in New York City, featuring a Leadership Conference for new sites, a Clinical Update Conference, and a User’s Conference for established NICHE sites

· Revised Clinical practice protocols complemented by the Hartford Insitute for Geriatric Nursing’s Try This Series. These protocols are published as a book (1^st edition in 1999, 2^nd edition in 2003, & 3^rd edition in 2007)

· Partners for Dissemination of Best Nursing Practices in Care for Older Adults Curriculum Guide, comprised of 21 pertinent topics, available on CD-ROM that includes fully organized clinical leadership designs and staff inservice plans.

· Sample course outlines in geriatric care illustrating how hospitals developed continuing education programs to parallel the implementation of NICHE models and protocols

· Geriatric nurse competencies for use by staff nurses, managers, and staff developers to evaluate an individual’s skill and knowledge of geriatric nursing care.

· A national listserv wherein NICHE sites, with interdisciplinary input, share resources and information around care of older adult patients.

 

Thus, NICHE has grown to include a national network of hospitals that share lessons learned, and collaborate to inform the further development of resources at the NYU College of Nursing.

In 2003 NICHE was expanded with three new initiatives. Marie Boltz, MSN, RN was hired as the first geriatric advanced practice nurse to lead the practice initiatives of the Hartford Institute. Next, the GIAP Benchmarking Service was moved to NYU under the direction of Susan Fairchild, MPH and, third, Dr. Liz Capezuti joined NYU & the Hartford Institute to initiate a GIAP Research Group which analyzes the GIAP database. NICHE experiences a significant “growth spurt” but is limited its ability to enlarge.

 

In 2006 the Hartford Institute received funding from Atlantic Philanthropies (U.S. Ageing Programme) to develop a business plan to expand its organizational capacity, which resulted in funding for this plan in 2007. The grant from Atlantic Philanthropies (U.S. Ageing Programme) will help NICHE to build its internal capacity, improve dramatically the program’s “toolkit”—particularly its measurement and reporting capacity—and initiate outreach to accelerate adoption of this program by additional hospitals.